Arousal, Behavior, and Stress Worksheet

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Arousal, Behavior, and Stress Worksheet Powered By Docstoc
					                             Instructions for Completing MH/DD/SAS Target Population Eligibility Matrices

Summary
   This workbook provides optional tools to help Area MH/DD/SAS Program staff determine a person's eligibility to receive publicly-funded
   mental health, developmental disability and/or susbstance abuse services as a member of one or more of NC's target populations. The
   worksheets entitled "Adult Eligibility Matrix" and "Child Eligibility Matrix" (accessible by clicking tabs at bottom of screen) are not required, but
   can simplify and standardize the eligibility decision process.
                         --- NOTE: If you choose to use these matrices, they must be treated as confidential client documents. ---

     The Child Eligibility Matrix is to be used for persons aged 3 through 17.The Adult Eligibility Matrix is for persons aged 18 and above.


     Answering the questions on the appropriate matrix automatically calculates the target population(s) for which a person qualifies. Eligibility is
     indicated by one or more bold italicized "Yes" in the yellow row at the top of the worksheet. NOTE: The target population box will not turn
     from "No" to "Yes" until all conditions necessary for eligibility have been met. The resulting target population codes can then be used to
     authorize services for the individual through the NC Integrated Payment and Reporting System (IPRS).

     The last two pages in this workbook are reference sheets. The Diagnoses By Population page indicates the diagnostic description and
     applicable target populations for each ICD-9 diagnosis code. The Definitions page provides definitions of the target population acronyms in
     the matrices and further details on terms, where needed for clarification.
Prior Preparation
    Prior to completing the worksheet, the person should be:
         * Admitted to the area program
         * Assessed clinically by a qualified staff member, using a Global Assessment of Functioning (GAF), NC SNAP and/or other appropriate
         assessment instruments
         * Assigned ICD-9 diagnoses as appropriate
Specific Instructions
    1. Immediately save the workbook under a new name , preferably one that uniquely identifies the person. [Example: Click on File Menu
    > Save As, choose your desired file folder, and name the file "MMJA123191 Eligibility."] NOTE: These forms contain confidential client
    information. Confidentiality of substance abuse client information is protected under Federal regulations 42 CFR Part 2. Redisclosure of information is
    explicitly prohibited except as provided in 42 CFR Part 2.
     2. Enter the individual's Identifying Information and the date on the first line of the matrix.
     3. Complete questions in the Characteristics Section (Questions CC1-CC5.2 or AC1-AC5.3) by typing answers in the blue boxes on the
     far right or by choosing an answer from the drop-down list. If a question does not apply to the person (for example, AC2.1 - AC2.3), you may
     leave the box blank.
     4. Answer the questions in the Functioning Section (Questions CF1-CF2.8 or AF1.1-AF1.8) by entering all of the person's ICD-9
     diagnoses from the drop-down list in the blue boxes. Enter one diagnosis per line. If the person has fewer than eight diagnoses, select
     "None" for the remaining blue boxes. If the person has a diagnosis that is not included in the drop-down list, select "Other" from the list.
     Diagnoses do not need to be entered in any particular order.

     5. As you enter each diagnosis, possible target populations that fit the individual will be indicated automatically by a bold italicized "?" or
     "Yes" in the boxes to the right on the same line. However, you will need to answer the questions related to that target population to make a
     final determination. To do so, complete the Disability Specific Section(s) that correspond to the color(s) of the boxes with "?" or "Yes"
     in them. You do not need to complete Disability Specific Sections for which the Functioning Section's boxes contain only "No's."

     6. After completing the appropriate sections, final eligibility decisions will show automatically in the yellow row at the top of the matrix. If a
     person does not show as eligible for any target population, complete the Transitional-Not Covered Section at the bottom of the matrix.
     Indicate which type of services the person will need for the rest of this fiscal year.
Completion
   1. Print and file a copy of the person's eligibility matrix. [NOTE: These forms contain confidential client information. Confidentiality of substance
   abuse client information is protected under Federal regulations 42 CFR Part 2. Redisclosure of information is explicitly prohibited except as provided in
   42 CFR Part 2.]
     2. Use the person's eligible target population codes to authorize and bill for services through IPRS.
Problems
    1. If a person does not show up as eligible for a population that you expect, review the Eligibility Criteria sheets in your IPRS manual and the
    answers on the matrix to pinpoint where the discrepancy might lie.
     2. If you have questions or identify errors in the way the matrix calculates eligibility, please notify IPRS.QandA@ncmail.net.




