Definition of case management and scope of case management duties
AL | CA | FL | GA | ID | IN | IA | KS | MS | MT | NE | NY | NC | OK | TX | VT | VA | WV "Section One: Overview
Patient 1st is a managed care program in which certain Medicaid recipients enroll or are assigned to a primary medical provider (PMP) who manages their health care needs. The PMP is responsible for the provision of primary care, appropriate referrals for specialty services, and authorization of specified Medicaid services...F. 'Patient Management' means being responsible for the health care management of he recipient with regard to that group of medical services within Patient 1st. If not directly provided, medical services that are necessary should be arranged for through referral or authorization by the PMP. (Section Five describes the Patient 1st services that the PMP is responsible for providing directly or through referral.)." Alabama PMP, pages 4-5.
"Section Five: PMP Functions and Duties
Responsibilities of PMPs include the following:
A. Provide patient management for the following: physicians' services, hospital outpatient services, ambulatory surgical center services (ASC), outpatient services, durable medical equipment services, and home services. Attachment Four contains a matrix detailing what services will and will not require a referral...E. Provide primary care and patient management services to each enrollee, in accordance with the provisions of this manual. All existing rules and regulations must be adhered to in the provision of services. PMP referral grants access only to service; it does not supersede benefit limits and/or other authorization processes.
F. Make referrals, when appropriate, and provide the PMP's Medicaid provider number for payment of such referrals. Referrals may be for services coordinated by the PMP or for services not required to be coordinated by the PMP. Referrals may be given also for second options. See Section Eight for further details on the referral process. All referrals must be documented in the patient's medical record.
G. Authorize treatment for certified emergency care in accordance with Patient 1st provisions relating to those services. Authorization doses not have to be given prior to treatment being rendered, but it must be approved within 24-48 hours of the service being rendered.
H. Ensure and coordinate the provision of age appropriate immunizations with notation in the enrollee's file of who provided the service, what was provided and the date. See Attachment Two for a form that has been developed to facilitate the recording of immunization information. This form is not required but is recommended to ensure complete documentation of services received. NOTE: Providers who participate in the Vaccine for Children (VFC) Program are required to record and report data as specified in the VFC agreement..." Alabama PMP, pages 9-11.
"J. Case Management means responsibility for referral, consultation, ordering of therapy, admission to hospitals, follow-up care, and prepayment approval of referred services. It includes responsibility for relocating, coordinating, and monitoring all medical care on behalf of a member." California Contract, page 3.
"ARTICLE V-DUTIES OF THE CONTRACTOR
In discharging its obligations under this contract, the Contractor will:A. Provision of Services
Provide or arrange for the provision of all covered services and provide case management to a voluntarily enrolled population of eligible beneficiaries. Covered services include the capitated services set froth in Attachment A, entitled 'Capitated Services,' consisting of 4 pages. Attachment A is incorporated herein and made part hereof by this reference...C. Health Care Service Case Management
Accept responsibility for case management of all health care services for each member." California Contract, page 17."Definitions...
12. Management - Coordination of the delivery of MediPass covered services. If not provided directly, necessary medical services must be arranged through referral and authorized by the primary care provider...4. Authorizations and Referrals. It is agreed that the MediPass provider will:
a. Make authorizations and referrals when medically necessary and appropriate. Such referrals may be for services covered under MediPass or for services not covered under MediPass. The provider to whom the patient is referred must be a Medicaid provider unless the prescribed treatment is not covered by Medicaid. The MediPass provider must provide the referral provider with his MediPass authorization number; this is the Medical ID number used by the MediPass provider for Medicaid billing. All authorizations and referrals must be documented in the patient's medical record along with the report from the treating provider." Florida Agreement, pages 2, 7."902. Case Management Responsibilities
In addition to providing primary health and medical care services, PCPs must provide the following case management services to GBHC members who choose or are assigned to the PCP's practice:
1. Refer members for specialty care, hospital care, and other services only when medically necessary.2. Authorize services provided by referred providers to members if it is determined by the PCP that those services are medically necessary...
4. Ensure GBHC members are provided timely access to needed HEALTH CHECK Services, either by directly providing the services or referring the services to a qualified HEALTH CHECK provider.
5. Coordinate the provision of other essential services, such as, dental services, immunizations, family planning and maternity care to ensure that such services are received by members as appropriate...
