TX HHS Form 8627. Request for Review of Individual Plan of Care (IPC) Cost Over Maximum Cost Ceiling Cover Sheet

The TX HHS Form 8627, Request for Review of Individual Plan of Care (IPC) Cost Over Maximum Cost Ceiling Cover Sheet, is a crucial document used to request a review of an IPC's cost when it exceeds the maximum cost ceiling. This form helps providers and caregivers navigate the process of seeking approval for services that exceed the allocated budget.

This cover sheet requires providers to submit a packet containing essential information, including a signed IPC form, screen print of the L02 CARE screen, and written justification supporting the requested services. The form also asks for provider and LA contact information, as well as individual information such as name, CARE ID number, and Medicaid number.

The TX HHS Form 8627 is typically used when a provider needs to request approval for services that exceed the maximum cost ceiling, which may include adaptive aids, minor home modifications, or dental dollars. Providers should submit the completed form along with supporting documentation to Program Enrollment/Utilization Review (PE/UR) at the Texas Health and Human Services Commission (HHSC).