VR-SFP Chapter 21: Employment Supports for Brain Injury

Employment Supports for Brain Injury (ESBI) is designed to integrate the therapeutic and employment needs of VR customers who have persistent functional limitations resulting from an acquired brain injury (traumatic and non-traumatic injuries). ESBI services are individualized and multidisciplinary with a focus on employment. ESBI may involve the coordinated services of multiple providers for the achievement and retention of competitive integrated employment consistent with the customer's unique strengths, resources, priorities, concerns, abilities, capabilities, interests, and informed choice.

Customers may:

• obtain employment on their own or by working with an employment service provider by participating in Bundled Job Placement or Supported Employment services while at the same time receiving cognitive and/or other therapeutic services from an ESBI contractor; or
• participate in work or volunteer experiences and other work readiness employment services while also receiving cognitive and/or other therapeutic services before obtaining a permanent job.

ESBI services focus on the customer's ability to obtain, maintain, and advance in employment and to participate in community reintegration activities to prepare for employment by:

• increasing skill development, performance, use of adaptive equipment, and/or assistive technology, and use of compensatory techniques in the following areas:
  • Activities of daily living required for employment
  • Adjustment to disability
  • Behavior management
  • Cognitive performance
  • Endurance
  • Mobility
  • Self-care
  • Speech and communication
• identifying and establishing the use of community resources that increase the customer's independence within the customer's home, community, and work settings; and
• evaluating and accommodating the customer's functional use of the community resources that have been established.

ESBI services can be performed in either a nonresidential or residential setting. The VR counselor and customer will determine which services are necessary to meet the customer's individual employment needs and circumstances.

Both the ESBI therapist and ESBI employment service provider(s) can provide evaluations and services to address the following:

• Determining the customer's abilities as they relate to obtaining and maintaining competitive integrated employment
• Identifying work tasks and work environments that best align with the customer's skills, abilities, and interests by engaging in:
  • simulated work activities;
  • job samplings;
  • situational assessments;
  • environmental work assessments; and/or
  • volunteer or paid work experiences
• Evaluating the customer's work environments and work tasks, making recommendations to modify and implement strategies to improve the customer's abilities and/or performance (this includes the final job for case closure)
• Teaching the customer's support system, such as parents, friends, spouse, employer, and other professionals how to foster the customer's independence within the work setting, home, and community
• Providing other support services that will address employment barriers and the development of skills necessary to perform effectively in a work setting

ESBI services will include one or more employment services, as described in this manual, such as:

• Environmental Work Assessments;
• Vocational Evaluations;
• Vocational Evaluation - Situational Assessments and Work Samples;
• Work Readiness Services (Vocational Adjustment Training);
• Work Experience (Placement, Training, and Monitoring);
• Bundled Job Placement Services;
• Job Skills Training; and
• Supported Employment Services (Supported Employment Assessment and Placement).

An ESBI employment service provider will assist the customer, when necessary, in obtaining competitive integrated employment for a successful employment outcome.

The customer's individualized plan for employment (IPE), Initial Assessment and Evaluation Plan (IAEP), Individualized Program Plan (IPP), and service authorization(s) will identify which assessments, evaluations, and services a customer will receive and who will provide the assessments, evaluations, and services.

The customer's participation in ESBI should lead to the customer obtaining competitive integrated employment, as defined in CFR §361.5(c)(9). The customer must also have unexpired employment authorization documents to participate in the ESBI services.

The VR counselor monitors the customer's progress throughout participation in ESBI services by meeting regularly with the customer and the customer's interested support system, as authorized; the ESBI provider; and other interdisciplinary team members, and by reviewing the documentation submitted.

When rehabilitation treatment is not leading to progress toward employment goals, the VR counselor works with members of the interdisciplinary team (IDT) to develop appropriate modifications to the plan. When this is not possible, the VR counselor may discontinue sponsorship of the treatment and address alternatives for independent living or other services as indicated.

