Centennial Care Provider Notification Grid
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1 Page 1 of 5 Ablative Procedure for Venous Insufficiency & Varicose Veins Accredited Residential Treatment Center (ARTC) Acute Inpatient Medical (incl. Detoxification services & LTACH)) Acute Inpatient Psychiatric Services (Freestanding Psych Hospitals and Hospital Psych Units) Adaptive Skills Building: Autism Dx Ambulance Services (Non Emergent) Ambulatory Surgical Center Services Anesthesia Services Apnea Monitor Assertive Community Treatment (ACT) Behavioral Health Professional Services Behavior Management Skills (BMS) Blepharoplasty and Brow Ptosis Repair (medical necessity) Bone Growth Stimulator Breast Reduction/Gynecomastia (medical necessity) Cardiac Rehab Case Management Cochlear Implants Comprehensive Community Support Services (CCSS) CPAP/BiPAP Day Treatment Services Dental Services (Comprehensive) Diabetes Monitoring Supplies
2 Page 2 of 5 Diagnositic Imaging and Therapeutic Radiology Services Dialysis Durable Medical Equipment (Purchase, Rental and Repair) Over $1000 Durable Medical Supplies (i.e., diapers/chux, ostomy supplies, indwelling Over $1000 caths, enterals for tube feeding, etc.) Drugs - Botox (non-cosmetic/medical necessity) Drugs - Synagis Early Periodic Screening Diagnosis and Treatment (EPSDT) Elective Inpatient Admissions Electroconvulsive Therapy Emergency Services (Medical and Behavioral Health) EPSDT Personal Care Services EPSDT Private Duty Nursing EPSDT Rehabilitation Services Family Planning Family Support Services (Behavioral Health) Federally Qualified Health Center Services Genetic Testing including BRCA Group Homes (GH) Hearing aids Hearing Exam/Evaluation High Frequency Chest Wall Compression Device Home Infusion (Nursing, per diem supplies) IV Outpt services Hospice services Hospital Beds > $1000 Hospital Outpatient Indian Health Services Inpatient Hospitaliation in Freestanding psychiatric Hospital Insulin Pump, > $1000
3 Page 3 of 5 Intensive Outpatient Program (IOP) Lab services Mechanical Stretching and Cont. Motion Passive Device Medication Assisted Treatment for Opioid Dependence (MAT) Midwife Services MRA (Magnetic Resonance Angiogram) MRI (Magnetic Resonance Imaging) Multisystemic Therapy Services (MST) Non-Accredited Residential Treatment Centers (RTC) Nursing Facility Services Nutritional Services Outpatient Behavior Health Professional Services and Partial Hospitalization in General Hospital Setting Outpatient health care professional services Oxygen and Oxygen ReAuthorizationorization Pain Management Services Panniculectomy and Body Contouring Procedures (medical necessity) PET Scan (Positron Emission Tomography) Pharmacy Services Physician Visits Plagiocephaly Podiatry Services Preventive Services Pregnancy Termination Procedure Prosthetic Devices & Orthotics Over $1000 Psychosocial Rehabilitation Services (PSR) Radiology (Imaging studies) Radiology Facilites Recovery Services (Behavioral Health)
4 Reproductive Health Services Respite (Behavioral Health) Rhinoplasty/Septoplasty/Turbinate Resection (medically necessary) Rural Health Clinic Services School Based Services Skilled Home Health: Physical/Occupational/Speech Therapies Sleep study Smoking Cessation Services SPECT MPI Stair Glides > $1000 Sterilization (hysterectomy, vasectomy, and tubal ligation) Suboxone Treatment Swing Bed Hospital Services Telehealth Tot-to-Teen Health Checks Transplant Services Transportation (for medically necessary services) Treatment Foster Care I (TFCI) Treatment Foster Care II (TFCII) Video EEG (medical necessity) Vision March Vision, External Vendor Wheel Chair (Manual) Over $1000 Wheel Chairs Power & Scooters Wound Vacuum Devices (Wound Vac) Page 4 of 5
5 AGENGY-BASED COMMUNITY BENEFITS (ABCB): Adult Day Health Eligibility for ABCB requires a NFLOC and services are based upon Assisted Living the Comprehensive Needs Assessment Behavior Support Consultation Community Transition Services Emergency Response Employment Supports Environment Modifications Home Health Aide Personal Care Services Private Duty Nursing for Adults Respite Skilled Maintenance Therapy Services SELF-DIRECTED COMMUNITY BENEFITS (SDCB): Behavior Support Consultation Customized Community Support Emergency Response Employment Supports Enviornment Modifications Home Health Aide Home maker/personal Care Nutritional Counseling Private Duty Nursing for Adults Related goods Respite Skilled Maintenance Therapy Services Specialized Therapies Transportation (Non Medical) Eligibility for SDCB requires a NFLOC and services are based upon the Comprehensive Needs Assessment and approved budget Page 5 of 5
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