| 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 |
| Appendix 03 |
Applicant Denial NOA |
| Appendix 04 |
Change in Services NOA |
| Appendix 05 |
Your Right to Appeal This Decision |
| Appendix 06 |
Request For State Hearing Form |
| Appendix 07 |
Hearing Withdrawal Form |
| Appendix 08 |
Participant Non-Discrimination Notice |
| Appendix 09 |
Language Assistance Taglines |
| Appendix 10 |
Medi-Cal Aid Codes |
| Appendix 11 |
CDA Waiver Referral |
| Appendix 12 |
Application |
| Appendix 13 |
Application for Institutional Deeming |
| Appendix 14 |
Request for Deinstitutional Services |
| Appendix 15 |
Participant Rights |
| Appendix 16 |
Your Rights Under California Public Benefits Programs |
| Appendix 17 |
AUDPHI |
| Appendix 18 |
Title 22 LOC Criteria |
| Appendix 19 |
LOC Predetermination |
| Appendix 19A |
LOC Predetermination Example |
| Appendix 20 |
LOC Predetermination with FNAG |
| Appendix 20A |
LOC Predetermination with FNAG Examples |
| Appendix 21 |
LOC Reference Guide for MSSP Sites |
| Appendix 22 |
PETIF |
| Appendix 23 |
MSSP Assessment Cover Sheet (Optional) |
| Appendix 24 |
Deinstitutional Services Assessment |
| Appendix 25 |
Initial Health Assessment |
| Appendix 26 |
Initial Psychosocial Assessment |
| Appendix 26A |
Psychological Functioning Instructions and Definitions |
| Appendix 27 |
MSSP Reassessment |
| Appendix 28 |
NCM ADV Assessment |
| Appendix 28A |
NCM ADV Assessment Example |
| Appendix 29 |
SWCM ADV Assessment |
| Appendix 30 |
Functional Needs Assessment Grid |
| Appendix 30A |
Funct Needs Assessment Grid Instructions |
| Appendix 31 |
Safety and Special Equipment Checklist |
| Appendix 32 |
Participant's Medications |
| Appendix 33 |
Approved Cognitive Screening Tools |
| Appendix 34 |
Determine Your Nutritional Health |
| Appendix 35 |
Participant's Physicians and Other Health Professionals |
| Appendix 36 |
Institutionalization Form |
| Appendix 37 |
Care Plan |
| Appendix 37A |
Care Plan Form Instructions |
| Appendix 38 |
Negotiated Risk Agreement Form |
| Appendix 38A |
Negotiated Risk Agreement Example A |
| Appendix 38B |
Negotiated Risk Agreement Example B |
| Appendix 39 |
SPUS Example |
| Appendix 40 |
Licensure & Certification - Provider Qualifications |
| Appendix 41 |
Vendor Application Form |
| Appendix 42 |
MSSP Vendor Licensing Form |
| Appendix 43 |
File Specifications |
| Appendix 44 |
Rate Sheet Sorted by EDS Procedure Code |
| Appendix 45 |
HCPCS Billing Codes |
| Appendix 46 |
Equipment and Property |
| Appendix 47 |
MOU CDSS-CDA |
| Appendix 48 |
PACE Policy Letter 17-01 |
| Appendix 49 |
HCBS Settings Requirements 42 CFR 441.301(c)(4) |
| Appendix 50 |
Requesting an Exemption to Minimum Qualifications for CM Staff |
| Appendix 51 |
NCM T&D Pathway |
| Appendix 52 |
NCM-SWCM T&D Plan |
| Appendix 53 |
SWCM-NCM Orientation Checklist |
| Appendix 54 |
SWCM TD Pathway |
| Appendix 55 |
SCM T&D Plan |
| Appendix 56 |
SCM Orientation Checklist |
| Appendix 57 |
SCM T&D Pathway |
| Appendix 58 |
Utilization Review Tool |