Regional Generic Provider Agreement - Ohio Department of Job and ...

Appendix G
Covered Families and Children (CFC) population
Page 10
iii. Comprehensive Case Management Program
1. The MCP must have a process to inform members and their
PCPs in writing that they have been identified as meeting the
criteria for case management, including their enrollment into case
management services.
2. The MCP must assure and coordinate the placement of the
member into case management – including identification of the
member’s need for case management services, completion of the
comprehensive health needs assessment, and timely development
of a care treatment plan. This process must occur within the
following timeframes for:
a) newly enrolled members, 90 days from the effective date
of enrollment; and
b) existing members, 90 days from identifying their need
for case management.
3. The MCP’s comprehensive case management program must
include, at a minimum, the following components:
a. Identification
The MCP must have a variety of mechanisms in place to
identify members potentially eligible for case management.
These mechanisms must include an administrative data review
(e.g., diagnosis, cost threshold, and/or service utilization) and
may include provider/self referrals, telephone interviews,
information as reported by MCEC during membership
selection, or home visits.
b. Assessment
The MCP must arrange for or conduct a comprehensive
assessment of the member’s physical and/or behavioral health
condition(s) to confirm the results of a positive identification,
and determine the need for case management services. The
assessment must be completed by a physician, physician
assistant, RN, LPN, licensed social worker, or a graduate of a
two- or four-year allied health program. If the assessment is
completed by another medical professional, there should be
oversight and monitoring by either a registered nurse or
physician.
For CSHCN, the comprehensive assessment must include, at a
minimum, the use of the ODJFS CSHCN Standard Assessment
Tool.