INSTRUCTIONS FOR INSPIRE (SNBC) CARE PLAN
|
|
- William Brooks
- 5 years ago
- Views:
Transcription
1 INSTRUCTIONS FOR INSPIRE (SNBC) CARE PLAN INFORMATION ABOUT ME 1. Name: Enter member s name. 2. My DOB: Enter member s date of birth. 3. Health Plan ID Number: Enter member s HealthPartners Member ID number. 4. SNBC Enrollment Date: Enter the date member enrolled with HealthPartners SNBC. 5. Care Plan Completion Date: Enter the date the care plan is completed. 6. Phone #: Enter member s phone number. 7. My Address: Enter member s address. 8. Assessment Date: Enter the date the assessment was completed. 9. Assessment Type: Choose the type of assessment that was completed. 10. Emergency Contact Name/Phone #: Enter member s emergency contact information. 11. If applicable, Legal guardian/representative Name/Phone#: Enter member s legal guardian/representative information. 12. Was Advance Directive/Health Care Directive Discussed? Document that a discussion occurred by checking yes or no. If no discussion occurred, document reason. 13. My Primary Language is: Check appropriate box. If the member s language is not on the list, check Other and document their language in this section. Include interpreter information. MY INTERDISCIPLINARY CARE TEAM (ICT) 14. Care Coordinator/Case Manager: Enter HealthPartners SNBC Care Coordinator name and phone number. 15. Primary Physician: Enter the name, phone number, and fax number of member s primary care provider. 16. Clinic: Enter the name of the member s primary care clinic. 17. If applicable, County Waiver CM Information: Enter Name, Phone, Fax, and of the County Waiver Case Manager if member is open to a waiver. 18. Date care plan was shared with County Waiver CM: Enter date that care plan was shared with the Waiver Case Manager. 19. Waiver Type: Indicate type of waiver member is on, if applicable. 20. Disability Type: Indicate member s disability type. 21. Mental Health Targeted Case Manager: Check yes or no. If yes, enter name and phone number 22. Other Interdisciplinary Care Team Members: Enter names of additional ICT members and their relationship to the member. Examples of other team members may include but is not limited to other physicians, specialists, psychiatrist, psychologist, etc. Document yes or no if the care plan is shared with these ICT members. Inspire (SNBC) Care Plan Instructions 1
2 WHAT S IMPORTANT TO ME? 23. What s Important to Me: Describe what is most important to the member, their wishes, dreams, and goals in life. Complete the first row at the initial/annual assessment. Updates should be dated and entered in the second row. Updates include six month check-ins or any other updates throughout the year. MY STRENGTHS 24. My Strengths: Enter member s supports and describe what works best for the member. Include a list of the member s skills, talents, and/or interests. Complete the first row at the initial/annual assessment. Updates should be dated and entered in the second row. Updates include six month check-ins or any other updates throughout the year. MY SUPPORTS AND SERVICES 25. My Supports and Services: Enter any requests that member has asked for assistance with. Enter any supports or services that member has requested. Complete the first row at the initial/annual assessment. Updates should be dated and entered in the second row. Updates include six month check-ins or any other updates throughout the year. MY CAREGIVER 26. Caregiver Listed on HRA: A caregiver is someone who provides unpaid support or who is paid but works beyond set paid hours. (Example, daughter is paid for 3 hours of PCA support, yet provides 24 hour support. Check yes or no to indicate if there is an informal caregiver. If yes, then check yes or no to indicate if there is a need for caregiver resources. If caregiver resources are needed document the date that resources were provided to caregiver on the Care Plan. Document caregiver resources provided and method resources were provided in chart or case notes. MANAGING AND IMPROVING MY HEALTH 27. Check if an educational conversation took place: CC/CM should have an educational conversation with the member or member s authorized representative about applicable conditions and/or regularly scheduled screenings. Check each box to show that an educational conversation took place for each applicable condition or screening. 28. Goal is Needed: If the member needs assistance with a risk or identified need, check the appropriate box and create a goal in Section VI. 29. Check if N/A, Contraindicated, Declined: Check applicable box if the Condition/Screening or goal is not applicable, contraindicated, or declined. 30. Notes: Free form area for any additional applicable information such as date of the screening, scores, or reason for declining a goal. 31. Diabetic routine checks as recommended by physician: CC/CM should inquire whether a member with diabetes has routine diabetic checks with their doctor. If not, CC/CM should encourage the member to schedule a visit and create a goal to address this in Section VI. CC/CM should review and discuss with member patient education topics such as the importance of an eye exam, diet (i.e. Cholesterol) and knowing their A1C level. 32. Medication Adherence: Check if educational conversation took place. If there are concerns regarding member not taking medications as prescribed mark goal is needed. Create goal in Section VI. Refer to Medication Therapy Management (MTM) if appropriate. 33. Other: Enter any other test or condition not addressed in this section. Inspire (SNBC) Care Plan Instructions 2
