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Big Sky Waiver Policy Manual

Big Sky Waiver Program Policy Manual

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Chapter

Subject

Form Number

Date Revised

001 Table of Contents   04/01/2017
002 Alpha Subject Index   03/01/2012

400

ELIGIBILITY FOR SERVICES

   
  401 HCBS Eligibility Requirements   04/01/2016
  402 Slot Categories   04/01/2016
  403 Prior Authorizations   04/01/2016
  404 Advance Notice SLTC-144 04/01/2017
  405 Referrals for Services   01/01/2012
  406 Wait List Criteria   01/01/2017
  406-1 Wait List Tool and Scoring SLTC-146 01/01/2017
  407 Medically Needy Billing Procedures   01/01/2012
  408 Residency Requirements   01/01/2012
  409 Out-of-State Services   01/01/2012
  410 Retainer Payments   01/01/2012
  410-1 Attachment A, Public Institutions   01/01/2012
  411 Individuals with Intellectual Disabilities   01/01/2017
  412 Termination/Denial of Services SLTC-137 04/01/2017
  413 Fair Hearings   04/01/2017
  414 Assisted Living At-Risk Slot Process   01/01/2017
  499-1 DPHHS Release of Information HPS 402   10/01/2015

500

PREADMISSION SCREENING

   
  501 Screening Requirements Preadmission Screening   01/01/2012
  502 Screening Referral Procedures   01/01/2012
  503 Level of Care Reevaluations   03/01/2011
  504 RESERVED    
  599-1 Screening Determination Form SLTC-61 03/01/2011

600

ADMINISTRATIVE REQUIREMENTS

   
  601 Provider Eligibility   01/01/2012
  602 Provider Responsibilities   07/01/2016
  602-1 Progress Notes   01/01/2017
  603 Provider Enrollment   04/01/2017
  604 Payment Requirements   01/01/2016
  604-1 Payment of Legally Responsible Individuals   01/01/2016
  605 Payment Processing   01/01/2012
  605 Policy Memo Re: Billing For Medical Escort   03/11/2015
  606 Reimbursement Methodology   01/01/2012
  607 Licensure Requirements   07/01/2016
  608 Quality Assurance Process   04/01/2016
  608-1 Quality Assurance Communication   01/01/2017
  609 Serious Occurrence Report   04/01/2017
  699-1 Provider Requirements   01/01/2016
  699-2 CMS 1500 Claim Form   02/01/2012
  699-3 File Transfer   01/01/2012
  699-4 RESERVED    
  699-5 HCBS Referral for Services Form   04/01/2007

700

SERVICES

   
  701 Covered Services   08/01/2011
  702 Service Limitations and Exclusions   08/01/2011
  703 Adult Day Health   08/01/2011
  704 Case Management   08/01/2011
  705 Community Supports   08/01/2011
  706 Community Transition   08/01/2011
  707 Consultative Clinical and Therapeutic Services   08/01/2011
  708 Consumer Goods and Services   08/01/2011
  709 Day Habilitation   08/01/2011
  710 Dietetic Services   08/01/2011
  711 Environmental Accessibility Adaptations   01/01/2016
  712 Family Training and Support   08/01/2011
  713 Financial Management Services   08/01/2011
  714 Health and Wellness   08/01/2011
  715 Homemaker   01/01/2012
  716 Homemaker Chore   01/01/2012
  717 Independence Advisor   08/01/2011
  718 Non-Medical Transportation   08/01/2011
  719 Nutrition   01/01/2012
  720 Occupational Therapy   08/01/2011
  721 Pain and Symptom Management   01/01/2012
  722 Personal Assistance Services   04/01/2016
  723 Personal Emergency Response System   07/01/2016
  724 Physical Therapy   08/01/2011
  725 Post Acute Rehabilitation Services   08/01/2011
  726 Prevocational Services   08/01/2011
  727 Private Duty Nursing   08/01/2011
  728 Residential Habilitation   01/01/2012
  729 Respiratory Therapy   08/01/2011
  730 Respite Care   08/01/2011
  731 Senior Companion   08/01/2011
  732 Special Child Care for Medically Fragile Children   08/01/2011
    Durable Medical Policy Memo   01/01/2017
  733 DME: Specialized Medical Equipment, Supplies and Technology   02/01/2017
  733-1 DME Specialized Medical Equipment, Supplies and Technology: Consultations   02/01/2017
  733-2 DME Specialized Medical Equipment, Supplies, and Technology: Commonly Covered Items under Big Sky Waiver   02/01/2017
  734 Speech Therapy and Audiology   08/01/2011
  735 Supported Employment   08/01/2011
  736 Supported Living   08/01/2011
  737 Vehicle Modification   10/01/2015
  799-1 Administrative Rules of Montana   10/01/2015
  799-2 CFC/PAS Consumer Referral Form SLTC-154 10/01/2015
  799-3 Service Animal: Case Management Team Role   10/01/2015
  799-4 Service Animal: Member Responsibilities   10/01/2015
  799-5 Service Animal: Acquisition Procedure   10/01/2015
  799-6 Consumer Recycling Agreement   03/01/2005

