Appendix XVII, Service or Score Code Guide
Revision 17-1; Effective March 15, 2017
| Service | Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, Score | Form 2101, Authorization for Community Care Services, Item 16 Service Code |
|---|---|---|
| Adult Foster Care | 18 | 18 |
| Consumer Managed Personal Assistant Services | Not required | 27 |
| Community Attendant Services (CAS) | 24 | 17D (CAS) 17DS (CAS/SRO) 17DV (CAS/CDS) |
| Individual Directed Services (CDS) – Financial Management Services | Not applicable | 63V 63VY (ICM) |
| CDS – Support Consultation | Not applicable | 57V (for PHC and CAS) 57CV (for FC) 57V4 (For PHC in ICM) |
| Day Activity and Health Services | Not required | 29 29Y (ICM) |
| Residential Care (RC) | 18 | 19I (RC Bed Hold, Non-Apt., Title XX) 19J (RC, Apt., Title XX) 19L (RC, Non Apt., Title XX) 19M (RC Emergency Care) 19N (grandfathered RC, R&B, Non-Apt.) 19O (grandfathered RC, R&B, Apt.) |
| Emergency Response Service | 20 | 20 |
| Family Care (FC) | 24 | 17C (FC) 17CS (FC/SRO) 17CV (FC/CDS) |
| Home-Delivered Meals | 20 | 25 |
Primary Home Care (PHC)
| 24 | 17 (PHC) 17S (PHC/SRO) 17V (PHC/CDS) 17Y (PHC/ICM) 17SY (PHC/SRO/ICM) 17VY (PHC/CDS/ICM) |
| Special Services to Persons with Disabilities | 9 | 28 |