3 34. Mental Health Diagnosis: If member declines to have goal included on his/her care plan, please indicate that you are aware of the mental health need and that you will continue to address it. This can be captured in case notes. 35. Disease Management Referral: Check yes, declined, or N/A. If yes, include the diagnosis. All health plans have different diseases and processes for their Disease Management Programs; please check with the member s health plan for direction. MY GOALS ISSUES, NEEDS, AND ALL AREAS OF CONCERN IDENTIFIED ON THE HRA/LTCC MUST BE ADDRESSED IN THE CARE PLAN Examples available at the end of instructions. 36. My Goals: List appropriate member centered goals to meet the risks identified on the HRA. Goals should be SMART (Specific, Measurable, Attainable, Relevant and Time bound. 37. My Intervention: Document any intervention(s) related to achieving this goal: What will the member need to do to accomplish the goal and how will the CC/CM help the member achieve the goal? 38. Target Date: List the target date (month/year) for completion of the goal. On-going yes or no are not acceptable target dates. Members should have at least one active or open goal on their care plan and the target date should extend to the next annual assessment. 39. Monitoring Progress/Goal Revision Date: This column can be used to document progress during the 6 month contact and/or as needed throughout the year. The CC/CM should have a discussion with the member about each goal and the member s progress toward meeting a goal. This discussion should include determining if the goal was met or not met and an evaluation of whether the goal will be discontinued, modified, or carried forward. The CC/CM should document the date (month/year) of the review and the outcome (e.g., discontinued, modified, or carried forward) in this column. If priorities change, please note. Reminder: The plan of care is a living document that should be updated at minimum twice a year. Best Practice Recommendation: The CC/CM should document their monitoring of the care plan and/or updates directly on the care plan. If CC/CM uses case notes to document progress on goals, the progress regarding each goal should be clearly indicated in the case notes. 40. Date Goal Achieved/Not Achieved: This column is used to document the date (month/year) the goal was achieved or if not achieved, the date (month/year) it was reviewed. This column may also be used to document progress notes and the final outcome (e.g., goal discontinued, modified, or carried forward to next year s care plan). BARRIERS TO MEETING MY GOALS (if applicable) 41. Initial/Annual: Describe any barriers to meeting goals. Update: Complete and date at time of designated follow up. MY FOLLOW-UP PLAN 42. CC/CM Follow-up Plan: Check box to indicate how frequently you will be following up with the member. If other, describe. Must be a minimum of every 6 months. You will be audited according to what you select. Inspire (SNBC) Care Plan Instructions 3
4 MY SAFETY PLAN 43. Essential Services Backup Plan: Essential services are services that if the member did not receive them, the member s health or ability to remain safety in their home would be compromised. What is their back up plan if essential services providers do not show up? Example, the member is receiving essential services such as Meals-on-Wheels, if that is their only source of nutrition, describe how this need will be met. CHOOSING COMMUNITY LONG TERM CARE Member/Authorized Representative checks the boxes 44. I have been given a choice of different types of services that can meet my needs: The member/authorized representative checks yes or no 45. I have been offered a choice of providers from available providers: The member/authorized representative checks yes or no. 46. I have annually received my appeal rights: Inform member/authorized representative that their annual appeal rights are sent with any DTR and with their annual Evidence of Coverage (EOC). The member/authorized representative should check yes or no. CC/CM can direct member/authorized representative to customer service if they need a copy of the appeal rights documents. 47. I am aware that healthcare information about me will be kept private (Data Privacy rights): Inform member/authorized representative that their privacy rights are sent annually. The member/authorized representative should check yes or no. CC/CM can direct members/authorized representative to customer service if they need a copy of their EOC, which contains data privacy information. 48. I have discussed my plan of care with my care coordinator/case manager and have chosen the services I want. The member/authorized representative checks yes or no. 49. I agree with the plan of care as discussed with my care coordinator/case manager. The member/authorized representative checks yes or no. 50. Member/Authorized Representative Signature and Date. CC/CM must obtain signature from member or authorized representative. 51. Member/Authorized Representative Printed Name: Enter or Print name of member or authorized representative that signed above. 52. Care Coordinator/Case Manager Signature and Date. CC/CM signs care plan. 53. Care Plan Mailed/Given to me on: Enter the Date Care Plan was Mailed/Given to the Member. 54. Care Plan or Summary Mailed/Given to My Doctor: Enter the Date Care Plan or Summary was Mailed/Given to PCP. Enter the method that care plan was shared (Verbal, Phone, Fax, Electronic Medical Record). 55. Member Name and HealthPartners ID: Enter member name and Health Partners ID HOME AND COMMUNITY BASED SERVICE PLAN/BUDGET WORKSHEET DHS s audit protocol requires documentation of type of service; amount, frequency, duration and cost of each service; and type of service provider, including non-paid caregivers and other informal community supports or resources. Services/Supports should be based on a determination of available benefits and resources. Fully completing this (or a similar) budget worksheet provides the required documentation for these audit elements. Inspire (SNBC) Care Plan Instructions 4
5 Name: My DOB: Phone #: My Address: Emergency Contact Name/Phone #: Inspire (SNBC) Care Plan Information About Me HealthPartners ID #: SNBC Enrollment Date: Care Plan Completion Date: Assessment Date: Assessment Type: Initial HRA Annual reassessment Change of Condition Other: If applicable, Legal guardian/representative Name/Phone#: Was Advance Directive/Health Care Directive Discussed? Yes No If No, Reason: Care Coordinator/Case Manager: Name: Phone #: My primary language is: English Other (Type in the other language) I need an interpreter: Yes No Name and Number of Interpreter (If applicable): My Interdisciplinary Care Team (ICT) Primary Physician: Phone #: Fax #: Clinic: 1
6 If applicable, County Waiver CM Information: Name: Phone: Fax: Date care plan was shared with County Waiver CM: Waiver Type: CAC CADI BI (TBI) DD Other Disability Type: Physical Developmental Mental Health I have a Mental Health Targeted Case Manager (MHTCM): Yes No Name of MHTCM: Phone Number of MHTCM: Other Members of My Team Relationship to Me Phone Number Care Plan Shared with Team Member 2