800

CASE MANAGEMENT SERVICES

   
  801 Case Management Requirements   01/01/2012
  802 Case Management Team Requirements   01/01/2012
  803 Service Areas   03/01/2012
  804 Record Requirements   01/01/2012
  805 Budget Requirements   03/01/2005
  806 Reporting Requirements   01/01/2012
  807 Contract Termination and Transition   03/01/2005
  808 Transfer of Members or Change in Member Classification   01/01/2012
  809-1 Service Plan Development   07/01/2016
  809-2 Service Plan Components   01/01/2012
  809-3 Service Plan Requirements   01/01/2012
  809-4 Service Plan Costs   01/01/2012
  809-5 Service Plan Reevaluations   01/01/2012
  809-6 Service Plan Amendment   01/01/2012
  809-7 Service Plan Annual Updates   01/01/2012
  810 Member Input   01/01/2012
  812 Risk Negotiation Process   01/01/2012

 

 

FORMS

   
  899-2 Reporting Requirements, Forms & Instructions   04/01/2016
  899-2a Internal Chart Audit Form   01/01/2009
  899-2b Utilization Report   01/01/2012
  899-2c Nursing Facility Transfer Report   01/01/2009
  899-3 CMS QA Performance Measures   01/01/2012
  899-4 HCBS Forms Requisition   01/01/2006
  899-5 Service Plan Cost Limits   10/01/2015
  899-6 Entrance into Medicaid Instructions SLTC-55 02/01/2007
  899-7 Request for Level of Care SLTC-85 01/01/2006
  899-8 Level of Care Determination   01/01/2016
  899-9 Residential Habilitation Care Calculation SLTC-132 01/01/2013
  899-10 Service Plan & Cost Sheet SLTC-134 01/01/2012
  899-11 Service Plan Instructions   04/01/2016
  899-11 HCBS Service Plan Form SLTC-135 04/01/2016
  899-11b Service Plan Short Form (135b) Instructions   04/01/2016
  899-11b Service Plan Short Form SLTC 135b 04/01/2016
  899-12 Intake Sheet Form Instructions SLTC-136 01/01/2016
  899-14 Authorized Services for Incurment SLTC-131 01/01/2012
  899-15 Re-Evaluation Form SLTC-139 01/01/2012
  899-16 Amendment Form ALTC-141 01/01/2012
  899-17 Psychosocial Summary Form Instructions SLTC-143 01/01/2016
  899-19 Level I Screen SLTC-145 01/01/2006
  899-21 Request for Prior Authorization CC3 SLTC-148 01/01/2012
  899-22 Request for Prior Authorization SLTC-149 03/01/2005
  899-23 Service Animals Provider Assurance Form Instructions SLTC-142 10/01/2015
  899-24 Service Animal Stewardship Agreement Instructions SLTC-147 10/01/2015
  899-25 Waiting List Database   03/01/2005
  899-26 State Supplement Instructions & Forms   02/01/2007
  899-27 Nursing Home Transition Process & Form   03/01/2011
  899-29 Risk Negotiation Policy Memo   07/01/2016
  899-29 Risk Negotiation Form & Instructions   01/01/2012

1100

Person Centered Planning

   
  1101 Person-Centered Planning Requirements Overview   04/01/2017
  1102 Plan Facilitator vs. Provider Responsibilities   04/01/2017  
  1103 Plan Facilitator Certification for CFC/PAS Providers   04/01/2017
  1104 Person Centered Planning Coordinated Visit   04/01/2017
  1105 Mountain Pacific Quality Health Authorization Documents   04/01/2017
  1106 Person Centered Planning Annual Visits   04/01/2017
  1111 Personal Emergency Response Systems (PERS)   04/01/2017
  1112 Person Centered Plan Form Instructions (SLTC 200) SLTC-200 04/01/2017

Appendix

       
  9901 Definitions   03/01/2005
  9902 Abbreviations/Acronyms/Initials   01/01/2017