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 that helps resolve issues related to excessive costs in individual care plans. This form is typically used by healthcare providers and caregivers who need to request a review of an IPC's cost when it exceeds the maximum cost ceiling.

This cover sheet requires the submission of specific information, including a signed IPC form, a screen print of the L02 CARE screen, and written justification supporting the requested services. The document also outlines key responsibilities, such as filing the enclosed documents with the original IPC in the individual's record. Additionally, it emphasizes that PE/UR authorization does not constitute prior approval for payment, and all amounts must meet billing and payment guidelines.

When submitting a request for review, providers should include the required information and follow the instructions outlined on the form. Key points to note include:

• The need to provide written justification supporting the requested services
• The requirement to file enclosed documents with the original IPC in the individual's record
• The importance of meeting billing and payment guidelines for all amounts