Big Sky Waiver Policy Manual 

Proposed Pursuant to MAR Notice 37-928

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Chapter Subject Form Number Date Revised
001 Table of Contents   10/01/2020

400

ELIGIBILITY FOR SERVICES

       
  401 Eligibility for Services   10/01/2020
    Applicant - Request for Information Notice BSW-101 10/01/2020
    BSW Program Approval Notice BSW-102 10/01/2020
    Member - Request for Information Notice BSW-104 10/01/2020
  402 Slot Categories   10/01/2020
  403 Prior Authorizations by the Community Services Bureau

 

10/01/2020
    Request for Initial Prior Authorization for CC3 SLTC-148 10/01/2020
    Request for Prior Authorization Form SLTC-149 10/01/2020
  405 Referrals for Services   10/01/2020
  406 Wait List Criteria   10/01/2020
    Wait List Placement Approval Notice BSW-103 10/01/2020
    Wait List-Deeming Form BSW-101-18 10/01/2020
    Wait List Criteria Tool SLTC-146 10/01/2020
  407 Medically Needy Billing Procedures   10/01/2020
    Authorized Services for Spend Down SLTC-131 10/01/2020
    Adult Residential Care Calculation SLTC-132 10/01/2020
  408 Residency Requirements   10/01/2020
  409 Out-of-State Services   10/01/2020
  410 Retainer Payments   10/01/2020
  410-1 Attachment A, Public Institutions   10/01/2020
  411 Individuals with Intellectual Disabilities and Severe Disabiling Mental Illness   10/01/2020
  412 Adverse Action   10/01/2020
    Termination of Coverage-Provider Notification SLTC-137 10/01/2020
    Termination or Denial of Program Coverage SLTC-144 10/01/2020
    Termination, Denial or Decrease of Service Form SLTC-150 10/01/2020
  413 Fair Hearings   10/01/2020
  414 Assisted Living At-Risk Slot Process   10/01/2020
  415 Temporary Absences   10/01/2020
  499-1 Authorization for the Use and Disclosure of Health Information Form HPS-402 10/01/2020

500

PREADMISSION SCREENING

       
  501 Screening Requirements   10/01/2020
  502 Screening Referral Procedures   10/01/2020
  503 Level of Care Reevaluations   10/01/2020

600

ADMINISTRATIVE REQUIREMENTS

       
    601 Provider Eligibility   10/01/2020
  602 Provider Responsibilities   10/01/2020
  602-1 Progress Notes   10/01/2020
  603 Provider Enrollment   10/01/2020
  604 Payment Requirements   10/01/2020
  604-1 Payment of Legally Responsible Individuals   10/01/2020
  605 Payment Processing   10/01/2020
  606 Reimbursement Methodology   10/01/2020
  607 Licensure Requirements   10/01/2020
  608 Quality Assurance Process   10/01/2020
  608-1 Quality Assurance Communication   10/01/2020
  608-2 Recoveries   10/01/2020
  609 Serious Occurrence Report   10/01/2020
  610 Quality Improvement Projects   10/01/2020
  699-1 Provider Requirements   10/01/2020

700

SERVICES

       
    701 Covered Services & Requirements   10/01/2020
  702 Service Limitations and Exclusions   10/01/2020
  703 Adult Day Health   10/01/2020
  704 Case Management   10/01/2020
  705 Community Supports   10/01/2020
  706 Community Transition   10/01/2020
  707 Consultative Clinical and Therapeutic Services   10/01/2020
  708