7 I. What s Important to Me? (e.g. living close to my family, visiting friends) Initial/Annual: Update: II. My Strengths: (e.g. skills, talents, interests, information about me) Initial/Annual: Update: III. My Supports and Services: (What do I want help with? Service and support I requested? From whom?) Update: IV. My Caregiver Informal Caregiver listed on HRA: (Caregivers are unpaid person(s) providing services) Yes No If Yes, is there a need for caregiver resources? Yes No If Yes, date resources provided to caregiver: 3
8 V. Managing and Improving My Health Check if educational conversation took place with me Screening for My Health Goal is Needed Check if N/A, Contraindicated, Declined Notes Annual Preventive Health Exam Mammogram (Within past 2 years ages 65-75) Cervical Cancer Care Colorectal Screening (Up to age 75) At Risk for Falls Flu shot (Annually, ages 50+ and persons at high risk.) Tetanus Booster (Once every 10 years) ADL/IADL Dependencies Hearing Exam Vision Exam Dental Exam Blood Pressure: (Blood Pressure Goal is <140/80 to age 75. 4
9 Check if educational conversation took place with me Goal is Needed Check if N/A, Contraindicated, Declined Notes Diabetic routine checks as recommended by physician Family Planning Rehabilitative Services Education and/or employment Child and Teen Check-Up (18-21) Chemical Health/ Chemical Dependency Medication Adherence/MTM Other: Mental Health Diagnosis: (If applicable) N/A Managed by Other Health Professionals? Yes No (Psychiatrist, Psychologist, Primary Care Physician) Need Goal?: Yes No *Declined *See care plan instructions Disease Management, Referral Yes Declined N/A Diagnosis: 5
10 VI. My Goals Discuss with Care Coordinator goals for: everyday life (taking care of myself or my home), my relationships and community connections, my safety, my health, and my future plans. My Goals My Interventions Target Date Monitoring Progress/Goal Revision Date Date Goal Achieved/ Not Achieved (Month/Year) 6
11 Initial/Annual: Update: VII. Barriers to meeting my goals (if applicable) VIII. My follow up plan: Care Coordinator/Case Manager Follow-up will occur: Once a Month for 3 Months Every 3 Months Every 6 Months Other Purpose of Care Coordinator Contact: IX. My Safety Plan Essential Services Backup Plan: (when providers of essential services are unavailable) I am receiving essential services Yes No Essential services I am receiving: If Yes, briefly describe provider s backup plan, as agreed to by me: If I am unable to evacuate independently in an emergency, my evacuation plan will be: Additional Case Notes: 7
12 X. Choosing Community Long Term Care Yes No I have been given a choice of different types of services that can meet my needs. Yes Yes Yes Yes Yes No I have been offered a choice of providers from available providers. No I have annually received my appeal rights. No I am aware that healthcare information about me will be kept private. (Data Privacy Rights) No I have discussed my plan of care with my care coordinator/case manager and have chosen the services I want. No I agree with the plan of care as discussed with my care coordinator/case manager. MEMBER/AUTHORIZED REPRESENTATIVE SIGNATURE: DATE: MEMBER/AUTHORIZED REPRESENTATIVE PRINTED NAME: DATE: CARE COORDINATOR/CASE MANAGER SIGNATURE: DATE: CARE PLAN MAILED/GIVEN TO ME ON: CARE PLAN OR SUMMARY MAILED/GIVEN TO MY DOCTOR (verbal, phone, fax, EMR): DATE: Member Name: HealthPartners ID: 8
13 XI. Home and Community Based Service and Support Plan Support/Service Provider Payment Type (Medicare, Medicaid, Waiver or Other) Schedule/Frequency Service Start Date and End Date (if applicable) Home and Community Based Services List of Equipment Member Has 9
14 List of Supplies Support/Service Provider Payment Type (Medicare, Medicaid, Waiver or Other) Schedule/Frequency Service Start Date and End Date (if applicable) Other: (supports, resources) 10
15 This information is available in other forms to people with disabilities by calling (voice) or (toll free), (TTY), (toll free TTY), 7-1-1, or through the Minnesota Relay direct access numbers at (TTY, Voice, ASCII, hearing carry over), or (Speech to Speech relay service). HPCare 2015 LB HPCare_87629 Approved 01/15/
16 VI. My Goals Inspire SNBC EXAMPLE GOALS for Inspire (SNBC) Care Plan Discuss with Care Coordinator goals for: everyday life (taking care of myself or my home), my relationships and community connections, my safety, my health, and my future plans. My Goals I will receive an annual physical. I will make an informed choice about completing an advanced directive. My Interventions Care Coordinator (CC) will provide list of available providers to member. I will choose a provider from list. I will schedule and attend annual physical appointment. CC will provide educational materials and an advanced directive form. I will review materials and make a decision about completing an advanced directive. Monitoring Progress/Goal Revision Target Date Date 9/30/ /1/2016- CC mailed list of providers to member. 3/16/17- Annual physical was complete on 11/7/16. 9/30/ /1/2016- CC mailed educational materials and advanced directive form. 3/16/17- Goal reviewed. See updates in case notes. Goal Achieved/Not Achieved (Mo/Yr) 3/16/17 - Goal complete. Annual physical was completed on 11/7/16. 3/16/17 - Goal complete. Advanced Directive complete. I will manage fall risk with use of appropriate devices or services. I will establish care with a dental provider. I will maintain services with mental health providers. I will continue to use walker, shower chair, and accept PCA services to prevent falls. I will notify CC if devices and services are no longer meeting needs. CC will provide list of available providers. I will review and choose a provider. I will schedule and attend appointment. CC available to further assist where needed. I will continue to attend appointments with therapist, psychiatrist, and ARMHS worker. I will notify CC if services are no longer meeting member's needs. 9/30/2017 9/30/2017 9/30/2017 3/16/17- Member continues to use walker, shower chair, and PCA services to prevent falls. 10/1/ CC mailed list of providers to member. 3/16/ Member has not scheduled appointment. See additional notes in case notes. 3/16/ Member continues to attend appointments with mental health providers. 9/30/2017- Member continues to use devices and services. Goal will continue to next care plan. 9/30/2017- Goal Complete. Member attended dental appointment in 4/ /30/2017-Goal is on-going. Goal will continue to next care plan. HealthPartners Confidential and Proprietary Last Reviewed November 2017 Inspire (SNBC) Care Plan Instructions 17
All related UCare forms can be found, HERE, all DHS forms can be found HERE, all DHS Bulletins can be found HERE.