                                                        d87ef7c2-f7eb-4634-96c0-e37f269d172d.xls
                                                                                                Child Eligibility Matrix for FY2007-08
             QP Provider Eligibility Evaluator: Name                                                           Provider Agency                                                               Responsible LME

                     Consumer Information: Name                                                                         DOB                    Medicaid No.                                  LME Consumer Record Number
                        Eligibility Evaluation Date                                Child Developmental Disabilities               Child Mental Health                                         Child Substance Abuse
                      Population Determination                  TANF               SN      AO                             SED    MED     DEF    PAT    ECD     AO            SAD       IP      SP     WOM       CJO      DWI     MAJ     AO

   This child is eligible for services as a member of the
                                                                 No                No     No                              No     No      No     No     No     No             No       No      No       No       No       No      No     No
   following target populations -------->
                                                            To determine eligibility for the population(s) above, record answers to the following questions in the blue boxes.
             Characteristics
CC1      Enter the person's age in years. If less than 1 year old, enter age as 0.25, 0.5 or 0.75.
CC2      Is the person homeless or at imminent risk of homelessness?
CC3      Does the person's family have an income of 200% or less of the federal poverty level?                                                    See Patient Accounting office for answer to this question.
         Is this person's permanent residence with an adult blood relative or legal custodian/guardian who is:                                                                                                                                  ------
CC4.1    A U.S. citizen or TANF-eligible immigrant under federal law?                                                                                          Click Definitions tab at bottom of this sheet for details.
CC4.2         A resident of North Carolina?
             Child Assessment Only Questions
CAO1   Has the child completed the current LME Screening/Triage/Referral (STR) process?
CAO2   Has the child received a current LME STR triage determination of "Urgent" or "Routine"?
CAO3   Was the child been referred by the LME STR to the provider for assessment?
CAO4   Has the provider determined the child is not eligible for any other MH, DD, or SA target population?
CAO5   Is the child eligible for Medicaid services?
       Indicate the primary, and as necessary, secondary, and tertiary service needs                                                                                                                                                            ------
CAO6.1      Developmental Disability services
CAO6.2      Mental Health services
CAO6.3      Substance Abuse services
                      Functioning                                         Yes      SN                                     SED    MED     DEF    PAT    ECD                   SAD       IP      SP     WOM       CJO      DWI     MAJ
CF1      If the person is age 4 or below, does she or he
                                                                 No        ?                                              No     No
         meet the criteria for atypical development?
CF2.1    Enter up to eight diagnoses.                      None             No                               No     No     No     No    No                  No      No     No       No      No       No                          No
CF2.2                                                      None             No                               No     No     No     No    No                  No      No     No       No      No       No                          No
CF2.3     If the person has a diagnosis that is not listed None             No                               No     No     No     No    No                  No      No     No       No      No       No                          No
CF2.4           in the drop-down box, enter "Other."       None             No                               No     No     No     No    No                  No      No     No       No      No       No                          No
CF2.5                                                      None             No                               No     No     No     No    No                  No      No     No       No      No       No                          No
CF2.6     If the person has less than 8 diagnoses, enter   None             No                               No     No     No     No    No                  No      No     No       No      No       No                          No
CF2.7             "None" in the remaining boxes.           None             No                               No     No     No     No    No                  No      No     No       No      No       No                          No
CF2.8                                                      None             No                               No     No     No     No    No                  No      No     No       No      No       No                          No
                                   If any diagnosis resulted in a "Yes" or "?" in the boxes above, answer the related section(s) of questions in the same color below to determine eligibility.
                               NOTE: After completing each related section below, verify that your answers resulted in the expected population eligibility (yellow section) at the top of the matrix.
             Child Developmental Disablility Questions
CDD1     Does the person's disability meet all of the following criteria?
            Is attributable to a mental and/or physical impairment                                             If the answer to CDD1 is Yes, continue with CDD2. Otherwise, skip CDD2. The person is not eligible for any DD
            Is manifested before age 22 or caused by a traumatic head injury after age 22                                                                            population.
            Is likely to continue indefinitely
            Results in substantial functional limitations in three or more of the following areas: (1) self-care, (2) receptive and expressive language, (3) capacity for independent living, (4) learning, (5) mobility, (6) self-direction,
