The SA (Special Assistance) Form CA-908 Deliverable is due the 5th day of each month for the previous months data.

Transcription

1 The SA (Special Assistance) Form CA-908 Deliverable is due the 5th day of each month for the previous months data. Secure the completed deliverable to and CC Should you have any questions regarding how to complete this deliverable contact Melissa Brown at Ext Every question must be answered with the exception of 1, 2, 3 and 7 if applicable (see details in table). For every Y answer documentation should be submitted as evidence. Evidentiary documentation should be named with the requesting question number (i.e. 5a, 7a, etc.). The SA Intake Date refers to the date the member was deemed SA and assigned a PMN (Person/Entity Meeting SA Needs) by OHR. You can find this date on PM Form or the CA-907 Deliverable Spreadsheet (Column X / Start Date ). Once all questions have been answered and all evidentiary documents are attached save the PDF and zip it along with the supporting evidence. The zip file should be named with the CIS number of the member receiving SA and/or the member s initials.

2 Complete all steps for each member and create a separate zip file for every member receiving SA at your IC Agency. Take all zip files created and combine them into one zip file with the name of the deliverable. Question Number 1 Question Number 2 Question Number 3 Submit the complete PM Form or documentation of the SA screening one time for each member. You do not need to re-send it each month. For screenings that occurred prior to the advent of PM Form submit evidence of the clinical record documentation (date of assessment, screening result). Once submitted leave Question 1 blank to indicate the information was submitted in a previous month. Submit the complete PM Form (Part A&B) one time for each member. You do not need to re-send it each month unless there has been an Updated Part B that has not yet been submitted. Once submitted leave Question 2 blank to indicate the information was submitted in a previous month. Submit the contact information one time for each member unless there has been a change in the PMN that has not yet been submitted. Must submit the full name and telephone number. Once submitted leave Question 3 blank to indicate the information was submitted in a previous month.

3 Question Number 7 Question Numbers 3, 4, 5, 6 and 7 If the reporting month did not contain any ISP, Treatment Plan or Service Option changes/updates/reviews leave the question unanswered; Do not mark yes or no. If multiple events occurred for the member, each event must include coordination with the PMN for Question 7 to be recorded by the RBHA as Yes. Providing supplemental documentation showing PMN coordination for events not listed on the SA Form (i.e. Assessment/Service Plan meeting, etc.) is optional. The RBHA will record Question 7 as Yes if all other events that occurred for the month are recorded as Yes, no events that occurred for the month are recorded as No or no other events occurred for the reporting period. Provide minimal documentation. For example, if a signature is required as evidence, it is not necessary to send all pages of the document; Just attach/zip along the page with the signature and a page showing the title of the event or another recognizable feature.

4 Diagram of Accurate/Acceptable Format Zip files for each individual member, CIS# is the title for each member s zip file File Folder containing the SA Form and all accompanying evidentiary documents. Member CIS ID # redacted (Your version will not include the black box, a CIS ID # should be present). Folder contents: SA Form and evidentiary documents

5 SA Form appearance without evidentiary documents