Minnesota Senior Health Options (MSHO) Care Coordination (CC) and Minnesota Senior Care Plus (MSC+) Community Case Management (CM) Requirements Updated 1.1.18 All Minnesota Senior Health Options (MSHO)
More informationUCare Connect Care Coordination Requirement Grid Updated effective
UCare Connect Care Coordination Requirement Grid Updated 8.1.18 effective 9.1.18 The assigned Care Coordinator (CC) must meet the required definition of a qualified professional. Care coordination services
More informationUCare Connect + Medicare Care Coordination Requirement Grid Updated
UCare Connect + Medicare Care Coordination Requirement Grid Updated 1.1.18 The assigned Care Coordinator (CC) must meet the required definition of a qualified professional. Care coordination services incorporate
More informationHealthPartners Inspire (SNBC) Overview
Draft HealthPartners Inspire (SNBC) Overview July 1, 2016 1 What is SNBC? Special Needs Basic Care (SNBC) began in 2008 Voluntary health plan option for enrollees with disabilities ages 18 through 64 who
More informationHCBS Waiver Review Initiative
HCBS Waiver Review Initiative Description of tool: This is a Community Support Plan used in Hennepin County for participants that choose Consumer Directed Community Supports (CDCS). These tools were originally
More informationMeasureable Goals and Outcomes. Collaborative Care Plan. SMART Goals
Measureable Goals and Outcomes Collaborative Care Plan SMART Goals SMART Goals Specific Specifically define the goal for the member using action verbs what member will do or maintain, and how. What exactly
More information(Referred to as the Care Plan Data Collection Guide in the DHS Triennial Compliance Assessment (TCA) conducted by the Minnesota Department of Health)
Minnesota Department of Human Services Managed Care (MSHO MSC+) Elderly Waiver Care Planning Audit (as required under 7.1.4.D., 7.8.3, 9.3.7 of the 2016 MSHO/MSC+ contract) 2017 Audit Protocol (Final 7.17.2017)
More informationGenerations Advantage Focus DC (HMO SNP) Diabetes Care Special Needs Plan GENERAL MODEL OF CARE (MOC) TRAINING
Generations Advantage Focus DC (HMO SNP) Diabetes Care Special Needs Plan GENERAL MODEL OF CARE (MOC) TRAINING Through this training you will learn: What is a SNP? What is Martin s Point Generations Advantage
More informationCommuniCare Advantage Cal MediConnect Plan (Medicare-Medicaid Plan): Summary of Benefits
This is a summary of health services covered by CommuniCare Advantage Cal MediConnect Plan for 2014. This is only a summary. Please read the Member Handbook for the full list of benefits. CommuniCare Advantage
More informationHealthPartners SNBC Inspire
Click to edit Master title style HealthPartners SNBC Inspire March 28 & 30, 2017 Agenda New Team Members DHS SNBC Audit 6 Month Follow Up Calls Benefit Exception Inquiry Form Adjustments HealthPartners
More informationSpecial Needs Plan Model of Care Chinese Community Health Plan
Special Needs Plan Model of Care 2017 2017 Chinese Community Health Plan Elements of CCHP SNP Model of Care Special Needs Plan (SNP) Goals CCHP Dual Eligible SNP Enrollment & Eligibility Vulnerable Beneficiaries
More informationSpecial Needs Plans (SNP) Model of Care (MOC) Initial and Annual Training
Special Needs Plans (SNP) Model of Care (MOC) Initial and Annual Training 2018 Learning Objectives Program participants will be able to: List the three overall goals of the SNP Model of Care Describe the
More informationStage 2 General Critical Element Pathway Facility Name: Facility ID: Date: Surveyor Name:
Facility Name: Facility ID: Date: Surveyor Name: Resident Name: Resident ID: Initial Admission Date: Care Area(s): Interviewable: Yes No Resident Room: Use Use this General Investigative Protocol to investigate
More informationLead Agency Quality Assurance Plan Survey for Medical Assistance Waiver Home and Community-Based Services
Lead Agency Quality Assurance Plan Survey for Medical Assistance Waiver Home and Community-Based Services Introduction: The Minnesota Department of Human Services (DHS) has, in years past, required counties,
More informationHealthPartners MSHO (HMO SNP) Enrollment Form
HealthPartners MSHO (HMO SNP) Enrollment Form HealthPartners Enrollment Telephone Numbers 952-883-5050 or 877-713-8215. TTY for the hearing impaired at 952-883-6060 or 800-443-0156. The call is free. HealthPartners
More information2015 Summary of Benefits
2015 Summary of Benefits Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) Los Angeles County, CA H3237_2015_0291 CMS Accepted 09082014 Health Net Cal MediConnect Summary of Benefits! This is a
More informationProvider Certification Standards Adult Day Care
Provider Certification Standards Adult Day Care December 2015 1 Definitions: Activities of Daily Living (ADL s)- Includes but is not limited to the following personal care activities: bathing, dressing,
More informationGuide to Accessing Quality Health Care Spring 2017
Guide to Accessing Quality Health Care Spring 2017 MolinaHealthcare.com 5771749DM0217 MyMolina MyMolina is a secure web portal that lets you manage your own health from your computer. MyMolina.com is easy
More informationEW Customized Living Contract Planning Worksheet, Part I
Purpose of This Worksheet This planning worksheet is designed to: 1. Delineate component services that can be included in EW customized living and 24 hour customized living packages. 2. Serve as a tool
More informationYour health comes first
Your health comes first Here are the many ways we re working to ensure the quality of your care At Amerigroup, our focus is on you. We want to help you get and stay healthy. That s why we have many programs
More informationADMISSION INFORMATION CHECKLIST
APPLICANT: ADMISSION INFORMATION CHECKLIST Below is a listing of information needed before scheduling the Pre-Admission Interdisciplinary meeting. NEED: 1. Release of Information 2. Fully Completed Application
More informationPassport Advantage (HMO SNP) Model of Care Training (Providers)
Passport Advantage (HMO SNP) Model of Care Training (Providers) 2018 Passport Advantage (HMO SNP) is an HMO Special Needs plan with a Medicare contract and an agreement with the Kentucky Department for
More informationInitial Needs Determination Report for Disability Waiver Residential and Support Services. Disability Services Division
DHS-6674-ENG This document is made available electronically by the Minnesota Legislative Reference Library as part of an ongoing digital archiving project. http://www.leg.state.mn.us/lrl/lrl.asp Initial
More information3 rd Quarter MSHO/MSC+ Care Coordination Training
3 rd Quarter MSHO/MSC+ Care Coordination Training Care Systems & UCare Care Coordinators: September 13 th, 2017 Recorded WebEx: September 14 th, 2017 Agenda STARS Cindy Radke Bus Pass Transportation Jeremy
More information2013 MSHO Model of Care Training
2013 MSHO Model of Care Training 1 MSHO Model of Care Training - Overview MSHO Overview Model of Care Definition Model of Care Training Requirement Model of Care Components Measurable Goals Staff Structure
More informationAt EmblemHealth, we believe in helping people stay healthy, get well and live better.
