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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

  *To obtain copies of this document contact Jean Perrotta 1-406-496-4955 or email: jperrotta@mt.gov    

001

Table of Contents

 

01/01/2019

002

Alpha Subject Index

 

03/01/2012

400

ELIGIBILITY FOR SERVICES

 

 

 

401

Eligibility for Services

 

01/01/2019

 

401

BSW Program Approval Notice

BSW-102

01/01/2019

 

402

Slot Categories

 

04/01/2016

 

403

Prior Authorizations

Policy

SLTC-148

SLTC-149*

01/01/2019

01/01/2018

07/01/2018

 

405

Referrals for Services

 

01/01/2012

 

406

Wait List Criteria

 

01/01/2019

 

406

Wait List Placement Approval Notice

BSW-103

01/01/2019

 

406

Wait List-Deeming Form

BSW-101-18

07/01/2018

 

406-1

Wait List Tool and Scoring

SLTC-146

01/01/2017

 

407

Medically Needy Billing Procedures

Policy 

SLTC-131

SLTC-132

01/01/2019

01/01/2018

01/01/2018

 

408

Residency Requirements

 

01/01/2012

 

409

Out-of-State Services

 

01/01/2012

 

410

Retainer Payments

 

01/01/2019

 

410-1

Attachment A, Public Institutions

 

01/01/2012

 

411

Individuals with Intellectual Disabilities

 

01/01/2017

 

412

Adverse Action

Policy

SLTC-137

SLTC-144

SLTC-150*

07/01/2018

01/01/2018

01/16/2018

07/01/2018

 

413

Fair Hearings

 

04/01/2017

 

414

Assisted Living At-Risk Slot Process

 

01/01/2017

 

415

Temporary Absences

 

07/01/2018

 

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*

01/01/2019

600

ADMINISTRATIVE REQUIREMENTS

 

 

 

601

Provider Eligibility

 

01/01/2012

 

602

Provider Responsibilities

 

01/01/2019

 

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

 

07/01/2018

 

606

Reimbursement Methodology

 

01/01/2012

 

607

Licensure Requirements

 

07/01/2016

 

608

Quality Assurance Process

 

07/01/2018

 

608-1

Quality Assurance Communication

 

04/01/2018

 

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

 

01/01/2019

 

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

 

04/01/2018

 

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

 

07/01/2018

 

718

Non-Medical Transportation

 

01/01/2019

 

719

Nutrition

 

01/01/2012

 

720

Occupational Therapy

 

08/01/2011

 

721

Pain and Symptom Management

 

01/01/2012

 

722

Personal Assistance Services

 

01/01/2019

 

723

Personal Emergency Response System

 

07/01/2016

 

724

Physical Therapy

 

08/01/2011

 

725

Post Acute Rehabilitation Services

 

07/01/2018

 

726

Prevocational Services

 

08/01/2011

 

727

Private Duty Nursing

 

01/01/2019

 

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

 

733

DME: Specialized Medical Equipment, Supplies and Technology

 

07/01/2018

 

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

 

04/01/2018

 

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

 

07/01/2018

 

802

Case Management Team Requirements

 

01/01/2012

 

803

Service Areas

 

03/01/2012

 

804

Record Requirements

 

07/01/2018

 

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

 

07/01/2018

 

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

SLTC-141

01/01/2018

 

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

 

899-10

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

 

 

Authorized Services for Spend Down

SLTC-131

01/01/2018

 

899-15

Re-Evaluation Form

SLTC-139

01/01/2012

 

899-17

Psychosocial Summary Form Instructions

SLTC-143

01/01/2016

 

899-19

Level I Screen

SLTC-145

01/01/2006

 

899-23

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 Form & Instructions

SLTC-157*

04/01/2018

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

 

1107

Person Centered Planning - Readmission

 

07/01/2017

 

1108

High Risk Admits

 

07/01/2017

 

1109

Change in Plan Facilitator

 

07/01/2017

 

1110

Short Term Admits

 

07/01/2017

 

1111

Personal Emergency Response Systems (PERS)

 

07/01/2017

 

1112

Person Centered Plan Form Instructions (SLTC 200)

SLTC-200*

04/01/2017

 

1113

Level of Care

 

07/01/2017

 

1115

Case Manager Role When Switching Agencies

 

07/01/2017

Appendix

 

 

 

 

 

9901

Definitions

 

03/01/2005

 

9902

Abbreviations/Acronyms/Initials

 

01/01/2017

 

 

*To obtain copies of this document contact Jean Perrotta 1-406-496-4955 or email: jperrotta@mt.gov