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Home and Community Based Waiver Manual

TABLE OF CONTENTS

	INDEXES	DATE REVISED
001	Index	03/01/12
002	Alpha Subject Index	03/01/12

400	ELIGIBILITY FOR SERVICES
401	H & C Based Services Eligibility Requirements	03/01/12
402	Care Categories	03/01/12
403	Prior Authorization by the CSB	03/01/12
404	Termination of Services	08/01/11
405	Referrals for Services	03/01/12
406	Waiting List Criteria	02/01/07
407	Medically Needy Billing Procedures	03/01/12
408	Residency Requirements	03/01/12
409	Out-of-State Services	03/01/05
410	Bed-Hold Days	3/1/2011
410A	Attachment A
411	Developmentally Disabled	02/01/07
499-1	Provider Information Memo (DPHHS-HCS-454)	03/01/05

500	PREADMISSION SCREENING
501	Screening Requirements	03/01/12
502	Screening Referral Procedures	03/01/12
503	Level of Care Reevaluations	3/1/2011
504	Reserved	01/01/06
504	ScAN
599-1	Screening Determination (DPHHS-SLTC-61)	3/1/2011

600	ADMINISTRATIVE REQUIREMENTS
601	Provider Eligibility	03/01/12
602	Provider Responsibilities	03/01/12
603	Provider Enrollment	01/01/06
604	Payment Requirements	02/01/07
604-1	Payment to Legally Responsible Individuals	03/01/12
605	Payment Processing	03/01/12
606	Reimbursement Methodology	03/01/12
607	Licensure Requirements	03/01/05
608	Quality Assurance Process	03/01/12
699-1	Provider Requirements	03/01/12
699-2	CMS 1500 Claim Form IN PDF FORMAT	04/01/07
699-3	HCBS Procedure Codes & Rates	03/01/12
699-4	Medicaid Nursing Facility Reimbursement Rates	01/01/06
699-5	Prior Authorization Form	04/01/07

700	SERVICES
701	Covered Services	08/01/11
702	Service Limitations & Exclusions	08/01/11
703	Adult Day Health	08/01/11
704	Adult Residential Care	08/01/11
705	Behavioral Programming	08/01/11
706	Case Management	08/01/11
707	Chemical Dependency Counseling	08/01/11
708	Cognitive Rehabilitation	08/01/11
709	Community Residential Rehabilitation	08/01/11
710	Comprehensive Day Treatment	08/01/11
711	Day Habilitation	08/01/11
712	Dietitian/Nutritionist	08/01/11
713	Environmental Accessibility Adaptations	08/01/11
714	Habilitation	08/01/11
715	Homemaker	03/01/05
716	Nutrition	03/01/05
717	Occupational Therapy	08/01/11
718	Personal Assistance	08/01/11
719	Personal Emergency Response System	3/1/2011
720	Physical Therapy	03/01/05
721	Prevocational Training	04/01/07
722	Private Duty Nursing	01/01/06
723	Psychosocial Consultation	08/01/11
724	Registered Nurse Supervision	08/01/11
725	Respiratory Therapy	08/01/11
726	Respite Care	08/01/11
727	Special Child Care for Medically Fragile Children	08/01/11
728	Specialized Medical Equipment & Supplies	08/01/11
729	Specially Trained Attendants	08/01/11
730	Speech Therapy and Audiology	08/01/11
731	Supported Employment	08/01/11
732	Supported Living	08/01/11
733	Transportation	08/01/11
734	Consumer/Family Intensive Support Service	08/01/11
735	Family Training and Support	08/01/11
799-1	Home & Community Based Services	03/01/05
799-1	Administrative Rules of Montana 37.40.1401 - 37.40.1488
799-2	PAS Consumer Referral/Overview (DPHHS-SLTC-154)	01/01/06
799-3	Service Animals - Case Management Team’s Role	03/01/05
799-4	Service Animals – Consumer’s Role	03/01/05
799-5	Directory of Assistive Technology Practitioners	03/01/05
799-6	Consumer Recycling Agreement	03/01/05
799-7	Field Memorandum FY95	01/01/06