At EmblemHealth, we believe in helping people stay healthy, get well and live better. Welcome to the 2017 course on Special Needs Plan Model of Care. This year s course is focused on how we can successfully
More informationSpecial Needs BasicCare
Minnesota Disability Health Options (MnDHO) Special Needs BasicCare (SNBC) Special Needs Purchasing Deb Maruska Program Coordinator Susan Kennedy Project Coordinator Managed Care Programs for People with
More informationSummit ElderCare. Each participant will receive his or her primary medical care from a PACE medical provider.
PA-SE-005-003 PROVISION OF PRIMARY CARE SERVICES Purpose: Each participant will receive his or her primary medical care from a PACE medical provider. Policy: Each participant has a primary care physician
More informationHOSPICE POLICY UPDATE
#02-56-13 Bulletin June 24, 2002 Minnesota Department of Human Services # 444 Lafayette Rd. # St. Paul, MN 55155 OF INTEREST TO County Directors Administrative contacts AC, EW, CAC, CADI, TBI DD Waiver
More informationFIDA. Care Management for ALL
Care Management for ALL In 2011, Governor Andrew M. Cuomo established a Medicaid Redesign Team (MRT), which initiated significant reforms to the state s Medicaid program. This included a critical initiative
More informationRevised: November 2005 Regulation of Health and Human Services Facilities
Revised: November 2005 Regulation of Health and Human Services Facilities This guidebook provides an overview of state regulation of residential facilities that provide support services for their residents.
More informationServices Covered by Molina Healthcare
Services Covered by Molina Healthcare Because you are covered by Medicaid, you pay nothing for covered services. As a Molina Healthcare member, you will continue to receive all medically necessary Medicaid-covered
More information2016 Member Incentive. Program Descriptions. Our mission is to improve the health and quality of life of our members
2016 Member Incentive Program Descriptions Our mission is to improve the health and quality of life of our members Member Incentive Program Descriptions I. Purpose Passport Health Plan (Passport) has developed
More information1.2 ADULT CLIENT INTAKE FORM: Client Information
1.2 ADULT CLIENT INTAKE FORM: Client Information FOR OFFICIAL USE ONLY: Client Number Effective Insurance No OH No CLIENT INFORMATION Client name of significant other CHILDREN INFORMATION of birth of birth
More informationMedical Management. G.2 At a Glance. G.2 Procedures Requiring Prior Authorization. G.3 How to Contact or Notify Medical Management
G.2 At a Glance G.2 Procedures Requiring Prior Authorization G.3 How to Contact or Notify G.4 When to Notify G.7 Case Management Services G.10 Special Needs Services G.12 Health Management Programs G.14
More informationMedical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management
G.2 At a Glance G.3 Procedures Requiring Prior Authorization G.5 How to Contact or Notify Medical Management G.6 When to Notify Medical Management G.11 Case Management Services G.14 Special Needs Services
More informationQUALITY IMPROVEMENT PROGRAM
QUALITY IMPROVEMENT PROGRAM EmblemHealth s mission is to create healthier futures for our customers and communities. We will do this by providing members with a broad range of benefits and conscientious
More informationComplete Senior Care Enrollment Agreement
Complete Senior Care Enrollment Agreement I have received the Enrollment Handbook and a copy of the Provider Network and have had the opportunity to ask questions. Name: Address: (First) (Middle) (Last)
More informationProvider Handbooks. Telecommunication Services Handbook
Provider Handbooks December 2016 Telecommunication Services Handbook The Texas Medicaid & Healthcare Partnership (TMHP) is the claims administrator for Texas Medicaid under contract with the Texas Health
More informationA Guide to Accessing Quality Health Care
A Guide to Accessing Quality Health Care Spring 2015 MolinaHealthcare.com 37894DM0115 Molina Healthcare s Quality Improvement Plan and Program Your health care is important to us. We want to hear how we
More informationLONG TERM CARE SETTINGS
LONG TERM CARE SETTINGS Long term care facilities assist aged, ill or disabled persons who can no longer live independently. In this section, we will briefly examine the history of long term care facilities
More informationTABLE OF CONTENTS. Primary Care 3. Child Health Services. 10. Women s Health Services. 13. Specialist Health Services 16. Mental Health Services.
