Case Management for Members Receiving Behavioral Health Services Sample Clauses

Case Management for Members Receiving Behavioral Health Services. The Contractor shall employ or contract with case managers with training, expertise and experience in providing case management services for members receiving behavioral health services. At a minimum, the Contractor shall provide case management services for any member at risk for inpatient psychiatric or substance abuse hospitalization, and for members discharged from an inpatient psychiatric or substance abuse hospitalization, for no fewer than ninety (90) calendar days following that inpatient hospitalization. Case managers shall contact members during an inpatient hospitalization, or immediately upon receiving notification of a member’s inpatient behavioral health hospitalization, and shall schedule an outpatient follow-up appointment to occur no later than seven (7) calendar days following the inpatient behavioral health hospitalization discharge. Case managers should use the results of health needs screenings and more detailed comprehensive health assessments to identify members in need of case management services. Case managers shall also monitor members receiving behavioral health services who are new to the Contractor’s plan to ensure that the member is expediently linked to an appropriate behavioral health provider. The case manager shall monitor whether the member is receiving appropriate services and whether the member is at risk of over- or under-utilizing services. OMPP shall provide access to its web-based interface CoreMMIS to allow the Contractor to monitor MRO utilization, which is covered by Medicaid FFS. Case managers shall regularly and routinely consult with both the member’s physical and behavioral health providers to facilitate the sharing of clinical information, and the development and maintenance of a coordinated physical health and behavioral health treatment plan for the member. In addition, with the appropriate consent, case managers shall notify both PMPs and behavioral health providers when a member is hospitalized or receives emergency treatment for behavioral health issues, including substance abuse. Case managers shall provide this notification within five (5) calendar days of the hospital admission or emergency treatment. Documentation of case management procedures, contacts, interventions and outcomes shall be made available to OMPP upon request.
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Case Management for Members Receiving Behavioral Health Services. The Contractor shall employ or contract with case managers with training, expertise and experience in providing case management services for members receiving behavioral health services. At a minimum, the Contractor shall offer to provide complex case management services to any member at risk for inpatient psychiatric or substance abuse hospitalization, and to members discharged from an inpatient psychiatric or substance abuse hospitalization, for no fewer than ninety (90) calendar days following that inpatient hospitalization. Case managers shall contact EXHIBIT 1. A SCOPE OF WORK
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Case Management for Members Receiving Behavioral Health Services. The Contractor shall employ or contract with case managers with training, expertise and experience in providing case management services for members receiving behavioral health services. At a minimum, the Contractor shall provide case management services for any member at risk for inpatient psychiatric or substance abuse hospitalization, and for members discharged from an inpatient psychiatric or substance abuse hospitalization, for no fewer than ninety (90) calendar days following that inpatient hospitalization. Case managers shall contact members during an inpatient hospitalization, or immediately upon schedule an outpatient follow-up appointment to occur no later than seven (7) calendar days following the inpatient behavioral health hospitalization discharge. Case managers should use the results of health needs screenings and more detailed comprehensive health assessments to identify members in need of case management services. Case managers shall also monitor members receiving behavioral health linked to an appropriate behavioral health provider. The case manager shall monitor whether the member is receiving appropriate services and whether the member is at risk of over- or under-utilizing services. OMPP shall provide access to its web-based interface CoreMMIS to allow the Contractor to monitor MRO utilization, which is covered by Medicaid FFS. behavioral health providers to facilitate the sharing of clinical information, and the development and maintenance of a coordinated physical health and behavioral health treatment plan for the member. In addition, with the appropriate consent, case managers shall notify both PMPs and behavioral health providers when a member is hospitalized or receives emergency treatment for behavioral health issues, including substance abuse. Case managers shall provide this notification within five (5) calendar days of the hospital admission or emergency treatment. Documentation of case management procedures, contacts, interventions and outcomes shall be made available to OMPP upon request.
Sample 1

Related to Case Management for Members Receiving Behavioral Health Services

  • Clinical Management for Behavioral Health Services (CMBHS) System 1. request access to CMBHS via the CMBHS Helpline at (000) 000-0000. 2. use the CMBHS time frames specified by System Agency. 3. use System Agency-specified functionality of the CMBHS in its entirety. 4. submit all bills and reports to System Agency through the CMBHS, unless otherwise instructed.