To provide services in the ESBI model the provider must maintain active TWC-VR contracts for ESBI. For Employment Services, the provider must also maintain a TWC-VR Employment Services contract that includes Supported Employment Services unless the provider has a formal partnership or subcontract with a TWC-VR Employment Services provider that has Supported Employment Services in its contract. The ESBI contractor must provide documentation, signed by all parties, that outlines the relationship and roles of the agreement to the ESBI-assigned contract manager and to the state office program specialist assigned to ESBI.

All residential and nonresidential contractors providing ESBI services must be current in their registration or licensure, with one or more of the following, as applicable and as required by Texas law:

• Home and Community Support Service Agencies (HCSSA)
• The Texas Board of Physical Therapy and Occupational Examiners
• Assisted Living Facility (ALF)
• Health Care Facilities – Required Qualifications

Facilities providing only psychological or neuropsychological services, evaluations and cognitive therapy are waved from the above requirements (registration or licensure) as long as all staff are appropriately licensed or certified, and all other standards and contracting requirements are met. Occupational therapy (OT) and physical therapy (PT) services must be provided from a facility with registration.

A residential ESBI provider also must maintain accreditation from:

• the Commission on Accreditation of Rehabilitation Facilities;
• the Joint Commission (accreditation of health care organizations); or
• the Disease-Specific Care Certification in brain injury or related rehabilitation program.

TWC-VR may grant a two-year grace period for a residential facility to obtain an accreditation listed above, when the residential facility is a new contractor with TWC-VR.

All contractors must maintain current proof of all required licenses, registrations, and accreditation with the contractor's assigned TWC-VR contract manager and state office program specialist assigned to the ESBI.

When the facility is inspected, the contractor is required to provide any monitoring and/or inspection report summaries by other agencies to the assigned TWC-VR contract manager and the state office program specialist assigned to the ESBI program within five business days of receiving the report.

TWC-VR will not refer new customers to an ESBI contractor whose licensure, registration, or accreditation is under an action to deny or suspend, is revoked, or is not renewed, until such action has been resolved. A facility currently providing services to VR customers is required to notify TWC-VR when the facility's licensure, registration, or accreditation is suspended or revoked within one business day of receiving notification. A facility that fails to timely notify TWC-VR of any such action is considered out of compliance with contract terms and conditions.

TWC-VR mandates that the facility must comply with the Americans with Disabilities Act (ADA) and must complete the "ADA Checklist for Existing Facilities," based on the 2010 ADA Standards for Accessible Design, found at ADA Checklist for Existing Facilities. This document must be kept on file and made available to TWC-VR staff upon request.

ESBI services are designed to integrate clinical therapies and employment services to result in the customer achieving competitive integrated employment. Clinical therapies are partnered with employment service providers to achieve the goals outlined in an IPP.

Evaluations and assessments are authorized by the VR counselor with a TWC-VR service authorization to determine if ESBI services are necessary. Assessments and evaluations cannot be performed without a service authorization.

When a customer has transferred from another therapy-based service to ESBI services, the evaluation(s) previously completed may be sufficient to determine whether ESBI services are necessary and to develop the customer's ESBI IPP. The IDT recommends when evaluations are necessary. The VR counselor determines the evaluations that will be provided via the service authorization.

The results of the initial assessments identify the goals for cognitive rehabilitation, goals for other therapies and employment services, and the need for any additional supports to be included in the customer's case-managed IPP. The IDT provides services and supports for the customer when authorized by the VR counselor with a service authorization.

Initial and continued funding for ESBI services is contingent on the availability of VR funds and the decision of the VR counselor on the customer's progress toward the established goals of preparing for, securing, retaining, or advancing in employment.

Below are descriptions of services available through ESBI services.

21.5.1. Case Management Service Definition

Case management services are client-centered, safe, timely, effective, efficient, and equitable, and are in alignment with customer's IAEP or IPP. Case management services are only available for customers in a nonresidential setting.

Case managers serving customers in a residential setting must provide the same tasks as those described below; the fee to perform the services is included in the residential service base rate.