TABLE OF CONTENTS Primary Care 3 Child Health Services. 10 Women s Health Services. 13 Specialist Health Services 16 Mental Health Services. 24 2 PRIMARY CARE What is it? Primary care is a patient's first
More informationHouseCalls Objectives
Overview Agenda Overview Objectives Background Case studies Member Experience Primary Care Provider Experience Referrals and Follow-up Influence on Centers for Medicare & Medicaid Services (CMS) Star Ratings
More informationSelect Summary YOU HAVE CHOICES ABOUT HOW TO GET YOUR MEDICARE BENEFITS TIPS FOR COMPARING YOUR MEDICARE CHOICES
INTRODUCTION TO THE SUMMARY OF BENEFITS FOR January 1, 2015 - December 31, 2015 Central Alabama and Mobile Area SECTION I INTRODUCTION TO THE SUMMARY OF BENEFITS This booklet gives you a summary of what
More informationMedicare: 2017 Model of Care Training 12/14/201 7
Medicare: 2017 Model of Care Training 12/14/201 7 What is the Model of Care? The Model of Care (MOC) is Allwell s plan for delivering our integrated care management program for members with special needs.
More informationPassport Advantage Provider Manual Section 10.0 Care Management
Passport Advantage Provider Manual Section 10.0 Care Management Table of Contents 10.1 Model of Care 10.2 Medication Therapy Management 10.3 Care Coordination 10.4 Complex Case Management Page 1 of 9 10.0
More informationHealth HAPPEN. Make. Prepare now to stay healthy during flu season. Inside
Inside How to lower your blood pressure Make Health HAPPEN Quarter 3, 2017 www.myamerigroup.com/medicare Prepare now to stay healthy during flu season Influenza, also known as the flu, can make you feel
More informationAssessment Content Map
Purpose: Provides an outline of the MnCHOICES Assessment to help certified assessors locate and become familiar with the content of the Assessment document. A Person Information Reason for Contact & Referral
More informationTriennial Compliance Assessment. HealthPartners. Performed under Interagency Agreement for: Minnesota Department of Human Services
Triennial Compliance Assessment Of HealthPartners Performed under Interagency Agreement for: Minnesota Department of Human Services By Minnesota Department of Health (MDH) Managed Care Systems Section
More informationSummary Of Benefits. IDAHO Ada, Bannock, Bingham, Bonner, Bonneville, Canyon, Kootenai, Nez Perce, and Twin Falls
Summary Of Benefits IDAHO Ada, Bannock, Bingham, Bonner, Bonneville, Canyon, Kootenai, Nez Perce, and Twin Falls 2018 Molina Medicare Options Plus (HMO SNP) (844) 239-4913, TTY/TDD 711 7 days a week, 8
More informationThe Healthy Michigan Plan Handbook
The Healthy Michigan Plan Handbook Introduction The Healthy Michigan Plan is a health care program through the Michigan Department of Community Health (MDCH). The Healthy Michigan Plan provides health
More informationPatient and Family Caregiver Interview Tool
Patient and Family Caregiver Interview Tool Instructions: We recommend you select at least 5-10 patients who have been readmitted to your organization within the past 30 days to include in the group of
More informationPPC2: Patient Tracking and Registry Functions
PPC2: Patient Tracking and Registry Functions Element F: Use of System for Population Management At we use our EMR, clinical event manager, and the ad hoc reporting system (Business Objects) for a multi-pronged
More informationINFORMED CONSENT FOR TREATMENT
INFORMED CONSENT FOR TREATMENT I (name of client) agree and consent to participate in behavioral healthcare services offered and provided by Methodist Services - Community Counseling Services (CCS). I
More informationSUMMARY OF BENEFITS 2009
HEALTH NET VIOLET OPTION 1, HEALTH NET VIOLET OPTION 2, HEALTH NET SAGE, AND HEALTH NET AQUA SUMMARY OF BENEFITS 2009 Southern Oregon Douglas, Jackson, and Josephine Counties, Oregon Benefits effective
More informationMedicaid Home- and Community-Based Waiver Programs
INFORMATION BRIEF Research Department Minnesota House of Representatives 600 State Office Building St. Paul, MN 55155 Danyell Punelli, Legislative Analyst 651-296-5058 Updated: October 2016 Medicaid Home-
More informationMEDICARE CARE1ST DUAL PLUS PLAN SUMMARY OF BENEFITS.
ine 1-800-544-0088 www.care1st.com CARE1ST DUAL PLUS PLAN SUMMARY OF BENEFITS MEDICARE 2009 COUNTIES: LOS ANGELES - ORANGE - SAN BERNARDINO - SAN DIEGO H5928_09_004_SNP_SB 10/2008 Section I Introduction
More informationServices Covered by Molina Healthcare
Services Covered by Molina Healthcare As a Molina Healthcare member, you will continue to receive all medically-necessary Medicaid-covered services at no cost to you. The following list of covered services
More informationAppendix B: Service and Support Plan (SSP) Template
Appendix B: Service and Support Plan (SSP) Template 3/1/16 Mi Via SSP Page 1 of 41 Mi Via Service and Support Plan INSTRUCTIONS The new Service and Support Plan (SSP) is organized by four (4) categories
More informationBenefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH PLANS INC.
Benefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN FEATURES Network Providers Annual Maximum Out-of-Pocket Amount $2,500 The maximum out-of-pocket limit applies to all
More informationCATARACT AND LASER CENTER, LLC
CATARACT AND LASER CENTER, LLC Patient Information Date: Patient Name: M F Address: Street City State Zip Home Phone: Work Phone: Cell Phone: E-Mail : Referred by: Medical Doctor: Who is your regular eye
More informationNetworkCares (PPO SNP) 2017 Model of Care Training. H5215_360r2_ NHIC 01/2017 m-hm-ncprovpres-0117
NetworkCares (PPO SNP) 2017 Model of Care Training H5215_360r2_092714 NHIC 01/2017 m-hm-ncprovpres-0117 Introduction This course is offered to meet the CMS regulatory requirements for Model of Care Training
More informationPassport Advantage Provider Manual Section 8.0 Quality Improvement
Passport Advantage Provider Manual Section 8.0 Quality Improvement Table of Contents 8.1 Quality Improvement Program 8.2 Clinical Practice Guidelines 8.3 Star s 8.4 Quality of Care Concerns 8.3 Practitioner
More informationSummary Of Benefits. WASHINGTON Pierce and Snohomish
Summary Of Benefits WASHINGTON Pierce and Snohomish 2018 Molina Medicare Choice (HMO SNP) (800) 665-1029, TTY/TDD 711 7 days a week, 8 a.m. 8 p.m. local time H5823_18_1099_0007_WAChoSB Accepted 9/26/2017
More informationmobility plus application package SECTION A: For completion by applicant
SECTION A: For completion by applicant York Region s shared ride, door-to-door, accessible public transit service for people with disabilities mobility plus application package Mobility Plus Application
More informationRyan White Part A. Quality Management
Quality Management Mental Health Services Broward County/Fort Lauderdale Eligible Metropolitan Area (EMA) The creation of this public document is fully funded by a federal Ryan White CARE Act Part A grant
More informationBenefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
The maximum out-of-pocket limit applies to all covered Medicare Part A and B benefits including deductible. Primary Care Physician Selection Optional There is no requirement for member pre-certification.
More informationSection IX Special Needs & Case Management
Section IX Special Needs & Case Management Special Needs and Case Management 181 Integrated Health Care Management (IHCM) The Integrated Health Care Management (IHCM) program is a population-based health
More informationHEALTH HISTORY QUESTIONNAIRE
Patient Name: of Birth: HEALTH HISTORY QUESTIONNAIRE Primary Care Physician: Other physicians you currently see: Emergency Phone #: Contact Person/Relationship: Reason for the Visit: Please list your medications
More informationChapter 2 Provider Responsibilities Unit 6: Behavioral Health Care Specialists
Chapter 2 Provider Responsibilities Unit 6: Health Care Specialists In This Unit Unit 6: Health Care Specialists General Information 2 Highmark s Health Programs 4 Accessibility Standards For Health Providers
More information2018 PROVIDER TOOLKIT
1100 Circle 75 Parkway Suite 1100 Atlanta, GA 30339 2018 PROVIDER TOOLKIT Understanding the Centers for Medicare and Medicaid (CMS) Stars Rating System What is CMS Quality Star Ratings program? CMS evaluates
More informationBEHAVIORAL HEALTH RETROSPECTIVE CLINICAL REVIEW FORM
BEHAVIORAL HEALTH RETROSPECTIVE CLINICAL REVIEW FORM (Please address each area. An incomplete form may result in a delay of your request.) Submit completed form to: MCO EMAIL/FAX # Date Form Completed:
More informationSchool Health Support Services Access to Care so Students Can Go on Learning
School Health Support Services Access to Care so Students Can Go on Learning Our School Health Support Services program ensures that children and youth receive the medical care or rehabilitation services
More informationMAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Patient Name: Date: Date of Birth: SSN: Male Female Guarantor Name: SSN: DOB: Home Phone: Cell Phone: Street Address: Apt#: City: State: Zip: Billing Address (if different): Email
More informationDEPARTMENT OF HEALTH AND HUMAN RESOURCES
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 2699 Park Avenue, Suite 100 Huntington, WV 25704 Earl Ray Tomblin Michael J. Lewis, M.D., Ph.
More informationPCMH 2014 Record Review Workbook (RRWB)
PCMH 2014 Record Review Workbook (RRWB) Purpose of the Record Review Workbook (RRWB) There are three elements in PCMH 2014 that require an accurate estimate of the percentage of patients for whom practices
More informationFor more information on the FMLA, visit the Department of Labor s website at https://www.dol.gov/whd/fmla/
For Office Use Only CERTIFICATION OF FAMILY AND MEDICAL LEAVE FOR FAMILY MEMBER S SERIOUS HEALTH CONDITION Person ID: ACSD: UDDS: Date Received: SECTION I: For Completion by the EMPLOYEE Employee s Name:
More information10/14/2014 COMMON MDS CODING ERRORS OVERVIEW OF SS/ACT SECTIONS SECTION B
COMMON MDS CODING ERRORS K AT H Y Y O S T E N, L C S W, P I P OVERVIEW OF SS/ACT SECTIONS Section B Vision, Speech, Hearing Section C Cognitive Patterns Section D Mood Section E Behaviors Section F Preferences
More informationMEDICAL REQUEST FOR HOME CARE
MEDICAL REQUEST FOR HOME CARE HCSP- M11Q 12/09/2014 Return Completed Form to: 1. CLIENT INFORMATION GSS District Office Address Zip Code Attn: Case Load No. Borough Tel. No. Date Returned to/received bygss
More informationCertification of Health Care Provider for Family Member's Serious Health Condition (Family and Medical Leave Act)
1 Horry County Human Resources Department 1301 Second Avenue Conway, SC 29526 Post Office Box 997 Conway, SC 29528-0296 Phone: (843) 915-5230 Fax: (843) 915-6230 E-mail: hagemeid@horrycounty.org bellamyf@horrycounty.org
More informationFALLON TOTAL CARE. Enrollee Information
