| Philosophy |
Philosophy Statement |
| Table of Contents |
Table of Contents |
| Summary of Changes |
Summary of Changes |
| Chapter 1 |
Introduction |
| Chapter 2 |
Site Staffing |
| Chapter 3 |
Program Components |
| Chapter 4 |
Quality Assurance and Program Review |
| Chapter 5 |
Participant Records and Information |
| Chapter 6 |
Participant Rights |
| Chapter 7 |
Information System Components |
| Chapter 8 |
Service Vendors |
| Chapter 9 |
Site Budget and Claims Reimbursement |
| Chapter 10 |
Equipment |
| Appendix 01 |
Right to State Medi-Cal Fair Hearing |
| Appendix 02 |
Termination of Services NOA (Available in other languages) |
| Appendix 02 - Arabic |
Termination of Services NOA |
| Appendix 02 - Chinese Simple |
Termination of Services NOA |
| Appendix 02 - Chinese Traditional |
Termination of Services NOA |
| Appendix 02 - Korean |
Termination of Services NOA |
| Appendix 02 - Russian |
Termination of Services NOA |
| Appendix 02 - Spanish |
Termination of Services NOA |
| Appendix 03 |
Change in Services NOA (Available in other languages) |
| Appendix 03 - Arabic |
Change in Services NOA |
| Appendix 03 - Chinese Simple |
Change in Services NOA |
| Appendix 03 - Chinese Traditional |
Change in Services NOA |
| Appendix 03 - Korean |
Change in Services NOA |
| Appendix 03 - Russian |
Change in Services NOA |
| Appendix 03 - Spanish |
Change in Services NOA |
| Appendix 04 |
Your Right to Appeal (Available in other languages) |
| Appendix 04 - Arabic |
Your Right to Appeal |
| Appendix 04 - Chinese Simple |
Your Right to Appeal |
| Appendix 04 - Chinese Traditional |
Your Right to Appeal |
| Appendix 04 - Korean |
Your Right to Appeal |
| Appendix 04 - Russian |
Your Right to Appeal |
| Appendix 04 - Spanish |
Your Right to Appeal |
| Appendix 05 |
Request for State Fair Hearing Form (Available in other languages) |
| Appendix 05 - Arabic |
Request for State Fair Hearing Form |
| Appendix 05 - Chinese Simple |
Request for State Fair Hearing Form |
| Appendix 05 - Chinese Traditional |
Request for State Fair Hearing Form |
| Appendix 05 - Korean |
Request for State Fair Hearing Form |
| Appendix 05 - Russian |
Request for State Fair Hearing Form |
| Appendix 05 - Spanish |
Request for State Fair Hearing Form |
| Appendix 06 |
Hearing Withdrawal Form |
| Appendix 07 |
Participant Non-Discrimination Notice |
| Appendix 08 |
Language Assistance Taglines |
| Appendix 09 |
Medi-Cal Aid Codes |
| Appendix 10 |
Institutional Deeming Waiver Aid Codes |
| Appendix 11 |
CDA Waiver Referral |
| Appendix 12 |
Application (Available in other languages) |
| Appendix 12 - Arabic |
Application |
| Appendix 12 - Chinese Simple |
Application |
| Appendix 12 - Chinese Traditional |
Application |
| Appendix 12 - Korean |
Application |
| Appendix 12 - Russian |
Application |
| Appendix 12 - Spanish |
Application |
| Appendix 13 |
Application for MSSP-Institutional Deeming (Available in other languages) |
| Appendix 13 - Spanish |
Application for MSSP-Institutional Deeming |
| Appendix 14 |
Deinstitutional Services Request (Available in other languages) |
| Appendix 14 - Spanish |
Deinstitutional Services Request |
| Appendix 15 |
Deinstitutional Services Data Tracking Form |
| Appendix 16 |
Participant Rights (Available in other languages) |
| Appendix 16 - Arabic |
Participant Rights |
| Appendix 16 - Chinese Simple |
Participant Rights |
| Appendix 16 - Chinese Traditional |
