(Revised 1/1/09 ML #3173)
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Purpose: The purpose of this form is to determine/redetermine functional eligibility for the Waiver programs or for minor children applying for the SPED program.
It is the responsibility of the County to trigger the screening either by telephoning DDM or by submitting information to DDM. The information is verified and documented in the completion of the materials identified in items 1 and 2 below. Item number 2 below is the ONLY form that needs to be submitted to DDM.
If you mail the screening information to DDM, the Level of Care Determination Form is the only form that needs to be submitted.
Forms are to be mailed to:
Dual Diagnosis Management (DDM)
North Dakota Review Staff
220 Venture Circle
Nashville, Tennessee 37228
Phone: 877-431-1388
Fax: 877-431-9568
Before conducting the telephone screening with DDM you must have completed the Level of Care Determination form. This includes having the client's Medicaid ID number. When conducting telephone screenings, you must have the written materials on file in the client's case records for verification of the information transmitted in the telephone screening.
When the telephone screening has been completed, send a copy of the completed Level of Care Determination form to DDM.
If you are unable to resolve screening issues with DDM, contact Medical Services at 701-328-4864.