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3.8.2.2.1 Accessing the PCS Benefit
Clients must be referred to DSHS before receiving the PCS benefit. A referral can be made by any person who recognizes a client may have a need for PCS, including, but not limited to, the following:
• The client, a parent, a guardian, or a responsible adult
•A primary practitioner, primary care provider, or medical home
•A licensed health professional who has a therapeutic relationship with the client and ongoing clinical knowledge of the client
•A family member
•Home health, personal assistance, and consumer-directed service agency providers
Referrals to DSHS can be made to the appropriate DSHS Health Service Region, based on the client's place of residence in the state. Clients, parents, or guardians may also call the TMHP PCS Client Line at 1-888-276-0702 for more information on PCS. PCS providers should provide the DSHS and/or TMHP PCS Client Contact Line contact information for the client or responsible adult.
Upon receiving a referral, DSHS assigns the client a case manager, who then conducts an assessment in the client's home with the input and assistance of the client or responsible adult. Based on the assessment, the case manager identifies whether the client has a need for PCS. If the case manager identifies a need for PCS, the client or responsible adultis asked to select a Medicaid-enrolled PCS provider in their area. Client choices for PCS providers may include licensed home health agencies, consumer-directed services agencies (CDSAs), SRO providers, or PAS-only providers.
Once a provider is selected, the DSHS case manager prior authorizes a quantity of PCS based on the assessment and requests TMHP to issue a prior authorization number (PAN) to the selected PCS provider. The PCS provider uses the PAN to submit claims to TMHP for the services provided. DSHS also contacts the client's primary practitioner (a licensed physician, APRN, or PA) or primary care provider to obtain a statement of need.
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