Members requiring emergency services should be immediately directed to an appropriate emergency medical facility. Members requiring non-emergency services should be given information about accessing services or advised how to handle medical problems during non-office hours. Section 803 provides an explanation of emergency and non-emergency services..." Georgia Agreement, pages IX-1 - IX-5."2. OBLIGATIONS OF PROVIDER.
2.1 Health Care Management. PROVIDER shall be responsible for making all reasonable efforts to monitor and manage PATIENT/RECIPIENTS' care, provide primary care services, and make referrals when medically necessary for Covered Services provided by other than PROVIDER. Covered Services are defined as the services covered under the State Medicaid Plan as set forth in Title 3, Chapter 9, and Title 3, Chapter 10 of 16 IDAPA." Idaho PCCM Agreement, page 1."3. Patient Management Services
The PMP must provide, on a timely basis, patient management services in accordance with the Hoosier Healthwise Provider Manual." Indiana Addendum, page 3."G. 'Patient management' is a managed health care option in Iowa Medicaid in which an individual physician is selected by or assigned to a recipient to provide medical services on a fee-for-service basis and managed health care services including monitoring appropriate utilization and authorization of payment for covered services." Iowa Agreement, page 1.
"Article I - Duties of the Case Manager...
B. Accept and provide health care to the beneficiaries assigned to the case manager by SRS...F. Provide primary, preventive care, and case management services to each assigned consumer. Inform beneficiaries of community-based long term care services, when appropriate, as care alternatives to institutional care. Services must be rendered pursuant to the Medicaid Professional Services Provider Manual (Sections 2200 and 8200), amendments thereto and applicable state and federal laws and regulations and amendments thereto.
G. Arrangements for a back up case manager shall be required prior to the absence of the case manager. The back up provider must be notified by the case manager of his/her absence and the case manager's answering service notified.
H. Promote and provide KAN Be Healthy (KBH) medical screens and continuous care services for all assigned beneficiaries under age 21 or provide a written referral to an appropriate specialist or health department for KAN Be Healthy medical screens.
KAN Be Healthy Screens
The KAN Be Healthy screening schedule follows the American Academy of Pediatrics (AAP) Periodicity Schedule. Refer to the Medicaid Professional Services Manual Section 2020 for screening schedule.Current SRS policy requires the following additional screening and services:
1. Participants may have a dental screening at the age of twelve (12) months, but must have a dental screening annually if three (3) years or older. Those beneficiaries requesting orthodontia must have a medical screening in addition to the dental screening. Some dental services require prior authorization.2. Participants must have a vision exam at the age of three (3) years. Examinations every two (2) years and treatment for medical conditions of the eye are covered.
3. Participants must have a hearing screen at the age of three (3) years. Examinations every three (3) years and treatment for medical conditions of the ear are covered.
4. Additional treatment and services which are covered only for KAN Be Healthy program participants which include, but are not limited to, elective surgery, antihistamine drugs, and additional specialized services are allowed.
I. Provide written referrals for assigned beneficiaries, when appropriate, for non emergent covered services (see listing of such services in the Medicaid Professional Services Provider Manual, Section 2200).
1. Authorize treatment of a specific condition and follow-up consultations by a specialist for the duration of treatment.2. Date of referral must be on or before date of service.
3. Written referrals must be medically necessary and consumer specific.
4. Verbal referral may be given but must be followed up with a written referral.
5. When verbal referral is provided, a written referral dated on or before the date of service must be provided within ten (10) calendar days of the verbal referral.
6. Refer the consumer for specialized service, when available, to specialists having an established treatment relationship with the consumer. A referral may be provided to cover services up to six (6) months.
7. Provide a written referral for a second opinion if appropriate and requested by the consumer. After the second opinion has been obtained, any treatment received by the consumer shall be rendered by the case manager or through a referral from the case manager.
8. Maintain documentation of all referrals in the consumer's medical record.
9. Medically necessary specialty services should occur within 30 days of the referral.
10. Emergent care services should occur within 24 hours of the referral.
11. Urgent care services should occur within two (2) days of the referral.
J. Review Medicaid consumer monthly utilization reports furnished by SRS and provide consumer education as appropriate.
K. Transfer within 30 calendar days, at the request of SRS or the consumer, a summary or a copy of the consumer's medical record when the consumer has been assigned to another case manager. The consumer may be charged for second and subsequent transfers.
