Integrated Coverage Determination Notice (ICDN) Models

Instructions

According to the three-way contract, FIDA Plans must notify a Participant when his/her Person-Centered Service Plan (PCSP) is created, renewed, or revised by the Interdisciplinary Team (IDT). FIDA Plans are also required to provide notice to a Participant upon denial, in whole or in part, of a request for coverage outside of the PCSP and upon discontinuation or reduction of a previously authorized course of treatment. In order to fulfill these notification requirements, FIDA Plans should use the applicable Integrated Coverage Determination Notice (ICDN) model:

• Model 1: The FIDA Plan must send this model notice every time a PCSP is created, updated with new services, or reauthorized without changes by the Participant's IDT. While there may be no overt or apparent denial, reduction, stoppage, or restriction in these cases, notice is still required in all instances. This notice informs the Participant about the new authorization and his or her appeal rights.
• Model 2: Sometimes the new PCSP issued by the IDT, when compared to the Participant's previous PCSP, amounts to a denial, reduction, stoppage, or restriction in benefits. This model notice should be used when the Participant had a certain level of care recorded in his or her prior PCSP and then the IDT denies, reduces, stops, or restricts at least one of the services in the new PCSP.
• Model 3: In accordance with the three-way contract and the IDT Policy, the FIDA Plan or a Specialist may have the authority to authorize covered items and services. These authorizations are technically independent of the PCSP. This model notice should be used when the FIDA Plan or Specialist denies, reduces, stops, or restricts an item or service.

To determine whether a Participant's initial FIDA PCSP fits under Model 1 or Model 2, the FIDA Plan should see if the Participant had a preexisting service plan, whether from FFS, NHTD Waiver, MLTC or from another FIDA Plan. If so, the FIDA Plan should compare the new FIDA PCSP to the preexisting service plan. If there are any differences that amount to a denial, reduction, stoppage, or restriction in benefits, then the FIDA Plan should use Model 2 to communicate the decrease in benefits to the Participant. If there are no changes or an increase in benefits, the FIDA Plan should use Model 1.