The case manager may provide the following:

21.5.1.1 Process and Procedures

Nonresidential

The ESBI provider receives a referral and a service authorization for case management and assigns a case manager.

Residential

When residential services are recommended, the VR counselor coordinates a referral with an ESBI provider and case management services begin with the coordination of initial evaluation and associated reports.

Nonresidential and Residential

The case manager performs the tasks listed in the service definition by completing a progress report to document the completed task(s).

The case manager ensures the requirements for the following are completed:

• 21.5.2 Initial Assessment and Evaluation Plan (IAEP),
• 21.5.4 Individual Program Plan (IPP),
• 21.4.11 Progress Reports,
• 21.4.9 Weekly Activity Schedules,
• 21.4.10 Weekly Time Logs, and
• 21.13 Billing Procedures.

The case manager submits the progress report that describes the tasks completed and submits the invoice.

21.5.1.2 Outcomes Required for Payment

Nonresidential

The case manager documents in descriptive terms the tasks completed for the following:

• Facilitation of the evaluation plan meeting and associated reports
• Coordination of the initial evaluation and associated reports
• Coordination of the initial IPP and associated reports
• Coordination of the monthly IPP reviews and associated reports
• Coordination of the discharge summary and associated reports

Payment for the above case management services is made when the VR counselor approves the submitted:

• progress report; and
• invoice.

21.5.1.3 Fee

See:

• 21.12.5 Nonresidential Rate Structure
• 21.12.6 Residential Rate Structure

21.5.2 Initial Assessment and Evaluation Plan Service Definition

The IAEP is completed to identify any therapy evaluations or employment services to be used to determine the customer's abilities related to obtaining and maintaining competitive integrated employment. During the meeting any existing evaluation(s) are reviewed to determine what evaluations, if any, need to be completed before the IPP is developed.

The IAEP must include measurable goals that identify:

• the evaluation(s) and assessment(s) that will be completed;
• the focus of each initial assessment(s) and/or evaluation(s);
• the licensed and/or certified professional and/or the qualified employment service provider that will complete the assessment(s) and/or evaluation(s);
• the amount of time approved to complete the assessment(s) and/or evaluation(s);
• the location where the assessment(s) and/or evaluation(s) will be completed (nonresidential or residential); and
• a functional behavior analysis (FBA), if applicable.

21.5.2.1 Process and Procedures

TWC-VR sends a referral packet to the ESBI provider.

The case manager:

• obtains any needed medical records and previously completed assessments and evaluations; and
• arranges the IAEP meeting.

The VR counselor outlines the TWC-VR expectations for the customer's participation in ESBI services.

The IDT completes the IPP.

The case manager obtains the required prescriptions.

TWC-VR issues service authorizations for therapies and employment services for the amount of time described in the IAEP.

21.5.2.2 Outcomes Required for Payment

The case management fee is available only for nonresidential services.

See the requirement for the case management services definitions for:

• facilitation of the evaluation plan meeting and associated reports; and
• coordination of initial evaluation and associated reports.

21.5.2.3 Fees

See:

• 21.12.5 Nonresidential Rate Structure: A case manager can bill for attendance, reporting and documentation related to the IAEP. A licensed and/or certified professional may bill one 15-minute increment for attendance of a customer's IAEP or IPP. 
• 21.12. 6 Residential Rate Structure: All IAEP member fees, including the case manager fee, are included in the residential base daily rate.

21.5.3 Initial Assessments and Evaluations Service Definition

The assessments and evaluations are performed by licensed and/or certified professionals, as previously defined, and/or by TWC-VR qualified Employment Services providers. Initial assessments are performed for both residential and nonresidential customers, as authorized by the VR counselor and as prescribed by the treating physician. Assessments and evaluations results must identify recommendations for:

• the customer's abilities, deficits, and potential to obtain and maintain competitive integrated employment;
• the customer's potential to secure, retain, and advance in employment;
• the customer's employment goal(s), transferable skills, and employment barriers;
• licensed and/or certified professional therapy service(s) and/or employment services to be provided; and
• the customer's measurable goals.

