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
2.1 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: 01 01 03 (39) Risk Status: Must be 01 (41) Current Services: 19 33 Other 19 33 Other 19 28 Other (42) Planned Services: As Planned 19 28 Other As Planned (44) Waiver Need Index (46) Final Action Planned: *** *** *** (47) Current MA Program: 07 07 04 None Needed: Payment Authorized (Reviewer): 07 07
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: 01 03 04 (39) Risk Status: (41) Current Services: 19 28 Other 19 WS RES Other (42) Planned Services: WS RES Other WS RES Other WS RES Other (44) Waiver Need Index: 001 001 004 (46) Final Action Planned: *** *** *** (47) Current MA Program: 04 00 02 None Needed: Payment Authorized (Reviewer): 01
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: 01 03 04 (39) Risk Status: (41) Current Services: 19 28 Other 19 WS RES Other (42) Planned Services: WS RES Other WS RES Other WS RES Other (44) Waiver Need Index: 001 001 004 (46) Final Action Planned: *** *** *** (47) Current MA Program: 04 00 01 None Needed: Payment Authorized (Reviewer): 01
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: 01 03 01 03 (39) Risk Status: 02 02 01 01 (41) Current Services: 19 28 Other 19 30 Other 19 30 Other 19 28 Other (42) Planned Services: 19 30 Other 19 30 Other 19 28 Other 19 28 Other (46) Final Action Planned: *** *** *** *** (47) Current MA Program: 00 or 04 00 or 05 00 or 05 00 or 04 Placement in NF, Results of Level II assessment None Needed: Payment Authorized (Reviewer): 04 04 07 07
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: 01 01 03 (39) Risk Status: Must be 01 (41) Current Services: 19 33 Other 19 33 Other 19 28 Other (42) Planned Services: As Planned 19 28 Other As planned (46) Final Action Planned: *** *** *** (47) Current MA Program: 00 or 06 00 or 06 04 Type of RTC services (MH, CD, METO) None Needed: Payment Authorized (Reviewer): 07 07 01
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: 01 03 (39) Risk Status: 03 (41) Current Services: 19 24 Other Res 19 24 (42) Planned Services: 19 24 Other Res 19 24 Other Res (46) Final Action Planned: 05 05 (47) Current MA Program: 06 06 None Needed: Payment Authorized (Reviewer): 05 :
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: 03 01 (39) Risk Status: 01 (41) Current Services: 19 28 Other 19 29 Other (42) Planned Services: 19 29 Other 19 29 Other (44) Waiver Need Index: 001, 002, 003 or 005 (46) Final Action Planned: 08 06 (47) Current MA Program: 04 04 Payment Authorized (Reviewer): 01
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: 03 01 (39) Risk Status: 03 or 04 (41) Current Services: 19 28 Other 19 52 Other (42) Planned Services: 19 52 Other 19 52 Other (44) Waiver Need Index: 001, 002, 003 or 005 (46) Final Action Planned: 06 (47) Current MA Program: 04 00 or 06 Placement in METO NON ICF/DD Bed Payment Authorized (Reviewer): 02
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: 03 01 (39) Risk Status: 01 (41) Current Services: 19 28 Other 19 53 Other (42) Planned Services: 19 53 Other 19 53 Other (44) Waiver Need Index: 001, 002, 003 or 005 (46) Final Action Planned: 06 (47) Current MA Program: 04 00 or 06 Placement in RTC Payment Authorized (Reviewer): 02