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Community First Choice Self-Direct Policy Manual

Community First Choice Program
Self-Direct Policy Manual

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Section/
 Subsection

Title/Content

 Forms

Issued/
Revised

 

 

Table of Contents

 

01/01/2018

 

 

Abbreviations*

 

04/2017

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
  403 General Provisions and Services Policy Memo   01/04/2018
  404 Service Limitations and Exclusions   01/01/2018
  404 Service Limitations and Exclusions Policy Memo   01/04/2018
  405 Reserved    
  406 Reserved    
  407 Denial of Services   04/2015
  408 Reserved    
  409 Reserved    
  410 Reserved    
  411 New Admissions   10/2017
  412 Request to Change Agencies   04/2017
  413 Switch in Options   07/2017
  414 High Risk Intake   04/2015
  415 Annual MPQH Reviews   04/2015
  416 Reserved    
  417 Temporary Authorization   04/2015
  418 Health Care Professional Authorization   10/2015
  419 Reserved    
  420 Reserved    
  421 Service Plan   04/2015
  421 Service Plan Policy Memo   01/04/2018

500

Mountain Pacific Quality Health

 

600

Administrative Requirements

 
  605 Fair Hearings   04/2017
  606 Policy Memo CFC/PAS Reimbursement*   06/2016
  606 Reimbursement   01/2016
  608 Quality Assurance Review   04/2016
  609 Quality Assurance Review Work Sheet   10/2016
  610 Quality Assurance Process-Provider Agency Reports   01/2017
  610 Quality Assurance Process-Provider Agency Reports Policy Memo   01/04/2018

700

Service Requirements

 
  701 Agency Requirements   07/2017
  702 Intake Visits   07/2017
  703 180 Day and Annual Recertification   07/2015
  704 Complaint Procedure   04/2015
  705 Termination, Discharge, and Temporary Absences   04/2017
  706 Training Attendants   04/2015
  707 Medical Escort and Medical Transportation Mileage   07/2015
  708 Shopping, Community Integration and Mileage   04/2017
  709 Serious Occurrence Report   04/2017
  710 Home and Community Based Waiver Program   07/2015
  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 Personal Representative   10/2015
  717 Flexibility Parameters   04/2015
  718 Service Delivery Records   04/2015
  719 Amendments   10/2017
  719 Amendments Policy Memo   01/04/2018
  720 Conflict of Interest   04/2015
  721 Skill Acquisition   07/2015
  722 Member Capacity and Compliance   04/2015

800

Rules and Resources

 

900

Forms

 
  901 General Information   01/01/2018
  902 General Utilization*   02/2015
  903 Reserved    
  904 Service Plan Form Instructions  SLTC-175 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* 01/01/2018
  909 Person Centered Planning Form Instruction  SLTC-200* 04/2017
  910 Reserved    
  911 Service Delivery Record Form Instructions  SLTC-222* 02/2015
  912 Mileage and Medical Escort Form Instructions  SLTC-221* 04/2017
  913 Request for Case Review Form Instructions  SLTC-MA128 02/2015
  914 Risk Negotiation Form Instructions  SLTC-230 02/2015
  915 Recertification Documentation Form Instructions  SLTC-210 02/2015
  916 Skills Acquisition Endorsement Form Instructions  SLTC-215 02/2015
  917 Skills Acquisition Training Form Instructions  SLTC-216 02/2015
  918 Reserved    
  919 Program Compliance Tool Form Instructions  SLTC-167 02/2015
  920 Health Care Professional Authorization Form SLTC-160 02/2015
  921 Member Agreement Form Instructions  SLTC-159 07/2015
  922 Reserved    
  923 Personal Representative Agreement Form Instructions SLTC-166 07/2015
  924 Agency Internal Quality Assurance Review SLTC-250* 01/01/2018
  925 Provider Prepared Standards SLTC-251 01/01/2018
  925 Provider Prepared Standards Policy Memo   01/04/2018
  926 Intake Internal Review SLTC-246* 01/01/2018
  927 Recertification Internal Review Worksheet SLTC-247* 01/01/2018

1000

Reserved

 

1100

CFC/PAS Person Centered Planning

 
  1101 PCP Requirements Overview   04/2017
  1102 Plan Facilitator vs. Provider Responsibilities   04/2017
  1103 Plan Facilitator Certification for CFC/PAS Providers   04/2017
  1104 PCP Coordinated Visits   04/2017
  1105 MPQH Authorization Documents   04/2017
  1106 PCP Annual Visits   04/2017
  1107 PCP Re-Admissions to CFC/PAS   04/2017
  1108 High Risk Admits   04/2017
  1109 Policy Memo: Plan Facilitator Policy Memo*   10/2016
  1109 Plan Facilitator Change: Intake to Waiver/Case Management,
Switch in Agency, and Waiver Discharge
  04/2017
  1110 Short Term Admits   04/2017
  1111 Personal Emergency Response Systems (PERS)   07/2017
  1112 PCP Planning Form Instructions SLTC-200* 04/2017
  1113 Level of Care   04/2017
  1115 Case Manager Plan Facilitator Role When Member Changes CFC/PAS Provider Agency   07/2017
 

Pre-printed Forms available from Central Office

  901* SD-Requisition Form - Self Direct   02/2015
    CFC/PAS Booklet Requisition Request Form SLTC-260 01/2018
    *These documents may be obtained by contacting Abby Holm, CFC Program Manager 406-444-4564 or by email: abholm@mt.gov    
    Please use the SLTC 901 Requisition Form to order forms which are re-printed by Central Office. Allow 2 weeks for delivery.