Enrollee Information FALLON TOTAL CARE- Current Edition 12/2012 2 The following section provides an overview on FTC enrollee rights and responsibilities, appeals and grievances and resources available
More informationRyan White Part A Quality Management
Quality Management Mental Health Services Broward County/Fort Lauderdale Eligible Metropolitan Area (EMA) The creation of this public document is fully funded by a federal Ryan White CARE Act Part A grant
More informationCMS-3819-F Condition of participation: Reporting OASIS information. (a) Standard: Encoding and transmitting OASIS data. An HHA must encode
CMS-3819-F 319 OASIS information to the public. 484.45 Condition of participation: Reporting OASIS information. HHAs must electronically report all OASIS data collected in accordance with 484.55. (a) Standard:
More information2015 Member Incentive. Program Evaluation. Our mission is to improve the health and quality of life of our members
25 Member Incentive Program Evaluation Our mission is to improve the health and quality of life of our members 25 Member Incentive Program Evaluation Annual Participation Rate Program Title: Member Incentive
More informationAdult Learning. Initiation Client identifies adult learning need(s). Date
Birth Adult Learning Client identifies adult learning need(s). Date Partner with client to establish and review educational and/or career goals. Document goal(s) and desired outcome(s). Goals: Assist client
More informationCare Management Policies
POLICY: Category: Care Management Policies Care Management 2.1 Patient Tracking and Registry Functions Effective Date: Est. 12/1/2010 Revised Date: Purpose: To ensure management and monitoring of patient
More informationSummary Of Benefits. FLORIDA Broward, Hillsborough, Miami-Dade, Palm Beach, Pinellas, and Polk
Summary Of Benefits FLORIDA Broward, Hillsborough, Miami-Dade, Palm Beach, Pinellas, and Polk 2018 Molina Medicare Options Plus (HMO SNP) (866) 553-9494, TTY/TDD 711 7 days a week, 8 a.m. 8 p.m. local
More informationSERVICES COVERAGE LIMITS/ EXCLUSIONS Alcohol, Drug, and Substance Abuse Services
SERVICES COVERAGE LIMITS/ EXCLUSIONS Alcohol, Drug, and Substance Abuse Services Alcohol, drug, and substance abuse treatment services are provided by the Department of Alcohol and Other Drug Abuse Services
More informationPage 1 of 5 ADMINISTRATIVE POLICY AND PROCEDURE
Page 1 of 5 SECTION: Recipient Rights SUBJECT: Services Suited to Condition DATE OF ORIGIN: 4/30/97 REVIEW DATES: 6/28/98, 7/1/01, 2/1/04, 3/1/05, 10/1/05, 6/1/08, 7/15/13, 10/4/14, 6/15/15, 5/27/16, 4/25/17
More informationMnCHOICES Assessment and Support Plan
MnCHOICES Assessment and Support Plan 11/01/2017 Minnesota Department of Human Services mn.gov/dhs 1 Beyond Assessment: Integration of assessment and support plan application State and federal requirements
More informationPatient Name:,, Address: Phones:,, Home Work Cell. Primary Physician: Emergency Contact: Phone#:
Patient Information Patient Name:,, Last First middle initial Address: Phones:,, Home Work Cell Sex: Female Male E-Mail: Date of Birth: / / Mo. Day Year Primary Physician: Marital Status: Single Married
More informationPractice Transformation: Patient Centered Medical Home Overview
Practice Transformation: Patient Centered Medical Home Overview Megan A. Housley, MBA Business Development Director Kentucky Regional Extension Center The Triple Aim Population Health TRIPLE AIM Per Capita
More informationTITLE: Processing Provider Orders: Inpatient and Outpatient
POLICY and PROCEDURE TITLE: Processing Provider Orders: Inpatient and Outpatient Number: 13211 Version: 13211.10 Type: Patient Care Author: Carol Vanetti; Provider Order Policy Committee Effective Date:
More informationBenefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
Benefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN FEATURES Network & Out-of- Annual Deductible This is the amount you have to pay out of pocket before the plan will pay
More informationHealthPartners Freedom Plan (Cost) 2011 Medical Summary of Benefits Wisconsin
HealthPartners Freedom Plan 2011 Medical Summary of Benefits Wisconsin HealthPartners Wisconsin Freedom Plan I HealthPartners Wisconsin Freedom Plan II 420421 (10/10) H2462_SB WI_151 CMS Approved 10/5/10
More informationProviderReport. Managing complex care. Supporting member health.
ProviderReport Supporting member health Managing complex care Do you have patients whose conditions need complex, coordinated care they may not be able to facilitate on their own? A care manager may be
More informationCMHC Conditions of Participation
CMHC Conditions of Participation Mary Rossi-Coajou Center for Clinical Standards and Quality/Clinical Standards Group The Centers for Medicare and Medicare Services March 4,2014 Key Themes The CMHC NPRM
More informationHealthPartners Minnesota Senior Health Options (MSHO) (HMO SNP)
2013 HealthPartners MSHO Summary of Benefits HealthPartners Minnesota Senior Health Options (MSHO) (HMO SNP) 420089 Individual MSHO (9/12) H2422_54016 CMS Accepted 9/1/2012 H2422 American Indian Language
More information5/1/2017 THE BEST DEFENSE IS A GOOD OFFENSE OBJECTIVES. Preparing for a Home Health Medicare Recertification Survey
THE BEST DEFENSE IS A GOOD OFFENSE Preparing for a Home Health Medicare Recertification Survey OBJECTIVES To gain an understanding how the Medicare Conditions of Participation (CoPs), the individual G-tags,
More informationTELECOMMUNICATION SERVICES CSHCN SERVICES PROGRAM PROVIDER MANUAL
TELECOMMUNICATION SERVICES CSHCN SERVICES PROGRAM PROVIDER MANUAL NOVEMBER 2017 CSHCN PROVIDER PROCEDURES MANUAL NOVEMBER 2017 TELECOMMUNICATION SERVICES Table of Contents 38.1 Enrollment......................................................................
More information