Frequently Asked Questions about ADvantage Program Forms
Q: What is the target date for these forms to be required by all agencies?
A: At this point, no target date has been set for the forms. However, due to new CMS performance measure expectations included in the new waiver renewal, agencies will be required to begin using the new 02CB011E, Service Plan Cost Sheet, and 02CB012E, Service Plan Cost Sheet Addendum, no later than June 1.
Q: What is the process for training case managers on new forms?
A: We are working on some instructional guides for each form. These will be sent out as we complete them and will hopefully address any questions you might have. If you would like to receive these guides, send an email to Provider Questions containing your name, agency, and email address. Other alternatives are being discussed to help make this transition easier.
Q: What if I have a question not listed?
A: Contact us at ProviderQuestions and we will be happy to assist you. As other questions come up, we will add them to this list.
Questions About Specific Forms
Q: How do I designate new forms that are not listed on the current ADv6f Checklist?
A: Until the checklist is updated, list forms under their current designation. For example, the 02CB011E, Service Plan Cost Sheet, would be listed under ADv6e.
Q: What if I have more than seven services?
A: The Word version of the cost sheet will expand to fit an unlimited number of service lines. After you finish entering information for the last service on the page, press Tab and a new page with additional lines will appear. Please note: the PDF version of this form is not functional at this time. Until it is, we request that you use the Word version only.
Q: What if I have more than two services to add or delete?
A: The Word version of the cost sheet will expand to fit an unlimited number of service lines. After you finish entering information for the service line, press Tab and a new line will appear. Please note: the PDF version of this form is not functional at this time. Until it is, we request that you use the Word version only.
Q: When is this form used?
A: This form replaces ADv6d and should be used by the Case Manager and Service Team to review, after all alternative options are explored, whether the proposed Environmental Modification will meet the service definition of promoting independence and preventing premature institutionalization.
Q: Do I need to submit other forms with this?
A: Forms 02CB031, Environmental Modification Decision Tool; 02CB032, Environmental Modification Permission and Verification; and 02CB033, Level of Function and Environmental Assessment should be submitted together.
Q: When is this form used?
A: This form combines ADv6d5, Owner's Permission to Modify Property, and ADv6d3, Verification of Service Delivery, for all environmental modifications except Durable Medical Equipment.
Q: Will the Case Manager need to submit this form prior to the modification, then again after the modification has been completed?
A: Yes. This form will be submitted twice. First prior to the modification being installed, then again after the modification has been finished.
Q: Do I need to submit other forms with this?
A: Forms 02CB031, Environmental Modification Decision Tool; 02CB032, Environmental Modification Permission and Verification; and 02CB033, Level of Function and Environmental Assessment should be submitted together.
02CB033E: Level of Function and Environmental Assessment
Q: When is this form used?
A: This form is to be given to the physical or occupational therapist for the pre-modification assessment of the member’s level of function and need for an environmental modification.
Q: Do I need to submit other forms with this?
A: This form will be submitted to ADvantage Administration with form 02CB031E Environmental Modification Decision Tool, and will replace the therapist’s use of individual provider agency forms.
02CB034E: Owner's Permission to Modify Property
Q: When is this form used?
A: This form replaces ADv6d5 and is to be used to request installation of any permanently installed durable medical equipment only. For environmental modifications, please use form 02CB032E.
Q: When is this form used?
A: This form is to be used only when requesting bathroom grab bars. To request grab bars for other locations, please use form 02CB034E, Owner's Permission to Modify Property.
Q: Will the Case Manager need to submit this form prior to the modification, then again after the modification has been completed?
A: Yes.
Q: Do I need to submit other forms with this?
A: This form must be must be submitted with form 02CB011E, Service Plan Cost Sheet, or form 02CB012E, Service Plan Cost Sheet Addendum.
Q: When is this form used?
A: This form is to be used when requesting any PERS.
Q: Do I need to submit other forms with this?
A: Disease Management and Fall Prevention Plans must be attached to the request or must be present in the Member's current Service Plan Goals. Either form 02CB011E, Service Plan Cost Sheet, or 02CB012E, Service Plan Cost Sheet Addendum, must also be submitted with this form.
Q: When is this form used?
A: This form replaced ADv6a1b and is used by the Case Manager to provide required information related to a Service Plan request for nutritional supplements (oral or enteral). The form must be completed each time authorization is requested throughout the Service Plan year reflecting the current nutritional status of the Member, current related health conditions and current goals.
Q: Do I need to submit other forms with this?
A: Nutritional goals must be attached to the request or must be present in the Member’s current Service Plan Goals. A new physician’s prescription is required with the initial request for each Service Plan year or more frequently if the number of prescribed refills is specifically limited. This form must be submitted with form 02CB011E, Service Plan Cost Sheet, or form 02CB012E, Service Plan Cost Sheet Addendum.
