Community First Choice Program
Agency Based Policy Manual

Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances. State Website Disclaimer.

If you experience any difficulty opening a policy from this page,
please email HHS Technology Services Center.

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.

CFC Agency Based Policy Manual

Community First Choice Program Agency Based Policy Manual

Section/ Subsection

Title/Content

Forms Number

Issue/ Revised

01/01/2019

Abbreviations*

04/2017

100

Reserved

200

Reserved

300

Reserved

400

Eligibility for Services

401

04/2015

402

01/2016

403

04/01/2018

403

11/21/2018

403

01/04/2018

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

415

04/2015

416

Reserved

417

07/01/2018

417

11/21/2018

418

Reserved

419

Reserved

420

Reserved

421

07/01/2018

500

Mountain Pacific Quality Health

600

Community First Choice Program
Agency Based Policy Manual