21.5.3.1 Therapy Evaluations

Therapy evaluations include the following:

• Cognitive rehabilitation evaluation
• Occupational therapy evaluation
• Speech therapy evaluation
• Physical therapy evaluation
• Neuropsychological evaluation
• Functional behavior assessment
• Community re-integration evaluation
• Functional capacity assessment
• Situational assessment     

21.5.3.2 Employment Service Evaluations

The following employment services can be used to conduct evaluation activities.

Vocational Evaluation is an assessment of an individual's work and training background, general functional capacities, and social and/or behavioral characteristics. The vocational evaluation must contain a detailed description of the customer's behaviors and must describe any implications for the workplace. The evaluation must be designed to determine the customer's present and future vocational potential. For a detailed service description, the process and procedures, and the outcomes required for payment, see  Chapter 4: Employment Assessments, 4.3 Vocational Evaluation.

Vocational Evaluation—Situational Assessments and Work Samples are tools to help the customer and VR counselor determine the customer's long-term goals related to obtaining competitive integrated employment. The prerequisite is a completed vocational evaluation. For a detailed service description, the process and procedures, and the outcomes required for payment, see Chapter 4: Employment Assessments, 4.4 Vocational Evaluation - Situational Assessments and Work Samples.

Environmental Work Assessment (EWA) is a diagnostic tool that assesses how the customer responds to variables in a work environment. The EWA is an accurate assessment of the correlations between a customer's performance and environmental variables and is critical to the customer's ability to obtain and maintain employment. Results of the assessment identify the variables in a work environment that affect the customer's ability to function at the customer's full potential. For a detailed service description, the process and procedures, and the outcomes required for payment, see Chapter 4: Employment Assessments, 4.5 Environmental Work Assessment.

Work experience services allow a customer to be placed at a business or an agency within the community to gain short-term experience to obtain skills that are transferable to future long-term competitive integrated employment. Work experience can assist in determining whether a customer is ready for competitive integrated employment; exploring career options; and/or developing skills to include in the individual's résumé for a certain vocation. There are three Work Experience Services. For detailed service descriptions, the process and procedures, and the outcomes required for payment of each service, see the applicable link below:

• 14.3 Work Experience Placement
• 14.4 Work Experience Monitoring
• 14.5 Work Experience Training

Supported Employment Assessment (SEA) is for customers with the most significant disabilities. The SEA is a person-centered evaluation that includes a discovery process that takes approximately 20–30 hours to:

• interview members of the customer's circle of support;
• observe the customer's work skills, life skills, and behaviors at home and in the community;
• tour current or potential work environments with the customer;
• identify and observe vocational interests, preferences, and themes;
• collect personal, school, and employer reference information;
• assess the customer's learning styles and needs for adaptive technology, accommodations, and on-site supports;
• assess and identify the customer's strengths, challenges, and transferable skills by exploring the customer's interests, capabilities, preferences, motivations, learning styles, challenges, ongoing support needs, and resources;
• learn about employment conditions related to the customer's preferences, resources, and support needs to achieve and maintain employment outcomes;
• understand the customer's need for Extended Services and supports at or away from the jobsite to ensure success in competitive integrated employment;
• complete informational interviews and work skills observations (completed by the customer); and
• complete the assessment summary.

For a detailed service description, the process and procedures, and the outcomes required for payment for each, see Chapter 18: Supported Employment Services.

21.5.3.3 Process and Procedures

The ESBI service provider and/or employment service provider receives the service authorization(s) for the approved assessment(s) and evaluation(s) identified in the customer's IAEP.

Assessments and evaluations are scheduled.

The assessments and/or evaluations are performed by licensed and/or certified professionals and/or by qualified TWC-VR employment service providers.

Weekly Activity Schedules and Weekly Time Logs are completed.

A licensed and/or certified professional or qualified employment service provider completes the required assessment and/or evaluation reports.

Reports are submitted to the VR counselor.