            and/or (7) economic self-sufficiency
            Reflects the person's need for a combination and sequence of special interdisciplinary or generic care, treatment or other services which are of a lifelong or extended duration and are individually planned and
            coordinated
CDD2     Enter the person's NC SNAP Score.
             Child Mental Health Questions
CMH1     Does the person have functional impairment that seriously interferes with or limits his/her role or functioning in family, school, or community activities?
         Indicate whether the person has experienced any of the following events in the past year:                                                                                                                                              ------
CMH2.1        Used acute crisis intervention services or intensive wraparound services to maintain community placement
CMH2.2        Had 3 or more state hospitalizations or at least 1 hospitalization of 60 continuous days
CMH2.3        Had DSS substantiated abuse, neglect or dependency
CMH2.4        Was expelled from 2 or more daycare or pre-kindergarten situations
CMH2.5        Was convicted of a felony or 2 or more Class A1 misdemeanors, or currently placed in a youth development center, prison, juvenile detention center, or jail
CMH2.6        Had special needs that exacerbated their situation (for example, physical disability that substantially interferes with functioning)
         Indicate whether the person has been assessed as either of the following:                                                                                                                                                              ------
CMH3.1        Deaf
CMH3.2        In need of specialized mental health services due to social, linguistic, or cultural needs associated with individual or familial deafness or hearing loss
CMH4     Is the person sexually aggressive?
CMH5     Does the person have a substance abuse and/or developmental disability diagnosis in addition to a mental health diagnosis?
CMH6     Does the person demonstrate significantly atypical behavior, socio-emotional, motor or sensory development?
             Child Substance Abuse Questions
         Indicate whether the person:                                                                                                                                                                                                           ------
CSA1.1       Has a primary diagnosis of substance abuse                                               If the answer to CSA1.1 is "Yes," skip toCSA4.1. If the answer is "No," continue with CSA1.2.
CSA1.2       Is using alcohol or other drugs at a pre-clinical level                                 If the answer to CSA1.2 is "Yes," skip to CSA2.1. If the answer is "No," continue with CSA1.3.
CSA1.3       Is at elevated risk for substance abuse
         Indicate whether the person currently has:                                                                                                                                                                                             ------
CSA2.1       Documented school-related problems or educational attainment difficulties, including school failure, truancy, suspension or expulsion, or dropping out of school
CSA2.2       Documented negative involvement with law enforcement or the courts, including formal and informal contacts such as arrest, detention, adjudication, warning, or escort
         Indicate whether one or both of the person's parents, legal guardians, or caregivers have:                                                                                                                                             ------
CSA3.1       One or more documented child abuse or neglect reports, investigations, or substantiations involving DSS
CSA3.2       A documented substance-related disorder
         Indicate whether the girl is:                                                                                                                                                                                                          ------
CSA4.1       Currently pregnant
CSA4.2       Legal custodian of at least one child under 18 years of age
CSA4.3       Currently seeking custody of a child under 18 years of age
CSA5     Does the person voluntarily consent to participate in substance abuse treatment services?
CSA6     Are the services for the person authorized by a TASC Program Care Manager?
         Indicate whether the person is:                                                                                                                                                                                                        ------
CSA7.1       An Intermediate Punishment offender
CSA7.2       Department of Correction releasee (parole or post-release) who completed a treatment program while in custody
CSA7.3       Community Punishment Violator at-risk for revocation
         Indicate whether the person has been arrested for:                                                                                                                                                                                     ------
CSA8.1       Driving while impaired (DWI)
CSA8.2       Commercial DWI
CSA8.3       Driving after consuming alcohol or drugs when less than 21 years old
         Indicate whether the person has:                                                                                                                                                                                                       ------
CSA9.1       Completed a DWI Assessment and been identified with a substance abuse handicap
CSA9.2       Paid the initial $125 in fees for assessment and treatment
This matrix contains confidential information. Confidentiality of substance abuse client information is protected under Federal regulations 42 CFR Part 2. Redisclosure of                                                      Matrix Last Revised on:
information is explicitly prohibited except as provided in 42 CFR Part 2.                                                                                                                                                       Jul 06, 2007
                                                                                           Adult Eligibility Matrix for FY2007-08
           QP Provider Eligibility Evaluator: Name                                                      Provider Agency                                                                    Responsible LME

