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Personal Care Assistance

Discontinue as provider of PCA services

Page posted: 02/04/10

Page reviewed:

Page updated: 04/19/11


Process to use when a provider chooses to discontinue PCA services for a recipient.


The provider discontinuing services must release T1019 units not used so DHS may enter a service agreement for the new provider.

The provider cannot bill for services provided after the last date of service documented on the change request.

PCA Provider Agency Responsibilities


Provider faxes the Personal Care Assistance Technical Change Request, DHS-4074A, (PDF) to DHS indicating:

  • • Technical change or correction to an existing services agreement
  • • Service agreement number
  • • Type of request
  • • Last date of service by the current provider
  • • Number of T1019 units released
  • • Other required information
  • Waiver: Contact the case manager.

    Managed Care: Contact the care coordinator.

    Recipient Responsibilities

    The recipient/responsible party is responsible to choose another PCA provider agency.

    Lead Agency Responsibilities

    Fee for service: The lead agency is responsible to offer resources for locating PCA provider agencies.

    Waiver: The case manager is responsible to:

  • • Locate PCA provider agencies
  • • Provide assistance with the transition on the authorization
  • Managed Care: The care coordinator is responsible to provide the assistance per health plan policy.

    DHS Responsibilities

    Fee for service:

    DHS staff will:

  • • Review the last billing/claims date
  • • End the line item for the provider on the service agreement based on the last billing/claims date
  • • Enter notes on the ADHS screen to indicate the number of units released over the daily average and the original end date of the agreement
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