MSSP Manual 2015 Appendices

AP Number Subject
Ap 01 Right to State Medi-Cal Hearing,
Welfare and Institutions Code Sections 10950-10967
Ap 02 Termination of MSSP Services (Notice of Action)
Ap 02-SPAN TTerminación de Servicios MSSP (Notificación de Acción)
Ap 03 File Specifications
Ap 04 Notice of Action- Change in MSSP Services
Ap 04-SPAN Notificación de Acción– Cambio en los Servicios MSSP
Ap 05 State Hearing Notice; Your Right to Appeal This Decision
Ap 05-SPAN Notificación de Audencia Estatal:
Su Derecho a Apelar Contra Esta Decisión
Ap 05a Request for State Hearing
Ap 05a-SPAN Formulario de Solicitud de Audiencia Estatal
Ap 06 Withdrawal of Request for State Hearing
Ap 07 Medi-Cal Aid Codes
Ap 08 CDA Waiver Referral
Ap 09 Application for the Multipurpose Senior Services Program (MSSP)
Ap 09-SPAN Solicitud de Ingreso en el Programa de MSSP
Ap 10 Application for the MSSP Under Medi-Cal Institutional Deeming Procedures
Ap 10-SPAN Solicitud de Ingreso en MSSP Según los Procedimientos
de Consideración Institucional de Medi-Cal
Ap 11 Deinstitutional Services
Ap 11a Deinstitutional Services Request
Ap 11a-SPAN Solicitud de Servicios de Deinstitutionalizacion
Ap 11b-Cover Deinstitutional Services Assessment Cover Sheet
Ap 11b Deinstitutional Services Assessment
Ap 11c Deinstitutional Services Functional Needs Assessment Grid (FNAG)
Ap 11d Definitions for Completing Deinstitutional Services
Functional Needs Assessment Grid (FNAG)
Ap 11e Deinstitutional Care Plan
Ap 11e-SPAN Plan de Cuidado de Deinstucional
Ap 11f Deinstitutional Care Plan Form Instructions
Ap 11h Deinstitutional Services Data Tracking Form
Ap 12 Client Rights in MSSP
Ap 12-SPAN Derechos del cliente en MSSP
Ap 13 Your Rights Under California Welfare Programs
Ap 14 Authorization for Use and Disclosure of Protected Health Information
Ap 14-SPAN Autorización para use y divulgación de información de salud protegida
Ap 15 Level of Care Criteria: California Code of Regulations Title 22
Ap 16 Level of Care Certification
Ap 17 Client Enrollment/Termination Information
Ap 18-Intro Initial Health Assessment Introduction
Ap 18-Cover Cover Page of Initial Health Assessment
Ap 18a Initial Health Assessment
Ap 18b Client’s Physician’s & Other Health Professionals OPTIONAL
Ap 18c Client’s Medications
Ap 18d Initial Health Assessment Summary
Ap 19 Intro Initial Psychosocial Assessment
Ap 19-Cover Cover Initial Psychosocial Assessment
Ap 19a Initial Psychosocial Assessment
Ap 19b Psychological Functioning
Ap 19c Psychological Functioning, Instructions and Definitions
Ap 19d Functional Needs Assessment Grid
Ap 19e Functional Needs Assessment Grid - Instructions
Ap 19f Cognitive Screening Tools
Ap 19h Initial Psychosocial Summary
Ap 20 Reassessment
Ap 20a Functional Needs Assessment Grid (Reassessment)
Ap 20b Functional Needs Assessment Grid - Instructions
Ap 20c Cognitive Screening Tool (Reassessment)
Ap 20e Client’s Physician’s & Other Health Professionals OPTIONAL
Ap 20f Client’s Medications (Reassessment)
Ap 20g-Cover Reassessment Summary Cover Sheet
Ap 20g-Intro Introduction to the Reassessment Summary
Ap 20g Reassessment Summary
Ap 21 Supplemental Assessment Tool
Ap 21a Determine Your Nutritional Health
Ap 22 Care Plan
Ap 22a Care Plan Instructions
Ap 22-SPAN Plan de Cuidado
Ap 23 Institutionalization OPTIONAL
Ap 24 Negotiated Risk Agreement
Ap 24a Negotiated Risk Agreement Example – Client A
Ap 24b Negotiated Risk Agreement Example – Client B
Ap 25 Service Planning and Utilization Summary (SPUS)
Ap 26 Provider Qualifications: Licensing and Certification
Ap 27 MSSP Service Vendor Application
Ap 28 MSSP Vendor Licensing Form
Ap 31 Site Rate Sheet Sorted by Procedure Code
Ap 33 Benchmark Memorandum
Ap 34 Equipment
Ap 34a Report of Property Furnished/Purchased with Agreement Funds
Ap 34b Report of Property Furnished/Purchased with
Agreement Funds form - Instructions
Ap 34c Request to Dispose of Property (CDA Form 248)
Ap 36 Title III Services
Ap 41 Requesting an Exemption to Minimum Qualifications
for Care Management Staff
Ap 41a Nurse Care Manager Exemption Criteria
Ap 41b Social Work Care Manager Exemption Criteria
Ap 41c Supervising Care Manager Exemption Criteria Rating Sheet
Ap 41d Nurse Care Manager Training and Development Pathway
Ap 41e Nurse Care Manager/Social Work Care Manager Exemption
Training and Development Plan
Ap 41f Social Work Care Manager Training and Development Pathway
Ap 41g Supervising Care Manager Training and Development Pathway
Ap 41h Supervising Care Manager Exemption Training and Development Plan
Ap 41i Nurse Care Manager/Social Work Care Manager Exemption
Recommended Orientation Checklist
Ap 41j Supervising Care Manager Exemption Recommended Orientation Checklist
Ap 42 Institutional Deeming (dated 4-23-03) -
All County Welfare Directors Letter # 03-22
Ap 44 Memorandum of Understanding between CDA
and Department of Social Services
regarding In-Home Supportive Services
Ap 47 Medical Abbreviations
Ap 49UR Electronic Utilization Review Tool
Ap 49b Electronic UR Tool Vendor Page

Updated May 13, 2013

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