                      Consumer Information: Name                                                                 DOB                     Medicaid No.                              LME Consumer Record Number
                          Eligibility Evaluation Date
                                                                             Adult
                                                                         Developmental                             Adult Mental Health                                             Adult Substance Abuse
                                                                          Disabilities
    Population Determination                                   TANF      MRI       SN     AO              SRE      SPM     SMI     DEF    PAT    AO            TER    CDR    CJO     DSS     DWI   HMT     WOM    DHH    HOM      AO

            This adult is eligible for services as a
            member of the following target populations         No        No       No     No               No       No      No      No     No     No            No     No     No      No      No     No     No      No     No     No
            ---------------------->
                                                        To determine eligibility for the population(s) above, record answers to the following questions in the blue boxes.
    Characteristics
AC1       Enter the person's age in years.
AC2       Does the person have special communication needs because of deafness or hearing loss?
AC3       Is the person homeless or at imminent risk of homelessness?
AC4       Does the person have a family income of 200% or less than the federal poverty level?                                                       See Patient Accounting office for the answer to this question.
          Is the person:                                                                                                                                                                                                               -------
AC5.1                 The blood relative or legal custodian/guardian of a child who is age 17 or under, or who is age 18 and is expected to graduate high school by his or her 19th birthday?
AC5.2                 A U.S. citizen or TANF-eligible immigrant under federal law?                                                           Click Definitions tab at bottom of this sheet for details.
AC5.3                 A resident of North Carolina?
              Adult Assessment Only Questions
AAO1      Has the person completed the current LME Screening/Triage/Referral (STR) process?
AAO2      Has the person received a current LME STR triage determination of "Urgent" or "Routine"?
AAO3      Was the person been referred by the LME STR to the provider for assessment?
AAO4      Has the provider determined the person is not eligible for any other MH, DD, or SA target population?
AAO5      Is the person eligible for Medicaid services?
          Indicate the primary, and as necessary, secondary, and tertiary service needs                                                                                                                                                ------
AAO6.1         Developmental Disability services
AAO6.2         Mental Health services
AAO6.3         Substance Abuse services
    Functioning                                                          MRI       SN                     SRE      SPM     SMI     DEF    PAT                  TER    CDR    CJO     DSS     DWI   HMT     WOM    DHH    HOM            Yes
AF1.1     Enter up to eight diagnoses.                       None      No    No                   No      No      No    No     No                 No     No    No     No      No    No     No      No                     No             ?
AF1.2                                                        None      No    No                   No      No      No    No     No                 No     No    No     No      No    No     No      No                     No
AF1.3       If the person has a diagnosis not listed in the  None      No    No                   No      No      No    No     No                 No     No    No     No      No    No     No      No                     No
AF1.4                drop-down list, enter "Other."          None      No    No                   No      No      No    No     No                 No     No    No     No      No    No     No      No                     No
AF1.5                                                        None      No    No                   No      No      No    No     No                 No     No    No     No      No    No     No      No                     No
AF1.6       If the person has less than 8 diagnoses, enter   None      No    No                   No      No      No    No     No                 No     No    No     No      No    No     No      No                     No
AF1.7               "None" in the remaining boxes.           None      No    No                   No      No      No    No     No                 No     No    No     No      No    No     No      No                     No
AF1.8                                                        None      No    No                   No      No      No    No     No                 No     No    No     No      No    No     No      No                     No
                                 If any diagnosis resulted in a "Yes" or "?" in the boxes above, answer the related section(s) of questions in the same color below to determine eligibility.
                             NOTE: After answering each related section below, verify that your answers resulted in the expected population eligibility (yellow section) at the top of the matrix.
    Adult Developmental Disabilities Questions
ADD1      Does the person's disability meet all of the following criteria?
                      Is attributable to a mental and/or physical impairment                                                  If the answer to ADD1 is Yes, continue with ADD2. Otherwise, skip ADD2. The person is not
                      Is manifested before age 22 or caused by a traumatic head injury after age 22                                                           eligible for any DD population.
                      Is likely to continue indefinitely
                      Results in substantial functional limitations in three or more of the following areas: (1) self-care, (2) receptive and expressive language, (3) capacity for independent living, (4) learning, (5) mobility,
                      (6) self-direction, and/or (7) economic self-sufficiency
                      Reflects the person's need for a combination and sequence of special interdisciplinary or generic care, treatment or other services which are of a lifelong or extended duration and are personally
                      planned and coordinated
ADD2      Does the person have a co-occuring diagnosis of Mental Illness in addition to meeting the Developmental Disability criteria in ADD1?
ADD3      Is the person a former Thomas S. class member?
ADD4      Enter NC SNAP Score
  Adult Mental Health Questions
AMH1     Enter Global Assessment of Functioning (GAF) Score
