| |
|
| Describe specifically how this action(s) will prevent or diminish the probability of future occurrences. |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| <b>Adequate policy </b>- Policies and procedures are complete, meet regulatory requirements, and are consistent with established standards and accepted practice expectations. Policies and procedures are clear and concise. |
|
| <b>Assessment</b> - There are adequate policy requirements for proper assessment of member health, behavioral, and other critical support needs and preferences. |
|
| <b>Communication and awareness</b> - There is adequate communication re: new policy requirements. Staff and others are aware of changes or revisions to policy or procedure. |
|
| <b>Consistent implementation of policy</b> – Reviewed, and modified as necessary, to assure that verbal instructions are the same as procedural requirements. Policies and procedures are up to date. |
|
| <b>Documentation </b>- There are adequate policy requirements for member records – including privacy – and documentation. |
|
| <b>Employee screening</b> - There were adequate policy requirements for screening employees. Individuals with established histories of behavior that could compromise member safety/care – including abuse and neglect – are not working with members. |
|
| <b>Environment reviewed and no changes required. Describe how this adverse incident was isolated with a minimal probability of a reoccurrence.</b> |
|
| <b>Equipment and supplies reviewed and no changes required. Describe how this adverse incident was isolated with a minimal probability of a reoccurrence.</b> |
|
| <b>Fiscal control</b> - There are adequate and consistent policy requirements for the management and control of member funds. |
|
| <b>Monitoring</b> - There are adequate policy requirements for monitoring services and supports to assure safety, meeting critical needs, and providing services in accordance with member plans and agency requirements. |
|
| <b>No resolution required. Describe how this adverse incident was isolated with a minimal probability of a reoccurrence.</b> |
|
| <b>No staffing changes required. Describe how this adverse incident was isolated with a minimal probability of a reoccurrence.</b> |
|
| <b>Other, describe</b> |
|
| <b>Other, describe</b> |
|
| <b>Other, describe</b> |
|
| <b>Other, describe</b> |
|
| <b>Planning</b> - There are adequate policy requirements for proper member planning and revision of supports based on changing needs. |
|
| <b>Policy</b> - Reviewed formal written policy or procedure governing the activity, and modified as needed. Staff are able to reference agency guidelines or protocols. |
|
| <b>Resolution following equipment and supplies review. Describe specifically how this action(s) will prevent or diminish the probability of future occurrences.</b> |
|
| <b>Resolution following member review. Describe specifically how revision(s) will prevent or diminish the probability of future occurrence(s).</b> |
|
| <b>Resolution following staffing review and /or training. Describe specifically how this action(s) will prevent or diminish the probability of future occurrences.</b> |
|
| <b>Resolution of systemic factor(s). Describe specifically how these reviews and/or assurances will prevent or diminish the probability of future occurrences.</b> |
|
| <b>Training</b> - There are adequate policy requirements for training. Staff are required by policy to meet any minimum training requirements or demonstrate competencies. |
|
| <b>Treatment plan reviewed and no changes required. Describe how this adverse incident was isolated with a minimal probability of a reoccurrence.</b> |
|
| 96152-Health and Behavior intervention - individual |
|
| 96153-Health and Behavior intervention - group |
|
| 96154-Health and Behavior intervention - family |
|
| 97802-Nutritional Counseling |
|
| 97803-Nutritional Counseling |
|
| abrasion |
|
| Abuse Report
|
|
| Abuse report |
|
| Accident |
|
| Accidental fall |
|
| Active |
|
| Additional Information Added
|
|
| Address
|
|
| Address
|
|
| Address |
|
| Affordable Care Act (ACA) |
|
| Affordable Care Act (ACA) |
|
| Age
|
|
| Aggressive behavior |
|
| aggressive behavior toward another without physical injury. |
|
| Aids/HIV |
|
| ALABAMA |
|
| ALASKA |
|
| Alert |
|
| allergic reaction |
|
| AMERICAN SAMOA |
|
| Amerigroup |
|
| Amerigroup Iowa
|
|
| AmeriHealth Caritas |
|
| AmeriHealth Caritas Iowa
|
|
| ApplicationLevel |
|
| Approval |
|
| Approve |
|
| ARIZONA |
|
| ARKANSAS |
|
| Armed Forces Americas |
|
| Armed Forces CA AFR EUR ME |
|
| Armed Forces Pacific |
|
| arrest |
|
| as identified under physical injury |
|
| Assault |
|
| Assessments
|
|
| Assessments |
|
| Assisted living |
|
| attempted, unable to reach |
