Oct. 8, 2024
When members are approved for a certain number of personal care service hours per week, they have the option to request a reduced number of hours on an ongoing basis. We encourage you to remind our members about the approval process below for their requests. This process is also outlined in Section 8 of the Turquoise Care Managed Care Policy Manual.
Why request approval is important: Missed visits may lead to recurring critical incident report submissions for providers. Providers should submit CIRs anytime there is an occurrence where the member goes without PCS that can lead to actual or potential harm to the well-being of the member.
Request approval process: Ask our members to first discuss their request for reduced hours with their care coordinator. For next steps:
- The care coordinator will reassess approved hours and meet with the member or their representative to determine if it’s appropriate to make a change.
- The member will then have to sign a new Community Benefit Member Agreement if their request is approved. This form will specify the reduced number of hours and any additional information about the reduction. We will maintain a record of this agreement.
- After the agreement is approved, the member will work with their PCS provider to revise their Individual Plan of Care to reflect their updated hours.
- Providers must send updated IPoCs to IPOC_mailbox@bcbsnm.com for review. We will update the personal care service authorization in AuthentiCare® to reflect the reduced hours.
Important reminders about member requests
- Requests for reduced PCS hours must be member driven.
- Requests should occur after at least 60 calendar days into the current approved authorization.
- Reassessments of approved hours can occur during the 60-day period.
- Members can’t request a temporary reduction.
- A change in hours is in place for the remainder of the member’s budget.
- We can deny a request if it’s determined that reducing the member’s hours puts the member at risk.
- The member can work with their care coordinator to increase their hours again if they experience a change in condition, natural supports or if another need arises.
If you have any questions, contact your assigned Network Representative.