AMH2     Was the person admitted to the area program on July 1, 2005 or before?
AMH3     Would the person be likely to decompensate significantly without continued treatments and support?
       Indicate whether the person has a history of:                                                                                                                                                                                   -------
AMH4.1             Two or more hospitalizations
AMH4.2             Two or more arrests
AMH4.3             Homelessness
AMH5   Is the person currently enrolled or eligible to be enrolled in AMSPM or AMSMI?
       Has/Does the person:                                                                                                                                                                                                            -------
AMH6.1             Successfully managed his/her illness in the community with no need for crisis services or hospitalization within the past 6 months?
AMH6.2             Had a safe, secure place to live in the community and not been homeless or forced to move within the past six months?
AMH6.3             Not been engaged in activities that resulted in arrest within the past six months?
AMH6.4             Participate in meaningful activities and employment of his/her own choosing in the community?
AMH6.5             Have family or friends with whom s/he has a positive ongoing relationship?
AMH6.6             Have an understanding of how to access health care to address physical health issues?
AMH6.7             Continue to need mediciation and/or occassional counseling or support related to his/her mental illness diagnosis?
    Adult Substance Abuse Questions
        Indicate whether the person has:                                                                                                                                                                                               -------
ASA1.1               Injected a drug under the skin, into a muscle or into a vein for non-medically sanctioned reasons in the last 30 days
ASA1.2               Been infected with HIV, tuberculosis, or hepatitis B, C or D
ASA1.3               Met the ICD-9 criteria for dependence to an opioid drug for least one year prior to admission and is enrolled in an opioid treatment program
        Indicate whether the woman is:                                                                                                                                                                                                 -------
ASA2.1               Currently pregnant
ASA2.2               Legal custodian of at least one child under 18 years of age
ASA2.3               Currently seeking custody of a child under 18 years of age
        Indicate whether the person:                                                                                                                                                                                                   -------
ASA3.1               Is legal custodian of at least one child under 18 years of age
ASA3.2               Is authorized for Work First Assistance and/or Services by DSS
ASA3.3               Is the subject of a report to Child Protective Services for child abuse, neglect or dependence that is being assessed, has been substantiated, or has resulted in a findng of need for Child Protective
                     Services?
ASA3.4               Has been convicted of a Class H or I Controlled Substance Felony in North Carolina and is an applicant for or a recipient of Food Stamps.
ASA4    Is the person voluntarily consenting to participate in substance abuse treatment services?
ASA5    Are services for the person authorized by a TASC Program Care Manager?
        Indicate whether the person is:                                                                                                                                                                                                -------
ASA6.1               An Intermediate Punishment offender
ASA6.2               A Department of Correction releasee (parole or post-release) who completed a treatment program while in custody
ASA6.3               A Community Punishment Violator at-risk for revocation
        Indicate whether the person has been arrested for:                                                                                                                                                                             -------
ASA7.1               Driving while impaired (DWI)
ASA7.2               Commercial DWI
ASA7.3               Driving after consuming alcohol or drugs when less than 21 years old
        Indicate whether the person has:                                                                                                                                                                                               -------
ASA8.1               Completed a DWI Assessment and been identified with a substance abuse handicap
ASA8.2               Paid the initial $175 in fees for assessment and treatment
ASA9    Is this person currently involuntarily committed to substance abuse treatment?
        Indicate whether the person:                                                                                                                                                                                                   -------
                     Is currently admitted with an Axis I principal alcohol or substance dependence diagnosis to an inpatient hospital or residential treament facility, a state operated hospital or ADATC, or a non-hospital
ASA10.1
                     medical or social setting detox facility?
ASA10.2              Has been discharged with an Axis I principal alcohol or substance dependence diagnosis from any of these facilities within the past 30 days?
ASA11 Does this person exhibit a pattern of recurring episodes of chronic use with unsuccessful attempts at recovery and one or more unsuccessful treatment episode?
        Indicate whether the person:                                                                                                                                                                                                   -------
ASA12.1              Has an Axis I principal substance dependence diagnosis of one or more stimulant drugs
ASA12.2              Is in an advanced stage of his/her disease
                                                                                                           NOTE: High Management adults may also exhibit high resistance to treatment, a co-occurring disorder and/or a
ASA12.3              Has limited social or environmental supports
                                                                                                                                                   moderate biomedical condition.
ASA12.4              Has few coping skills
ASA 13 Does this person require primary substance abuse assessment and treatment initaion, engagement and/or continuity of treatment services and supports from a licensed, certified, or registered substance abuse
          professional for relapse prevention and recovery stability?

