What’s an SDR?
What does SDR stand for?
Service Determination Request
How many days does the IDT have to respond to an SDR?
Three calendar days
A participant asks for a different shower chair—Is this an SDR?
Yes – It’s a request for a service/item.
What must happen when a discipline approves an SDR on the spot?
1) Document the SDR 2) Notify compliance immediately 3) Make the participant aware of the decision on the spot
Who should be informed of an SDR decision?
The participant and their designated representative (if applicable).
What triggers an SDR?
Any request made by the participant, designated representative, caregiver or contractor providing direct care for a service, for an item, or level of care, whether granted or denied.
What must happen if an SDR is denied?
An in person assessment is required to provide documentation with why it was denied.
A participant asks the Homecare Coordinator for more home care hours, it's denied on the spot —Is this an SDR before it's denied?
Yes – A denied request is still considered an SDR.
True or False: In person assessment are required for a Denial or Partially Denial SDR?
True- In person assessment is required for any SDR that is denied or partially denied
What’s one way to explain a denied SDR with empathy?
“We understand why this is important to you. After reviewing your care needs and available options, we’ve made this decision because…”
True or False: An SDR is required only if a service is being denied.
False – An SDR is required for all service requests, whether approved or denied.
True or False: An SDR must always be approved by a single discipline.
False – The IDT makes SDR decisions collectively, not just one discipline.
A participant doesn’t like the food and wants to change menus—Is this an SDR?
No – this is a grievance
Why does Compliance need to know about SDR outcomes?
1. Tracking timelines, 2. Compliance sends out Required notifications, 3. Ensures SDR P&P and regs being followed
What should you do if a participant doesn’t understand the SDR outcome?
Use plain language, visual aids if needed, and offer to meet with them again to clarify.
When is an SDR extension appropriate?
The extension is in the participant's interest because the IDT needs additional information from an individual not directly employed by the PACE organization that may change the IDT's decision to deny a service.
What written communication is required after an SDR decision?
A written notice to the participant (and representative, if applicable) stating approval or denial, reason, and appeal rights.
A participant asks to switch from group PT to 1:1 sessions—Is this an SDR?
Yes – It involves a request for a different level or modality of care.
If an SDR is approved, what must be updated in the chart or EMR?
The care plan, service orders, and relevant assessments.
What’s a respectful way to introduce the appeals process to a participant or family?
“If you disagree with this decision, you have the right to file an appeal. We can help you with that process.”
When is an SDR not submitted?
When a request is made before the initial care plan has been completed.
What happens if the SDR timeline is not met?
Failure to meet SDR timeline constitutes an adverse decision, and the participant's request must be automatically processed by the PACE organization as an appeal.
A participant asks for help scheduling their routine eye exam that is already part of their care plan. The scheduler assists them. Is this an SDR?
No. This is not an SDR because the request is part of the participant’s existing care plan and no change is being made to the services.
If the SDR is approved - how can the reassessment be completed?
How quickly should the participant be notified of the SDR decision?
Within 24 hours