Community First Choice Program
Agency Based Policy Manual

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Section/ Subsection

Title/Content

Forms Number

Issue/ Revised

   
 
   
 
Table of Contents
 
04/01/2019
   
 
   
 
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
   
 
   
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
   
 
   
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
   
 
   
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.