PHP has a 90-day Continuity of Care period when all waiver claims are paid without prior authorization. During first 30 days of enrollment, the member’s assigned Care Manager will contact you to gather the information regarding the services you provide, discuss goals, and invite you to the member’s Life Plan (LP) meeting.
You will be expected to discuss any issues related to the member’s employment, goals, and supports needed. You will also have to identify the type of service the member needs (Extensive or Intensive).
PHP’s Life Plan serves as a prior authorization of services (Section IV). The Life Plan will include the type of service you are authorized to provide, along with the number of units authorized.
The standard authorization is for a 6-month period. No approval is needed from the DDRO.
Please note that authorizations for individual and group SEMP are grouped into a single authorization and separate authorizations for individual and group services are not necessary.
There is a separate distinction in the coding for Intensive SEMP and Extended SEMP and separate authorizations are necessary.
Additional units may be requested at any point during the LP cycle. The member’s Care Manager must be notified of your request so they can schedule an Interdisciplinary Team (IDT) meeting to assess the member’s need for additional units.
If the additional services are agreed upon, an addendum to the LP will be completed to reflect changes to the SEMP authorization. The DDRO is not part of PHP’s approval process (no SARF or SAM needed).
Any units billed in excess of the authorized units noted in the member’s Life Plan will be denied.
The member’s Care Manager must be notified as soon as the member’s services need to change to adjust the authorization accordingly to avoid claim denials (for example: change from Extended to Intensive).
No, PHP has the flexibility to waive this requirement.
This service is not a covered PHP benefit and continues to be funded by the State.
No. PHP issues new authorizations every 6 months, with the standard units of 100 hours for Extended and 125 hours for Intensive SEMP.
Please reach out to our Provider Relations team by using our ticketing system: https://www.phpcares.org/provider-assistance
- Select DD Agency and Claim or Authorization Issue to ensure your inquiry is routed to the correct team member
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