L. If the case manager discontinues providing care or the consumer changes case manager, the current case manager must provide the consumer with a written referral to another case manager for services. The current case manager must be responsible for the consumer's care until the consumer's name is removed from the case manager's caseload roster.
M. Notify each beneficiary and the SRS Fiscal Agent 60 days prior to discontinuing primary care case management services...
O. Shall not charge for after hours calls from HealthConnect beneficiaries..." Kansas Contract, pages 1-5.
"CASE MANAGER: Any duly licensed Doctor of Medicine or Doctor of Osteopathy, ARNP, FQHC, RHC, or medical group practice who has entered into a PCCM contract with SRS.
CASE MANAGEMENT: The case manager will make accessible to his/her caseload, needed primary care services either by providing the service or through referral for services that are beyond his/her scope; and monitoring to assure that services are received timely, are cost effective, of good quality, in sufficient quantity, continuous, not duplicated and appropriate...PRIMARY CARE CASE MANAGEMENT: A service delivery control system in which physicians, ARNPs, in independent or group practices, local health departments, or clinics act as primary care providers. FQHCs and RHCs shall enroll as case managers. Case managers are responsible for initiating or approving specified medical services for participating consumers. This system was formerly known as a Primary Care Network (PCN)." Kansas Contract, Appendix B, pages 15-17.
"The Medicaid HealthMACS Primary Care Provider agrees to: ...
3. Manage the health care of HealthMACS enrollees as detailed in the Managed Care section of the relevant provider manual and which includes but is not limited to:a. Providing medical care, making referrals and authorizing services needed to meet health care needs of all PCP's assigned enrollees;
b. Providing and/or working to ensure that essential preventive services (e.g., EPSDT screenings, immunizations, family planning, perinatal high risk management and Women, Infant and Children referrals) are obtained by enrollees as appropriate;
c. Sharing medical and health information with other physicians and health care professionals when necessary for treatment and evaluation of enrollees..." Mississippi Manual, page A-1.
"III. DEFINITIONS...
I. 'Patient management' means directing and overseeing the delivery of PASSPORT-managed services. Medical services which the primary care provider determines are necessary but cannot provide directly should be arranged (through referral) or authorized by the primary care provider...A. The PCP agrees to:
1. Provide patient management for PASSPORT-managed services. Family planning services are specifically excluded from PASSPORT patient management and may be obtained by the PASSPORT enrollee from the provider of choice." Montana Agreement, page 4."7.71 Case Management: The Contractor shall provide case management." Nebraska Contract, page 71.
"10.15(a) Adults with Chronic Illnesses and Physical or Developmental Disabilities
The PCPCP and the PCP/Contractor agrees to implement all of the following to meet the needs of their adult Enrollees with chronic illnesses and physical or developmental disabilities: ...(iii) Satisfactory case management systems to ensure all required services are furnished on a timely basis...
10.15(b) Children with Special Health Care Needs...
The PCPCP and PCP/contractor will be responsible for performing all of the same activities for this population as for adults. In addition, the PCPCP and the PCP/Contractor will implement the following for these children...10.15(c) Member Needs Relating to HIV...
To adequately address the HIV prevention needs of uninfected Enrollees, as well as the special needs of HIV positive (+) individuals who do enroll in managed care, the PCPCP and the (PCP/Contractor) shall have in place all of the following: ...(iv) Satisfactory case management systems to ensure that all necessary services are furnished on a timely basis. Special attention should be paid to establishing linkages with traditional HIV providers, such as Aids Designated Treatment Centers (ADTCs), community provider, and clinical education programs as a means of obtaining the most current treatment guidelines and standards." New York Contract, pages 29-32.