|
| audio file extension |
|
| Audio video interleave file extension |
|
| Behavioral
|
|
| Behavioral needs |
|
| Billing / Claims
|
|
| Billing / Claims |
|
| bit map file extension |
|
| bit map file extension |
|
| bit map file extension |
|
| bit map file extension |
|
| bit map file extension |
|
| bit map file extension |
|
| bit map file extension |
|
| bit map file extension |
|
| bit map file extension |
|
| bit map file extension |
|
| bit map file extension |
|
| bit map file extension |
|
| bit map file extension |
|
| bit map file extension |
|
| Bit map file extension |
|
| Bit map file extention |
|
| BMC Software Patrol UNIX Icon File |
|
| Brain Injury |
|
| Breast and Cervical Cancer (BCCT)
|
|
| Breast and Cervical Cancer (BCCT) |
|
| burn |
|
| by the member to another individual |
|
| CALIFORNIA |
|
| Case Management Comprehensive Assessment |
|
| Case Manager Date Informed:
|
|
| CCO Budget |
|
| CDAC Agreement |
|
| Cell |
|
| Change staff |
|
| Child Care Medical Services Documents |
|
| Children’s Mental Health |
|
| City
|
|
| City |
|
| City |
|
| City: |
|
| Claim Attachment |
|
| Claimed |
|
| Claims Detail |
|
| CMH Waiver |
|
| CMH Waiver Documents |
|
| Coding
|
|
| Coding |
|
| cohabitation with a registered sex offender |
|
| COLORADO |
|
| Comma Separated Values file extension |
|
| Communication with member, family and/or other staff |
|
| Community |
|
| Community Based Neurobehavioral Rehabilitation Services Documents |
|
| Community job |
|
| Community job |
|
| Completed
|
|
| Completed
|
|
| Completed
|
|
| Completed
|
|
| Completed
|
|
| Completed
|
|
| Completed (Investigation Completed)
|
|
| Comprehensive Assessment and Social History (CASH) |
|
| concussion |
|
| Condition / situation identified under law enforcement |
|
| Condition / situation identified under physical injury |
|
| Condition / situation identified under physical injury |
|
| Conditional |
|
| Conditional |
|
| Conditional |
|
| CONNECTICUT |
|
| Consumer Choices Option (CCO)
|
|
| Consumer Choices Option (CCO) |
|
| ControlLevel |
|
| contusion / bruise |
|
| Copy of EHR invoice or contract |
|
| Copy of invoice for EHR training |
|
| Copy of invoice for hardware purchase/lease agreement |
|
| Copy of invoice for online connectivity |
|
| Correctional facility / jail |
|
| Cost Reporting
|
|
| Cost Reporting |
|
| Covid-19 |
|
| Criminal
|
|
| Crisis stabilization |
|
| Crossover Claims
|
|
| Crossover Claims |
|
| cruel punishment |
|
| Date CM contacted Member |
|
| Date Contacted
|
|
| Date Contacted:
|
|
| Date Informed |
|
| Date Informed |
|
| Date of Birth
|
|
| Date of Report |
|
| Date of Report |
|
| Date Received |
|
| Day program |
|
| Day program |
|
| DCP |
|
| Death
|
|
| Death |
|
| DELAWARE |
|
| Deleted |
|
| Delta Dental |
|
| DemographicsTab |
|
| DemographicsTab |
|
| DemographicsTab |
|
| Denial of critical care |
|
| denial of critical care |
|
| denial of critical care |
|
| Deny |
|
| Dept. of Inspection & Appeals (DIA) Date of Report:
|
|
| Describe other: |
|
| Describe:
|
|
| Describe:
|
|
| Describe:
|
|
| DHS Date of Report:
|
|
| diagnosed prior to death |
|
| Dining |
|
| Disciplinary action |
|
| Discovered |
|
| discovered at time of death |
|
| dislocation |
|
| DISTRICT OF COLUMBIA |
|
| documentation error |
|
| DocumentsTab |
|
| Elderly |
|
| electric shock |
|
| Electronic Health Records (EHR)
|
|
| Electronic Health Records (EHR) |
|
| Electronic Visit Verification (EVV)
|
|
| Electronic Visit Verification (EVV) |
|
| Eligibility Diagnosis: for BI waiver members (Initial level of care for BI Diagnosis must still be uploaded through Upload document to IME) |
|
| Email
|
|
| Emergency Mental Health
|
|
| Emergency mental health |
|
| Emergency Needs Assessment |
|
| emergency room treatment |
|
| EPSDT / Care for Kids
|
|
| EPSDT / Care for Kids |
|
| Exception to Policy Documents |
|
| exclusionary timeout |
|
| Expired |
|
| Exploitation |
|
| exploitation |
|
| eXtensible markup language file extension |
|
| eye emergency |
|
| Facility LOC Cert Form |
|
| Family |
|
| Family Planning Program (FPP)/ Iowa Family Planning Network (IFPN)
|
|
| Family Planning Program (FPP)/ Iowa Family Planning Network (IFPN) |
|
| Family Planning Services
|
|
| Family Planning Services |
|
| Featured Functionality that are displayed in the default.aspx |
|
| FEDERATED STATES OF MICRONESIA |
|
| Female
|
|
| File processing has started. |
|
| fire |
|
| First Name |
|
| First Name |
|
| First Name:
|
|
| flooding |
|
| FLORIDA |
|
| Foster care/family life home |
|
| FosterCareTab |
|
| fracture |
|
| GEORGIA |
|
| Good |
|
| Group |
|
| GUAM |
|
| Guardian Date Informed:
|
|
| H0004-BEHAVIORAL HEALTH CNSL&TX-15 MIN |
|
| H0018-Crisis out of home stabilization |
