Section 16.03.10.508 - ADULT DEVELOPMENTAL DISABILITY SERVICES PRIOR AUTHORIZATION: DEFINITIONS01.Adult. A person eighteen (18) years old or older.02.Assessment. A process under Section 509 of these rules for program eligibility and Section 512 of these rules for plan of service.03.Clinical Review. A process of professional review that validates the need for continued services.04.Community Crisis Support. Intervention for participants who are at risk of losing housing, employment, or income, or who are at risk of incarceration, physical harm, family altercations, or other emergencies.05.Concurrent Review. A clinical review to determine the need for continued prior authorization of services.06.Department-Approved Assessment Tool. Any standardized assessment tool approved by the Department for use in determining DD eligibility, waiver eligibility, skill level to identify the participant's needs for the plan of service, and for determining the participant's budget.07.Duplication of Services. When goals are not separate and unique to each service provided, or when more than one (1) service is provided at the same time, unless otherwise authorized.08.Exception Review. A clinical review of a plan that falls outside the established standards due to a health or safety risk.09.Health. The prevention of deterioration of one's physical or mental health condition, cognitive functioning, or an increase in maladaptive behavior, and is related to the effects of one's disability.10.Health Risks. Must be established through written documentation and current treatment recommendations from a licensed practitioner of the healing arts under these rules, or other professional licensed by the State of Idaho whose recommendation is within the scope of their license. Such documentation must establish:a. The current physical or mental condition, or cognitive functioning that will likely deteriorate, or the current maladaptive behavior(s) that will likely increase; andb. The specific supports or services being requested, including type and frequency if applicable, that will address the identified need.c. To comply with the documentation requirement, the Department may require the participant to obtain additional consultation or assessment, available to the participant and covered by Medicaid, from a professional licensed by the State of Idaho acting within the scope of their license. If the Department requires additional consultation or assessment, the Department will specify the nature of the consultation or assessment and the necessary documentation.11.Interdisciplinary Team. A team of professionals, determined by the Department, that reviews requests for reconsideration.12.Level of Support. An assessment score derived from a Department-approved assessment tool that indicates types and amounts of services and supports necessary to allow the individual to live independently and safely in the community.13.Person-Centered Planning Process. A meeting facilitated by the participant or plan developer, comprised of family and individuals significant to the participant who collaborate with the participant to develop the plan of service.14.Person-Centered Planning Team. The group who develops the plan of service. This group includes the participant and the service coordinator or plan developer chosen by the participant. The person-centered planning team may include others identified by the participant or agreed upon by the participant and the Department as important to the process.15.Plan Developer. A paid or non-paid person identified by the participant responsible for developing one (1) plan of service and subsequent addenda that cover all services and supports, based on a person-centered planning process.16.Plan Monitor. A person who oversees the provision of services on a paid or non-paid basis.17.Plan of Service. An initial or annual plan that identifies all services and supports based on a person-centered planning process. Plans are authorized every three hundred sixty-five (365) days.18.Prior Authorization (PA). A process for determining a participant's eligibility for services and medical necessity prior to the delivery or payment of services as provided by these rules.19.Provider Status Review. The written documentation that identifies the participant's progress toward goals defined in the plan of service.20.Right Care. Accepted treatment for defined diagnosis, functional needs, and abilities to achieve the desired outcome. The right care is consistent with best practice and continuous quality improvement.21.Right Place. Services delivered in the most integrated setting in which they normally occur, based on the participant's choice to promote independence.22.Right Price. The most integrated and least expensive services that are sufficiently intensive to address the participant's needs. The amount is based on the individual's needs for services and supports as identified in the assessment.23.Right Outcomes. Services based on assessed need that ensure the health and safety of the participant and result in progress, maintenance, or delay or prevention of regression for the participant.24.Safety. Prevention of criminal activity, destruction of property, or injury or harm to self or others.25.Safety Risks. Must be documented by the following: a. Current incident reports;c. Assessments from a licensed practitioner of the healing arts under these rules or a professional licensed in Idaho and whose assessment is within the scope of their license; ord. Status reports and implementation plans that reflect the type and frequency of intervention(s) in place to prevent the risk and the participant's progress under such intervention(s).e. Such documentation must establish: i. An imminent or likely safety risk; andii. The specific supports or services that are being requested, including the type and frequency if applicable, that are likely to prevent that risk.26.Service Coordination. An activity that assists individuals eligible for Medicaid in gaining and coordinating access to necessary care and services appropriate to the needs of an individual.27.Service Coordinator. An individual who provides service coordination to a Medicaid-eligible participant, is employed by a service coordination agency, and meets the training, experience, and other requirements under Sections 729 through 732 of these rules.28.Services. Services paid for by the Department that enable the individual to reside safely and effectively in the community.29.Supports. Formal or informal services and activities, not paid for by the Department, that enable the individual to reside safely and effectively in the setting of their choice.Idaho Admin. Code r. 16.03.10.508