MAA ACTIVITY CODES & EXAMPLES

Transcription

1 MAA ACTIVITY CODES & EXAMPLES CODE 1 OTHER PROGRAMS/ACTIVITIES Non Medi-Cal health and wellness activities Social services Educational services Teaching services Employment and job training Providing or administering Education programs, Lead Poisoning Prevention Programs, etc Teaching parenting skills and healthier child raising tactics Facilitating family support groups Home visits that focus on social, educational, housing and transportation needs Assisting a client in securing child care services Appearing in court on behalf of a client Providing a client with job training information CODE 2 DIRECT PATIENT CARE Direct care Treatment Counseling services to an individual Administrative activities that are an integral part of a medical services Extension of a medical service Providing Medical exams; medical or mental health diagnosis, etc. Administering first aid, emergency care of prescribed injection to an individual Developing a mental health assessment 1

2 Counseling a client on his/her substance abuse issues Diagnostic testing or medical screening Performing child health screening including: vision, hearing and scoliosis Providing speech, occupational, physical or other therapies Medication monitoring over the telephone Diagnosis of a mental illness by a clinician Development and writing of a client health plan CODE 3 OUTREACH TO NON MEDI-CAL PROGRAMS Providing information about the Woman, Infants and Children (WIC) program at a health fair Informing individuals about smoking cessation classes offered by the County Arranging for an individual to attend a health lifestyles class Overseeing the creation of the Non Medi-Cal portion of a general outreach campaign Scheduling and promoting activities which educate individuals about the benefits of healthy lifestyles and practices IDEA funded child find activities Talking with groups about free legal services offered in the county Outreach activities in support of programs that are funded 100% by State General Funds Parent conferences on truancy, drugs, gangs, etc General health education programs or campaigns addressed to the general populations 2

3 CODE 4 MEDI-CAL OUTREACH Sending teams of employees into the community to contact homeless alcoholics or drug abusers Establishing a telephone or walk-in service for referring to Medi-Cal services or eligibility offices Operating drop-in community centers for underserved populations Designing and implementing strategies to identify pregnant women who may be at high risk of poor health outcomes because of drug usage, poor nutrition, or lack of appropriate prenatal care Designing and implementing strategies to identify developmentally delayed children who may be at risk of poor health outcomes because of abuse or neglect Designing and implementing strategies to respond to emergency health problems effecting groups of individuals who are at risk for tuberculosis, hepatitis, or Human Immunodeficiency Virus (HPV) Talking with medical providers about the medical services performed by the county public health department Outreach programs directed towards groups of individuals that require SPMP knowledge to identify medically at-risk individuals and to inform eligible or potentially eligible individuals about Med-Cal services and how to access care through the Medi-Cal system Providing information to Medi-Cal eligible people about Medi-Cal covered services at the health fair Informing the general population or groups of individuals about the availability of Medi-Cal services such as TCM Developing and presenting materials to explain Medi-Cal services which are available to Medi- Cal eligible individuals Informing families about the Medi-Cal covered services provided by the local public health department Educating women about the availability of specific Medi-Cal services such as prenatal care and family planning services 3

4 Informing children and their families on how to use health resources and maintain their involvement in the EPSDT Participating in or coordinating outreach trainings that improve the delivery of Medi-Cal services Going to a homeless shelter to talk to individuals about Medi-Cal Compiling and distributing Medi-Cal flyers CODE 5 REFERRAL, COORDINATION, AND MONITORING OF NON MED-CAL SERVICES Public Health Nurse makes client referral to a local vocational trade school Receiving and giving advice related to social and educational services Referring a client to legal aid Following up with a client to ensure that she went to the local Food Bank Referral to Section 8 housing Making referrals to medical services not covered by Medi-Cal CODE 6 REFERRAL, COORDINATION, AND MONITORING OF MEDI-CAL SERVICES Identifying and referring adolescents to family planning services Making a referral for a client to receive a physical examination Talking with other medical professionals about the child s needs or care Speaking with a physician or other health care professional about the need for a physical exam or other medical evaluation Using medical expertise in providing information to other personnel on the child s medical services Coordinating the completion of prescribed services, termination of services, and the referral of the individual to other Medi-Cal service providers as may be required to provide continuity of care and drawing on their medical knowledge in performing this activity 4

