Form 1013, PASRR Plan of Care – General Revenue

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Effective Date

5/2026

Instructions

Update: 5/2026

Purpose

The local intellectual and developmental disability authority (LIDDA) uses Form 1013 to request preauthorization for:

  • Preadmission Screening and Resident Review (PASRR);
  • intellectual and developmental disability habilitative specialized services (IHSS); and 
  • habilitation coordination. 

The form also identifies any changes in the frequency, amount and duration of each service.

When to prepare

The habilitation coordinator (HC) completes and updates Form 1013 when PASRR IHSS is started, renewed or revised. The HC submits the form to the HHSC PASRR unit for preauthorization.

Detailed Instructions

Section 1 – Demographic Information

Person’s Name – Enter the person’s name.

Medicaid No. – Enter the person’s Medicaid number.

Local Case No. (LCN) – Enter the LIDDA’s local case number for the person.

Plan Begin Date – Enter the plan begin date.

Plan End Date – Enter the plan end date.

Plan Effective Date – Enter the plan effective date. For a revision, this is the date the plan was updated.

Plan Type – Select if this plan of care is an initial, an annual renewal or revised.

Nursing Facility (NF) Name – Enter the NF’s name.

NF Area Code and Phone No. – Enter the NF’s area code and phone number.

NF Vendor No. — Enter the NF’s vendor number.

Local Intellectual and Developmental Disability Authority (LIDDA) – Enter LIDDA’s name.

LIDDA Comp Code – Select the LIDDA’s component code.

Habilitation Coordinator (HC) Name – Enter the assigned HC's name.

HC Area Code and Phone No. – Enter the assigned HC’s area code and phone number.

HC Email Address – Enter the assigned HC’s email address.

Service Provider Agency Name – Enter the selected service provider agency name. Use LIDDA name for IHSS manual process.

Service Provider Agency Contract No. – Enter the selected service provider agency’s contract number. Use LIDDA contract number for IHSS manual process.

Is this person refusing Habilitation Coordination? – Select Yes or No.

Section 2 – Service Requests

The HC fills out the frequency, amount, duration and status update for each selected service. They use the specified service type such as day habilitation and independent living skills training.

Note: Leave the service request line blank for if a specific service is not being requested. 

Frequency – Select the frequency of the service, such as one time per week.

Amount – Select the amount of the service, such as one hour.

Duration – Select the Service Begin Date and Service End Date.

Note: The service begin date is always when the service is added to the plan of care. The service end date is always the plan end date located in section 1 for newly added services. 

Status – Select the type of service update or status that is occurring.

  • New- Newly added service
  • Ongoing- The service is continued with no changes.
  • Increase- The service’s frequency or amount is increasing.
  • Decrease- The service’s frequency or amount is decreasing.
  • Discontinued- The service is being discontinued, or the originally requested frequency and amount is changing. Increases or decreases in frequency or amount is documented on a separate line.

Note: If a service’s frequency or amount is changing before the plan end date, the discontinued-on date is the day before that service’s frequency and amount was changed. This is the effective date.

Discontinued On — Select the date the service was discontinued, if applicable.

Add Service — Add a line for service changes throughout the plan year.

Remove Service — Remove the previously added line.

Signatures

Select the date of the SPT meeting when development of the plan of care was agreed to.

Person’s Printed Name – Enter the person’s name.

Person’s Signature – The person signs their name.

Date – Enter the signature date.

Legally Authorized Representative (LAR) Printed Name – Enter the LAR’s name if applicable.

LAR Signature – The LAR signs their name.

Date – Enter the signature date.

HC Printed Name – Enter the name of the assigned HC.

HC Signature – The assigned HC signs their name.

Date – Enter the signature date.

IHSS Provider Printed Name – Enter the IHSS provider’s name.

IHSS Provider Signature – The IHSS provider signs their name.

Date – Enter the signature date.