1. IDD Directors’ Consortium CFC Summit
MCO Functional Assessment Panel

2. MCO General Process
Receipt of status and intake of documents from the SFTP site
Review of documentation by the service coordinator
Contact to LIDDA within 7 days
Joint meeting with the member
Following provider selection by the member:
Negotiation of service start date
Transmission of authorization with copy of H6516
Verification that services are in place
Ongoing service coordination

3. Exceptions Processes Member is under 21 or in STAR Health
ID/RC completed by the LIDDA
Functional assessment completed by the MCO
ID/RC reassessment completed by the LIDDA
Member has been upgraded to STAR+PLUS Waiver
CFC eligibility will be based on the member’s MN/LOC (which is required for SPW), rather than an ID/RC
No ID/RC is needed from the LIDDA
MCO performs the functional assessment

4. Exceptions Processes (cont’d)
All reassessment activities performed by the MCO
Member changes MCOs
Upload of documentation to SFTP site
LIDDA/MCO collaboration
Continuity of care
Member requests an increase in services
Referral via SFTP site
Functional assessment by the LIDDA
Review and authorization by the MCO

5. Recent Updates to LIDDA/MCO Functions
LIDDA and MCO staff highlight updates to the shared spreadsheet when changes are made
LIDDA staff schedule the joint meeting with the member at the time the assessment is conducted (3 weeks out from the assessment date)
LIDDA staff obtain the member’s preference for receipt of a provider list from the MCO
Changes to the H6516 after the joint meeting (if any) are made by the LIDDA and uploaded to the SFTP site within 3 business days

6. Recent Updates to LIDDA/MCO Functions (cont’d)
MCOs have two established contact points:
Leadership – contracting and MOU questions, triage or escalation of questions or concerns
Operational – referral questions, verification of member contact information, confirmation of send/receipt through the SFTP site
Reference material for this information is available on the DADS website via this link:

7. Member Appeals Members have the opportunity to appeal:
When a service is denied
When a service is reduced
When they disagree with the initial hours for a service
When a service is denied or reduced, members exercise their appeal rights by following the instructions on the denial letter they receive from the MCO
When there is disagreement with initial hours, members exercise their appeal rights by declining to sign the H6516, which will trigger the MCO to initiate the denial/appeal process

8. Process Elements Pending/Under Development
Reassessment submission packet contents
Habilitation documentation for providers
Community First Choice Fair Hearing Processes (effective 05/02/16)
Pertains to notification processes for LOC denials
Revisions to Appendix XVI, Long Term Services and Supports Codes and Modifiers (effective 06/01/16)
Pertains to S+P members under age 21

9. Troubleshooting The MCO service coordinator should be involved if:
The provider or LIDDA are having difficulty contacting the member
There has been a disruption of the member’s services
The member indicates he or she is unhappy with their services, or would like an increase
The member has questions regarding their benefits or other services they might access
The member has a need not met by CFC

10. Troubleshooting (cont’d)
The MCO Leadership Contact should be involved if:
The MCO service coordinator has been unable to assist with a need or concern
Urgent or escalated needs arise
There are global questions regarding the MCO’s processes for CFC
There are questions regarding other MCO functions – provider support, contracting, claims, etc.

11. Questions/Discussion
What questions did we not answer today?
What if any are the current pain points around CFC processes?
What can we work together to do even better where CFC is concerned?