|
| H0023-BEHAVIORAL HEALTH OUTREACH SERVICE |
|
| H0024-BHVAL HLTH PRV INFORM DISSEMIN SRVC |
|
| H0025-Crisis intervention follow along |
|
| H0031-Behavior Programming Assessment |
|
| H0032-Behavioral Programming Development |
|
| H0036-Mental Health Outreach |
|
| H0037-Community Psychiatric Supportive Treatment Program , per diem |
|
| H0046-MENTAL HEALTH SERVICES NOS |
|
| H2001-Rehabilitation Program – per half day |
|
| H2011Crisis Intervention |
|
| H2014-Skills Training and Development |
|
| H2015-Comprehensive Community Support Services |
|
| H2015HI-COMP CMTY SUPPORT SRVC PER 15 MIN |
|
| H2016-Comp Comm Support - home based hab or SCL |
|
| H2016HI-Comp Comm Support - SCL |
|
| H2016U3-COMP CMTY SUPPORT SRVC PER DIEM |
|
| H2019-THERAPEUTIC BEHAVIORAL SRVC 15 MIN |
|
| H2021-CMTY-BASED WRAP-AROUND SRVC 15 MIN |
|
| H2023-SUPPORTED EMPLOYMENT PER 15 MINUTES |
|
| H2024UC-SUPPORTED EMPLOYMENT PER DIEM |
|
| H2025-ONGOING SUPP MNTAIN EMPLOY 15 MIN |
|
| Habilitation |
|
| Habilitation Review Information |
|
| Habilitation Services Documents |
|
| HAWAII |
|
| hawk-I
|
|
| Hawki |
|
| HCBS QA Oversight |
|
| Health Disability (formerly Ill & Handicapped) |
|
| Health Home |
|
| Health Insurance Premium Payment (HIPP)
|
|
| Health Insurance Premium Payment (HIPP) |
|
| Health Risk Assessment |
|
| Helpful Hints that are displayed in the default.aspx |
|
| holding face down |
|
| Home |
|
| Home- and Community-Based Services (HCBS)
|
|
| Home- and Community-Based Services (HCBS) |
|
| Homeless/shelter/street |
|
| Homicide / violence |
|
| Hospice |
|
| Hospital / clinic |
|
| Hospital / medical clinic |
|
| Hospital Retrospective & Program Integrity Documents |
|
| html file extension |
|
| html file extension |
|
| human/animal bite |
|
| IA Health Link (managed care)
|
|
| IA Health Link (managed care) |
|
| ICF / nursing facility |
|
| ICF/MR |
|
| ICF/PMI |
|
| ID, BI, EW, AIDS, PD, HD Waiver, NF, ICF/ID and PACE Documents |
|
| IDAHO |
|
| IHAWP Prior Authorization |
|
| ILLINOIS |
|
| IME ACO (Accountable Care Organization) |
|
| IME ACO(Accountable Care Organization)-76
|
|
| IME Adult Rehab |
|
| IME Adult Rehab |
|
| IME Adult Rehab-43
|
|
| IME Ambulance |
|
| IME Ambulance-11 |
|
| IME Ambulatory Surgical Center |
|
| IME Ambulatory Surgical Center-36
|
|
| IME Area Education Agency |
|
| IME Area Education Agency-40
|
|
| IME Assertive Community Treatment (ACT) |
|
| IME Assertive Community Treatment (ACT)-67
|
|
| IME Audiologist |
|
| IME Audiologist-17 |
|
| IME Behavioral Health |
|
| IME Behavioral Health Intervention Srvcs (BHIS) |
|
| IME Behavioral Health Intervention Srvcs (BHIS)-63
|
|
| IME Behavioral Health-62
|
|
| IME Birthing Center |
|
| IME Birthing Center-39
|
|
| IME Brenda Testing |
|
| IME CDAC-Consumer Directed Attendant Care |
|
| IME Certified Nurse Midwife |
|
| IME Certified Nurse Midwife-38
|
|
| IME Chiropractor |
|
| IME Chiropractor-16
|
|
| IME Clinic |
|
| IME Clinic-14 |
|
| IME Clinical Social Worker |
|
| IME Clinical Social Worker-48
|
|
| IME CMS 1500 |
|
| IME Community Based ICF/ID |
|
| IME Community Based ICF/ID-27
|
|
| IME Community Based Neuro-Rehabilitation |
|
| IME Community Based Neuro-Rehabilitation-79
|
|
| IME Community MH |
|
| IME Community MH-21
|
|
| IME County Relief |
|
| IME Crisis Response Services |
|
| IME Crisis Response Services-80
|
|
| IME CRNA |
|
| IME CRNA-44
|
|
| IME Dental ADA |
|
| IME Dentist |
|
| IME Dentist-04 |
|
| IME Early Access Service Coordinator |
|
| IME Early Access Service Coordinator |
|
| IME Electronic |
|
| IME Family Planning |
|
| IME Family Planning-22
|
|
| IME Federal Qualified Health Center |
|
| IME Federal Qualified Health Center-49
|
|
| IME General Hospital |
|
| IME General Hospital-01 |
|
| IME General IMPA Information |
|
| IME General Provider Notification |
|
| IME General Provider Notification |
|
| IME Genetic Consultation Clinic |
|
| IME Genetic Consultation Clinic |
|
| IME Habilitation Services |
|
| IME Habilitation Services-64
|
|
| IME Health Home |
|
| IME Health Home-71
|
|
| IME Health Maintenance Organ. |
|
| IME Hearing Aid Dealer |
|
| IME Hearing Aid Dealer-31
|
|
| IME HIPP |
|
| IME HIPP-47
|
|
| IME Home Health Agency |
|
| IME Home Health Agency-09
|
|
| IME Hospice |
|
| IME Hospice-45
|
|
| IME ICF/ID State |
|
| IME ICF/ID State-25
|
|
| IME IHAWP HMO |
|
| IME IHAWP Marketplace |
|
| IME IHAWP MarketPlace Provider |
|
| IME IHAWP MarketPlace Provider-75
|
|
| IME IMPA System |
|
| IME Independent Lab |
|
| IME Independent Lab-10
|
|
| IME Independent Speech Pathologist |
|
| IME Independent Speech Pathologist |
|
| IME Independent Speech Pathologist-69
|
|
| IME Indian Health Service |
|
| IME Indian Health Service-59
|
|
| IME Infant and Toddler |
|