21.5.3.4 Outcomes Required for Payment

The VR counselor receives the following accurate and descriptive documents associated with the licensed and/or certified professional evaluation or assessment or qualified employment service evaluations:

• A copy of the customer's weekly activity schedule
• A weekly time log recording all billable time for evaluations completed by the licensed and/or certified professional
• Evaluation and/or assessment reports for all evaluations and assessments identified in the IAEP and service authorizations
• Any employment services provided, as identified in the IAEP and service authorization documentation submitted
• The updated IAEP summary, which records the results of completed assessments and evaluations

The assessment and evaluation results contain:

• the customer's abilities, deficits, and potential to obtain and maintain competitive integrated employment;
• the customer's potential to secure, retain, and advance in employment;
• the customer's employment goal(s), transferable skills, and employment barriers;
• recommendations for the licensed and/or certified professional therapy service and/or employment services to be provided; and
• the customer's measurable goals.

Assessments and evaluations are paid based on:

• the approved time listed in the IAEP;
• the time recorded on the customer's weekly time log; and
• the time recorded on the assessment and/or evaluation reports.

Payment for assessment and evaluation services are paid when the VR counselor approves the submitted:

• weekly time log(s);
• assessment and/or evaluation reports;
• employment service documentation; and
• invoice.

21.5.3.5 Fees

A case manager can bill for attendance, reporting, and documentation related to the IAEP for Nonresidential services. A licensed and/or certified professional may bill one 15-minute increment for attendance of a customer's IAEP or IPP.

See:

• 21.12.5 Nonresidential Rate Structure
• 21.12.6 Residential Rate Structure

21.5.4 Individual Program Plan Service Definition

The IPP is completed to identify any therapy or employment services interventions to be provided to improve the customer's skills and abilities related to obtaining and maintaining competitive integrated employment. During the initial meeting, goals are established; goal status is reported in monthly meetings; and goals are updated, added, and removed as necessary. The customer's IPP is updated at a minimum of every 30 calendar days or more frequently to respond to a customer's change needs that require immediate attention for safety or continued engagement in the program and at discharge. The completed IPPs must be submitted three business days after the IPP meeting is held. The IPP must be approved and signed by the VR counselor, with a service authorization issued before service delivery.

The IPP must include measurable goals that identify:

• the therapy and/or employment services to be provided;
• the focus of each therapy and/or employment service to be provided;
• the licensed and/or certified professional and/or qualified employment service provider that will provide the therapy and/or employment service;
• the amount of time approved for each therapy and/or employment service;
• the location where the therapy and/or employment service will be completed (nonresidential or residential);
• the discharge location;
• discharge date; and
• a behavior plan, if applicable.

21.5.4.1 Process and Procedures

TWC-VR sends the case manager and the employment service provider the service authorizations.

The case manager arranges the IPP meeting.

The IDT completes and updates the IPP.

The case manager obtains the required prescriptions.

TWC-VR issues service authorization for therapy, employment service, and any ancillary good/service as defined in the IPP.

21.5.4.2 Outcomes Required for Payment

Case management fee is only available for nonresidential services.

See requirement for case management service definition for the following:

• Coordination of Initial IPP and Associated Reports
• Coordination of Monthly IPP Reviews and Associated Reports

21.5.4.3 Fees

See:

• 21.12.5 Nonresidential Rate Structure: Only a case manager can bill for attendance, reporting, and documentation related to the IPP.
• 21.12.6 Residential Rate Structure: All IDT members, including the case manager's fee, are included in the Residential base daily rate.

21.5.5 Therapy Services—Definition

Therapy services are performed by licensed and/or certified professionals. Services are performed for both residential and nonresidential customers, as authorized by the VR counselor and prescribed by the treating physician. Residential therapy services are limited to 120 cumulative calendar days of therapy, unless a TWC-VR manager approves additional days of therapy. Nonresidential hours must total 20 hours or fewer per week, for no more than 12 weeks. Additional times require VR manager approval.

