§ 460.121 Service determination process.

(a) Written procedures. Each PACE organization must have formal written procedures for identifying and processing service determination requests in accordance with the requirements of this Part.

(b) What is a service determination request—(1) Requests that constitute a service determination request. Except as provided in paragraph (b)(2) of this section, the following requests constitute service determination requests:

(i) A request to initiate a service.

(ii) A request to modify an existing service, including to increase, reduce, eliminate, or otherwise change a service.

(iii) A request to continue coverage of a service that the PACE organization is recommending be discontinued or reduced.

(2) Requests that do not constitute a service determination request. Requests to initiate, modify, or continue a service do not constitute a service determination request if the request is made prior to completing the development of the initial plan of care. For all requests identified in this section, the interdisciplinary team must—

(i) Document the request; and

(ii) Discuss the request during the care planning meeting, and either:

(A) Approve the requested service and incorporate it into the participant's initial plan of care, or

(B) Document their rationale for not approving the service in the initial plan of care.

(c) Who can make a service determination request. Any of the following individuals can make a service determination request:

(1) The participant.

(2) The participant's designated representative.

(3) The participant's caregiver.

(d) Method for making a service determination request. An individual may make a service determination request as follows:

(1) Either orally or in writing.

(2) To any employee or contractor of the PACE organization that provides direct care to a participant in the participant's residence, the PACE center, or while transporting participants.