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Targeted Case Management

Targeted Case Management. MO Division Of DD. Targeted Case Management. MO HealthNet Service Since 1991 Services are “targeted” to persons eligible for Division of DD services

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Targeted Case Management

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  1. Targeted Case Management MO Division Of DD

  2. Targeted Case Management • MO HealthNetService Since 1991 • Services are “targeted” to persons eligible for Division of DD services • Qualified case managers/support coordinators are employees of Regional Offices, County SB-40 Boards, or Other Not-for-Profit entities approved as providers

  3. Eligibility At the time the Case Management Service is furnished the consumer must: • Be enrolled with the Missouri Division of DD • Be eligible for MO HealthNet through MO Family Support Division • Cannot reside in ICFs/ID or other MO HealthNet- funded institutions unless person has a transition plan

  4. The Principle TCM Service Is Support Coordination • A group of activities in gaining access to needed medical, social, educational, and other services (42 CFR 440.169 and 42 CFR 441.18)

  5. CFR and MO HealthNet State Plan Service Components • Comprehensive Assessment and Periodic Reassessment • Develop and revise a specific care plan (ISP) based on assessment • Referral and related activities to assist person to obtain needed services • Monitoring and follow up to ensure effective plan implementation

  6. TCM Provider Qualifications • Only Division of DD Regional Offices, County SB-40 Boards and other not-for-profit TCM entities approved by the Division may enroll as TCM providers • Minimum qualification and experience for service coordinators is the same as for Developmental Disability Professional (DDP) and Division of DD Case Manager I

  7. TCM Requirements • Persons must be given a free choice of any qualified TCM provider • An individual’s access to other MO HealthNet services cannot be restricted by TCM activities • Support coordinators must assure free choice of waiver providers

  8. TCM Requirements (Cont’d) • TCM must not duplicate payments made to public agencies or private entities under MO HealthNet • Support coordinators may assist guardians and others to obtain access to needed services, but may not replace or function as the guardian

  9. TCM Activities • May take place in or out of the presence of the individual being assisted • Includes contact with others, assessments, planning and documentation on behalf of the eligible individual

  10. Administration of Home and Community-Based Waivers Support Coordinators administer the Division of DD waiver programs, including but not limited to: • Evaluate Level of Care for waiver applicants • Support development of the ISP • Provide service monitoring

  11. Administration of Home and Community-Based Waivers • Assure individuals have free choice of Division of DD Waiver services (and other MO HealthNet services) and providers • Ensure waiver services are adequate and sufficient to meet intended need • Ensure the ISP addresses any health & safety needs of participants

  12. Administration of Home and Community-Based Waivers • Due Process and Notice of Right to Appeal • Whenever adverse action or decision made related to: • MO HealthNet eligibility • Division of DD Waiver participation • Or access to specific waiver services

  13. Billable TCM Codes • 000020 Planning Supports • 000021 Linking Resources • 000022 Quality Enhancement; Service Monitoring • 000023 Quarterly Review of Progress on Person-Centered Plans • 000030 Documentation • 000040 Transfer of Case Responsibility • 20000T Consumer Transition • 022001 Case Closure

  14. 000020 Planning Supports • Identifying Needs • Gathering Information from documents • Gathering information from people • Conducting assessments • Writing the profile • Action Planning • Planning Meetings • Developing strategies for action steps

  15. 000021 Linking Resources • Researching existing resources • Making referrals • Writing service authorizations

  16. 000022 Quality Enhancement; Service Monitoring • Monitoring and assessment of the quality, timeliness and effectiveness of supports • Can be done through: • Direct contacts with the individual • Review of provider documentation during face-to-face visits

  17. 000022 QE; Service Monitoring (Cont’d) • May also include connecting persons and their families with other persons, organizations that can support and empower them in meeting their own needs • Use for quarterly monitoring of non-funded services and/or for purchased services that do not require monthly progress reporting (e.g., transportation)

  18. 000023 Quarterly Monitoring of ISP • Evaluating whether services and supports provided are helping the person attain the outcomes in the plan • Completed every three months from the beginning of the ISP implementation date • Used for individuals with purchased services funded through federal, state, and/or County Board funds. (Note: Use 000022 code for review of non-purchased services or, for purchased services-where provider monthly reports not submitted) • Includes review of provider services progress notes

  19. 000030 Documentation • Much of the time spent documenting can be logged under the other codes; e.g. writing the ISP can be logged under “planning” • Examples of documentation: Writing letters/memos, completing transfer and discharge summaries

