Only SPW services/benefits are captured on this form.
What is 1700-1?
100
Every member has a right to request this process if they receive an adverse determination.
What is a Fair Hearing?
100
When an initial assessment is performed this is the document that must be received before the MNLOC can be submitted.
What is MD signature form?
100
A member will convert to this service/program if they get MN approved but do not want any waiver services and only want PAS and ERS.
What is CFC?
100
This is the service/company that an SC would refer a member to if they have caries.
What is Dentaquest?
200
This is the form that tells the SC the effective dates for the start and end of requested waiver benefits.
What is 2065D?
200
This is the entity that determines the member's RUG level and approves their medical necessity.
What is TMHP?
200
When the BIMS score does not correlate with what the SC observes an explanation for this will be documented here.
What is in the comment section?
200
The SC will explain that this form will be sent out to the member in a SASE for signature upon completion/delivery of services and to please sign and return it.
What is the process for completing the 1700-A1?
200
This is the waiver benefit that helps the member get employment.
What is employment assistance?
300
This is the form where the SC will document all the non waiver third party resources that the member will be utilizing for the ISP year.
What is 1700-B?
300
This is the form the PSU sends to SHP and documents approval of SPW.
What is the 2065D?
300
This is the date that is used to establish the look back period.
What is assessment date?
300
This SC must complete this in the members chart when a member refuses a service identified as important to their health or safety or is not authorized.
What is the reason for documentation of refusal of services?
300
This is the member who loses all benefits if they do not meet MN.
What is MAO?
400
This is the form that lists the SPW items with the rational for those services identified.
What is the 1700-A?
400
This is how long TMHP has to evaluate an MNLOC to determine approval or denial.
What is 5 days?
400
This is when an MNLOC is required to be completed.
What is Initial, Annual(Reassessment), and change of condition
400
This is the process/reason that an SC will initiate these benefits for a member (RP 13) while they are waiting for MD signature to start the Waiver services.
What is the reason an SC will/can complete an Auth template and start non waiver services?
400
Medicare is the primary payer when the member has either of these eligibility codes.
What is payer for eligibility codes A4 and A5?
500
The member on the interest list will have this additional form sent out by PSU.
What is 3676 MC?
500
What is required if the SC checks the box on the MNLOC that states the member has less than 6 months to live.
What is verified by the MD and/or the Hospice service?
500
This is the program that is utilized when the MNLOC is submitted.
What is Filenet?
500
The SC will fill out the section B of this form when completing the Interest list assessment.
What is H3676-MC?
500
DAHS and Acute care nursing are considered this type of service.