MO HealthNet for the Aged, Blind, and Disabled

0820.030.10.05 Referrals to DHSS/DSDS

IM-25 04/08/15

The referral process for authorization for HCB waiver services is as follows:

  1. Within two business days of the approval of spend down or non spend down coverage, or the decision that a division of assets will be required prior to approval, fax or scan and email the completed IM-54A (Home and Community Based Referral) to the DHSS/DSDS Call Center for registration and distribution.
    • Fax to 1-573-526-2915 (A cover sheet is not necessary).

      NOTE: The fax machine date stamp is verification that it has been faxed.


    • Scan the IM-54A and email to
  2. DHSS will return the IM-54A with their decision to the Eligibility Specialist by fax or mail.
    • If the form is not returned within four weeks after faxing or emailing, call local DSDS staff to discuss the delay.

NOTE: The case must be approved for MHABD non-spend down or spend down before faxing or scanning the request, if eligible.

The HCB application must not be approved until the IM-54A has been received from DSDS showing the participant was determined eligible for Aged and Disabled Waiver services. If the DSDS determines the claimant does not require NF Level of Care or Aged and Disabled Waiver services, reject the HCB application.

NOTE: Do not delay approving the application for MHABD non-spend down or spend down while waiting for the HCB determination to be completed.