| IME Infant and Toddler-57
|
|
| IME Institutional - General |
|
| IME Institutional - General-60
|
|
| IME Integrated Health Home |
|
| IME Integrated Health Home-73
|
|
| IME Intermediate Care Facility |
|
| IME Intermediate Care Facility-20
|
|
| IME Lead Investigation Agency |
|
| IME Lead Investigation Agency-55
|
|
| IME Lien Holder |
|
| IME Local Education Agency |
|
| IME Local Education Agency-56
|
|
| IME Long Term Care |
|
| IME Maternal Health Center |
|
| IME Maternal Health Center-35
|
|
| IME Medical Supplies |
|
| IME Medical Supplies-12
|
|
| IME Medically Needy Only |
|
| IME Medically Needy Only |
|
| IME Medically Needy Only-83
|
|
| IME Mental Health Substance Abuse Plan |
|
| IME Mental Health Substance Abuse Plan-53
|
|
| IME Mental Hospital |
|
| IME Mental Hospital-26
|
|
| IME MEP Case Manager |
|
| IME MEP Case Manager |
|
| IME NEMT Broker (Non-Emergency Transport) |
|
| IME NEMT Broker (Non-Emergency Transport)-65
|
|
| IME NEMT Provider |
|
| IME NEMT Provider-77
|
|
| IME Neurological Rehabilitation Facility |
|
| IME Neurological Rehabilitation Facility-78
|
|
| IME Non Provider Mail Only |
|
| IME Non Provider Mail Only-86
|
|
| IME Nurse Practitioner |
|
| IME Nurse Practitioner-50
|
|
| IME Nursing Facility - Mental Ill |
|
| IME Nursing Facility - Mental Ill-52
|
|
| IME Occupational Therapist Independent |
|
| IME Occupational Therapist Independent-33
|
|
| IME Optician |
|
| IME Optician-07
|
|
| IME Optometrist |
|
| IME Optometrist-06
|
|
| IME Orthopedic Shoe Dealer |
|
| IME Orthopedic Shoe Dealer-34
|
|
| IME Other Practitioner - General |
|
| IME Other Practitioner - General-61
|
|
| IME PACE |
|
| IME PACE-58
|
|
| IME Paper |
|
| IME Para Professional |
|
| IME Pharmacy |
|
| IME Pharmacy |
|
| IME Pharmacy-08
|
|
| IME Physical Therapist |
|
| IME Physical Therapist-15
|
|
| IME Physician Assistant |
|
| IME Physician Assistant-68
|
|
| IME Physician DO |
|
| IME Physician DO-03
|
|
| IME Physician MD |
|
| IME Physician MD-02
|
|
| IME Podiatrist |
|
| IME Podiatrist-05
|
|
| IME Prepaid Health Plan |
|
| IME Provider Information Letters - Billing Types |
|
| IME Provider Information Letters - Claim Types |
|
| IME Provider Information Letters - Provider Types |
|
| IME Provider Policy Clarifications- Provider Types |
|
| IME Psych Medical Inst Children PMIC |
|
| IME Psych Medical Inst Children PMIC-41
|
|
| IME Psychologist |
|
| IME Psychologist-29
|
|
| IME Public Health Agency |
|
| IME Public Health Agency |
|
| IME Public Health Agency-72
|
|
| IME RCF Guardian |
|
| IME Rehab Agency |
|
| IME Rehab Agency-19
|
|
| IME Release Notes |
|
| IME Remedial Services |
|
| IME Remedial Services |
|
| IME Residential Care Facility |
|
| IME Residential Care Facility-23
|
|
| IME Rural Health Clinic |
|
| IME Rural Health Clinic-13
|
|
| IME Screening Center |
|
| IME Screening Center-30
|
|
| IME Skilled Nursing Facility |
|
| IME Skilled Nursing Facility-18
|
|
| IME Sub-acute Mental Health Services |
|
| IME Sub-acute Mental Health Services-81
|
|
| IME Tape Intermediary |
|
| IME Targeted Case Manager |
|
| IME Targeted Case Manager-42
|
|
| IME Therapeutic Treatment Service |
|
| IME Therapeutic Treatment Service |
|
| IME Therapeutic Treatment Service-51
|
|
| IME UB04 |
|
| IME Waiver |
|
| IME Waiver |
|
| IME Waiver-99
|
|
| impair sensory capabilities |
|
| Improve team building |
|
| in-patient hospitalization (medical unit) |
|
| in-patient hospitalization (mental health unit) |
|
| Inactive |
|
| Inactive |
|
| incarceration |
|
| Incident Reporting
|
|
| Incident Reporting |
|
| Increase number of staff |
|
| Increase staff hours |
|
| Increase supervision of staff |
|
| INDIANA |
|
| Individual needs |
|
| Information Letter |
|
| Informational Letters Programs List |
|
| Informational Letters Provider Topics List |
|
| Ingested / aspiration / choking |
|
| Initial (Pending Further Investigation)
|
|
| Initiated
|
|
| Initiated
|
|
| Initiated
|
|
| Initiated
|
|
| Initiated
|
|
| Initiated
|
|
| Integrated Health Home |
|
| Intellectual Disability (formerly MR) |
|
| International Classification of Diseases, 10th Edition (ICD-10)/(ICD-9)
|
|
| International Classification of Diseases, 10th Edition (ICD-10)/(ICD-9) |
|
| interRAI Child and Youth Mental Health |
|
| interRAI Community Mental Health |
|
| interRAI Home Care |
|
| interRAI Pediatric Home Care |
|
| IOWA |
|
| Iowa Health and Wellness Plan (IHAWP)
|
|
| Iowa Health and Wellness Plan (IHAWP) |
|
| Iowa Total Care |
|
| Iowa Total Care |
|
| Is Public |
|
| Join |
|
| KANSAS |
|
| KENTUCKY |
|
| laceration |
|
| Last Name |
|
| Last Name |
|
| Last Name: |
|
| Law Enforcement
|
|
| Law enforcement |
|
| License issued by Iowa Board of Physician Assistants, showing license number |
