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Home and Community Based Waiver Manual

TABLE OF CONTENTS

	INDEXES	DATE REVISED
001	Index	3/1/2011
002	Alpha Subject Index	3/1/2011

400	ELIGIBILITY FOR SERVICES
401	H & C Based Services Eligibility Requirements	01/01/06
402	Care Categories	01/01/06
403	Prior Authorization by the CSB	04/01/07
404	Termination of Services	04/01/07
405	Referrals for Services	04/01/07
406	Waiting List Criteria	01/01/06
407	Medically Needy Billing Procedures	3/1/2011
408	Residency Requirements	01/01/06
409	Out-of-State Services	03/01/05
410	Bed-Hold Days	3/1/2011
410A	Attachment A
411	Developmentally Disabled	03/01/05

500	PREADMISSION SCREENING
501	Screening Requirements	03/01/05
502	Screening Referral Procedures	01/01/06
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	03/01/05
602	Provider Responsibilities	03/01/05
603	Provider Enrollment	01/01/06
604	Payment Requirements	01/01/06
604-1	Payment to Legally Responsible Individuals	3/1/2011
605	Payment Processing	3/1/2011
606	Reimbursement Methodology	03/01/05
607	Licensure Requirements	03/01/05
608	Quality Assurance Process	3/1/2011
699-1	Provider Requirements	03/01/05
699-2	CMS 1500 Claim Form IN PDF FORMAT	04/01/07
699-3	HCBS Procedure Codes & Rates	04/01/07
699-4	Medicaid Nursing Facility Reimbursement Rates	01/01/06
699-5	Prior Authorization Form	04/01/07

700	SERVICES
701	Covered Services	03/01/05
702	Service Limitations & Exclusions	01/01/06
703	Adult Day Health	03/01/05
704	Adult Residential Care	3/1/2011
705	Behavioral Programming	03/01/05
706	Case Management	03/01/05
707	Chemical Dependency Counseling	03/01/05
708	Cognitive Rehabilitation	03/01/05
709	Community Residential Rehabilitation	3/1/2011
710	Comprehensive Day Treatment	3/1/2011
711	Day Habilitation	04/01/07
712	Dietitian/Nutritionist	03/01/05
713	Environmental Accessibility Adaptations	3/1/2011
714	Habilitation	3/1/2011
715	Homemaker	03/01/05
716	Nutrition	03/01/05
717	Occupational Therapy	03/01/05
718	Personal Assistance	3/1/2011
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	01/01/06
724	Registered Nurse Supervision	03/01/05
725	Respiratory Therapy	03/01/05
726	Respite Care	03/01/05
727	Special Child Care for Medically Fragile Children	01/01/06
728	Specialized Medical Equipment & Supplies	3/1/2011
729	Specially Trained Attendants	3/1/2011
730	Speech Therapy and Audiology	03/01/05
731	Supported Employment	03/01/05
732	Supported Living	04/01/07
733	Transportation	03/01/05
734	Consumer/Family Intensive Support Service	3/1/2011
735	Family Training and Support	04/01/07
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	01/01/06
802	Case Management Team Requirements	3/1/2011
803	Service Areas	03/01/05
804	Record Requirements	3/1/2011
805	Budget Requirements	01/01/06
806	Reporting Requirements	03/01/05
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	3/1/2011
809-2	Plan of Care: Components	3/1/2011
809-3	Plan of Care: Requirements	3/1/2011
809-4	Plan of Care: Costs	01/01/06
809-5	Plan of Care: Reevaluations	3/1/2011
809-6	Plan of Care: Amendments	3/1/2011
809-7	Plan of Care: Annual Updates	3/1/2011
810	Consumer Advisory Councils	01/01/06
811	Year-End Money	01/01/06
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	3/1/2011
899-2c	Nursing Facility Transfer Report	3/1/2011
899-3	Reserved	03/01/05
899-4	HCBS Forms Requisition Page 2	01/01/06
899-5	Plan of Care Cost Limits	01/01/06
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	3/1/2011
899-10	Plan of Care Cost Sheet
	(DPHHS-SLTC-134) Instructions	01/01/06
899-11	Plan of Care (DPHHS-SLTC-135)
	Instructions	3/1/2011
899-11B	Plan of Care Short Form	3/1/2011
	(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	3/1/2011
899-15	Reevaluation Form (DPHHS-SLTC-139)
	Instructions	3/1/2011
899-16	Amendment Form (DPHHS-SLTC-141)
	Instructions	3/1/2011
899-17	Psychosocial Summary (DPHHS-SLTC-143)
	Instructions	3/1/2011
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	01/01/06
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	3/1/2011
899-29a	Risk Assesment Document	3/1/2011

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