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Home Health Policy Manual

Home Health Policy Manual

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Section/ Subsection Title/Content Forms Number Issue/ Revised
    Table of Contents   10/2016
100   RESERVED    
200   RESERVED    
300   RESERVED    
400   ELIGIBILITY FOR SERVICES    
  401 Medicaid Eligibility Requirements   04/2015
  402 Program Eligibility   01/2016
  403 General Provisions and Services   07/2015
  404 Service Limitations and Exclusions   07/2015
  405 RESERVED    
  406 RESERVED    
  407 Denial of Services   04/2015
  408 RESERVED    
  409 RESERVED    
  410 RESERVED    
  411 New Admissions   07/2016
  412 Request to Change Agencies   04/2015
  413 Switch in Options   04/2015
  414 High Risk Intake   04/2015
  415 Annual MPQH Reviews   04/2015
  416 RESERVED    
  417 Temporary Authorization   04/2015
  418 RESERVED    
  419 RESERVED    
  420 RESERVED    
  421 Service Plan   04/2015
   

 

   

 

 

 

 

 

 

 

500   MOUNTAIN PACIFIC QUALITY HEALTH    
 

 

 

 

 

 

 

 

 

 

600   ADMINISTRATIVE REQUIREMENTS    
  605 Fair Hearings   07/2016
  606 Policy Memo CFC/PAS 606 Reimbursement   06/2016
  606 Reimbursement   01/2016
  608 Quality Assurance Review   04/2016
  609 Quality Assurance Review Worksheet   10/2016
  610 Provider Agency Quality Assurance Process   01/2016
         
700   SERVICE REQUIREMENTS    
  701 Agency Requirements   10/2015
  702 Intake Visits   04/2015
  703 180 Day and Annual Recertification   07/2015
  704 Complaint Procedure   04/2015
  705 Termination, Discharge and Temporary Absences   04/2015
  706 Training Attendants   07/2015
  707 Medical Escort and Medical Transportation Mileage   07/2015
  708 Shopping, Community Integration and Mileage   10/2015
  709 Serious Occurrence Report   10/2015
  710 Home and Community Based Waiver Program   04/2015
  711 Live-In Attendants, Family and Significant Others   04/2015
  712 Home Health and Hospice Benefit and Third Party Programs   04/2015
  713 Services to Children Under the Age of 21 years   04/2015
  714 Services to Members with Developmental Disabilities   04/2015
  715 Services to Pregnant Women   04/2015
  716 RESERVED    
  717 Flexibility Parameters   04/2015
  718 Service Delivery Records   07/2015
  719 Amendments   07/2015
  720 Conflict of Interest   04/2015
  721 Skill Acquisition   04/2015
  722 RESERVED    
  723 Shared Cases   04/2015
         
800   RULES AND RESOURCES    
         
900   FORMS    
         
  901 General Information/Forms Requisition  SLTC 100 02/2015
  902 General Utilization   02/2015
  903 RESERVED    
  904 Service Plan Form Instructions SLTC 170 02/2015
  905 Member Referral Form Instructions SLTC-154 02/2015
  906 Change in Demographics Form Instructions SLTC-157 02/2015
  907 Unable to Admit/Discharge Form Instructions SLTC-158 02/2015
  908 Agency Start of Care Form Instructions SLTC-163 02/2015
  909 Person Centered Planning Form Instructions SLTC-200 02/2015
  910 RESERVED    
  911 Service Delivery Record Form Instructions - Sample SLTC-220 02/2015
  912 Mileage and Medical Escort Form Instructions SLTC-221 02/2015
  913 Request for Case Review Form Instructions SLTC-MA-128 02/2015
  914 Risk Negotiation Form Instructions SLTC-230 02/2015
  915 Recertification Documentation Instructions SLTC-210 02/2015
  916 Skills Acquisition Endorsement Form Instructions SLTC-216 02/2015
  917 Skills Acquisition Training Plan Form Instructions SLTC-216 02/2015
  924 Internal Quality Assurance Review Summary SLTC-252 01/2016
  925 Provider Prepared Standards SLTC-253 01/2016
  930 PERS Prior Authorization Form Instructions SLTC-240 10/2016
  931 PERS Referral Form Instructions SLTC-241 10/2016
         
1000   RESERVED    
         
1100   CFC/PAS PERSON CENTERED PLANNING (PCP)    
  1101 PCP Requirements Overview   01/2015
  1102 Plan Facilitator vs. Provider Responsibilities   01/2015
  1103 Plan Facilitator Certification for CFC/PAS Providers   01/2015
  1104 PCP Coordinated Visits   01/2015
  1105 MPQH Authorization Documentation   01/2015
  1106 PCP Annual Visits   01/2015
  1107 PCP Re- Admission to CFC/PAS   01/2015
  1108 High Risk Admits   01/2015
  1109 Policy Memo: Plan Facilitator Policy Memo   10/2016
  1109 Plan Facilitator Change: Intake to Waiver/Case Management, Switch in Agency, and Waiver Discharge   01/2015
  1110 Short Term Admits   01/2015
  1111 Personal Emergency Response Systems (PERS)   04/2016
  1112 Person Centered Planning Form Instructions   01/2015
  1113 Level of Care   01/2015
  1115 Case Manager Plan Facilitator Role When a Member Changes CFC/PAS Provider Agency   04/2016
Appendix   Agency Based Electronic Forms (These forms have been approved by Central Office for use by providers).    
         
  901 AB-Requisition Form - Agency Based *   07/2014
  901 CM-Requisition Form - Case Managers *   02/2015
  902 General Utilization Form   11/2015
  SLTC 154 MPQH Referral Form   02/2015
  SLTC 157 Change in Demographics Form   07/2014
  SLTC 158 Agency Discharge Form   11/2015
  SLTC 163 Agency Start of Care Form   11/2015
  SLTC 215 Skill Acquisition Endorsement Form   11/2015
  SLTC 216 Skill Acquisition Training Form   11/2015
  SLTC 220 Service Delivery Record Form (Sample: Providers must include required information. Customized form must approved by Central Office)   11/2015
  SLTC 221 Mileage and Medical Escort Record Form   02/2015
  SLTC 230 SLTC 230 Risk Negotiation Form   02/2015
  SLTC 240 SLTC 240 PERS Prior Authorization Form   10/2016
  SLTC 241 SLTC 241 PERS Referral Form (Sample: Providers must include required information on customized form)   10/2016
  SLTC MA-128 SLTC MA-128 Request for Case Review   02/2015
  SLTC 252 SLTC 252 Internal Quality Assurance Review Summary Form   01/2016
  SLTC 253 SLTC 253 Provider Prepared Standards Form   01/2016
         
    Pre-printed Forms available from Central Office    
         
  SLTC 170 Agency Based Service Plan*   11/2015
  SLTC 200 Person Centered Plan (PCP) Form*   07/2014
  Handbook CFC/PAS PCP Pre-Planning Guide*   01/2014
  SLTC 210 Recertification Documentation Form*   11/2015
    *Please use the SLTC 901 Requisition Form to order forms which are pre-printed by Central Office. Allow 2 weeks for delivery.