|
| Limited Emergent Services
|
|
| Limited Emergent Services |
|
| Location Unknown/Elopement
|
|
| Location Unknown/elopement |
|
| LOCUS/CALOCUS |
|
| Long Term Care
|
|
| Long Term Care |
|
| loss of consciousness |
|
| loss/tearing of body part |
|
| LOUISIANA |
|
| Mailing Address |
|
| Main |
|
| MAINE |
|
| Male
|
|
| manufacture or possession of a dangerous substance |
|
| MARSHALL ISLANDS |
|
| MARYLAND |
|
| MASSACHUSETTS |
|
| Mayo Portland Assessment (MPAI) |
|
| MCNA |
|
| mechanical restraint for behaviors |
|
| MED Exception to Policy Dental X-ray |
|
| MED Exception to Policy Digital Image |
|
| Med MDS Validation |
|
| Medicaid AR |
|
| Medical
|
|
| Medical Prior Authorization |
|
| Medical Prior Authorization Dental X-ray |
|
| Medical Support for Claims Documents |
|
| Medicare Savings Program (MSP) (QMB, SLMB)
|
|
| Medicare Savings Program (MSP) (QMB, SLMB) |
|
| Medication Refusal |
|
| Medication Refusal |
|
| Member's physical environment evaluated and modified if necessary for safety issues |
|
| Member's physical environment evaluated and modified if necessary to increase accessibility |
|
| Member’s interpersonal relationships within their environment evaluated, and accommodated / modified if necessary, for safety reasons |
|
| Member’s legal residence |
|
| MemberTab |
|
| MemberTab |
|
| MemberTab |
|
| Mental Health
|
|
| Mental Injury |
|
| mental injury |
|
| Message |
|
| Message file extension |
|
| Message that displays as a popup |
|
| Message that displays in webpart |
|
| MFP |
|
| MICHIGAN |
|
| Microsoft 2007 Excel file extension |
|
| Microsoft 97 - 2003 Excel file extension |
|
| Microsoft 97-2003 file extension |
|
| Microsoft Word 2007 file extension |
|
| MINNESOTA |
|
| Miscellaneous Documents |
|
| missed dosage |
|
| missed dosage |
|
| MISSISSIPPI |
|
| MISSOURI |
|
| Molina Healthcare |
|
| Money Follows the Person (MFP)
|
|
| Money Follows the Person (MFP) |
|
| MONTANA |
|
| movement / inhibited |
|
| N/A
|
|
| N/A
|
|
| N/A
|
|
| N/A
|
|
| Name |
|
| Name of Location or Facility |
|
| NEBRASKA |
|
| Necessary equipment needs to be purchased |
|
| Necessary equipment needs to be repaired |
|
| Necessary equipment needs to be replaced |
|
| Neighbor |
|
| NEVADA |
|
| NEW HAMPSHIRE |
|
| NEW JERSEY |
|
| NEW MEXICO |
|
| NEW YORK |
|
| No
|
|
| No
|
|
| No
|
|
| No
|
|
| No
|
|
| No
|
|
| No
|
|
| No
|
|
| No
|
|
| No |
|
| No |
|
| No |
|
| No |
|
| No |
|
| No |
|
| No |
|
| No |
|
| No |
|
| No |
|
| no |
|
| No |
|
| no |
|
| no |
|
| No |
|
| No |
|
| No |
|
| No the Provider is accepting new medicaid clients |
|
| No Value Chosen |
|
| Non-MCO
|
|
| NORTH CAROLINA |
|
| NORTH DAKOTA |
|
| NORTHERN MARIANA ISLANDS |
|
| Not verifying correct member
|
|
| Notice of Action |
|
| Off-Year Assessment |
|
| Officer Name & Contact Information |
|
| OHIO |
|
| OKLAHOMA |
|
| OREGON |
|
| Other |
|
| Other |
|
| other |
|
| Other |
|
| Other (Describe)
|
|
| Other (Non-Waiver)
|
|
| Other Entity Contacted, specify:
|
|
| Other Member |
|
| Other, describe |
|
| Other, describe |
|
| other, describe |
|
| Other, describe |
|
| Other, Describe |
|
| other, describe |
|
| other, describe |
|
| Other, describe |
|
| other, describe |
|
| Other, specify |
|
| Other; describe |
|
| Other; describe |
|
| other; describe |
|
| Out of State Facility Prior Authorization |
|
| out-patient mental health |
|
| Overdose
|
|
| Overdose
|
|
| PageLevel |
|
| PALAU |
|
| pc paintbrush file extension |
|
| PENNSYLVANIA |
|
| perpetrator |
|
| perpetrator |
|
| perpetrator |
|
| perpetrator |
|
| perpetrator |
|
| perpetrator |
|
| perpetrator |
|
| perpetrator |
|
| perpetrator |
|
| perpetrator |
|
| Perpetrator |
|
| Perpetrator |
|
| Personal harm
|
|
| Personal harm |
|
| Phone #
|
|
| Phone # |
|
| Phone #: |
|
| Phone# |
|
| Physical Address |
|
| Physical Disability |
|
| Physical Injury
|
|
| Physical injury |
|
| Physical Injury |
|
| physical injury |
|
| physical injury |
|
| PICA behavior / Ingestion of harmful substance |
|
| PMIC Prior Authorization |
|
| poisoning / toxin ingestion |
|
| Policy Clarification |
|
| Portable Document File extension |
|
| Positive and supportive relationships |
|
| Powerpoint file extension |
|
| presence of illegal drugs |
|
| Presumptive Eligibility
|
|
| Presumptive Eligibility |
|
| Prior Authorization
|
|
| Prior Authorization |
|
| Private residence/household – Living alone |
|
| Private residence/household – Living with relatives |
|
| Private residence/household – Living with unrelated persons |
|
| PRN meds for behavior |
|
| Program Integrity
|
|
| Program Integrity |
|
| ProgramServicesTab |
|
| ProgramServicesTab |
|
| ProgramServicesTab |
|
| prone restraint |
|
