Big Sky Waiver Program Policy Manual

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*To obtain copies of this document, contact Jean Perrotta (406) 496-4955 or email JPerrotta@mt.gov

Chapter		Subject	Form Number	Date Revised
001	Table of Contents			10/01/2019
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*	01/01/2019 01/01/2018 07/01/2018
	405	Referrals for Services		01/01/2012
	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
	406-1	Wait List Tool and Scoring	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 01/16/2018 07/01/2018
	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		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		10/01/2019
	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		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 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

001

10/01/2019

002

03/01/2012

400

ELIGIBILITY FOR SERVICES

401

04/01/2019

401

01/01/2019

402

04/01/2016

403

SLTC-149*

01/01/2019

01/01/2018

07/01/2018

405

01/01/2012

406

10/01/2019

406

01/01/2019

406

07/01/2018

406-1

10/01/2019

407

01/01/2019

01/01/2018

01/01/2018

408

01/01/2012

409

01/01/2012

410

01/01/2019

410-1

01/01/2012

411

01/01/2017

412

Policy

SLTC-150*

10/01/2019

01/01/2018

01/16/2018

07/01/2018

413

04/01/2017

414

04/01/2019

415

07/01/2018

499-1

10/01/2015

500

PREADMISSION SCREENING

501

01/01/2012

502

01/01/2012

503

03/01/2011

504

RESERVED