Therapy services should develop and improve the customer's:

• abilities, deficits, and potential to obtain and maintain competitive integrated employment;
• transferable skills;
• potential to secure, retain, and advance in employment; and
• knowledge and use of adaptive equipment, assistive technology, and compensatory techniques to address employment barriers.

Time spent completing documentation, phone calls, emails, and travel are not counted as therapy services. A licensed and/or certified professional may bill one 15-minute increment for attendance of a customer's IAEP or IPP.

When therapy services are performed in the community setting, the ESBI provider can bill for travel once per day. See 21.12.4 Premium Payments.

Therapy services include, but are not limited to the following:

• Cognitive Rehabilitation Therapy (provided by a psychologist, neuropsychologist, OT, PT, or SLP)
• Occupational Therapy(OT) (provided by OT only)
• Speech Therapy (SLP) (provided by a SLP only)
• Physical Therapy (PT) (provided by a PT only)
• Neuropsychological Service (provided by a neuropsychologist only)
• Behavior Interventions (created by a behavior analyst, cognitive therapist; LCSW, LPC, and/or psychologist or neuropsychologist, implemented by the IDT).
• Community Reintegration (provided by an OT, PT, SLP, CTRS, or CBIS)
• Simulated Work Activities (provided by an OT, PT, SLP, CTRS, or CBIS for the purpose of community reintegration)
• Job Samplings (provided by an OT, PT, or SLP)
• Transportation Training (provided by an OT, PT, SLP, CTRS, or CBIS for the purpose of community reintegration)

All services must be prescribed by a treating physician. In the case of cognitive rehabilitation therapy, psychological and neuropsychological services, the neuropsychologist/psychologist is allowed to diagnose and/or provide cognitive therapy without an additional prescription.

21.5.5.1 Process and Procedures

The case manager obtains prescriptions from the treating physician.

Therapy services are scheduled.

Therapy services are provided, as defined in the customer's IPP.

Therapy services are performed by licensed health care professionals and as defined in the customer's IPP.

Weekly activity schedules and weekly time logs are completed.

Licensed and/or certified professionals complete the required progress report describing each treatment session in detail.

Reports are submitted to the VR counselor.

The status of goals is updated in the monthly IPP meetings.

21.5.5.2 Outcomes Required for Payment

VR counselor receives the following complete, accurate, and descriptive documents:

• A copy of the customer's weekly activity schedule
• Weekly time logs recording all billable time for therapies completed by the licensed and/or certified professionals
• Therapy reports for each therapy service provided, as identified in the IPP and service authorization for the reporting period

The therapy documentation contains progress notes and recommendations related to:

• the customer's abilities, deficits, and potential to obtain and maintain competitive integrated employment;
• the customer's potential to secure, retain, and advance in employment;
• the customer's employment goal(s), transferable skills, and employment barriers; and
• additional therapy and/or employment services, if necessary.

The time to attend the IPP meeting and update the IPP is not billable.

Therapy services are paid based on:

• the approved time listed in the IPP;
• the time recorded on the customer's weekly time log; and
• the time recorded in the therapy reports.

Payment for therapy services is made when the VR counselor approves the submitted:

• weekly time log;
• therapy report(s); and
• invoice.

Providers must develop a discharge summary for each employed customer that includes:

• the strengths, abilities, needs, and preferences of the customer;
• the date of discharge;
• the physical location;
• the amount of supervision that the customer will need for safety, decision-making, and to maintain the skills learned in ESBI services;
• how medical restrictions, precautions, contraindications, and medical care needs will be monitored;
• the family's, caregiver's, and customer's support system training;
• the discharge status of each goal established in the IPP;
• a description of the customer's current employment, including:
  • the employer;
  • the customer's job title;
  • the supervisor's name and title;
  • the customer's soft and hard skills;
  • the work environment; and
  • any compensatory strategies necessary to maintain long-term employment;
• referrals, recommendations, and strategies to help the customer retain and advance in employment.

