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Exit Survey
 
Non-Dual MTLC Eligibility (can be designated as ‘not applicable’ if the member is dual eligible)
Compliant Non compliant Not Applicable
Non-dual members score 5 or higher on the initial and current UAS assessment.
Non-dual members receive at least 1 of 3 required services: MOW, SADC, or environmental social supports.
Other
 
 
 
Non-Dual MLTC eligibility justification for issuing non compliant:
   
 
 
Enrollment Agreement:
Compliant Non compliant Not applicable
Enrollment agreement is present and signed by member/representative.
If signed by representative, there is a POA, HCP, or other documentation on file.
Enrollment agreement is complete and accurate.
Enrollment date is indicated on the agreement.
Enrollment agreement is free from pre-filled boxes or other inappropriate altering.
Other
 
 
 
Enrollment agreement justification for issuing non compliant:
   
 
 
CDPAS:
Compliant Non compliant Not Applicable
Enrollment agreement is present and signed by member/representative.
If signed by representative, there is a POA, HCP, or other documentation on file.
Enrollment agreement is complete and accurate.
Enrollment date is indicated on the agreement.
Enrollment agreement is free from pre-filled boxes or other inappropriate altering.
Other
 
 
 
CDPAS justification for issuing non compliant::
   
 
 
Consent & Release of Information Form:
Compliant Non compliant Not applicable
For members enrolled prior to November 9, 2013 the plan utilizes their own release template that is present and signed by the member/representative. The form is complete and accurate.
For members enrolled subsequent to November 9, 2013 the plan utilizes OCA Form 960 for new enrollees when seeking authorization for release of protected health information. The form is complete and accurate.
If signed by representative, there is a POA, HCP, or other documentation on file.
Consent and release form is free from pre-filled boxes or other inappropriate altering.
Other
 
 
 
Consent & release of information form justification for issuing non compliant:
   
 
 
Advance Directives:
Compliant Non compliant Not applicable
Documentation is present that advance directives have been discussed outside the UAS assessment
If advance directives are indicated, there are copies in the record.
Other
 
 
 
Advance directives justification for issuing non compliant: