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Effective Date: 
7/2019

Documents

Updated: 07/2019

 

Instructions

 

Purpose

 


A local intellectual and developmental disability authority (LIDDA) is responsible for completing Form 1040 to accompany a packet of materials the LIDDA is responsible for sending to a Medicaid managed care organization (MCO). The packet of materials includes documents related to a person’s eligibility or reassessment for Community First Choice (CFC) services provided through a Medicaid MCO.

When to Prepare

The LIDDA completes Form 1040 when submitting CFC non-waiver eligibility or reassessment packets to MCOs.

Submittal

The LIDDA submits this form, along with the CFC packet, to the appropriate CFC MCO Secure File Transfer Protocol (SFTP) folder.

Detailed Instructions

Person Information

Date –Enter the current date.
Medicaid ID – Enter the person’s Medicaid number.
CARE ID –Enter the person’s Client Assignment and Registration (CARE) System identification number.
Last Name –Enter the person’s last name.
First Name –Enter the person’s first name.
Area Code and Telephone No. –Enter the person’s area code and telephone number.
Alternate Area Code and Telephone No. –Enter the person’s alternate area code and telephone number.
Mailing Address of Person –Enter the mailing address for the person.
Name of Legally Authorized Representative (LAR), if applicable –Enter the name of the person’s LAR, if applicable. If there is no LAR, enter N/A.
LAR Area Code and Telephone No. –Enter the area code and telephone number of the LAR. If there is no LAR, enter N/A.
LAR Alternate Area Code and Telephone No. –Enter the alternate area code and telephone number of the LAR. If there is no LAR, enter N/A.
Mailing Address of LAR –Enter the mailing address for the LAR. If there is no LAR, enter N/A.
LIDDA Information
LIDDA Name –Enter the name of the LIDDA submitting the form.
LIDDA Component Code –Enter the three-digit component code of the LIDDA.
Name of LIDDA Contact –Enter the name of the LIDDA staff to be contacted regarding this form.
LIDDA Contact Email Address –Enter the email of the staff identified as the LIDDA contact.
LIDDA Contact Telephone No. and Area Code – Enter the area code and phone number of the staff identified as the LIDDA contact.
LIDDA Contact Area Code and Fax No. –Enter the area code and fax number of the staff identified as the LIDDA contact.
Name of Alternate LIDDA Contact –Enter an alternate name of LIDDA staff to be contacted regarding this form.
Alternate LIDDA Contact Telephone No. and Area Code –Enter the area code and phone number of the staff identified as the alternate LIDDA contact.
Managed Care Organization (MCO) Information
MCO Name –Enter the name of the person’s MCO.
MCO Component Code –Enter the three-digit component code of the MCO.
MCO Contact Email Address –Enter the email address of the MCO contact.
Name of MCO Contact –Enter the name of the MCO staff to be contacted regarding this form.
MCO Contact Area Code and Telephone No. –Enter the area code and phone number of the staff identified as the MCO contact.
MCO Contact Area Code and Fax No. –Enter the area code and fax number of the staff identified as the MCO contact.
Name of Alternate MCO Contact –Enter an alternate name of MCO staff to be contacted regarding this form.
Alternate MCO Contact Telephone No. and Area Code –Enter the area code and phone number of the staff identified as the alternate MCO contact.

Initial – CFC Packet Checklist for MCO Submission
Select every form included with the packet submission for the initial enrollment.

Reassessment – CFC Packet Checklist for MCO Submission
Select every form included with the packet submission for the reassessment. 

LIDDA Staff Completes the Section Below for Internal Use

Send list of providers for the checked services to:

Name –Enter the name of the person to receive services.
By Email –Select this option and enter the email for the person if they choose to receive the provider list by email.
By Mail –Select this option and enter the full address for the person if they choose to receive the provider list by mail. 
Check the box for CFC Personal Assistance Services, CFC Habilitation, CFC Emergency Response Services or CFC Financial Management Services Agency.
Joint meeting is scheduled for:
Date –Enter the date the next joint meeting is scheduled.
Time –Enter the time the next meeting is scheduled.
Location –Select the same address entered to the left or enter a new address for the scheduled meeting.
Check Yes or No indicating if Form 1582, Consumer Directed Services Responsibilities, was given to the person.