When the customer is not employed at discharge, the providers must provide a detailed description documenting the following:

• Why the customer is not able to reach a successful employment outcome
• The strengths, abilities, needs, and preferences of the customer
• The date of discharge
• The physical location
• The amount of supervision that the customer will need for safety, decision-making, and to maintain the skills learned in ESBI services
• How medical restrictions, precautions, contraindications, and medical care needs will be monitored
• The family's, caregiver's, and customer's support system training
• The discharge status of each goal established in the IPP
• The alternatives that were tried to achieve employment and the barriers that were identified
• The types of work simulations experienced and the current level of job skills
• Recommendations for suitable work environments
• Recommendations for suitable work tasks
• Recommendations for next steps

21.7.1 Process and Procedures

The case manager ensures that the IDT completes the discharge plan, including all required information prescribed in the discharge plan service description.

At discharge, the discharge plan is implemented, and a summary is developed by the case manager, with input from all members of the IDT. Each clinical therapy service must complete and attach a formal discharge summary. For any employment services the provider will attach the required documentation for the applicable service, as defined in this manual's service description, the process and procedures, and the outcomes required for payment.

21.7.2 Outcomes Required for Payment

The case manager's completed discharge summary with all required information submitted simultaneously to the VR counselor and the unit program specialist within 10 business days of the customer's discharge.

When case management is not a covered expense by comparable benefit, an invoice must be submitted with the discharge report.

21.7.3 Fees

Nonresidential Rate Structure (link to 21.12.5 Nonresidential Rate Structure):

Only a case manager can bill for attendance, reporting, and documentation related to the IPP.

Residential Rate Structure (link to 21.12.6 Residential Rate Structure):

All IDT members, including the case manager's fee, are included in the Residential base daily rate.

Goods and services related to an individual's acquired brain injury, which are not therapy services and are not delivered as part of ESBI nonresidential or residential services, are considered to be supports of ESBI services. The provider must submit an IPP that identifies the goods and services needed for the customer to obtain a service authorization from the VR counselor.

The IPP must include:

• the goods and services recommended;
• a justification of the need related to the established goal (for example, by including assessments and quotes for costs); and
• supporting documentation (such as prescriptions).

 These services may include, but are not limited to:

• orthotics;
• prosthetics;
• psychological services (provided by a psychologist only);
• assistive technology evaluations and devices;
• medications that are not part of an ESBI contract;
• prescribed medical equipment and supplies;
• home and/or vehicle evaluations;
• home and/or vehicle modifications; or
• transportation.

TWC-VR will consider purchasing support services when required to enable participation in an ESBI-approved service. These support services are paid according to the Maximal Affordable Payment Schedule (MAPS) or the durable medical equipment (DME) contract as applicable.

ESBI services provided as a day program or as outpatient therapy services are nonresidential services. The facility must meet all applicable requirements outlined in 21.3 ESBI Provider Qualifications and 21.4 ESBI Provider Requirements. Nonresidential services can be provided while the customer is receiving an initial assessment or evaluation, as described in the customer's IAEP and/or during the implementation of the customer's IPP. All services provided must be provided by individuals who meet the staff qualifications described in 21.2 Staff Qualifications, Ratios, and Training. A nonresidential service provider must offer cognitive therapy but is not required to provide all of the other core services described in 21.5.2 Initial Assessment and Evaluation Plan Service Definition and 21.12.5.1 Core Services. The IDT will be coordinated to include other service providers, as needed.

Time spent for documentation, for communication (such as emails and phone calls), cannot be billed as a core service or as an ancillary service. When a customer is absent from nonresidential services for any reason, the ESBI provider is not eligible to invoice TWC-VR for any fees, including no-show fees. The nonresidential service provider must notify the VR counselor of an absence greater than one day. For information about the ESBI Nonresidential service fees go to 21.12.5 Nonresidential Rate Structure. A service authorization will identify the type and amount of nonresidential services and must be obtained before service delivery. The customer must actively participate in the program and make progress towards the goals in either the IAEP or IPP for continued sponsorship by TWC-VR for Nonresidential Services.

