Big Sky Waiver Policy Manual

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*To obtain copies of this document, contact Jean Perrotta (406) 852-0322 or email   JPerrotta@mt.gov

Chapter Subject Form Number Date Revised
001 Table of Contents   07/01/2020
002 Alpha Subject Index   03/01/2012

400 

ELIGIBILITY FOR SERVICES

    
  401 Eligibility for Services BSW-101 04/01/2019
  401 BSW Program Approval Notice BSW-102 01/01/2019
  402 Slot Categories   04/01/2016
  403 Prior Authorizations Policy
SLTC-148
SLTC-149*		 04/01/2020
01/01/2018
07/01/2018
  405 Referrals for Services   07/01/2020
  406 Wait List Criteria   10/01/2019
  406 Wait List Placement Approval Notice BSW-103 01/01/2019
  406 Wait List-Deeming Form BSW-101-18 07/01/2018
  406 Wait List Criteria Tool SLTC-146 10/01/2019
  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		 10/01/2019
01/01/2018
07/01/2020
07/01/2020
  413 Fair Hearings   04/01/2017
  414 Assisted Living At-Risk Slot Process   04/01/2019
  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   07/01/2020
  502 Screening Referral Procedures   07/01/2020
  503 Level of Care Reevaluations   07/01/2020
  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   10/01/2019
  608-2 Recoveries   04/01/2020
  609 Serious Occurrence Report   04/01/2017
  610 Quality Improvement Projects   04/01/2020
  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   07/01/2020
  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   07/01/2020
  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   07/01/2020
  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   07/01/2020
  735 Supported Employment   08/01/2011
  736 Supported Living   10/01/2019
  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   04/01/2019
  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   10/01/2019
  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 Assurances   04/01/2020
  899-4 HCBS Forms Requisition   01/01/2006
  899-5 Service Plan Cost Limits   07/01/2020
  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 1-406-852-0322 or email: jperrotta@mt.gov