Consumer Directed Goods and Services

  10/01/2020
  709 Day Habilitation   10/01/2020
  710 Dietetic Services   10/01/2020
  711 Environmental Accessibility Adaptations   10/01/2020
  712 Family Training and Support   10/01/2020
  713 Financial Management Services   10/01/2020
  714 Health and Wellness   10/01/2020
  715 Homemaker   10/01/2020
  716 Homemaker Chore   10/01/2020
  717 Independence Advisor   10/01/2020
  718 Non-Medical Transportation   10/01/2020
  719 Nutrition   10/01/2020
  720 Occupational Therapy   10/01/2020
  721 Pain and Symptom Management   10/01/2020
  722 Personal Assistance Services   10/01/2020
  723 Personal Emergency Response System   10/01/2020
  724 Physical Therapy   10/01/2020
  725 Post Acute Rehabilitation Services   10/01/2020
  726 Prevocational Services   10/01/2020
  727 Private Duty Nursing   10/01/2020
  728 Residential Habilitation   10/01/2020
  729 Respiratory Therapy   10/01/2020
  730 Respite Care   10/01/2020
  731 Senior Companion   10/01/2020
  732 Special Child Care for Medically Fragile Children   10/01/2020
  733 DME: Specialized Medical Equipment, Supplies and Technology   10/01/2020
  733-1 DME Specialized Medical Equipment, Supplies and Technology: Consultations   10/01/2020
  733-2 DME Specialized Medical Equipment, Supplies, and Technology: Commonly Covered Items under Big Sky Waiver   10/01/2020
  734 Speech Therapy and Audiology   10/01/2020
  735 Supported Employment   10/01/2020
  736 Supported Living   10/01/2020
  737 Vehicle Modification   10/01/2020
  799-2 CFC/PAS Consumer Referral Form SLTC-154 10/01/2020
  799-3 Service Animals/Case Management Team's Process & Responsibility   10/01/2020
  799-4 Member Responsibilities for a Service Animal   10/01/2020
  799-5 Service Animal: Acquisition Procedure   10/01/2020

800

CASE MANAGEMENT SERVICES

       
  801 Case Management Requirements   10/01/2020
  802 Case Management Team Requirements   10/01/2020
  804 Record Requirements   10/01/2020
  805 Budget Requirements   10/01/2020
  806 Reporting Requirements   10/01/2020
  807 Contract Termination and Transition   10/01/2020
  808 Member Transfer or Change of Classification   10/01/2020
  809-1 Service Plan Development   10/01/2020
  809-2 Service Plan Components   10/01/2020
  809-3 Service Plan Requirements   10/01/2020
  809-4 Service Plan Costs   10/01/2020
  809-5 Service Plan Reevaluations   10/01/2020
  809-6 Service Plan Amendment   10/01/2020
    Service Plan Amendment Form SLTC-141  
  809-7 Service Plan Annual Updates   10/01/2020
  810 Member Input   10/01/2020
  812 Risk Negotiation Process   10/01/2020
    Risk Negotiation Form SLTC-157 10/01/2020

 

FORMS

       
    899-2 Internal Audit Requirements   10/01/2020
  899-2a Chart Audit Report Form   10/01/2020
  899-2b Monthly Utilization Report   10/01/2020
  899-3 CMS Assurances   10/01/2020
  899-5

Service Plan (SP) Cost Limits

  10/01/20200
  899-7 Level of Care (SLTC 85) Request Instructions   10/01/2020
    Request for Level of Care Form SLTC-85 10/01/2020
  899-8 Level of Care Determination   10/01/2020
  899-11 Service Plan Instructions   10/01/2020
    HCBS Service Plan Form SLTC-135 10/01/2020
  899-11b Service Plan Short Form (135b) Instructions   10/01/2020
    Service Plan Short Form SLTC-135b 10/01/2020
  899-12 Intake Sheet Form Instructions (SLTC 136)   10/01/2020
    BSW Intake Sheet SLTC-136 10/01/2020

1100

Person Centered Planning

       
    1101 Person-Centered Planning Requirements Overview   10/01/2020
  1102 Plan Facilitator vs. Provider Responsibilities   10/01/2020
  1103 Plan Facilitator Certification for CFC/PAS Providers   10/01/2020
  1104 Person Centered Planning Coordinated Visit   10/01/2020
  1105 Mountain Pacific Quality Health Authorization Documents   10/01/2020
  1106 Person Centered Planning Annual Visits   10/01/2020
  1107 Person Centered Planning - Readmission to CFC/PAS   10/01/2020
  1108 High Risk Admits   10/01/2020
  1109 Plan Facilitator Change: Intake to Waiver/Case Management, Switch in Agency and Waiver Discharge   10/01/2020
  1110 Short Term Admits   10/01/2020
  1111 Personal Emergency Response Systems   10/01/2020
  1112 Person Centered Planning Form Instructions (SLTC 200)   10/01/2020
    Person Centered Plan Form SLTC-200 10/01/2020
  1113 Level of Care   10/01/2020
  1115 Case Manager Plan Facilitator Role When Member Changes CFC/PAS Provider Agency   10/01/2020
 

Appendix

   

 

  9902 Abbreviations/Acronyms/Initials   10/01/2020