5 Documenting medical information pertinent to the individual s case that is required for the physician, specialist or other health care professional in determining the needs of the child and the diagnostic or treatment services Public Health Nurse makes client referral to local public health department for mental health services The referral of a child to a Medi-Cal program for services Making referrals to for and/or coordinating medical or physical examinations and necessary medical evaluations. Working with individuals, their families, and other personnel and providers to identify, arrange for, and coordinate services under Medi-Cal that may be required as a result of a screens, evaluations or examinations Providing information to other personnel on the individual s medical services Gathering information that may be required in advance of referrals of evaluations Arranging for or any diagnostic or treatment services Preparing the evaluation summaries and coordinating meetings where the need for a referral to a Medi-Cal service will be discusses Participating in a meeting to coordinate or review a client s need for Medi-Cal services Coordinating the completion of prescribed services, termination of services, and the referral of the client to other Medi-Cal service providers Providing information to other personnel on the individual s medical services CODE 7 FACILITATION NON MEDI-CAL APPLICATION Temporary Assistance for Needy Families (TANF) Food Stamps (CalFresh or SNAP) Women, Infants, and Children (WIC) Legal Assistance Programs Social programs Educational programs Assisting a client to complete the food stamp eligibility application 5

6 Gathering information related to the application and eligibility determination for Non Medi-Cal programs for a client Providing necessary forms and packaging all forms in preparation for a non Medi-Cal program eligibility determination Explaining eligibility rules and eligibility process of the Head Start program to a prospective client Assisting a client with their Medicare Part D application Helping a client become eligible for Legal Aid CODE 8 FACILITATING MEDI-CAL APPLICATION Discussing the eligibility requirements Referring to application assisters Explaining the application process, Medi-Cal rules and regulations Providing the One e-app and Medi-Cal/Healthy Families form (MC 210 2/10) and instructions Assisting the applicant fill out the application, with redeterminations, with Medi-Cal portion of One e-app Gathering Documents and Information, including Third Party Liability Delivering ap to Eligibility Personnel or hard copy or electronic version Assisting a client to complete the Medi-Cal eligibility application Assisting individuals to provide third party resource information at Medi-Cal eligibility intake Verifying a client s current Medi-Cal status Explaining Medi-Cal eligibility rules and the eligibility process to families Providing all forms and packaging all forms in preparation for the Medi-Cal eligibility determination Assisting individuals with the Medi-Cal appeal(s) processes (including the Medi-Cal administrative hearing process) Gathering additional information on the Supplemental Security Income (SSI)/Medi-Cal application process for a client 6

7 Time spent by a participant assisting a client fill out a SSI application CODE 9 ARRANGING AND/OR PROVIDING TRANSPORTATION TO A NON MEDI-CAL COVERED SERVICE Arranging and/or providing transportation to a diabetes luncheon, sobriety camping, swimming program, etc. Arranging and/or providing transportation for individuals to visit a community center Scheduling a client s appointment with legal aid Scheduling/arranging or providing transportation to social, vocational, educational or any other Non Medi-Cal services Transporting a client to a county facility to apply for food stamps CODE 10 ARRANGING AND/OR PROVIDING NON-EMERGENCY, NON MEDI-CAL TRANSPORTATION TO A MEDI-CAL COVERED SERVICE Scheduling or Arranging in-person or by phone or online Providing through vehicles or transit payment Accompanying if needed, but not medically needed Providing transportation services to a Medi-Cal eligible individual to a Medi-Cal service provider Assisting a client secure bus tokens in order that he/she may visit with their primary care provider Driving a client to a scheduled a mental health counseling session Arranging transportation from a client s home to a Medi-Cal covered service and back home (round trip). Transporting a client to the pharmacy to pick up the individual s prescribed medication Accompanying a client to a physician visit to translate from Spanish to English, medically related information between the MD and the client Driving client to a physician s office for a scheduled physical exam 7