| Proof of a contract to provide services or employment agreement in support of incentive payment assignment |
|
| Proof of other costs associated with EHR implementation (such as lost productivity, or purchase of REC services) |
|
| Proof of ownership of RHC |
|
| Proof of patient volume, including location(mailing address) of service |
|
| Provider Address
|
|
| Provider EFT |
|
| Provider EHR Attachment |
|
| Provider Enrollment
|
|
| Provider Enrollment |
|
| Provider/Agency Name
|
|
| Psych Evaluation |
|
| PUERTO RICO |
|
| puncture wound |
|
| Rates
|
|
| Rates |
|
| RCF |
|
| RCF/MR |
|
| RCF/PMI |
|
| Recreating |
|
| removal of mobility aids |
|
| Replaced |
|
| Report #:
|
|
| Representative: POA/Guardianship |
|
| Representative: POA/Guardianship |
|
| Request |
|
| Request Form |
|
| Resolution of environmental review includes changes to the member’s existing environmental conditions |
|
| Resolution of environmental review includes long-term facility placement for member. |
|
| Resolution of environmental review includes short-term facility placement for member. |
|
| resolved by case manager |
|
| resolved by natural supports |
|
| resolved by outside entity |
|
| resolved by provider staff |
|
| RHODE ISLAND |
|
| Rich Text File extension |
|
| Rights |
|
| rights violation |
|
| Roommate |
|
| Root Cause (Describe what lead to or contributed to the incident): |
|
| S0215-NON-EMERG TRANSPORTATION PER MILE |
|
| S5100-ADULT DAY CARE SERVICES/15 MIN |
|
| S5101-Adult Day Care Services/Half Day |
|
| S5102-DAY CARE SERVICES |
|
| S5105-Center Based Adult Day Care |
|
| S5120-CHORE SERVICES PER 15 MINUTES |
|
| S5125-ATTENDANT CARE SERVICES/AGENCY |
|
| S5125U3-ATTENDANT CARE SERVICES/AGENCY |
|
| S5130-Homemaker Service, NOS |
|
| S5135-COMPANION CARE ADULT PER 15 MIN |
|
| S5150-Unskilled Respite Care - basic individual |
|
| S5150U3-UNSKLD RESPITE CARE NOT HOSPICE 15 |
|
| S5160-EMERG RESPONSE SYSTEM INSTL&TST |
|
| S5161-EMERG RESPONSE SYS SRVC FEE-MONTH |
|
| S5165-Home Modification |
|
| S5170UF-HOME DEL MEALS INCL PREP MEAL |
|
| S5170UG-HOME DELIVERED MEALS |
|
| S5170UH-HOME DELIVERED MEALS |
|
| S5170UJ-HOME DELIVERED MEALS |
|
| S5199-PERSONAL CARE ITEM NOS EACH |
|
| S9122-Home Health Aid, Per Hour |
|
| S9123-Nursing Care Service - RN, Per Hour |
|
| S9124-Nursing Care Service - LPN, Per Hour |
|
| School |
|
| School |
|
| seclusion / isolation |
|
| Seizure |
|
| self injurious / self mutilation behavior without physical injury. |
|
| self-denial of critical care |
|
| Self-denial of critical care |
|
| Self-mutilation / self injurious behavior |
|
| Service Name: |
|
| Service Plan |
|
| Services were being provided. |
|
| Services were not being provided. |
|
| sexual abuse |
|
| sexual abuse |
|
| Sexual abuse |
|
| Shopping |
|
| SIS Family Friendly Long Report |
|
| SIS Family Friendly Report |
|
| SIS Long Report |
|
| SkipTCN |
|
| social environment |
|
| Social History (Social History for initial HAB must still be uploaded through Upload document to IME) |
|
| SOUTH CAROLINA |
|
| SOUTH DAKOTA |
|
| sprain |
|
| Staff |
|
| Staff distracted
|
|
| Staff Reviewer |
|
| Staff trained / retrained on equipment use |
|
| State
|
|
| State
|
|
| State |
|
| State facility |
|
| State Innovation Model (SIM)
|
|
| State Innovation Model (SIM) |
|
| State MHI |
|
| State resource center |
|
| State: |
|
| suicidal ideation |
|
| Suicide |
|
| Suicide attempt |
|
| Swing Bed Documents |
|
| T1002-RN SERVICES UP TO 15 MINUTES |
|
| T1003-LPNLVN SERVICES UP TO 15 MINUTES |
|
| T1004-SERVICES OF A QUALIFIED NURSING/HH AIDE |
|
| T1004U3-SERVICES OF A QUALIFIED NURSING/HH AIDE |
|
| T1005-Respite Care Services - group |
|
| T1005U3-RESPITE CARE SERVICES TO 15 MIN |
|
| T1016-Case Management |
|
| T1017-Targeted Case Management |
|
| T1019-PERSONAL CARE SERVICES PER 15 MINS |
|
| T1019U3-PERSONAL CARE SERVICES PER 15 MINS |
|
| T1021-Home Health Aide, Per Visit |
|
| T1021U3-HOME HLTH AIDECERT NURSE ASST VST |
|
| T1030-Nursing Care Service - RN, Per Visit |
|
| T1030U3-NRS CARE HOME REGISTERED NURSE-DIEM |
|
| T1031-Nursing Care Service - LPN, Per Visit |
|
| T1031U3-NURSING CARE THE HOME LPN PER DIEM |
|
| T2003-NON-EMERG TRNSPRT ENCOUNTERTRIP |
|
| T2014-HABILITATN PREVOCATIONL WAIVRDIEM |
|
| T2015-Habilitation, Prevocational per Hour |
|
| T2018UC-HABILITATN SUPP EMPLMNT WAIVRDIEM |
|
| T2020-Day Habilitation, Waiver/Diem |
|
| T2021-Day Habilitation - 15 Minutes |
|
| T2025-Waiver Services NOS- FMS payment |
|
| T2028-SPECIALIZED SUPPLY NOS WAIVER |
|
| T2029-SPECIALIZED MEDICAL EQP NOS WAIVER |
|
| T2036-Therapy Camping Overnight |
|
| T2037-TX CAMPING DA WAIVER EA SESS |
|
| T2038-CMTY TRANSITION WAIVER PER SERVICE |
|
| T2038U3-CMTY TRANSITION WAIVER PER SERVICE |
|
| T2039-Vehicle Modification |
|
| tagged image file format extension |
