Current through Vol. 42, No. 1, September 16, 2024
Payment is made for early intervention case
management
(1)
Adults.
There is no coverage.
(2)
Children. Coverage for children (age o to age 3) is as follows:
(A)
Description.
(i) Services under case management are not
comparable in amount, duration and scope. The target group for case management
services are developmentally disabled infants and toddlers (ages 0-3) who are
eligible for early intervention services under Oklahoma's implementation plan
to meet provisions of the Individuals with Disabilities Education Act (IDEA),
Amendments of 1997.
(ii) Case
management refers to services provided to assist a client in gaining access to
needed medical, social, educational and other services essential to meeting
basic human needs. Case management may include, but is not limited to:
(I) referral, coordination and linkage to
needed services;
(II) arranging for
service delivery to ensure access to needed services;
(III) monitoring and follow-up of client's
activities to insure access, quality and delivery of needed services;
and
(IV) preparation of case record
documentation documenting the above activities.
(B)
Non-Duplication of services.
To the extent any eligible recipients in the identified targeted population are
receiving TCM services from another provider agency, as a result of being
members of other covered targeted groups, the providers assure that case
management activities are coordinated to avoid unnecessary duplication of
service. To the extent any of the services required by the client are a
Medicaid covered benefit of a managed care organization of which the client is
a member, the provider will assure that timely referrals are made and that
coordination of care occurs. Case management services shall be directed through
a case manager who is an individual solely dedicated to that function. OHCA
reimbursement will require that case managers may not provide clinical services
and clinical staff may not provide case management services.
(C)
Providers. Case management
services must be provided by a qualifying provider of early intervention case
management as certified by the State Department of Education, pursuant to the
requirements of the Individuals with Disabilities Education Act, Amendments of
1997.
(3)
Special
Health Care Needs program. For children who are not eligible for
Medicaid, and the application has been approved for Special Health Care Needs
services through the Oklahoma Department of Human Services, a request for prior
authorization for services must be submitted to the Medical Authorization Unit
of OHCA for review and approval.
(4)
Individuals eligible for Part B of
Medicare. Case Management Services provided to Medicare eligible
recipients should be filed directly with the fiscal agent.
Added at 12 Ok Reg
751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
7-27-95; Amended at 16 Ok Reg 1927, eff 6-11-99
