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CFC Agency Based Policy Manual

Community First Choice Program
Agency Based Policy Manual

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Section/ Subsection

Title/Content

Forms Number

Issue/ Revised

 
 
Table of Contents
 
01/01/2019
 
 
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
 
403
General Provisions and Services Policy Memo - supercedes policy memo 403 General Provisions and Services Policy Memo dated 01/04/2018
 
11/21/2018
 
403
General Provisions and Services Policy Memo
 
01/04/2018
 
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
 
417
Temporary Authorization Policy Memo
 
11/21/2018
 
418
Reserved
 
 
 
419
Reserved
 
 
 
420
Reserved
 
 
 
421
Service Plan
 
07/01/2018

500

Mountain Pacific Quality Health

600

Administrative Requirements

 
605
Fair Hearings
 
04/2017
 
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
Quality Assurance Process-Provider Agency Reports
 
01/01/2019

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
 
04/2015
 
718
Service Delivery Records
 
07/2015
 
719
Amendments
 
07/01/2018
 
719
Amendments Policy Memo
 
11/21/2018
 
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
 
04/2017
 
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.