|
| take down |
|
| Tax Entity |
|
| TENNESSEE |
|
| Terminal illness / natural causes |
|
| Terminate staff |
|
| Test |
|
| TEXAS |
|
| Text file extension |
|
| The file has been successfully uploaded through the File Upload web page AND all rows have been successfully processed in the nightly batch. Processed files contain rows that contain errors and no errors. Errors documented are based on IMPA eligibility. |
|
| The file has been successfully uploaded through the File Upload web page AND all rows have NOT been successfully processed in the nightly batch. |
|
| Third Party Liability (TPL) or Other Health Insurance (OHI)
|
|
| Third Party Liability (TPL) or Other Health Insurance (OHI) |
|
| This file can be deleted within 60 minutes of the Date/Time Uploaded. If you delete this file it will not be processed nor will it be retained. |
|
| This file or some of the rows did not fully process. There has been a request for this file NOT to continue processing, but has been corrected with a different file. |
|
| This file or some of the rows did not fully process. There has been a request for this file to be reprocessed through the nightly batch.See Status Matrix for available status changes. |
|
| This file or some of the rows did not process nor has the issue been corrected for a period of 3 or more days. The file will not be processed nor will it continue to hold up all other processing; it will be ignored in its entirety. |
|
| Time CM contacted Member |
|
| to the member |
|
| tornado / storm |
|
| treatment by a health care professional |
|
| Treatment plan reviewed and/or revised due to behavioral issues |
|
| Treatment plan reviewed and/or revised due to cognitive abilities |
|
| Treatment plan reviewed and/or revised due to communication needs |
|
| Treatment plan reviewed and/or revised due to level of need and support |
|
| Treatment plan reviewed and/or revised due to medical / health status, including medication review |
|
| Treatment plan reviewed and/or revised due to physical abilities |
|
| Treatment plan reviewed and/or revised due to unidentified risk or safety issues; safety plan reviewed / modified |
|
| Treatment plan reviewed and/or revised to reflect member’s goals |
|
| unauthorized administration |
|
| unauthorized administration |
|
| Under certain conditions they will take new medicaid clients. |
|
| United Healthcare |
|
| UnitedHealthcare Community Plan
|
|
| Unknown
|
|
| Unknown |
|
| unknown |
|
| unsafe/ unhealthy physical environment |
|
| Uploaded means that the file was successfully uploaded and is waiting for processing. |
|
| UTAH |
|
| Vehicle |
|
| Vehicular accident |
|
| VERMONT |
|
| victim |
|
| victim |
|
| victim |
|
| victim |
|
| victim |
|
| victim |
|
| victim |
|
| victim |
|
| victim |
|
| victim |
|
| Victim |
|
| Victim |
|
| VIRGIN ISLANDS |
|
| VIRGINIA |
|
| W0574-Targeted Case Management Child |
|
| W0578-Targeted Case Management Adult |
|
| W0579-TCM Adult CMI |
|
| W0580-TCM CMH Waiver |
|
| W0719-Community Living Skills Training Services Hourly |
|
| W0720-Community Living Skills Training Services Daily |
|
| W0721-Employment Related Services Hourly |
|
| W0722-Employment Related Services Daily |
|
| W0723-Day Program for Skills Training Hourly |
|
| W0724-Day Programs for Skills Training Daily |
|
| W0725-Day Program for Skills Development Hourly |
|
| W0726-Day Programs for Skills Development Daily |
|
| W0810-Targeted Case Management - Child |
|
| W0811-Targeted Case Management - Adult |
|
| W0812-Targeted Case Management - CMI |
|
| W0813-Targeted Case Management - CMH Waiver |
|
| W0814-Case Management - Habilitation |
|
| W0815-Case Management - BI Waiver |
|
| W0816-Case Management - Elderly Waiver |
|
| W0817-Targeted Case Management - Transitional |
|
| W0818-Targeted Case Management - CMI - Transitional |
|
| W1002-Adult Day Care-Full Day |
|
| W1003-Homemaker |
|
| W1004-Obsolete - Home Health Aide |
|
| W1010-Consumer Choices Option |
|
| W1021-Adult Day Care-Half Day |
|
| W1022-Personal Emergency Response-Initial |
|
| W1023-Personal Emergency Response-Ongoing |
|
| W1024-Obsolete - Home Health Aide |
|
| W1025-Homemaker |
|
| W1026-Obsolete - Nursing |
|
| W1029-Chore |
|
| W1030-Home Delivered Meals |
|
| W1031-Home and Vehicle Modifications |
|
| W1033-Transportation: RTA |
|
| W1035-Transportation |
|
| W1037-Counseling-Individual |
|
| W1038-Counseling-Group |
|
| W1039-Obsolete - Home Health Aide |
|
| W1040-Homemaker |
|
| W1041-Obsolete - Nursing |
|
| W1047-Senior Companion |
|
| W1048-Assistive Devices |
|
| W1049-Nutritional Counseling |
|
| W1060-Mental Health Outreach |
|
| W1203-Adult Day Care-Extended Day |
|
| W1204-Day Habilitation(per day) |
|
| W1205-Day Habilitation(1/2 day) |
|
