Big Sky Waiver Program Policy Manual

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Chapter		Subject	Form Number	Date Revised
	*To obtain copies of this document contact Jean Perrotta 1-406-496-4955 or email: jperrotta@mt.gov
001	Table of Contents			01/01/2019
002	Alpha Subject Index			03/01/2012
400	ELIGIBILITY FOR SERVICES
	401	Eligibility for Services		01/01/2019
	401	BSW Program Approval Notice	BSW-102	01/01/2019
	402	Slot Categories		04/01/2016
	403	Prior Authorizations	Policy SLTC-148 SLTC-149*	01/01/2019 01/01/2018 07/01/2018
	405	Referrals for Services		01/01/2012
	406	Wait List Criteria		01/01/2019
	406	Wait List Placement Approval Notice	BSW-103	01/01/2019
	406	Wait List-Deeming Form	BSW-101-18	07/01/2018
	406-1	Wait List Tool and Scoring	SLTC-146	01/01/2017
	407	Medically Needy Billing Procedures	Policy SLTC-131 SLTC-132	01/01/2019 01/01/2018 01/01/2018
	408	Residency Requirements		01/01/2012
	409	Out-of-State Services		01/01/2012
	410	Retainer Payments		01/01/2019
	410-1	Attachment A, Public Institutions		01/01/2012
	411	Individuals with Intellectual Disabilities		01/01/2017
	412	Adverse Action	Policy SLTC-137 SLTC-144 SLTC-150*	07/01/2018 01/01/2018 01/16/2018 07/01/2018
	413	Fair Hearings		04/01/2017
	414	Assisted Living At-Risk Slot Process		01/01/2017
	415	Temporary Absences		07/01/2018
	499-1	DPHHS Release of Information HPS 402		10/01/2015
500	PREADMISSION SCREENING
	501	Screening Requirements Preadmission Screening		01/01/2012
	502	Screening Referral Procedures		01/01/2012
	503	Level of Care Reevaluations		03/01/2011
	504	RESERVED
	599-1	Screening Determination Form*	SLTC-61*	01/01/2019
600	ADMINISTRATIVE REQUIREMENTS
	601	Provider Eligibility		01/01/2012
	602	Provider Responsibilities		01/01/2019
	602-1	Progress Notes		01/01/2017
	603	Provider Enrollment		04/01/2017
	604	Payment Requirements		01/01/2016
	604-1	Payment of Legally Responsible Individuals		01/01/2016
	605	Payment Processing		07/01/2018
	606	Reimbursement Methodology		01/01/2012
	607	Licensure Requirements		07/01/2016
	608	Quality Assurance Process		07/01/2018
	608-1	Quality Assurance Communication		04/01/2018
	609	Serious Occurrence Report		04/01/2017
	699-1	Provider Requirements		01/01/2016
	699-2	CMS 1500 Claim Form		02/01/2012
	699-3	File Transfer		01/01/2012
	699-4	RESERVED
	699-5	HCBS Referral for Services Form		04/01/2007
700	SERVICES
	701	Covered Services		08/01/2011
	702	Service Limitations and Exclusions		01/01/2019
	703	Adult Day Health		08/01/2011
	704	Case Management		08/01/2011
	705	Community Supports		08/01/2011
	706	Community Transition		08/01/2011
	707	Consultative Clinical and Therapeutic Services		08/01/2011
	708	Consumer Goods and Services		08/01/2011
	709	Day Habilitation		08/01/2011
	710	Dietetic Services		08/01/2011
	711	Environmental Accessibility Adaptations		04/01/2018
	712	Family Training and Support		08/01/2011
	713	Financial Management Services		08/01/2011
	714	Health and Wellness		08/01/2011
	715	Homemaker		01/01/2012
	716	Homemaker Chore		01/01/2012
	717	Independence Advisor		07/01/2018
	718	Non-Medical Transportation		01/01/2019
	719	Nutrition		01/01/2012
	720	Occupational Therapy		08/01/2011
	721	Pain and Symptom Management		01/01/2012
	722	Personal Assistance Services		01/01/2019
	723	Personal Emergency Response System		07/01/2016
	724	Physical Therapy		08/01/2011
	725	Post Acute Rehabilitation Services		07/01/2018
	726	Prevocational Services		08/01/2011
	727	Private Duty Nursing		01/01/2019
	728	Residential Habilitation		01/01/2012
	729	Respiratory Therapy		08/01/2011
	730	Respite Care		08/01/2011
	731	Senior Companion		08/01/2011
	732	Special Child Care for Medically Fragile Children		08/01/2011
	733	DME: Specialized Medical Equipment, Supplies and Technology		07/01/2018
	733-1	DME Specialized Medical Equipment, Supplies and Technology: Consultations		02/01/2017
	733-2	DME Specialized Medical Equipment, Supplies, and Technology: Commonly Covered Items under Big Sky Waiver		02/01/2017
	734	Speech Therapy and Audiology		08/01/2011
