Service Type:
Agency-Directed ServicesConsumer-Directed Services

Assessment Date:

Recipient:

Medicaid ID#:

Provider:

Provider ID#:

DD WAIVER: WRITE THE AMOUNT OF TIME FOR EACH TASK TO THE NEAREST 15 MINUTES

This Section Must Be Completed in its Entirety for Agency- & Consumer-Directed Services

LEVEL OF CARE (LOC)

A (Score 0 – 6) Maximum Hours of 25/Week

B (Score 7 – 12) Maximum Hours 30/Week

C (Score 9 + wounds tube feedings etc.) Maximum Hours 35/Week

D Exceeds 35 Hours per Week

E Exceptions by Department

Reason Plan of Care Submitted:

New Admission

Increase in Hours

Decrease in Hours

Transfer
Reason for change/additional instructions for the aide:

Backup Plan (Person’s name) for CD Services:

Total Weekly Hours:

Plan of Care Effective Date:

Recipient / Care Giver Signature:

Date:

RN or SF Signature:

Date:

Instructions for the DMAS-97A/B (09/05)

Provider Notification To Client
This Plan of Care has been revised based on your current needs and available support. If you agree with the changes no action is required on your part. If you do not agree with the changes please contact the RN Supervisor who has signed the plan of care to discuss the reason that you disagree with the change. If the provider agency is unwilling or unable to change the information and you still disagree you have the right to an appeal by notifying in writing The Appeals Division The Department of Medical Assistance Services 600 East Broad Street Suite 1300 Richmond Virginia 23219. The request for an appeal must be filed within thirty (30) days of the time you receive this notification. If you file a request for an appeal before the effective date of this action ____________ (effective date) services may continue unchanged during the appeal process.

Instructions for Completion of the DMAS-97A/B

Category/Tasks
FOR DD WAIVER ONLY: Write the amount of time for each task to be done to the nearest 15 minutes. This should be done for each task for each day. Then put the total time for each category for each day.
OTHER WAIVERS: Place a check mark for each task and put the total time for each category for each day. Writing the amount of time for each task to the nearest 15 minutes is not necessary but it greatly assists in the review of authorization requests.
Level of Care Determination For Maximum Weekly Hours
Enter a score for each activity of daily living (ADL) based on the client’s current functioning. Sum each ADL rating & enter the composite score under the appropriate category: A B C D or E. The amount of time allocated under TOTAL DAILY TIME to complete all tasks MUST NOT EXCEED the maximum weekly hours for the specified LOC of A B or C. Check LOC D if the amount of hours per week exceeds 35. Category D can only be used with prior approval from DMAS or the PA contractor. Prior-authorization (PA) must be obtained prior to initiating a change outside the authorized LOC category.
Provider Notification To Client
Anytime the RN Supervisor or Service Facilitator (SF) changes the plan of care that results in a change in the total number of weekly hours the RN or SF must complete the entire front section of this form. If the change the agency is making does not require PA approval the RN Supervisor or SF is required to enter the effective date on the Provider Agency Client Notification Section which gives the client their right to appeal. The client should get a copy of both the front and back of the form.
PA Contractor Notification To Client
If the changes to the Plan of Care require PA approval the entire front portion of this form and the DMAS-98 must be completed and forwarded to PA contractor for approval. If supervision is requested please remember to attach the Request for Supervision form (DMAS-100). Once received by the PA contractor the analyst will review the care plan and indicate whether the request is pended approved or denied. The recipient will receive by mail the decision letter from the DMAS Fiscal Agent.
Recipient / Care Giver Signature
The recipient’s signature is necessary on the original plan of care and decreases to the hours of care. It is not needed if the hours increase in a new plan of care. The provider may substitute the signature with documentation in the recipient’s record that shows acceptance of the plan of care.

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