Goods and services related to an individual's acquired brain injury, which are not delivered as part of ESBI nonresidential services, maybe considered ancillary if approved by the VR counselor. Refer to 21.9 Other Support Goods and Services.

21.13.1 Co-Pay and Coinsurance

If a VR customer has comparable benefits, the provider must bill the comparable benefits before billing the VR program.

If comparable services and benefits are available, the VR program may participate in the cost of services if the combined amount of the VR payment and the comparable benefit payment does not exceed the maximum amount allowed by the following, as appropriate:

• MAPS rate
• Contracted payment rate
• The retail or negotiated lower price (for non-MAPS, noncontract items)

All other pay sources must be exhausted before the VR program is billed for services.

When a customer has health insurance, Medicare, or Medicaid, the ESBI provider first submits a timely claim to these entities, as applicable, for payment of the provided ESBI services. An Explanation of Benefits (EOB) is sent by the insurer to the ESBI provider to document the payment made per benefit coverage and the patient's payment responsibility (the customer's portion). The ESBI provider submits to the VR counselor a copy of the EOB with the provider's invoice in order for the VR payment responsibility to be determined.

If the comparable benefit denies the service, the EOB is reviewed to determine the reason for the denial. If the service was denied for insufficient documentation, the VR counselor contacts the ESBI provider and requests that the provider resubmit the claim with the proper documentation. The VR program is not responsible for payment of services when an ESBI provider fails to file the claim with the comparable benefit in a timely manner.

If the comparable benefit is paid by:

• Major medical insurance, a health maintenance organization, or preferred provider organization—the VR program may pay the customer's portion (co-payment, coinsurance, and any unmet deductible), not to exceed the MAPS rate, contract rate, or retail price, as applicable;
• Medicare—the VR program may pay the customer's portion (co-payment, coinsurance, and any unmet deductible), not to exceed the MAPS rate, contract rate, or retail price, as applicable; or
• Medicaid—the VR program pays nothing. The VR program does not supplement a Medicaid payment for a specific service or procedure.

21.13.2 Family Cost Share

In some cases, customers will be required to participate in the cost of services. In those cases, the customer and the provider will be notified of the customer's share. The provider may not bill beyond that cost and will not collect from the customer until the VR payments and/or any comparable benefits payments have been received.

The provider is responsible for billing and collecting or writing off cost-share amounts owed by the liable party.

21.13.3 Invoices

For information on VR invoicing requirements, refer to Chapter 3: Basic Standards.

When applicable, billing must be submitted to third-party payers promptly. Billing to VR must be submitted upon partial payment or denial of payment from third-party payers. If the family is required to share in the cost of services, the customer and the provider will be notified of the customer's share. The provider may not bill beyond that cost and will not collect from the customer until the VR payment and/or any comparable benefits payments have been received. When the provider's facility is closed or a customer is not present for the service within a customer's dates of service, payment is not made for that date.

Invoices must be submitted at least monthly, no later than the 15th day of each month, on one of the following forms:

• UB-04 Centers for Medicare and Medicaid (CMS 1450)
• Health Insurance Billing Form (CMS 1500)

The provider must submit invoices to the address on the VR service authorization, comply with the terms and conditions of the customer contract, and include, at a minimum, the:

• vendor's complete name and address;
• vendor's 14-digit Texas identification number (TIN) or nine-digit federal employee identification number (FEIN);
• vendor's contact name and telephone number;
• service authorization number;
• delivery address;
• contract number;
• description of the goods or services provided, including CPT codes;
• dates of service;
• quantity and unit-cost being billed, as documented on the service authorization;
• IAEP or IPP signed by the interdisciplinary team (for initial billing for services only);
• weekly time logs;
• Progress reports for services received;
• monthly meeting summaries, signed by the IDT (for monthly services that are not admission or discharge services); and
• customer's discharge summary, signed by the IDT, and the discharge documentation (upon final billing).

The provider must:

• respond to billing-related inquiries from VR program staff members within two business days; and
• submit all documentation requested within five business days following the request.