	735	Supported Employment		08/01/2011
	736	Supported Living		08/01/2011
	737	Vehicle Modification		04/01/2018
	799-1	Administrative Rules of Montana		10/01/2015
	799-2	CFC/PAS Consumer Referral Form	SLTC-154	10/01/2015
	799-3	Service Animal: Case Management Team Role		10/01/2015
	799-4	Service Animal: Member Responsibilities		10/01/2015
	799-5	Service Animal: Acquisition Procedure		10/01/2015
	799-6	Consumer Recycling Agreement		03/01/2005
800	CASE MANAGEMENT SERVICES
	801	Case Management Requirements		07/01/2018
	802	Case Management Team Requirements		01/01/2012
	803	Service Areas		03/01/2012
	804	Record Requirements		07/01/2018
	805	Budget Requirements		03/01/2005
	806	Reporting Requirements		01/01/2012
	807	Contract Termination and Transition		03/01/2005
	808	Transfer of Members or Change in Member Classification		07/01/2018
	809-1	Service Plan Development		07/01/2016
	809-2	Service Plan Components		01/01/2012
	809-3	Service Plan Requirements		01/01/2012
	809-4	Service Plan Costs		01/01/2012
	809-5	Service Plan Reevaluations		01/01/2012
	809-6	Service Plan Amendment	SLTC-141	01/01/2018
	809-7	Service Plan Annual Updates		01/01/2012
	810	Member Input		01/01/2012
	812	Risk Negotiation Process		01/01/2012
		FORMS
	899-2	Reporting Requirements, Forms & Instructions		04/01/2016
	899-2a	Internal Chart Audit Form		01/01/2009
	899-2b	Utilization Report		01/01/2012
	899-2c	Nursing Facility Transfer Report		01/01/2009
	899-3	CMS QA Performance Measures		01/01/2012
	899-4	HCBS Forms Requisition		01/01/2006
	899-5	Service Plan Cost Limits		10/01/2015
	899-6	Entrance into Medicaid Instructions	SLTC-55	02/01/2007
	899-7	Request for Level of Care	SLTC-85	01/01/2006
	899-8	Level of Care Determination		01/01/2016
	899-10	Service Plan & Cost Sheet	SLTC-134	01/01/2012
	899-11	Service Plan Instructions		04/01/2016
	899-11	HCBS Service Plan Form	SLTC-135	04/01/2016
	899-11b	Service Plan Short Form (135b) Instructions		04/01/2016
	899-11b	Service Plan Short Form	SLTC 135b	04/01/2016
	899-12	Intake Sheet Form Instructions	SLTC-136	01/01/2016
		Authorized Services for Spend Down	SLTC-131	01/01/2018
	899-15	Re-Evaluation Form	SLTC-139	01/01/2012
	899-17	Psychosocial Summary Form Instructions	SLTC-143	01/01/2016
	899-19	Level I Screen	SLTC-145	01/01/2006
	899-23	Service Animals Provider Assurance Form Instructions	SLTC-142	10/01/2015
	899-24	Service Animal Stewardship Agreement Instructions	SLTC-147	10/01/2015
	899-25	Waiting List Database		03/01/2005
	899-26	State Supplement Instructions & Forms		02/01/2007
	899-27	Nursing Home Transition Process & Form		03/01/2011
	899-29	Risk Negotiation Form & Instructions	SLTC-157*	04/01/2018
1100	Person Centered Planning
	1101	Person-Centered Planning Requirements Overview		04/01/2017
	1102	Plan Facilitator vs. Provider Responsibilities		04/01/2017
	1103	Plan Facilitator Certification for CFC/PAS Providers		04/01/2017
	1104	Person Centered Planning Coordinated Visit		04/01/2017
	1105	Mountain Pacific Quality Health Authorization Documents		04/01/2017
	1106	Person Centered Planning Annual Visits		04/01/2017
	1107	Person Centered Planning - Readmission		07/01/2017
	1108	High Risk Admits		07/01/2017
	1109	Change in Plan Facilitator		07/01/2017
	1110	Short Term Admits		07/01/2017
	1111	Personal Emergency Response Systems (PERS)		07/01/2017
	1112	Person Centered Plan Form Instructions (SLTC 200)	SLTC-200*	04/01/2017
	1113	Level of Care		07/01/2017
	1115	Case Manager Role When Switching Agencies		07/01/2017
Appendix
	9901	Definitions		03/01/2005
	9902	Abbreviations/Acronyms/Initials		01/01/2017
		*To obtain copies of this document contact Jean Perrotta 1-406-496-4955 or email: jperrotta@mt.gov

Big Sky Waiver Policy Manual

Big Sky Waiver Program Policy Manual

Chapter

Subject

Form Number

Date Revised

400

ELIGIBILITY FOR SERVICES

500

PREADMISSION SCREENING

600

ADMINISTRATIVE REQUIREMENTS

700

SERVICES

800

CASE MANAGEMENT SERVICES

FORMS

1100

Person Centered Planning

Appendix

Senior and Long Term Care