Participant Rights |
| Appendix 16 - Korean |
Participant Rights |
| Appendix 16 - Russian |
Participant Rights |
| Appendix 16 - Spanish |
Participant Rights |
| Appendix 17 |
Your Rights Under California Public Benefits Programs |
| Appendix 18 |
Authorization for Use and Disclosure of Personal Health Information (Available in other languages) |
| Appendix 18 - Arabic |
Authorization for Use and Disclosure of Personal Health Information |
| Appendix 18 - Chinese Simple |
Authorization for Use and Disclosure of Personal Health Information |
| Appendix 18 - Chinese Traditional |
Authorization for Use and Disclosure of Personal Health Information |
| Appendix 18 - Korean |
Authorization for Use and Disclosure of Personal Health Information |
| Appendix 18 - Russian |
Authorization for Use and Disclosure of Personal Health Information |
| Appendix 18 - Spanish |
Authorization for Use and Disclosure of Personal Health Information |
| Appendix 19 |
Title 22 LOC Criteria |
| Appendix 20 |
LOC Certification |
| Appendix 21 |
Participant Enrollment Termination Form |
| Appendix 22 |
Cover - ALL Assessments (Optional) |
| Appendix 23 |
Deinstitutional Assessment |
| Appendix 24 |
Initial Health Assessment |
| Appendix 24A |
Initial Health Assessment Summary (Optional) |
| Appendix 25 |
Initial Psychosocial Assessment |
| Appendix 25A |
Initial Psychosocial Assessment Summary (Optional) |
| Appendix 26 |
Psychological Functioning |
| Appendix 26A |
Psychological Functioning Instructions |
| Appendix 27 |
Reassessment Summary |
| Appendix 28 |
Functional Needs Assessment Grid |
| Appendix 28A |
Functional Needs Assessment Grid Instructions |
| Appendix 29 |
Participant's Medications |
| Appendix 30 |
Approved Cognitive Screening Tools |
| Appendix 31 |
Determine Your Nutritional Health |
| Appendix 32 |
Participant's Physicians and Other Health Professionals (Optional) |
| Appendix 33 |
Institutionalization Form (Optional) |
| Appendix 34 |
Care Plan (Available in other languages) |
| Appendix 34 - Arabic |
Care Plan |
| Appendix 34 - Chinese Simple |
Care Plan |
| Appendix 34 - Chinese Traditional |
Care Plan |
| Appendix 34 - Korean |
Care Plan |
| Appendix 34 - Russian |
Care Plan |
| Appendix 34 - Spanish |
Care Plan |
| Appendix 34A |
Care Plan Instructions |
| Appendix 35 |
Negotiated Risk Agreement Form |
| Appendix 35A |
Negotiated Risk Agreement Form- Example A |
| Appendix 35B |
Negotiated Risk Agreement Form- Example B |
| Appendix 36 |
Service Planning and Utilization Summary (SPUS) |
| Appendix 37 |
Licensure & Certification - Provider Qualifications |
| Appendix 38 |
MSSP Service Vendor Application |
| Appendix 39 |
Vendor Licensing Form |
| Appendix 40 |
File Specifications |
| Appendix 41 |
Rate Sheet Sorted by EDS Procedure Code |
| Appendix 42 |
HCPCS Billing Codes |
| Appendix 43 |
Property/Equipment Instructions |
| Appendix 44 |
Title III Services |
| Appendix 45 |
MOU DSS-CDA |
| Appendix 46 |
PACE Policy Letter 17-01 |
| Appendix 48 |
HCBS Settings Requirements 42 CFR 441.301(c)(4) |
| Appendix 49 |
Requesting an Exemption to Minimum Qualifications for CM Staff |
| Appendix 50 |
NCM TD Pathway |
| Appendix 51 |
NCM-SWCM TD Plan |
| Appendix 52 |
SWCM-NCM Checklist |
| Appendix 53 |
SWCM TD Pathway |
| Appendix 54 |
SCM TD Plan |
| Appendix 55 |
SCM Orientation Checklist |
| Appendix 56 |
SCM Pathway |
| Appendix 57 |
Electronic Utilization Review Tool (Available on FIFO) |