Enter a three-digit reason code when the recipient on DD Waiver has a short or long-term facility stay. The reason code generates letters to all providers notifying them the service agreement (SA) is closed.

Leave the reason code field blank unless closure of SA applies.

Enter reason code 844 when closing the DD waiver SA due to a hospital or nursing facility (NF) stay of 30 or more days.

Enter reason code 961 when closing DD waiver SA for a hospital or NF stay of less than 30 days, admission to Institution for Mental Diseases (IMD) or other facility acute care or long-term stay.

Enter Y in the send recipient letter field (Box 15).

MMIS defaults field entry to Y. Keep the Y in the send provider letter field.

Enter Y (yes) or N (no) to indicate if the recipient has a responsible party (Box 18). Completion of the responsible party field is required when the SA includes personal care assistance (PCA) services.

Enter Y (yes) or N (no) to indicate if the recipient lives with the responsible party (Box 20). Completion of the lives with responsible party field is required when the SA includes PCA services.

Enter first and last name of the responsible party (Box 22). Enter additional name(s) on the AHC3 panel when recipient has more than one responsible party. Completion of the responsible party name field is required when the SA includes PCA services.

Enter Y (yes) or N (no) when services include PCA (Box 19). Yes indicates a PCA Choice provider. A fiscal intermediary is required when the provider is a PCA Choice Provider. Leave the fiscal intermediary field blank when the SA does not include PCA services.

The excluded time field is mandatory when services include consumer directed community supports (CDCS) (Box 21). Enter Y (yes) or N (no) to indicate if excluded time is applicable. Leave the excluded time field blank when the SA does not include CDCS.