"* Medical Case Management: case management is a health care method in which medical, social, and other services are coordinated by one entity. The objective of case management is to provide medically necessary quality care and to assure access and continuity of care for a patient. In medical case management, this responsibility includes diagnosis of health risk, identification of disease, development of a treatment plan, referred services, locating, coordinating and monitoring all plan-covered and Medicaid covered medical care on behalf of a Medicaid enrollee. It may also entail coordinating social services which the patient may be eligible for or require. Medical case management services, include:
NCmanagement of the medical and health care of Enrollees to assure that necessary services are made available in a timely manner referrals to all medically necessary and appropriate care assistance to Enrollees in obtaining and scheduling referral care, including inpatient hospitalization, coordinating with referral providers, and participating in inpatient hospital discharge planning monitoring and follow-up on an Enrollee's plan of care, including all referrals, consultations, and laboratory and radiological findings, and interpreting such findings to the Enrollee and the Enrollee's family obtaining information and maintaining involvement in all medical and health care treatment and outcomes, with an emphasis on continuity of care maintenance of a comprehensive medical record for each Enrollee provision of access to 24 hour/day, 7day/week primary care... Comprehensive Medicaid Case Management (CMCM): A program which provides 'social work' case management referral services to a targeted population (e.g., pregnant teens, mentally ill). A CMCM case manager will assist a client in accessing necessary services in accordance with goals contained in a written case management plan. CMCM programs do not provide services directly, but refers to a wide range of service providers. Some of these services are: medical, social, psycho-social, education, employment, financial, and mental health. CMCM referral to community service agencies and/or medical providers requires the case manager to work out a mutually agreeable case coordination approach with the agency/medical provider. Consequently, if an Enrollee of the Contractor is participating in a CMCM program, the Contractor should work collaboratively with the CMCM case manager to coordinate the provision of services covered by the Contractor. CMCM programs will be instructed on how to identify a managed care recipient on EMEVS and informed on the need to contact the Contractor to coordinate service provision." New York Contract, Appendix L, pages 1-2, 5-6. "Patient Care Coordination - The manner or practices of providing, directing, and coordinating the health care and utilization of health care services of enrollees with regard to those services listed in section IV.4.2, that must be authorized by the primary care provider. If not provided directly necessary medical services must be arranged through the primary care provider...
The Carolina ACCESS Contractor agrees to do the following:
4.1 Be listed as a primary care provider in the Carolina ACCESS program for the purpose of making themselves available to provide care to enrollees. Accept enrollees pursuant to the terms of this agreement and manage their health care needs.
4.2 Provide patient care coordination for the following services (These services require primary care provider authorization):
physician services; hospital inpatient and outpatient services; specialist referrals; emergency room services; home health agency services; radiology/pathology services billed with a hospital number, ambulatory surgical center services; screening and preventive services; personal care services; durable medical equipment; private in-home nursing services; dialysis, and nurse midwife services.[Although they do not require authorization by the primary care provider, the provider may coordinate and/or assist the enrollee in obtaining the following Medicaid-covered services for continuity of care; ambulance; anesthesiology; at risk case management; CAP services; certified nurse anesthetist (MQB); child care coordination; dental; developmental evaluation centers; eye care services (limited to CPT codes: 92002, 92004, 92104 and diagnosis codes related to conjunctivitis: 370.3, 370.4, 372.1, 372.3); family planning (including Norplant); health department services; hearing aids (under age 21) hospice; independent and hospital lab services; maternity care coordination; optical supplies/visual aids; pharmacy; psychiatric/mental health services (psychiatric hospitals, are mental health programs, psychiatric facilities, and inpatient and outpatient services filled with a hospital provider number with a primary or secondary diagnosis of 290-319); radiology/pathology (this does not include services filled with a hospital number); services provided by schools and Head Start programs.)" North Carolina Agreement, pages 1-2.
"C. CASE MANAGEMENT - includes, but is not limited to:
TXproviding direct health care to patients; providing medically necessary specialty referrals, including standing referrals; coordinating admissions to hospital making appropriate referrals to the Women, Infants and Children (WIC) program; coordinating and monitoring all family centered medical care on behalf of a member coordinating with community mental health professionals and Indian Health Services, tribal and urban Indian providers; and/or educating patients to appropriately use medical resources such as emergency rooms and medical advice lines." Oklahoma Agreement, page 2. "'E. CASE MANAGEMENT SERVICES'
All members in managed care programs must be tracked and monitored, but only a portion of the enrollees require a case manager. Effective, targeted case management is one of the keys to the effectiveness of a primary care case management program. A strong and focused case management program supports the most vulnerable members and fosters healthy behavior of members and the appropriate use of services. A well-developed case management program coupled with effective support of the provider network (including practice profiling) are the two principal factors that lead to behavior change, improved outcomes, and cost savings in primary care case management programs.CONTRACTOR will structure a case management program carefully tailored to the diverse needs of the TDH STAR Health Plan member population. The ratios of case managers to members is determined by the types of member problems and the intensity of the interventions required to provide effective service. These metrics are described elsewhere in this document. A Case Management Intervention Continuum that depicts the types of problems and conditions addressed by case managers follows this narrative.