                  This matrix contains confidential information. Confidentiality of substance abuse client information is protected under Federal regulations 42 CFR Part 2.                                             Matrix Last Revised
                                                   Redisclosure of information is explicitly prohibited except as provided in 42 CFR Part 2.                                                                              on: Jul 17, 2007
                                                                                              IPRS Diagnosis/Target Population Crosswalk 05-06
          Valid Diagnoses for Target Populations FY2007-08




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290.0 Senile dementia, uncomplicated                      X   X   X   X
290.10 Presenile dementia, uncomplicated                  X   X   X   X
290.11 Presenile dementia with delirium                   X   X   X   X
290.12 Presenile dementia with delusional features        X   X   X   X
          Presenile dementia with depressive features
290.13                                                    X   X   X   X
290.20    Senile dementia with delusional features        X   X   X   X
290.21    Senile dementia with depressive features        X   X   X   X
290.3     Senile dementia with delirium                               X
290.40    Arteriosclerotic dementia, uncomplicated        X   X   X   X
290.41    Arteriosclerotic dementia with delirium         X   X   X   X
          Arteriosclerotic dementia with delusional
290.42 features                                           X   X   X   X
          Arteriosclerotic dementia with depressive
290.43    features                                        X   X   X   X
          Other specified senile psychotic conditions
290.8                                                     X   X   X   X
290.9     Unspecified senile psychotic condition          X   X   X   X
291.0     Alcohol withdrawal delirium                                     X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
291.1     Alcohol amnestic syndrome                                       X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
291.2     Other alcoholic dementia                                        X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
291.3     Alcohol withdrawal hallucinosis                                 X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
291.4     Idiosyncratic alcohol intoxication                              X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
291.5     Alcoholic jealousy                                              X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
291.81    Alcoholic withdrawal                                            X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
291.89    Other specified alcoholic psychosis                             X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
291.9     Unspecified alcoholic psychosis                                 X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
291.99    Unspecified alcoholic psychosis                                                                                               X
292.0     Drug withdrawal syndrome                                        X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
          Drug-induced organic delusional syndrome
292.11                                                                    X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
292.12    Drug-induced hallucinosis                                       X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
292.2     Pathological drug intoxication                                  X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
292.81    Drug-induced delirium                                           X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
292.82    Drug-induced dementia                                           X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
292.83    Drug-induced amnestic syndrome                                  X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
292.84    Drug-induced organic affective syndrome                         X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
          Other specified drug-induced mental disorders
292.89                                                                    X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
292.9     Unspecified drug-induced mental disorder                        X   X   X   X   X       X   X   X   X                         X            X   X   X                  X           X          X
293.0     Acute delirium                                              X                                                         X   X   X   X    X
293.1     Subacute delirium                                           X                                                         X   X   X   X    X
293.81    Organic delusional syndrome                                 X                                                         X   X   X   X    X
293.82    Organic hallucinosis syndrome                               X                                                         X   X   X   X    X
293.83    Organic affective syndrome                      X       X   X                                                         X   X   X   X    X
293.84    Organic anxiety syndrome                                    X                                                         X   X   X   X    X
          Other specified transient organic mental
293.89 disorders                                                      X                                                         X   X   X   X    X
          Unspecified transient organic mental disorder
293.9                                                                 X                                                         X   X   X   X    X
294.0     Amnestic syndrome                                           X                                                         X   X   X   X    X
          Dementia in conditions classified elsewhere
          without behavioral disturbance
294.10                                                                X                                                         X   X   X   X    X
          Dementia in conditions classified elsewhere
294.11    with behavioral disturbance                     X   X   X   X                                                         X   X   X   X    X
          Other specified organic brain syndromes
294.8     (chronic)                                                   X                                                         X   X   X   X    X
          Unspecified organic brain syndrome (chronic)
294.9                                                                 X                                                         X   X   X   X    X


