Common use of CARE MANAGEMENT AND COORDINATION Clause in Contracts

CARE MANAGEMENT AND COORDINATION. 5.1. General Care Management and Coordination Requirements As part of the Care Management System, the CONTRACTOR shall be responsible for the management, coordination, and Continuity of Care for all its Membership and shall develop and maintain a Programmatic-Level of Policies and Procedures to address this responsibility. The CONTRACTOR shall: 5.1.1. Make a best effort to conduct an initial screen of each Enrollee’s needs, within 90 Days of the effective date of Enrollment for all new Enrollees, including subsequent attempts if the initial attempt to contact the Enrollee is unsuccessful. 5.1.2. Utilize appropriate assessment tools and Health Care Professionals in assessing a members physical and Behavioral Health care needs. 5.1.3. Develop Programmatic-Level Policies and Procedures for Care Management and Coordination of services. 5.1.4. Use Care Management and Coordination as a continuous process for: 5.1.4.1. The assessment of a Member’s physical health, Behavioral Health and social support service and assistance needs, 5.1.4.2. The identification of physical health services, Behavioral Health Services and other social support services and assistance necessary to meet identified needs, and 5.1.4.3. The assurance of timely access to and provision, coordination and monitoring of the identified services associated with physical health, Behavioral Health, and social support service and assistance to help the member maintain or improve his or her health status. 5.2. National Standards Requirements The CONTRACTOR’s Care Management Program and Care Coordination activities shall conform to the requirements and industry standards stipulated in the NCQA requirements for complex Case Management and by the Standards of Practice of Case Management released by the Case Management Society of America (CMSA). 5.2.1. Complex Case Management Standards (NCQA) The CONTRACTOR’s shall: 5.2.1.1. Develop a detailed Program description for complex Case Management. 5.2.1.2. Have Policies and Procedures for the assessment of characteristics and needs of its Member population (including children/adolescents, individuals with disabilities and individuals with Serious and Persistent Mental Illness (SPMI), and/or Serious Emotional Disorders (SED)). 5.2.1.3. Have a Case Management System based on sound evidence. 5.2.1.4. Have a systematic process for identifying Members with complex conditions and referring them for Case Management services. 5.2.1.5. Determine the need for enhanced services that may be necessary for the member enrolled with the CONTRACTOR. 5.2.1.6. Have a mechanism in place to allow a member direct access to a specialist as appropriate for the members condition and needs. 5.2.1.7. Have automated systems to support the Case Management staff. 5.2.1.8. Have a Case Management System that ensures appropriate documentation and follow-up. 5.2.1.9. Have a Case Management System with processes for initial assessment and ongoing management of members. 5.2.1.10. Measure its performance and member satisfaction. 5.2.1.11. Have Procedures to improve performance when necessary. 5.2.1.12. Have a process to review and revise care planning and Case Management at least once every twelve (12) months or when the members circumstances or needs change significantly or at the request of the member. 5.3. Member Risk Stratification Requirements The CONTRACTOR shall stratify its Members based on risk.

CARE MANAGEMENT AND COORDINATION. 5.1. General Care Management and Coordination Requirements As part of the Care Management System, the CONTRACTOR shall be responsible for the management, coordination, and Continuity of Care for all its Membership and shall develop and maintain a Programmatic-Level of Policies and Procedures to address this responsibility. The CONTRACTOR shall: 5.1.1. Make a best effort to conduct an initial screen of each Enrollee’s needs, within 90 ninety (90) Days of the effective date of Enrollment for all new Enrollees, including subsequent attempts if the initial attempt to contact the Enrollee is unsuccessful. 5.1.2. Utilize appropriate assessment tools and Health Care Professionals in assessing a members physical and Behavioral Health care needs. 5.1.3. Develop Programmatic-Level Policies and Procedures for Care Management and Coordination of services. 5.1.4. Use Care Management and Coordination as a continuous process for: 5.1.4.1. The assessment of a Member’s physical health, Behavioral Health and social support service and assistance needs, 5.1.4.2. The identification of physical health services, Behavioral Health Services and other social support services and assistance necessary to meet identified needs, and 5.1.4.3. The assurance of timely access to and provision, coordination and monitoring of the identified services associated with physical health, Behavioral Health, and social support service services and assistance to help the member maintain or improve his or her health status. 5.2. National Standards Requirements The CONTRACTOR’s Care Management Program and Care Coordination activities shall conform to the requirements and industry standards stipulated in the NCQA requirements for complex Case Management and by the Standards of Practice of Case Management released by the Case Management Society of America (CMSA). 5.2.1. Complex Case Management Standards (NCQA) The CONTRACTOR’s CONTRACTOR shall: 5.2.1.1. Develop a detailed Program description for complex Case Management. 5.2.1.2. Have Policies and Procedures for the assessment of characteristics and needs of its Member population (including children/adolescents, individuals with disabilities and individuals with Serious and Persistent Mental Illness (SPMI), and/or Serious Emotional Disorders (SED)). 5.2.1.3. Have a Case Management System based on sound evidence. 5.2.1.4. Have a systematic process for identifying Members with complex conditions and referring them for Case Management services. 5.2.1.5. Determine the need for enhanced services that may be necessary for the member enrolled with the CONTRACTOR. 5.2.1.6. Have a mechanism in place to allow a member direct access to a specialist as appropriate for the members condition and needs. 5.2.1.7. Have an automated systems to support the Case Management staff. 5.2.1.8. Have a Case Management System that ensures appropriate documentation and follow-up. 5.2.1.9. Have a supporting Case Management System staff with processes for initial assessment and ongoing management of members. The Case Management System shall: 5.2.1.7.1. Ensure appropriate documentation and follow-up. 5.2.1.105.2.1.7.2. Measure its performance and member satisfaction. 5.2.1.115.2.1.8. Have Procedures to improve performance when necessary. 5.2.1.125.2.1.9. Have a process to review and revise care planning and Case Management at least once every twelve (12) months or when the members circumstances or needs change significantly or at the request of the member. 5.3. Member Risk Stratification Requirements The CONTRACTOR shall stratify its Members based on risk.