  20. 000040 Transition/Transfer of Case Responsibility • TCM-defined activities in support of transferring a person’s case from one TCM entity to another • Purpose to achieve a smooth, successful case transfer • Billable Case transfer activities from each agency must be distinct or independent, and not duplicative in any way • Requires close communication between Support Coordinators at each TCM agency • Case transfer activities to be completed with in 30 days

  21. 20000T Consumer Transition • Billable code only used when supporting an individual transitioning to a community living arrangement from a Title XIX facility

  22. 20000T Consumer Transition (Cont’d) • TCM is billable for: • Up to last 180 consecutive days person received services in a qualifying institution • Service cannot be billed to MO HealthNet until person is discharged into community services • Service location should designate ICF/ID, nursing facility, or skilled nursing facility

  23. 022001 Case Closure • Terminating a person from service delivery system. e.g., Discharge summaries • If you remove someone from the service delivery system due to the individual’s death, a non-billable code (such as 111111) needs to be used to prevent billing to MO HealthNet

  24. Division of DD TCM Documentation • Division of DD TCM documentation requirements as per 13 CSR 70-3.030.13

  25. Case Notes: Why Are They Important? • To Document Services Billed to MO HealthNet. All billed services are subject to audit.

  26. Case Notes Should Contain Information About: • First and last names of persons with whom you spoke/ saw • What you did • Why you did it • Location of activity • Amount of time spent on activity • Total Travel time if applicable • If a reference is made to a supporting document - indicate location of document in record

  27. Some Words Are Better Than Others – Acceptable Words/terms

  28. Words That Indicate a Direct Service – Not Billable TCM

  29. Edits in the System • Logged data is edited for: • Individual is MO HealthNet Eligible • Billable Service Code • Place of Service (service location)

  30. Service Location • MO HealthNet requires each claim to include a Place of Service • In CIMOR Support Coordinators must indicate a Service Location • Home • ICF/ID Facility • Office • Custodial Care Facility • Nursing Facility • Skilled Nursing Facility • Other Place of Service

  31. Edit--Service Location • MO HealthNet will not reimburse TCM services for persons who reside in Title XIX-funded facilities • MO HealthNet will reimburse for services up to 180 days for persons who are transitioning from Title XIX facilities to a community living arrangement (e.g., living arrangement funded through the waiver)

  32. 111111 Non-billable Case Management • Gives support coordinators a means to account for their time • This logged activity is not billed to MO HealthNet

  33. Activities Which Are NOT TCM • Building Relationships • Networking • Intake services that assess for Division of DD eligibility • Utilization Review • Other gatekeeper functions • Quality Assurance • Direct Support • Direct Crisis Intervention • Transporting • Certification Survey Functions (unless person specific) • Going to Conferences and Seminars • Conducting Abuse and Neglect Investigations

  34. Intake and Eligibility Determination – Non-billable • Time spent collecting information and determining a person eligible for Division of Division of DD Regional Office services is not billable as TCM • Time spent assisting an individual apply for MO HealthNet is not billable as TCM

  35. Codes Not billed to MO HealthNet • 000050 Quality Improvement • 395001 Client Advocacy • 900001 Other Community Indirect Services • 910001 Client Consultation • 960001 Clinical Services Supports • 960003 Personal Plan Mentoring • 970001 Staff Development • 120001 Psychosocial Evaluation • 201002 Case Coordination • 033001 Abuse Neglect Investigation

  36. Past Problems Resulting in Billing Adjustments • Direct Supports • Transporting • Training • Conducting services not specific to an individual • Crisis Intervention • Insufficient information in log note • Combining billable and non-billable activities

  37. Prohibition Against False Claims • Federal False Claims Act • Imposes liability on any person who prepares and/or submits a claim to the federal government that he or she knows (or should know) is false • Examples: • False case note created for a consumer • Intentionally enters excessive time spent in providing coordination on a log note to gain credit for time worked

  38. Prohibition Against False Claims References: • Deficit Reduction Act of 2005, Section 6032 - Social Security Act Section 1902(a)(68) – Employee Education about false claims recovery • MO Anti-Fraud Laws Related to Health Care: • MO State Statutes 191.900-191.910 • MO Code of State Regulations 13 CSR 70-3.030

  39. Prohibition Against False Claims • Reporting Medicaid Fraud: • Contact Department of Social Services, Division of Legal Services – Investigations Unit (573-751-3285) • DLS Hotline: (877) 770-8055 • DLS Fraud E-mail to ask.mhd@dss.mo.gov • Write to DSS Division of Legal Services - Investigations Unit at P.O. Box 1527, Jefferson City, MO 65109 • Or contact MMAC Fraud Hotline: (573) 751-3285 • MMAC Fraud E-mail: MMAC. ReportFraud@dss.mo.gov

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