8 **TCM** TRANSPORTATION COSTS AND TCM - Transportation shall not be claimed as CMAA when performed by a TCM Case Manager CODE 11 CONTRACT ADMINISTRATION FOR NON MEDI-CAL SERVICES Contracting for non Medi-Cal programs Reviewing and processing invoices Ensuring compliance RFQ/RFP/RFB activities Administering a contract with a service provider to install security alarms within the building Negotiations a contract between local school district and county social services department for child welfare services Managing contract for county legal services with probation department Providing technical assistance to Non Medi-Cal sub-contractors regarding county, state and federal regulations CODE 12 CONTRACT ADMINISTRATION (A) FOR MEDI-CAL SERVICES SPECIFIC FOR MEDI-CAL POPULATIONS Contracting for Medi-Cal programs that only serve Medi-Cal beneficiaries Ensuring/overseeing the quality of services provided by the contractor RFQ/RFP/RFB activities Ensuring compliance Reviewing/processing invoices Administering a Medi-Cal services contract with a service provider Conducting a local agency meeting to provide an orientation for potential Medi-Cal contract providers Developing a comprehensive network of Medicaid providers through a request for information (ROI), request for proposal (RFP), and/or an open enrollment process 8

9 Draft, evaluate, negotiate and execute Medi-Cal services contracts with CBOs and service providers Maintain contractual records and documentation related to Medi-Cal services contracts Authorizing payments consistent with the contract terms for a Medi-Cal services contract Ensure compliance with the terms of the Medi-Cal services contracts CODE 13 CONTRACT ADMINISTRATION (B) FOR MEDI-CAL SERVICES SPECIFIC FOR MEDI-CAL AND NON MEDI-CAL POPULATIONS Contracting for Medi-Cal programs Ensuring/overseeing the quality of services provided by the contractor RFQ/RFP/RFB activities Ensuring compliance Auditing contract providers Reviewing and processing invoices Administering a Medi-Cal services contract with a service provider Conducting a local agency meeting to provide an orientation for potential Medi-Cal contract providers Developing a comprehensive network of Medicaid providers through a request for information (ROI), request for proposal (RFP), and/or an open enrollment process Draft, evaluate, negotiate and execute Medi-Cal services contracts with CBOs and service providers Maintain contractual records and documentation related to Medi-Cal services contracts Authorizing payments consistent with the contract terms for a Medi-Cal services contracts Ensure compliance with the terms of the Medi-Cal services contracts CODE 14 PROGRAM PLANNING AND POLICY DEVELOPMENT FOR NON MEDI-CAL SERVICES Developing strategies for expanding the CalWorks program 9

10 Monitoring the probation department s caseload system Evaluating the need for child welfare services in relation to specific populations or geographic area Analyzing food stamp eligibility data related to a specific program, population or geographic area Developing Section 8 housing referral sources Developing strategies to assess and/or increase the capacity of job training programs throughout the county CODE 15 PROGRAM PLANNING AND POLICY DEVELOPMENT (A) (NON-ENHANCED) FOR MEDI-CAL SERVICES FOR MEDI-CAL CLIENTS Developing strategies to Increase Medi-Cal system capacity or Close Medi-Cal service gaps Analyzing Medi-Cal data for planning purposes to close Medi-Cal service gaps The County Public Health Department and the County Mental Health Department work together to develop protocols and procedures to better serve the mental health needs of their clients Systematically focusing Medi-Cal services on a specific population or a geographic area Reducing overlap and duplication of Medi-Cal services Recruiting a new medical/dental/mental health providers into the Medi-Cal network of providers Providing technical assistance and support to new providers about Medi-Cal Providing information to providers on Medi-Cal policy and regulations: Developing Medi-Cal service/provider directories Working with Medi-Cal resources, such as managed care plans, to locate and develop health services referral relationships Developing future referral capacity with specialty Medi-cal providers by discussing medical health programs, including client needs and service delivery requirements 10