800	CASE MANAGEMENT SYSTEM
801	Case Management Requirements	03/01/12
802	Case Management Team Requirements	03/01/12
803	Service Areas	03/01/05
804	Record Requirements	3/1/2011
805	Budget Requirements	01/01/06
806	Reporting Requirements	03/01/12
807	Contract Termination & Transition	03/01/05
808	Transfer of Consumers or Change of
	Consumer’s Classification	3/1/2011
809-1	Plan of Care: Development	03/01/12
809-2	Plan of Care: Components	03/01/12
809-3	Plan of Care: Requirements	03/01/12
809-4	Plan of Care: Costs	03/01/12
809-5	Plan of Care: Reevaluations	03/01/12
809-6	Plan of Care: Amendments	03/01/12
809-7	Plan of Care: Annual Updates	03/01/12
810	Consumer Advisory Councils	03/01/12
811	Year-End Money	01/01/06
812	Risk Negotiation Process	03/01/12
899-1	Year-End Money Form	03/01/05
899-2	Reporting Requirements	3/1/2011
899-2a	Provider Prepared Standards CMT	3/1/2011
899-2b	Utilization Report	03/01/12
899-2c	Nursing Facility Transfer Report	3/1/2011
899-3	Reserved	03/01/12
899-4	HCBS Forms Requisition Page 2	01/01/06
899-5	Plan of Care Cost Limits	03/01/12
899-6	Entrance Into Medicaid & HCBS
	(DPHHS-SLTC-55) Instructions	03/01/05
899-7	Request for Level of Care
	(DPHHS-SLTC-85) Instructions	01/01/06
899-8	Level of Care Determination
	(DPHHS-SLTC-86) Instructions	01/01/06
899-9	Adult Residential Care Calculation Page 2
	(DPHHS-SLTC-132) Instructions	03/01/12
899-10	Plan of Care Cost Sheet
	(DPHHS-SLTC-134) Instructions	03/01/12
899-11	Plan of Care (DPHHS-SLTC-135)
	Instructions	3/1/2011
899-11B	Plan of Care Short Form	03/01/12
	(DPHHS-SLTC-135B) Instructions	01/01/06
899-12	Intake Sheet (DPHHS-SLTC-136)
	Instructions	01/01/06
899-13	Discharge Sheet (DPHHS-SLTC-137)
	Instructions	01/01/06
899-14	Authorized Services for Incurment
	(DPHHS-SLTC-131) Instructions	03/01/12
899-15	Reevaluation Form (DPHHS-SLTC-139)
	Instructions	03/01/12
899-16	Amendment Form (DPHHS-SLTC-141)
	Instructions	03/01/12
899-17	Psychosocial Summary (DPHHS-SLTC-143)
	Instructions	03/01/12
899-18	Letter of Notification (DPHHS-SLTC-144)
	Instructions	01/01/06
899-19	Level I Screen (DPHHS-SLTC-145)
	Instructions	01/01/06
899-20	Waiting List Criteria Tool (DPHHS-SLTC-146)
	Instructions	04/01/07
899-21	Request for Prior Authorization CC3
	(DPHHS-SLTC-148) Instructions	03/01/12
899-22	Request for Prior Authorization
	(DPHHS-SLTC-149) Instructions	03/01/05
899-23	Service Animals - Provider Assurances
	(DPHHS-SLTC-142) Instructions	03/01/05
899-24	Service Animals - Stewardship Agreement
	(DPHHS-SLTC-142) Instructions	03/01/05
899-25	Waiting List Database Instructions	03/01/05
899-26	State Suppliment	3/1/2011
899-27	Nursing Home Transition Request	3/1/2011
899-28	Assisted Living Reserved Slots Form	3/1/2011
899-29	Risk Negotiation Form	03/01/12
899-29a	Risk Assesment Document	3/1/2011

9900	APPENDIX
9901	Definitions	03/01/05
9902	Abbreviations/Acronyms/Initials	03/01/12