Community ICF/DD Scenarios
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1 Community ICF/DD Scenarios This section contains the more frequently used sequencing charts for 1. Community ICF/DD to METO: not MA certified bed to Community ICF/DD 2. Community ICF/DD to DD Conversion 3. Community ICF/DD to DD Diversion 4. Community ICF/DD to Nursing Facility to Community ICF/DD 5. Community ICF/DD to RTC that is not an ICF/DD-RTC to Community ICF/DD 6. Community ICF/DD to Semi Independent Living Services 7. ICF/DD to METO ICF/DD-RTC 8. ICF/DD to METO RTC 9. ICF/DD to RTC Not METO Acronyms: CAC = Community Alternative Care Waiver CADI = Community Alternatives for Disabled Individuals DD = Developmental Disability ICF = Intermediate Care Facility for Persons with Developmental Disability METO Minnesota Extended Treatment Option NF = Nursing Facility RC = Related Condition RTC = Regional Treatment Center SILS = Semi-Independent Living Services TBI = Traumatic Brain Injury
2 2.1 DD SCREENING DOCUMENT SCENARIO: Community ICF/DD to METO: not MA certified bed to Community ICF/DD (23) Action Date: METO In-Date Team Convened Date ICF/DD In-Date (24) Action Type: (39) Risk Status: Must be 01 (41) Current Services: Other Other Other (42) Planned Services: As Planned Other As Planned (44) Waiver Need Index (46) Final Action Planned: *** *** *** (47) Current MA Program: None Needed: Payment Authorized (Reviewer): 07 07
3 2.2 DD SCREENING DOCUMENT SCENARIO: Community ICF/DD to DD Conversion (23) Action Date: Team Convened Date ICF/DD Out Date Waiver In Date (24) Action Type: (39) Risk Status: (41) Current Services: Other 19 WS RES Other (42) Planned Services: WS RES Other WS RES Other WS RES Other (44) Waiver Need Index: (46) Final Action Planned: *** *** *** (47) Current MA Program: None Needed: Payment Authorized (Reviewer): 01
4 2.3 DD SCREENING DOCUMENT SCENARIO: Community ICF/DD to DD Diversion (23) Action Date: Team Convened Date ICF/DD Out Date Waiver In Date (24) Action Type: (39) Risk Status: (41) Current Services: Other 19 WS RES Other (42) Planned Services: WS RES Other WS RES Other WS RES Other (44) Waiver Need Index: (46) Final Action Planned: *** *** *** (47) Current MA Program: None Needed: Payment Authorized (Reviewer): 01
5 2.4 DD SCREENING DOCUMENT SCENARIO: Community ICF/DD to Nursing Facility to Community ICF/DD (23) Action Date: Team Convened Date NF In Date Team Convened Date ICF/DD In Date (24) Action Type: (39) Risk Status: (41) Current Services: Other Other Other Other (42) Planned Services: Other Other Other Other (46) Final Action Planned: *** *** *** *** (47) Current MA Program: 00 or or or or 04 Placement in NF, Results of Level II assessment None Needed: Payment Authorized (Reviewer):
6 2.5 DD SCREENING DOCUMENT SCENARIO: Community ICF/DD to Regional Treatment Center (RTC) that is not an ICF/DD-RTC to Community ICF/DD (23) Action Date: RTC In Date Team Convened Date ICF/DD In Date (24) Action Type: (39) Risk Status: Must be 01 (41) Current Services: Other Other Other (42) Planned Services: As Planned Other As planned (46) Final Action Planned: *** *** *** (47) Current MA Program: 00 or or Type of RTC services (MH, CD, METO) None Needed: Payment Authorized (Reviewer):
7 2.6 DD SCREENING DOCUMENT SCENARIO: Community ICF/DD to Semi Independent Living Services (23) Action Date: ICF/DD Out Date SILS In Date (24) Action Type: (39) Risk Status: 03 (41) Current Services: Other Res (42) Planned Services: Other Res Other Res (46) Final Action Planned: (47) Current MA Program: None Needed: Payment Authorized (Reviewer): 05 :
8 2.7 DD SCREENING DOCUMENT SCENARIO: ICF/DD to METO ICF/DD-Regional Treatment Center (23) Action Date: End of Coverage Date Team Convened Date (24) Action Type: (39) Risk Status: 01 (41) Current Services: Other Other (42) Planned Services: Other Other (44) Waiver Need Index: 001, 002, 003 or 005 (46) Final Action Planned: (47) Current MA Program: Payment Authorized (Reviewer): 01
9 2.8 DD SCREENING DOCUMENT SCENARIO: ICF/DD to METO Regional Treatment Center (23) Action Date: End of Coverage Date Team Convened Date (24) Action Type: (39) Risk Status: 03 or 04 (41) Current Services: Other Other (42) Planned Services: Other Other (44) Waiver Need Index: 001, 002, 003 or 005 (46) Final Action Planned: 06 (47) Current MA Program: or 06 Placement in METO NON ICF/DD Bed Payment Authorized (Reviewer): 02
10 2.9 DD SCREENING DOCUMENT SCENARIO: ICF/DD to Regional Treatment Center Not METO (23) Action Date: End of Coverage Date Team Convened Date (24) Action Type: (39) Risk Status: 01 (41) Current Services: Other Other (42) Planned Services: Other Other (44) Waiver Need Index: 001, 002, 003 or 005 (46) Final Action Planned: 06 (47) Current MA Program: or 06 Placement in RTC Payment Authorized (Reviewer): 02
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