11 Conducting a local agency meeting to provide an orientation for potential Medi-Cal contract providers FOR MEDI-CAL ELIGIBLE CLIENTS ONLY! CODE 16 PROGRAM PLANNING AND POLICY DEVELOPMENT SKILLED PROFESSIONAL MEDICAL PERSONNEL (SPMP) (A) (ENHANCED) FOR MEDI-CAL SERVICES FOR ONLY MEDI-CAL CLIENTS ***When the skills, knowledge or licensure of an SPMP is required for, and when the PP&PD is only for Medi-Cal beneficiaries PP&PD SPMP (A) Developing strategies to: Increase Medi-Cal system capacity Close Medi-Cal service gaps Analyzing Medi-Cal data related to a specific program or specific group Consulting with Medical professionals regarding Medi-Cal covered services Interagency coordination to improve delivery of Medi-Cal services When involvement in the activity requires SPMP status CODE 17 PROGRAM PLANNING AND POLICY DEVELOPMENT (B) (NON-ENHANCED) FOR MEDI-CAL SERVICES FOR MEDI-CAL AND NON MEDI-CAL CLIENTS Developing strategies to Increase Medi-Cal system capacity, Close Medi-Cal service gaps, Analyzing Medi-Cal data, Interagency coordination to improve delivery of Medi-Cal services, Developing resource directories of Medi-Cal services/providers Analyzing Medi-Cal date for planning purposes to close Medi-Cal service gaps The County Public Health Department and the County Mental Health Department work together to develop protocols and procedures to better serve the mental health needs of their clients Systematically focusing Medi-Cal services on a specific population or a geographic area Reducing overlap and duplication of Medi-Cal services 11

12 Recruiting a new medical/dental/mental health providers into the Medi-Cal network of providers Providing technical assistance and support to new providers about Medi-Cal Providing information to providers on Medi-Cal policy and regulations Developing Medi-Cal service/provider directories Working with Medi-Cal resources, such as managed care plans, to locate and develop health services referral relationships Developing future referral capacity with specialty Medi-Cal providers by discussing medical health programs, including client needs and service delivery requirements Conducting a local agency meeting to provide an orientation for potential Medi-Cal contract providers CODE 18 PROGRAM PLANNING AND POLICY DEVELOPMENT (SPMP) (B) (ENHANCED) FOR MEDI-CAL SERVICES FOR MEDI-CAL AND NON MEDI-CAL CLIENTS Developing strategies to increase capacity, close gaps, Analyzing Medi-Cal data, Interagency coordination, Improving Medi-Cal services delivery A nurse (SPMP) conducting a needs assessment to improve Medi-Cal services for Medi-Cal eligibles Quality Assurance activities required for development, implementation, evaluation and revision of clinical practical guidelines Utilization review and training activities Utilization review and training activities related to monitoring of public health s integrity standards, including services provided by subcontractors The County Health Department conducts inter-agency utilization review meetings on the Medi- Cal covered services the it provides Quality Improvement (QI) Committee meetings Completion of a Utilization Management Manual Updating the Public Health Department s Medi-Cal services manual Assessing the necessity for and the adequacy of medical care and services provided by the county 12

