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DHS updated the following forms:
DHS-3426 OBRA Level 1 Criteria – Screening
for Developmental Disabilities or Mental Illness
Changes made:
- Form
version 6-18
- Current
DHS logo added
- Demographic
fields from the first page are automatically added to the second page
- Instructions
are clearer that person must meet any of the listed criteria for DD or related
condition
- Instructions
are clearer that person must meet all the listed criteria for Mental Illness
DHS-3427 LTC Screening document – AC, BI,
CAC, CADI, ECS, EW, MHM, MSC+, and MSHO
Changes
made:
- Version
date 7-18
- Includes
activity type 10 and assessment result 12
- Removes
HRA assessment results 35, 39, and 50 (now placed on new document 3427H)
- Removes
SNBC program type 28
- Adds
new field 100a for the PCA Complex field
- Adds
new fields Service (108), Provider NPI (109) and Person (110) for managed care
members to identify if they are using Elderly Waiver (EW) adult day, customized living or foster
care at their next reassessment after July 31, 2018. If so, the new fields
on the ALT5 screen (112 – 134) are required based on the answer in the Services
field.
DHS-3427H Health Risk Assessment Screening
Document – MSC+, MSHO and SNBC
This
new form replaces DHS-3427 for Health Risk Assessments (HRAs) for
mailed survey, telephone, and visits and also used when the member is not
found or declines the HRA conducted on or after August 1, 2018. The
fields can be imported from the new DHS-3428H. Please note that some MMIS
fields are no longer mandatory or fields have new valid values. New fields
on this form as well as in the MMIS are: dental concerns, have a dentist,
family planning, sex activity, and return to community.
DHS-3427T LTC Screening Document –
Telephone Screening
Changes
made:
- Form
version date 7-18
- DHS
logo added
- Removed
Social Security number field
- Removed
field numbers
- Added
calendars and drop down menus for field values
DHS-3428B AC, BI, CADI, EW Case Mix
Classification Worksheet
Changes made:
- Form
version date 1-18
- Step
6 includes additional clarification
DHS-3428H Minnesota Health Risk Assessment
Form
This
new form was developed to record Health Risk Assessments (HRAs) and replaces the
use of DHS-3428 or DHS-3428A when completing the mailed survey, telephone, and
visits. It is also used when the member is not found or declines the HRA. The
fields can be merged to the new DHS-3427H. Please note the new fields and
their values are to be added to the MMIS for activity type dates of August 1, 2018
and later.
DHS-3428Q
Person’s Evaluation of Foster Care, Customized Living, or Adult Day Service
This
new form is used by case managers/care coordinators to complete an evaluation of
certain services with EW participants in managed care. The form includes fields
for the data entry of service, provider ID, and person information on the MMIS
ALT4 screen and the response to the evaluation questions on the ALT5 screen of
the LTC screening document. See also the LTC screening
document DHS-3427 version date 7-18.
- These
fields must be completed for persons enrolled in managed care and receiving
Elderly Waiver services.
- It
identifies if the person is receiving adult day, customized living, or foster
care. It records their satisfaction with the provider.
- Lead
agencies may use this form and MMIS data entry for EW participants in
fee-for-service, but it is not required.
- The
questions are completed at the next reassessment visit on or after August 1,
2018. See Bulletin 18-25-04 for complete information about the EW
evaluation.
- There are two versions of this form. One
version of the form may be completed online and the other form version may
be printed and completed by hand.
- See
both versions of the form by using the form number on eDocs.
This
information was covered in Bulletin 18-25-04 and in the June 21, 2018 videoconference "EW Participants in
Managed Care Evaluate Certain Services at Reassessments"
Videoconference archive: http://stream5.video.state.mn.us:8080/MNIT/ewpmcecsr062118.html
DHS-4669 Instructions for Completing and
Entering the LTCC Screening Document and Health Risk Assessment into MMIS for
the MSC+ and MSHO Programs
This
version replaces the October 2017 manual.
DHS-5020A
Instructions for Completing and Entering the Health Risk Assessment into MMIS
for the Special Needs BasicCare (SNBC)
This
version replaces the October 2017 manual.
DHS-6037A HCBS Waiver, AC, and ECS Case
Management Transfer and Communication Form: Scenarios for People on AC,
EW, or ECS
Changes
made:
- Form
version date is 4-18
- New
form title
- MN
DHS logo added
- Essential
Community Supports program added
- Links
to manuals DHS-4625 and DHS-4669
- Removed
bulletin 13-25-01
- Corrected
scenarios 2 and 5 for the service agreement
- Corrected scenario 10, item 2
All
forms can be found using eDocs: https://mn.gov/dhs/general-public/publications-forms-resources/edocs/
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