Community First Choice Program
Self-Direct Policy Manual

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Section/
 Subsection

Title/Content

 Forms

Issued/
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
 
04/01/2018
 
418
Health Care Professional Authorization
 
10/2015
 
419
Reserved
 
 
 
420
Reserved
 
 
 
421
Service Plan
 
04/01/2018

500

 

Mountain Pacific Quality Health

 
 
501
Prior Authorization Contract Requirements (MPQH)
 
04/01/2019
 
504
MPQH Service Profile
 
04/01/2019

600

Administrative Requirements

 
 
605
Fair Hearings
 
04/2017
 
606
Policy Memo CFC/PAS Reimbursement*
 
06/2016
 
606
Reimbursement
 
01/2016
 
608
Quality Assurance Review
 
04/2016
 
609
Quality Assurance Review Work Sheet
 
10/2016
 
610
Quality Assurance Process-Provider Agency Reports
 
01/01/2019

700

Service Requirements

 
 
701
Agency Requirements
 
07/2017
 
702
Intake Visits
 
04/01/2018
 
703
180 Day and Annual Recertification
 
07/2015
 
704
Complaint Procedure
 
04/2015
 
705
Termination, Discharge, and Temporary Absences
 
04/2017
 
706
Training Attendants
 
04/2015
 
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
 
07/2015
 
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
Personal Representative
 
04/01/2019
 
717
Flexibility Parameters
 
04/2015
 
718
Service Delivery Records
 
04/2015
 
719
Amendments
 
04/01/2018
 
720
Conflict of Interest
 
04/2015
 
721
Skill Acquisition
 
07/2015
 
722
Member Capacity and Compliance
 
04/2015

800

Rules and Resources

 

900

Forms

 
 
901
General Information
 
01/01/2018
 
902
General Utilization*
 
02/2015
 
903
Reserved
 
 
 
904
Service Plan Form Instructions
 SLTC-175
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*
01/01/2018
 
909
Person Centered Planning Form Instruction
 SLTC-200*
04/2017
 
910
Reserved
 
 
 
911
Service Delivery Record Form Instructions
 SLTC-222*
02/2015
 
912
Mileage and Medical Escort Form Instructions
 SLTC-221*
04/2017
 
913
Request for Case Review Form Instructions
 SLTC-MA128
02/2015
 
914
Risk Negotiation Form Instructions
 SLTC-230
02/2015
 
915
Recertification Documentation Form Instructions
 SLTC-210
02/2015
 
916
Skills Acquisition Endorsement Form Instructions
 SLTC-215
02/2015
 
917
Skills Acquisition Training Form Instructions
 SLTC-216
02/2015
 
918
Reserved
 
 
 
919
Program Compliance Tool Form Instructions
 SLTC-167
02/2015
 
920
Health Care Professional Authorization Form
SLTC-160
11/2015
 
921
Member Agreement Form Instructions
 SLTC-159
07/2015
 
922
Reserved
 
 
 
923
Personal Representative Agreement Form Instructions
SLTC-166
07/2015
 
924
Agency Internal Quality Assurance Review
SLTC-250*
01/01/2018
 
925
Provider Prepared Standards
SLTC-251
01/01/2018
 
925
Provider Prepared Standards Policy Memo
 
01/04/2018
 
926
Intake Internal Review
SLTC-246*
01/01/2018
 
927
Recertification Internal Review Worksheet
SLTC-247*
01/01/2019

1000

Reserved

 

1100

CFC/PAS Person Centered Planning

 
 
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 Documents
 
04/2017
 
1106
PCP Annual Visits
 
04/2017
 
1107
PCP Re-Admissions 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
PCP Planning Form Instructions
SLTC-200*
04/01/2019
 
1113
Level of Care
 
04/2017
 
1115
Case Manager Plan Facilitator Role When Member Changes CFC/PAS Provider Agency
 
07/2017
 
Pre-printed Forms available from Central Office
 
901*
SD-Requisition Form - Self Direct
 
02/2015
 
 
CFC/PAS Booklet Requisition Request Form
SLTC-260
01/2018
 
 
*These documents may be obtained by contacting Abby Holm, CFC Program Manager 406-444-4564 or by email: abholm@mt.gov
 
 
 
 
Please use the SLTC 901 Requisition Form to order forms which are re-printed by Central Office. Allow 2 weeks for delivery.