Community First Choice Program
Agency Based Policy Manual

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Section/ Subsection		Title/Content	Forms Number	Issue/ Revised
		Table of Contents		04/01/2020
		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		04/01/2018
	404	Service Limitations and Exclusions		10/01/2018
	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		07/01/2018
	413	Switch in Options		07/2017
	414	High Risk Intake		04/01/2018
	415	Annual MPQH Reviews		04/2015
	416	Reserved
	417	Temporary Authorization		07/01/2018
	418	Reserved
	419	Reserved
	420	Reserved
	421	Service Plan		07/01/2018
500	Mountain Pacific Quality Health (MPQH)
	501	Prior Authorization Contract Requirements		04/01/2019
	504	MPQH Service Profile		04/01/2019
600	Administrative Requirements
	605	Fair Hearings		04/2017
	606	Policy Memo CFC/PAS 606 Reimbursement*		06/2016
	606	Reimbursement		01/2016
	607	Recoveries		04/01/2020
	608	Quality Assurance Review		04/2016
	609	Quality Assurance Review Worksheet		10/2016
	610	Quality Assurance Process-Provider Agency Reports		01/01/2019
	611	Quality Assurance Communications		10/01/2019
700	Service Requirements
	701	Agency Requirements		07/01/2018
	702	Intake Visits		04/01/2018
	703	180 Day and Annual Recertification		07/01/2018
	704	Complaint Procedure		04/2015
	705	Termination, Discharge and Temporary Absences		04/2017
	706	Training Attendants		07/2015
	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		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		10/01/2019
	718	Service Delivery Records		07/2015
	719	Amendments		07/01/2018
	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*	01/01/2018
	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*	04/2017
	909	909 Person Centered Planning Form Instructions	SLTC-200*	04/2017
	910	Reserved
	911	Service Delivery Record Form Instructions - Sample	SLTC-220*	02/2015
	912	Mileage and Medical Escort Form Instructions	SLTC-221*	04/2017
	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-215	02/2015
	917	Skills Acquisition Training Plan Form Instructions	SLTC-216	02/2015
	924	Internal Quality Assurance Review Summary	SLTC-252*	01/01/2018
	925	Provider Prepared Standards	SLTC-253*	01/01/2019
	925	Provider Prepared Standards Policy Memo		01/04/2018
	926	Intake Internal Review Worksheet	SLTC-244*	01/01/2018
	927	Recertification Internal Review Worksheet	SLTC-245*	01/01/2019
1000	Reserved
1100	CFC/PAS Person Centered Planning (PCP)
	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 Documentation		04/2017
	1106	PCP Annual Visits		04/2017
	1107	PCP Re- Admission 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	Person Centered Planning Form Instructions		04/01/2019
	1113	Level of Care		04/2017
	1115	Case Manager Plan Facilitator Role When a Member Changes CFC/PAS Provider Agency		07/2017
		Pre-printed Forms available from Central Office
	SLTC 901	CFC/PAS Requisition Form*
		CFC/PAS Booklet Requisition Request Form	SLTC-260	01/01/2018
		*Documents may be obtained by contacting Abby Holm, CFC Program Manager 444-4564 or emailing: abholm@mt.gov
		**Please use the SLTC 901 Requisition Form to order forms which are pre-printed by Central Office. Allow 2 weeks for delivery.

CFC Agency Based Policy Manual

Community First Choice Program Agency Based Policy Manual

Section/ Subsection

Title/Content

Forms Number

Issue/ Revised

04/01/2020

Abbreviations*

04/2017

100

Reserved

200

Reserved

300

Reserved

400

Eligibility for Services

401

04/2015

402

01/2016

403

04/01/2018

404

10/01/2018

405

Reserved

406

Reserved

407

04/2015

408

Reserved

409

Reserved

410

Reserved

411

10/2017

412

07/01/2018

413

07/2017

414

04/01/2018

Community First Choice Program
Agency Based Policy Manual