New Hampshire Department of Health & Human Services



Waiver Request Form DATE OF REQUEST: FORMTEXT ?????DATE REC BMHS: FORMTEXT ?????CMHC or Program Name and Address: Requested by: FORMTEXT ?????Phone: FORMTEXT ?????E-Mail: FORMTEXT ?????Legal name of client or staff (First - Last): FORMTEXT ?????Medicaid Identification Number: FORMTEXT ?????Indicate below an “X” to all that apply for this waiver request: FORMCHECKBOX Initial Waiver FORMCHECKBOX Renewal ( Prior Waiver #): FORMTEXT ????? FORMCHECKBOX Staff FORMCHECKBOX Adult Client FORMCHECKBOX Child Client FORMCHECKBOX Case Management FORMCHECKBOX FSS FORMCHECKBOX Prior Authorization FORMCHECKBOX Other: FORMTEXT ?????Effective Date: FORMTEXT ?????Expiration Date: FORMTEXT ?????Indicate the rule for this waiver: He-M FORMTEXT ?????Quote the specific language you seek to waive directly from the rule: FORMTEXT ?????Provide a full description of why a waiver is necessary and a full explanation of the alternate provisions and procedures proposed by the Community Mental Health Program, Agency, or Provider: FORMTEXT ?????Submit completed waiver requests:Via secure e-mail to: HYPERLINK "mailto:DBHWaiverSubmissions@dhhs." DBHWaiverSubmissions@dhhs. julia.mcnamara@dhhs. , or Fax to: 603-271-5040, orUS mail to: New Hampshire Department of Health and Human Services Division for Behavioral Health Bureau of Mental Health Services 105 Pleasant Street, Concord, New Hampshire 03301Waiver number: FORMTEXT ?????Approval date: FORMTEXT ?????Comments: FORMTEXT ?????The Bureau of Mental Health Services will provide approval decisions for only those rules for which they have oversight responsibility, there is a waiver provision in the rule, and as designated by the Commissioner. Laws and statutes cannot be waived and entire rule or “global” waivers are outside of the scope of the BMHS to approve.BMHS rules and the specific waiver provisions are: He-M 401 and 401.15 ; He-M 402 and 402.10; He-M 403 and 403.16; He-M 405 and 405.17; He-M 406 and 406.10; He-M 408 and 408.14; He-M 426 and 426.24; and He-M 1202 and 1202.12. The following rules and the specific waiver provisions require additional review and approval from the Office of Licensing and Certification: He-M 1002 and 1002.18; He-M 1007 and 1007.13; He-P 830 and 830.10.Supporting Documents: Additional documentation submitted with the waiver request in order to substantiate and support the approval decision includes: Supporting Documents for Client Waivers: Eligibility determination form. (required)Individual Services Plan/Treatment Plan. (required)Case Management Plan and Area Agency ISP (for dual TCM waivers only) Quarterly ReviewsSupporting Documents for Staff Waivers: Resume of staff employment, education, and relevant experience or signed employment application. For initial criminal history waivers, State of NH criminal records & Bureau of Elderly and Adult Services (BEAS) checks completed within 90 days of the waiver request. Staff waivers must also include the supervision the staff will be receiving on the request form.Prior Authorization: A Prior Authorization (PA) is required in order for the provider to exceed the service limits identified in rule 426.12 (p): Additional Information required for PA waivers:Current treatment plan must include updates service frequencies to identify services needing overagesProcedure Codes and units needed for each code must be included on the request form. Allowable codes:H2010: Comprehensive Medication SupportH2019: Therapeutic Behavioral Support (TBS)H2019 HQ: Group TBSH0034: Medication Training and SupportT1027: Family Training and SupportH2015: Any combination of above codes (total units for all codes)Unexpected overages of service limits should be submitted as soon as possible prior to billing and will be reviewed on a case by case basisGuidelines: Incomplete waivers will not be processed and the agency will receive notification of this. It will be the agency’s responsibility to review the waiver and submit a complete version.Timelines for Processing:Waiver requests should be submitted a minimum of 30 days prior to the requested start dateThe bureau will process all waiver requests within 45 days of receipt, but strive to process within 1 week. If a request needs to be expedited please indicate this when submittingStaff waiver requests will be processed within 48 business hours of receiptWaivers that require DHHS legal consultation or review/consultation with another DHHS department may exceed 45 days for approval decision.Duration of WaiversThe bureau may approve waivers up to 5 years maximum. Below are some guidelines for common types of requests:Staff Education waivers: Up to 5 years or if in school; through anticipated graduationEligibility waivers: up to 2 years or until eligibility assessment expiresPrior Authorizations: Up to 1 year or until ISP/TP expiresDual CM waivers: Up to 1 year or until CM plan expiresStaff Training waivers: Up to 1 year or until next available trainingAll requests are initiated by a single point of contact from the CMHC or agency. All follow-up communication will occur between the Bureau and the Agency contact.It is preferred that waiver requests and supporting documentation be sent via secure e-mail.Subject line is: “WAIVER from [agency name] to BMHS on [mmddyy]”E-mail to HYPERLINK "mailto:DBHWaiverSubmissions@dhhs." DBHWaiverSubmissions@dhhs. julia.mcnamara@dhhs. Requests may be faxed to 603-271-5040 Or mailed to:New Hampshire Department of Health and Human ServicesDivision for Behavioral HealthBureau of Mental Health Services105 Pleasant Street, Concord, New Hampshire 03301Agencies will be formally notified of decision by letter from BMHS via an encrypted email. If you have not heard back with an approval decision from the Bureau within 30 days please contact the BMHS Program Planner for a status update. If you receive an automated e-mail that the Program Planner is out for more than two days please forward your request to the Administrator of CMHP Kerri Swenson at Kerri.R.Swenson@dhhs. ................
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