| W1206-Day Habilitation(Hourly) |
|
| W1207-Home-based habilitation (hourly) |
|
| W1208-Home-based habilitation (daily) |
|
| W1250-Counseling-Individual |
|
| W1251-Counseling-Group |
|
| W1252-Obsolete - Nursing |
|
| W1258-Home Delivered Meals |
|
| W1260-Morning Meal |
|
| W1261-Noon Meal |
|
| W1262-Evening Meal |
|
| W1263-Liquid Supplement Meal |
|
| W1265-CDAC-Agency (Hourly) |
|
| W1266-CDAC-Agency (Daily) |
|
| W1267-CDAC-Individual (Hourly) |
|
| W1268-CDAC-Individual (Daily) |
|
| W1300-Supported Community Living (Daily) |
|
| W1302-Home and Vehicle Modifications |
|
| W1303-Personal Emergency Response-Initial |
|
| W1304-Personal Emergency Response-Ongoing |
|
| W1305-Obsolete - Nursing |
|
| W1306-Obsolete - Home Health Aide |
|
| W1311-Supported Community Living (Hourly) |
|
| W1320-Supported Community Living (Residential Based) |
|
| W1330-Case Management |
|
| W1401-Supported Community Living (Daily) |
|
| W1407-Personal Emergency Response - Ongoing |
|
| W1408-Personal Emergency Response-Initial |
|
| W1409-Case Management |
|
| W1410-Case Management |
|
| W1414-Transportation |
|
| W1417-Home and Vehicle Modifications |
|
| W1418-Specialized Medical Equipment |
|
| W1419-Behavioral Programming |
|
| W1420-Family Counseling and Training |
|
| W1421-Supported Community Living (Hourly) |
|
| W1425-Pre-Vocational Services |
|
| W1426-Pre-Vocational Services (1/2 day) |
|
| W1430-Supported Employment, obtain a job |
|
| W1431-Supported Employment, maintain employment/job coaching |
|
| W1432-Supported Employment, maintain employment/personal care |
|
| W1433-Supported Employment, maintain employment/enclave |
|
| W1518-Interim Medical Monitoring & Treatment - SCL |
|
| W2500-Respite-HHA specialized |
|
| W2501-Respite-HHA basic individual |
|
| W2502-Respite-HHA group |
|
| W2503-Respite-Home Care Agcy & Non-Facility, Specialized |
|
| W2504-Respite-Home Care Agcy & Non-Facility, Basic Individual |
|
| W2505-Respite- Home Care Agcy & Non-Facility, Group |
|
| W2506-Respite-hospital or nursing facility/skilled |
|
| W2507-Respite-nursing facility |
|
| W2508-Respite-ICF/MR |
|
| W2509-Respite-foster group care |
|
| W2510-Respite-camps |
|
| W2511-Respite- adult day care |
|
| W2512-Respite- child care center |
|
| W2513-Interim Medical Monitoring & Treatment-HHA |
|
| W2514-Interim Medical Monitoring & Treatment-Nurse |
|
| W2515-Interim Medical Monitoring & Treatment-Registered/Licensed Child Care |
|
| W2516-Respite-RCF/MR |
|
| W2517-CDAC-Assisted Living |
|
| W2518-Interim Medical Monitoring & Treatment-HHA |
|
| W2519-Interim Medical Monitoring & Treatment-Nurse |
|
| W2520-Interim Medical Monitoring & Treatment- registered/licensed child care |
|
| W2521-Respite Resident Camp - Weeklong overnight recreational respite |
|
| W2522-Group Summer Day Camp - Group recreational respite camp |
|
| W2523-Group Specialized Summer Day Camp - Group Recreational respite camp for individuals requiring additional support |
|
| W2524-Teen Day Camp - Day Camp providing recreational activities for teens age 13 to 21 years old |
|
| W2525-Weekend On-site Respite - Camp based recreational overnight respite |
|
| W3245-Environmental Modifications, Adaptive Devices, and Theraputic Resources |
|
| W3246-Family & Community Supports |
|
| W3247-In-Home Family Therapy |
|
| W4021-Adult Day Care (Hourly) |
|
| W4414-Transportation – Trip |
|
| W4425-Pre-Vocational Services (Hourly) |
|
| W5001-Crisis Intervention-In home technical assistance |
|
| W5002-Crisis Intervention-out of home crisis stabilization |
|
| W5003-Crisis Intervention-Follow-along |
|
| W5004-Nurse Delegation |
|
| W5005-Transition Services-Individual Budget |
|
| W5006-Money Follows Person |
|
| W5007-Community Provider Participation |
|
| W5008-ICF MR Staff Participation |
|
| W5019-Supported Employment - Job Development |
|
| W5020-Supported Employment - Employer Development |
|
| W5021-Supported Employment - Enhanced Job Search |
|
| Waiver Prior Authorization |
|
| WASHINGTON |
|
| Welfare Check
|
|
| WEST VIRGINIA |
|
| WISCONSIN |
|
| Witnessed |
|
| word perfect graphic file extension |
|
| Work activity |
|
| Work activity |
|
| Worksheets 1 and 2 for Payment Justification |
|
| Wraparound Payment Request |
|
| Wraparound Payments
|
|
| Wraparound Payments |
|
| wrong dosage |
|
| wrong dosage |
|
| wrong medication |
|
| wrong medication |
|
| wrong time |
|
| wrong time |
|
| WYOMING |
|
| Yes
|
|
| Yes
|
|
| Yes
|
|
| Yes
|
|
| Yes
|
|
| Yes
|
|
| Yes
|
|
| Yes
|
|
| Yes
|
|
| Yes
|
|
| Yes
|
|
| Yes
|
|
| Yes
|
|
| Yes |
|
| Yes |
|
| Yes |
|
| Yes |
|
| Yes |
|
| Yes |
|
| Yes |
|
| Yes |
|
| yes |
|
| yes |
|
| Yes |
|
| Yes |
|
| Yes |
|
| Yes the Provider is accepting new medicaid clients |
|
| Zip
|
|
| Zip
|
|
| Zip |
|
| Zip: |