         Last Updated: 09/30/2005                                                                                  Page 4
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                                                           SN
                                                    D
                                                   C
                                                               S
                                                           C
                                                       D
                                                   C
                                                                   I
                                                      W
                                                    SD
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                                                      JO
                                                    SC
                                                   C
                                                       M
                                                      O
                                                    SW
                                                   C
                                                      P
                                                    SS
                                                   C
                                                       P
                                                    SI
                                                   C
                                                          D
                                                        A
                                                     SS
                                                   C
                                                           J
                                                         A
                                                     SM
                                                   C
                                                        S
                                                     SC
                                                   C
                                                           T
                                                       PA
IPRS Diagnosis/Target Population Crosswalk 05-06




                                                     M
                                                   C
                                                         EF
                                                       D
                                                     M
                                                   C
                                                           D
                                                       EC
                                                    M
                                                   C
                                                         ED
                                                       M
                                                    M
                                                   C
                                                           D
                                                       SE
                                                    M
                                                   C
                                                         S
                                                       C
                                                     M
                                                   C
                                                           I
                                                         R
                                                       M
                                                     D
                                                   A
                                                       SN
                                                     D
                                                   A
                                                         S
                                                       C
                                                     D
                                                   A
                                                        ER
                                                     ST
                                                   A
                                                           M
                                                        O
                                                     SH
                                                   A
                                                          H
                                                        H
                                                     SD
                                                   A
                                                           M
                                                         O
                                                     SW
                                                   A
                                                           T
                                                        M
                                                     SH
                                                   A
                                                           I
                                                        W
                                                     SD
                                                   A
                                                        SS
                                                     SD
                                                   A
                                                        JO
                                                     SC
                                                   A
                                                        S
                                                     SC
                                                   A
                                                          R
                                                        D
                                                     SC
                                                   A
                                                         EF
                                                       D
                                                     M
                                                   A
                                                           E
                                                       SR
                                                     M
                                                   A
                                                           T
                                                       PA
                                                     M
                                                   A
                                                           I
                                                       SM
                                                    M
                                                   A
                                                           M
                                                       SP
                                                     M
                                                   A
                                                         S
                                                       C
                                                     M
                                                   A
                                                       CODE    DESCRIPTION
                                                        DX
                                                           SN
                                                    D
                                                   C
                                                               S
                                                           C
                                                       D
                                                   C
                                                                   I
                                                      W
                                                    SD
                                                   C
                                                      JO
                                                    SC
                                                   C
                                                       M
                                                      O
                                                    SW
                                                   C
                                                      P
                                                    SS
                                                   C
                                                       P
                                                    SI
                                                   C
                                                          D
                                                        A
                                                     SS
                                                   C
                                                           J
                                                         A
                                                     SM
                                                   C
                                                        S
                                                     SC
                                                   C
                                                           T
                                                       PA
IPRS Diagnosis/Target Population Crosswalk 05-06




