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Minnesota Department of Human Services Community-Based Services Manual (CBSM)
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Screening documents and service agreements

Page posted: 10/1/03

Page reviewed:

Page updated: 3/24/15

Legal authority

DD Screening Document – Minn. Stat. §256B.092, subd. 8 (b)
DD Service Agreement – Minn. Stat. §256B.092, subd. 3
Long Term Care Screening Document – Minn. Stat. §256B.0911, subd. 3a
Long Term Care Service Agreement – Minn. Stat. §256B.49, subd.18

Definitions

Screening document (SD): Document used to record the outcome of assessments, screenings or case management activities.

Service agreement (SA): Document used to identify services, providers and payment information for a person receiving home care, Alternative Care (AC), or waiver services, allows providers to bill for approved services and allows DHS to audit usage and payment data.

Waiver services

Lead agencies are responsible to:

  • • Screen people to determine program eligibility and services
  • • Enter screening documents and service agreements into MMIS before DHS can pay claims.
  • Screening document

    Screening documents are stored in MMIS within the Prior Authorization Application subsystem under Screenings. Enter screening documents in a sequential order. Screening documents are date sensitive. There are two types of screening documents.

    DD screening document

    Use the DD Screening Document DHS-3067 (PDF) to:

  • • Screen persons with a diagnosis of developmental disability or a related condition
  • • Document the results of Omnibus Budget Reconciliation Act (OBRA) screenings
  • IMPORTANT: The original paper DD full-team screening document (activity type 01) must be kept in the person’s hard copy file as well as entered into MMIS.

    Refer to the DD Screening Document Codebook for further details and instructions on how to complete the DD screening document.

    LTC screening document

    The LTC Screening Document DHS-3427 (PDF) is used to screen persons residing in the community or nursing home. It is also used to screen for eligibility and services in the following programs:

    The LTC screening document is used as a health risk assessment tool for SNBC to collect data. Once a person goes onto a waiver, the SNBC case manager no longer enters the LTCC. The waiver case manager is responsible to enter the LTCC.

    Refer to the following instructional manuals when using MMIS to view or add a LTC screening document:

    Instructions for Completing and Entering the LTC Screening Document and Service Agreement into MMIS DHS-4625 (PDF) 

    Instructions for Completing and Entering the LTCC Screening Document into MMIS for the SNBC Program DHS-5020A (PDF)

    Instructions for Completing and Entering the LTCC Screening Document into MMIS for the MSHO and MSC+ Programs DHS-4669 (PDF)

    LTCC – AC, BI, CADI, EW Case Mix Classification Worksheet

    DHS-3428B, accessible through Forms (eDocs), gives instructions on how to determine the case mix classification for persons age 18 and older.

    LTCC – Supplemental form for children under age 18

    The LTCC Supplemental Form for Assessment of Children under 18 DHS-3428C (PDF) is a required form when screening a child age 18 years or under. It provides a guide for determination of age-appropriate dependencies for the eight activities of daily living (ADLs).

    Service agreement

    The AC, BI, CAC, CADI, DD and EW programs use the same Service Agreement DHS-3070 (PDF) to authorize services. Service agreements are stored in MMIS within the Prior Authorization Applications subsystem under Prior Authorization. Service agreements are program span and date sensitive.

    IMPORTANT: Before a waiver or AC service agreement can be entered into MMIS, an approved screening document to open, reopen, or extend the person’s program must be entered into MMIS first. See Waiver Program Eligibility Spans for additional details about waiver dates.

    Once a service agreement is entered into MMIS, MMIS generates notices to the case manager/service coordinator and to each provider listed on the service agreement. Service agreement notices include the following information as appropriate:

  • • MHCP provider name and NPI number
  • • Case manager/service coordinator name and phone number
  • • Diagnosis code (on provider letters)
  • • Procedure codes
  • • Modifiers
  • • Payment rates
  • • Date span in which the services can be provided
  • Due to data privacy issues, provider notices contain information pertaining only to services listed for that specific provider. It does not contain information about other services/providers that are listed on the service agreement. The case manager/service coordinator and recipient notices contain a complete list of all provider activities listed on a person’s service agreement.

    MMIS will also create a notice for the recipient if MMIS is prompted to generate a notification. Otherwise, the lead agency is responsible to create and send notification to the person.

    Program eligibility spans

    An eligibility span is the period of time that identifies both the start and end date for the specific program that the person has been approved to receive HCBS services. This span and program type is generated by the LTC or DD screening document and is shown on the RWVR screen of the recipient subsystem.

    The Alternative Care LTC screening document generates a major program AC span on the RELG screen of the recipient subsystem.

    The service agreement header and line item(s) start and end dates must be within an approved span and the program type must match the recipient’s program type. For example, if the waiver span program type is CADI diversion, then the SA must be CADI diversion.

    Edits

    Edits post at the bottom of the MMIS screen to warn staff that a possible problem has occurred. The edit prompts staff to review and to make corrections as needed. MMIS will not allow approval of an SA until edits are corrected and an approved screening document is saved. See MMIS Exception Codes for a complete and detailed list of MMIS Prior Authorization edits.

    Resource Center

    The DSD Resource Center is a county help desk that provides technical assistance to county agencies for MMIS SA and screening document system problems.

    Additional resources

    DSD MMIS Reference Guide
    Instructions for Completing and Entering the LTC Screening Document and Service Agreement into MMIS DHS-4625 (PDF)

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