Current through Reg. 49, No. 38; September 20, 2024
The following are the essential components of Case
Management for Children and Pregnant Women services and explanation of billable
components.
(1) Intake--A case
manager's contact with the client/family/guardian that includes the collection
of demographic, health, and other information relevant to the determination of
the client's potential eligibility.
(2) Comprehensive visit--A case manager's
face-to-face meeting with the client/family/guardian that includes the
development of a:
(A) Family Needs
Assessment. A comprehensive face-to-face assessment of client needs to
determine the need for any medical, educational, social, or other services
required to address short- and long-term health and well-being of the client.
These assessment activities must be documented on a Family Needs Assessment
form and must include:
(i) taking a client's
history;
(ii) identifying the
client's needs, assessing and addressing family issues that impact the client's
health condition/risk or high-risk condition and completing related
documentation; and
(iii) gathering
information from other sources, such as family members, medical providers,
social workers, and educators (if necessary), to form a complete assessment of
the client.
(B) Service
Plan. A document developed with the client that determines a planned course of
action based upon the information collected through the assessment. The Service
Plan must be documented on a Service Plan form and must:
(i) include activities and goals that are
developed in consultation with the client, involve the participation of the
client, and address the medical, social, educational, and other services needed
by the client;
(ii) identify a
course of action to respond to the assessed needs of the client, including
identifying the individual responsible for contacting the appropriate health
and human service providers, and designating the time frame within which the
client should access services; and
(iii) include a Service Plan Addendum if
there are revisions or if additional needs have been identified following the
initial Service Plan development. The Service Plan Addendum shall be completed
and documented during a follow-up visit.
(3) Referral and related activities to help
the client obtain needed services, including activities that help link the
client with:
(A) medical, social, and
educational providers; and
(B)
other programs and services that can provide needed services, such as making
referrals to providers for needed services and scheduling appointments for the
client.
(4) Follow-up
contacts by a case manager necessary to ensure the service plan is implemented
and adequately addresses the client's needs.
(A) Follow-up contacts shall be conducted as
frequently as necessary to determine whether the following conditions are met:
(i) services are being furnished in
accordance with the client's service plan;
(ii) services in the service plan are
adequate; and
(iii) the service
plan and service arrangement are modified when the client's needs or status
change.
(B) Follow-up
contacts by case manager for clients who are pregnant women with a high-risk
condition shall occur as needed through the 59th day postpartum.
(5) Case management may include
collateral contacts with non-eligible individuals that are directly related to
identifying the needs and supports for helping the client access services and
managing the client's care.
(6) The
case management components that are eligible for Medicaid reimbursement are the
comprehensive visit and each follow-up contact performed in accordance with
this section.
(7) Case management
services are not reimbursable if they:
(A)
are provided to clients who do not meet the definition for client eligibility
in §
27.5 of this
title (relating to Client Eligibility);
(B) are not prior-authorized in accordance
with §
27.13 of this
title (relating to Prior Authorization); or
(C) are provided to a client who has already
received another case management service on the same day from the same billing
provider.
