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

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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.
Appendix G Covered Families and Children (CFC) population Page 11 c. Care Treatment Plan The care treatment plan is defined by ODJFS as the one developed by the MCP for the member. The development of the care treatment plan must be based on the comprehensive health assessment and reflect the member's primary medical diagnosis and health conditions, any co-morbidities, and the member's psychological, behavioral health and community support needs. The care treatment plan must also include specific provisions for periodic reviews (i.e., no less than semiannually ) of the member's condition and appropriate updates to the plan. The member and the member's PCP must be actively involved in the development of and revisions to the care treatment plan. The designated PCP is the provider, or specialist, who will manage and coordinate the overall care for the member. Ongoing communication regarding the status of the care treatment plan may be accomplished between the MCP and the PCP's designee (i.e., qualified health professional). Revisions to the clinical portion of the care treatment plan should be completed in consultation with the PCP. The elements of a comprehensive care treatment plan include: Goals and actions that address medical, social, behavioral and psychological needs; Member level interventions (i.e., referrals and making appointments) that assist members in obtaining services, providers and programs; Continuous review, revision and contact follow-up, as needed, to insure the care treatment plan is adequately monitored including the following: • Documentation that services are provided in accordance with the care treatment plan; • Re-evaluation to determine if the care treatment plan is adequate to meet the member's current needs; • Identification of gaps between recommended care and actual care provided; • A change in needs or status from the re-evaluation that requires revisions to the care treatment plan; • Active participation by the member or representative in the care treatment plan development; • Monitoring of specific service delivery including service utilization; and
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APPENDIX A OAC RULES 5101:3-26 The
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Appendix C Covered Families and Chi
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Appendix J Page 8 6. NOTIFICATION O
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Appendix N Covered Families and Chi
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Appendix O Covered Families and Chi
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Appendix P Covered Families and Chi
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