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Effective Date: 
6/2017

Documents

Instructions

Updated: 6/2017

 

Purpose

To serve as the documentation certifying completion/delivery of specific STAR+PLUS Home and Community Based Services (HCBS) program items/services indicated on Form H1700-1, Individual Service Plan — SPW (Pg. 1), and Form H1700-A, Rationale for HCBS STAR+PLUS Waiver Items/Services.

 

Procedure

When to Prepare

The managed care organization (MCO) must prepare this form when the contracted provider/vendor has completed or delivered the specific item(s)/service(s) listed above to the satisfaction of the MCO representative and member. Multiple forms should be used if item(s)/services(s) will be completed/delivered with different dates.

Form Retention

Each MCO must keep Form H1700-1 according to the retention requirements found in all Medicaid Managed Care contracts and federal regulations. Keep all originals/electronic copies of this form in the member's folder/electronic record for five years after services are terminated.

Supply Source

This form is found in the STAR+PLUS Handbook.

 

Detailed Instructions

I. Member Information

1. Member Name — Enter the name of the member.

2. Medicaid No. — Enter the member's Medicaid number.

3. Individual Service Plan (ISP) Start and End Date — Enter the ISP start date and end date.

II. Items and Services

4. Check and specify the STAR+PLUS HCBS Program Item(s)/Service(s) — Enter the following item/service listed on the ISP and indicated on Form H1700-A.

  • Adaptive Aids — Enter the adaptive aid(s) being purchased after Items 1 through 5. Use the comments section if additional adaptive aids are required throughout the ISP period.
  • Emergency Response Services Installation — This section is only to be used for those members who are not eligible for Emergency Response Services available through Community First Choice (medical assistance only-members).
  • Minor Home Modifications — Enter each minor home modification being purchased after Items 1 through 5. Use the comments section if additional minor home modifications are required throughout the ISP period.

5. Authorization Date — Enter the date the item(s)/service(s) was authorized.

6. Completion or Delivery Date — Enter the date the item(s)/service(s) was completed or delivered. Multiple forms should be used if the item(s)/service(s) will be completed/delivered with different dates.

7. Total Amount Paid — Enter the total amount paid for each item(s).

8. Total Lifetime Costs — Enter the lifetime costs paid to date for each category, as appropriate.

III. Comments

Document in the Comments any changes, delays and/or discrepancies in item(s)/service(s) delivered.

IV. Certification

Signature–Member/Authorized Representative — The member/authorized representative signs to certify that the item(s)/service(s) was completed/delivered to the member's satisfaction. Verbal satisfaction is permitted in lieu of signature. When using verbal satisfaction, follow the verbal satisfaction field below.

Date — Enter the date the information on this form is certified.

Signature–MCO Representative — The MCO representative signs to certify that the item(s)/service(s) was completed/delivered to both the satisfaction of the MCO representative and member. The MCO must ensure all services are provided in accordance with applicable state or local building codes prior to obtaining the member/authorized representative signature. The MCO representative signing off must be an employee of the MCO.

Date — Enter the date the information on this form is certified.

Printed Name — Print the name of each person who signed the form.

Name of Person Providing Verbal Satisfaction — Enter the name of the person providing verbal satisfaction.

Date — Enter the date the verbal satisfaction was obtained.