13 Review of complex medical billings for service utilization data by an SPMP Acting as a liaison on the medical aspects of a program with service providers and other agencies that provide medical care ******NEED EXMPLES FOR NON MEDI-CAL CLIENTS CODE 19 MAA/TCM COORDINATION AND CLAIMS ADMINISTRATION Drafting, revising, and submitting Claiming Unit Plans, Cost Reports, Performance Monitoring Plans Serving as MAA/TCM Liaison with Claiming Units, TCM providers, State and Federal Government agencies Administering LGA claiming Overseeing, preparing, compiling, Submitting claims, Revising and correcting invoices Monitoring Claiming Unit Performance, Desk, Site Reviews, Technical Assistance Plan, Attend, Facilitate MAA/TCM related, Trainings, Meetings, Conferences Training LGA Staff on State, Federal, and local requirements Ensuring Non-duplication of Medi-Cal services, Non-duplication of TCM case management, Coordination with Managed Care Plans Reviewing time study results to ensure accurate claiming Monitoring the performance of CMAA Claim plans Attending and participating in MAA conferences and phone calls Preparing and submitting CMAA Claim plan amendments Pulling financial data together for completing the CMAA invoice CODE 20 MAA/TCM IMPLEMENTATION TRAINING Attending, Giving, Coordinating MAA or TCM Time Survey Training, Re-training or refresher training on MAA or TCM CODE 20 EXAMPLES Participating in the CMAA/TCM Time Study Training Time Spent filling out the Time Survey Time Spent correcting a Time Survey 13

14 CODE 21 GENERAL ADMINISTRATION General information s General and non-medical Staff Meetings Non program specific meetings Developing and Monitoring Program Budgets Site Management Supervision of Staff (not Case Managers) Paid Staff Break Time Personnel Management Attending general meetings, breaks, training unrelated to CMAA/TCM, or other programs, etc. Reviewing departmental, local agency or unit procedures and rules Attending of facilitating general agency or unit personnel meetings or board meetings Providing general supervision of staff and evaluation of employee performance Processing payroll/personnel-related documents Maintaining inventories and ordering supplies Developing budgets and maintaining records Reviewing technical literature and research articles Staff training Developing and improving local agency improvement plans Activities related to provider and consumer complaints and grievances Assisting a consumer with a Client Satisfaction Survey CODE 22 PAID TIME OFF Vacation, sick leave, paid holiday time, paid jury duty, and any other paid employee time off 14

15 TCM CODES CODE 23 NON-TARGETED CASE MANAGEMENT Providing a referral to a medical service for a Developmentally Disabled Services client Providing a referral to needed medical services for a Multipurpose Senior Services Program client CODE 24 PROVIDING TCM SERVICE COMPONENTS The service components are: 1. Comprehensive Assessment and periodic reassessment of an individual s needs 2. Development (and periodic revision) of a specified care plan 3. Referral and related activities 4. Monitoring and follow-up activities Follow-up on a referral to the food bank, as identified as a need in the client s comprehensive needs assessment CODE 25 TCM ENCOUNTERS RELATED ACTIVITIES Interagency and Team Meetings to coordinate and staff cases Setting Client Encounter appointments Case Records work Case Manager Training (Non-SPMP) CODE 26 TRAVEL RELATED TO PROVIDING TCM Travel time to provide TCM services and any TCM related activity(-ies) to a TCM eligible recipient Prorate time spent on TCM services and related activities at a specific location NOT FOR CLIENT TRANSPORTATION CODE 27 SUPERVISION OF CASE MANAGERS A case manager s supervisor reviews the client s goals and needs assessment along with the care plan to ensure appropriate actions are taken to meet the client s goals and needs 15

16 CODE 28 ENCOUNTER ENTRY INTO TCM ON-LINE SYSTEM Maintenance of Encounter Log(s) and related encounter activities Entry of Medi-Cal data from the Encounter Log into the TCM data collection system CODE 29 TCM DATA SYSTEMS AND CLAIMING COORDINATION Preparing, reviewing and revising TCM Claims *Prohibited for Case Managers CODE 30 TCM QUALITY ASSURANCE/PERFORMANCE MONITORING TCM free care and TPL compliance TCM case documentation compliance Monitoring a TCM provider system capacity *Prohibited for Case Managers CODE 31 TCM SUBCONTRACT ADMINISTRATION Identify and recruit community agencies to be TCM contract providers Monitor TCM provider contracts Provide technical assistance to TCM subcontractors regarding county, federal, and state regulations *Prohibited for Case Managers CODE 32 TCM PROGRAM PLANNING & POLICY DEVELOPMENT Planning to increase TCM system capacity and close gaps Interagency coordination to improve TCM service delivery Developing TCM resource directories 16