Big Sky Waiver Program Policy Manual

 

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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 Disabling 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
         

Big Sky Waiver/Covid-19 Responses

    
Southwest Montana Veterans Home

Big Sky Waiver Review Workgroup
Community Services - Independent Living
Healthy Living
Home and Living Options
Protective and Legal Services
Financial Planning
Service Partners and Providers
Electronic Visit Verification (EVV)
Eligibility
Governor's Conference on Aging
Oversight of State Medicaid Claiming and Program Integrity Expectations

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