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.
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