                                                     M
                                                   C
                                                         EF
                                                       D
                                                     M
                                                   C
                                                           D
                                                       EC
                                                    M
                                                   C
                                                         ED
                                                       M
                                                    M
                                                   C
                                                           D
                                                       SE
                                                    M
                                                   C
                                                         S
                                                       C
                                                     M
                                                   C
                                                           I
                                                         R
                                                       M
                                                     D
                                                   A
                                                       SN
                                                     D
                                                   A
                                                         S
                                                       C
                                                     D
                                                   A
                                                        ER
                                                     ST
                                                   A
                                                           M
                                                        O
                                                     SH
                                                   A
                                                          H
                                                        H
                                                     SD
                                                   A
                                                           M
                                                         O
                                                     SW
                                                   A
                                                           T
                                                        M
                                                     SH
                                                   A
                                                           I
                                                        W
                                                     SD
                                                   A
                                                        SS
                                                     SD
                                                   A
                                                        JO
                                                     SC
                                                   A
                                                        S
                                                     SC
                                                   A
                                                          R
                                                        D
                                                     SC
                                                   A
                                                         EF
                                                       D
                                                     M
                                                   A
                                                           E
                                                       SR
                                                     M
                                                   A
                                                           T
                                                       PA
                                                     M
                                                   A
                                                           I
                                                       SM
                                                    M
                                                   A
                                                           M
                                                       SP
                                                     M
                                                   A
                                                         S
                                                       C
                                                     M
                                                   A
                                                       CODE    DESCRIPTION
                                                        DX
                                                                  IPRS Eligibility Matrix Definitions



 TERM / ACRONYM                                                                             DEFINITION
AO                     Assessment Only
CDR                    Injecting Drug User / Communicable Disease - Adult Population
CS                     Crisis Services Only
CJO                    Criminal Justice Offender - Child or Adult Population
DEF                    Deaf or Hearing-Impaired - Child or Adult Mental Health Population
DHH                    Deaf or Hearing-Impaired Child or Adult Substance Abuse Population
DSS                    Substance Abuser with Division of Social Services Involved - Adult Population
DWI                    Driving While Intoxicated Treatment - Child or Adult Population
ECD                    Early Childhood Disorder
HMT                    High Management Substance Abuser - Adult Population
HOM                    Homeless Child or Adult Substance Abuse Population
IP                     Indicated Prevention - Child Population
MED                    Seriously Emotionally Disturbed - Child Population
MRI                    MR/MI
PAT                    Homeless (PATH) - Child or Adult Mental Health Population
SAD                    Substance Abuse Disorder - Child Population
SED                    Severely Emotionally Disturbed with Out-of-Home Placement - Child Population
SMI                    Serious Mental Illness - Adult Population
SN1-SN5                Developmental Disability Level 1-5 - Child or Adult Population
SP                     Selective Prevention - Child Population
SPM                    Severe and Persistant Mental Illness - Adult Population
SRE                    Stable and Recovery
TANF                   Temporary Assistance to Needy Families
TER                    Treatment, Engagement, and Recovery
TNC                    Transitional - Not Covered category: This is a temporary population assignment to allow funding of services during fy2002-03 while transitioning to
                       community resources a current client who is not eligible for continued services as part of a target population.
WOM                    Women with Substance Abuse Disorders - Child or Adult Population

Atypical development

Developmental delay
Family
Homelessness        Lacking a fixed, regular, adequate night-time residence; OR having a primary night-time residence that is a temporary shelter, a temporary
                    residence for individuals who would otherwise be institutionalized, or a place not designed/used as a regular sleeping accommodations for human
                    beings.
Residence
TANF-eligible       An immigrant who receives Medicaid services, other than emergency Medicaid services, would be eligible for TANF funding. See the Work First
immigrant           Manual, Section 11: Citizenship/Immigrant Rules for further details.

				
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