Policy & Procedure Manual FY2024
Action Notices & Appeal Information
- Adequate Action Notice – NFLOCD (applicants)
- Adequate Action Notice – Waiver Slot Capacity Notice
- Administrative Hearings Brochure
- Advance Action Notice – NFLOCD (existing participants)
- Completing an Adverse Benefit Determination
- Exception Criteria
- Notice of Adverse Benefit Determination
- Request for Administrative Hearing – DCH-0092
Administrative Forms/ Templates
- Staff Meeting Agendas
- Administrative Database Change
- New Employee Benchmarks
- New Employee Orientation Checklist and Training Requirements
- Peer Review Form
- CQAR Corrective Action Plan Document
- UPCAP fax cover sheet template
- UPCAP Letterhead – fillable
- UPCAP Long-Term Care Programs Organizational Chart
- UPCAP Long-Term Care Programs Quality Organizational Chart
Consent Forms
- Email & Text Communication Consent Form
- Medical Consent and Release w/ Allergy
- UPCAP Consent _ Authorization Form
Job Aides
- Assessment Flow Charts
- CAPABLE Toolkit (updated July 2021) – QMP Initiave
- Chart Set Up Key
- Checklist for Changes to Participant PCSP
- Checklist for Initial Assessment
- Checklist for New Participants
- Checklist for Nursing Home Admission
- Checklist for Participant Hospitalization
- Checklist for Participant Re-Assessments & PCSP Review
- COMPASS iHC Assessment Guide – Full
- COMPASS PCSP Guide
- FY2023 HCPCS Codes -Fund Codes-Provider Codes
- Decision Guide for Notices.07212022
- Monthly Monitoring Contact Process Guide
- SW Interdisciplinary Consultation Process – fillable
- RN Interdisciplinary Consultation Process – fillable
- Time-Frame Cheat Sheet
MI Choice Contracts
- Approved 1915(b) Waiver Application – effective 12/1/2023
- Approved 1915(c) Waiver Application – effective 12/1/2023
- Medicaid Provider Manual – Full
- Mi Choice Contract FY 24 – Attachment C – Managed Care Requirements
- MI Choice Waiver Program (michigan.gov)
NEMT Transportation
NFLOCD
- Freedom of Choice
- Nursing Facility Level of Care Determination (NFLOCD)
- Michigan Medicaid NFLOCD Field Definition Guidelines
- Michigan Medicaid NFLOCD Exception Process
- Michigan Medicaid NFLOCD Supporting Documentation Examples
- Brief Interview for Mental Status (BIMS)
- Brief Interview for Mental Status User Guide
- Mini-Mental Status Examination (MMSE)
- Mini-Mental Status Examination User Guide
- Michigan Medicaid NFLOCD Door 0 Documentation Examples
Participant
- Assessment
- MDHHS-Medicaid
- BRIEF Health Literacy Tool
- Care Plan Costs-Review
- Compass Status Form
- Cost Share Form
- Home Repair-Modification Provider Bid Form.pdf
- Home Repair-Modification Request Form.pdf
- Informed Risk Agreement Form – fillable
- Informed Risk Agreement Form – SAMPLE
- MI Choice Disenrollment Form
- MI Choice Enrollment Form
- Non Compliance Letter -SAMPLE
- Participant Rights & Responsibilities
- Post Assessment Letter – Participant
- Post Assessment Letter – Referral Source
- Plan of Care Signature Page
- Sample Back Up Plan
- UPCAP Caregiver Registration Wellsky
- UPCAP Participant Registration Wellsky
Participant Informational Folder
- Advance Directives MDHHS
- Be prepared for extreme heat
- DCH-0092 Request of Heaing
- Elder Abuse Pamphlet
- Estate Recovery Pamphlet
- Fraud Waste and Abuse Pamphlet
- MI Choice Participant Handbook
- Person-Centered Planning Info- for Participant
- PRIVACY NOTICE For Medicaid and Other Medical Assistance Programs Effective December 1 2018
- What To Do In Severe Weather Handout-template
Providers
- Add Provider to COMPASS Request Form
- FY2024 Aging Grant Providers and Services
- FY2022 HCPCS Codes-Provider Codes-Fund Codes 3-5-22
- Medicaid Provider Manual – Providers
- Medicaid Provider Manual – MI Choice Section 4 – Services
- Medicaid Provider Manual – MI Choice Section 9 – Providers
- Provider Background Check Form
- UPCAP Non Recurrent Agreement _ Direct Purchase Application
- Vendor View Providers 2023
Referrals-Scheduling Assessments
- MI Choice Waiver 211 Intake/Referral Form Fillable PDF
- Initial Assessment Confirmation Letter – 2024
- Initial Assessment Confirmation Letter – 2024 (Non-Letterhead)
- Initial Assessment Verifications List
- PCP Info Letter – template
- Post Assessment Letter – Referral Source
- Self-Determination Info Letter – template
Residential Services
Resources
- Covid-19
- Health Literacy
- Home Modifications & Adaptation
- Monitoring Contacts
- Social Determinants of Health
- Other
Self-Determination program
- GT Financial Documents
- NHCS Documents
- Back Up Worker Agreement
- Fiscal Intermediary vs Agency with Choice
- Hiring _ Managing Personal Assistants
- Self Determination Disenrollment Form
- Self Determination Enrollment Agreement
UPHP Forms
- Consent _ Authorization – UPHP _ UPCAP
- HCBS Waiver Application and Consent Form
- UPHP MI Health Link MOS Version 11 – 2023
- UPHP MI Health Link MOS – State Plan Personal Care Services
- PCA Fillable Script Form1007 1-20-21
- Required Documentation for NFLOCD Submissions 071316 (3)
- UPCAP Altruista guide_revised 3.10.2022
- UPHP Care Manager Contact List 4.18.2022
- UPHP CTA and Transition Plan
- UPHP Document Type _ Description – uploading instructions
- UPHP-UPCAP MI Health Link Process Guidelines Updated_ 3.23.2022
Veterans Program
- SD Program Explanation VA
- UPCAP Reauth Request Form – VA
- VA Consent Form
- VDC Case Mix Rate Calculator FY2024
Work Orders
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