The TDH STAR Health Plan case management program complements and supplements the efforts of the provider network and the continuous quality improvement staff: Many Medicaid clients have circumstances that complicate the effective management of their health care. Case Managers are an important resource to the provider network. Primary Care Providers can refer patients with complex or unusual needs to case managers for support and appropriate intervention. Utilization review nurses rely on case managers to assist them in assuring that members with complex illnesses and conditions are moved through the continuum of care appropriately, and that community resources are enlisted to help these members leave the hospital or institution as soon as their medical condition permits.
The FirstHelp and member services helplines are both strong sources of referrals for members in need of case management services. In addition, as the program becomes well-established and known in the community, referrals for case management are received from community based agencies and other government offices that have contact with TDH STAR Health Plan members. Information and referrals from these sources can identify members with chronic conditions for whom case management can prevent hospitalizations and improve the member's ability to manage their illness in the community. Case managers are particularly effective in helping parents manage children with asthma, and in helping persons with diabetes, chronic obstructive pulmonary disease and other chronic conditions to manage their conditions.
Members who use Medicaid services inappropriately benefit greatly from the skills of a case manager. These members may over or underuse services, attempt to self-refer to specialists, or use emergency services inappropriately. Others may be non-compliant members who miss appointments and do not follow medical advice.
CONTRACTOR has found that case managers can educate, encourage, problem solve, and resolve all but a small portion of inappropriate utilization problems by telephone. This approach permits a much larger number of enrollees to be served by one case manager.Significant case management resources will be devoted to children and adolescent members to ensure high rates of compliance with the Texas Health Steps (THSteps) screening and immunization guidelines as well as to provide the necessary support for children with special health needs who are identified through the screening process.
Case Management efforts for THSteps children and adolescents will span the continuum portrayed in the Case Management Intervention table. That is, in some instances the case manager's efforts will be preventive and focus on compliance with periodicity schedules, and with needed specialty follow-up services. In other instances case managers may be alerted by PCPs to cases of suspected child abuse or teen eating disorders. At the other end of the continuum, children with acute and catastrophic diseases (e.g. cancer) or serious chronic diseases (e.g. asthma) will benefit from the case management efforts.Some adults as well as some children with special health needs who are STAR Plus and SSI aged, blind, and disabled members will require an intensive form of case management. By definition, these are the highest-cost, most at-risk clients. Clinical and financial success with this population is focused on minimizing inpatient days and maximizing the use of community based services to support these member's and enable them to remain in the community. Often the problems of these members, and the numbers of different providers involved with their care require the creation of a treatment team led by a case manager and a primary care physician (who may be a specialist). The team creates an individualized plan of care that is overseen by the case manager who facilitates its implementation. Due to the complexity of the problems of these members, the ratio of case managers to members is considerably higher than for other at-risk populations. However, the additional costs of case management staff are more than justified by better outcomes and overall cost savings." Texas Contract, Amendment 1, pages 23-25.
"14. The PCD will authorize all inpatient hospital admissions, except those that require Prior Authorization by OVHA's Prior Authorization agent. Emergency admissions do not require prior authorization by the PCD, but must be authorized for payment. PCDs may allow other PCDs in their practice to authorize admissions on their behalf, at local option." Vermont Agreement, page 3.
"1. Function in the role of PCP for MEDALLION. In this role, Provider will carry out all routine preventative and treatment services to MEDALLION patients assigned to the PCP's practice. This will include Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services and maintenance of a comprehensive medical record for each patient assigned to the PCP's MEDALLION panel. In particular, the PCP will provide and/or coordinate patient management for all preventive, primary and specialty health care services. The PCP must have admitting privileges at a local accredited hospital or must make arrangements for admissions with a physician who does have admitting privileges." Virginia Agreement, Appendix A, page A-1.
"III. DEFINITIONS: ...
F. Patient management: responsibility for management of the assigned recipient's health care through direct service provision, arrangement by referral and/or approval of PAAS included medical services and maintenance of a unified medical record." West Virginia PAAS, page 2.