  • Behavioral Health Services Behavioral health services include the evaluation, management, and treatment for a mental health or substance use disorder condition. For the purpose of this plan, substance use disorder does not include addiction to or abuse of tobacco and/or caffeine. Mental health or substance use disorders are those that are listed in the most updated volume of either: • the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association; or • the International Classification of Disease Manual (ICD) published by the World Health Organization. This plan provides parity in benefits for behavioral healthcare services. Please see Section 10 for additional information regarding behavioral healthcare parity. This plan covers behavioral health services if you are inpatient at a general or specialty hospital. See Inpatient Services in Section 3 for additional information. This plan covers services at behavioral health residential treatment facilities, which provide: • clinical treatment; • medication evaluation management; and • 24-hour on site availability of health professional staff, as required by licensing regulations. This plan covers intermediate care services, which are facility-based programs that are: • more intensive than traditional outpatient services; • less intensive than 24-hour inpatient hospital or residential treatment facility services; and • used as a step down from a higher level of care; or • used a step-up from standard care level of care. Intermediate care services include the following: • Partial Hospital Program (PHP) – PHPs are structured and medically supervised day, evening, or nighttime treatment programs providing individualized treatment plans. A PHP typically runs for five hours a day, five days per week. • Intensive Outpatient Program (IOP) – An IOP provides substantial clinical support for patients who are either in transition from a higher level of care or at risk for admission to a higher level of care. An IOP typically runs for three hours per day, three days per week.

  • Mental Health Services This agreement covers medically necessary services for the treatment of mental health disorders in a general or specialty hospital or outpatient facilities that are: • reviewed and approved by us; and • licensed under the laws of the State of Rhode Island or by the state in which the facility is located as a general or specialty hospital or outpatient facility. We review network and non-network programs, hospitals and inpatient facilities, and the specific services provided to decide whether a preauthorization, hospital or inpatient facility, or specific services rendered meets our program requirements, content and criteria. If our program content and criteria are not met, the services are not covered under this agreement. Our program content and criteria are defined below.

  • Health Services At the time of employment and subject to (b) above, full credit for registered professional nursing experience in a school program shall be given. Full credit for registered professional nursing experience may be given, subject to approval by the Human Resources Division. Non-degree nurses shall be placed on the BA Track of the Teachers Salary Schedule and shall be ineligible for movement to any other track.

  • Surgery Services This plan covers surgery services to treat a disease or injury when: • the operation is not experimental or investigational, or cosmetic in nature; • the operation is being performed at the appropriate place of service; and • the physician is licensed to perform the surgery. This plan covers reconstructive surgery and procedures when the services are performed to relieve pain, or to correct or improve bodily function that is impaired as a result of: • a birth defect; • an accidental injury; • a disease; or • a previous covered surgical procedure. Functional indications for surgical correction do not include psychological, psychiatric or emotional reasons. This plan covers the procedures listed below to treat functional impairments. • abdominal wall surgery including panniculectomy (other than an abdominoplasty); • blepharoplasty and ptosis repair; • gastric bypass or gastric banding; • nasal reconstruction and septorhinoplasty; • orthognathic surgery including mandibular and maxillary osteotomy; • reduction mammoplasty; • removal of breast implants; • removal or treatment of proliferative vascular lesions and hemangiomas; • treatment of varicose veins; or • gynecomastia.

  • Disease Management If you have a chronic condition such as asthma, coronary heart disease, diabetes, congestive heart failure, and/or chronic obstructive pulmonary disease, we’re here to help. Our tools and information can help you manage your condition and improve your health. You may also be eligible to receive help through our care coordination program. This voluntary program is available at no additional cost you. To learn more about disease management, please call (000) 000-0000 or 0-000-000-0000. Our entire contract with you consists of this agreement and our contract with your employer. Your ID card will identify you as a member when you receive the healthcare services covered under this agreement. By presenting your ID card to receive covered healthcare services, you are agreeing to abide by the rules and obligations of this agreement. Your eligibility for benefits is determined under the provisions of this agreement. Your right to appeal and take action is described in Appeals in Section 5. This agreement describes the benefits, exclusions, conditions and limitations provided under your plan. It shall be construed under and shall be governed by the applicable laws and regulations of the State of Rhode Island and federal law as amended from time to time. It replaces any agreement previously issued to you. If this agreement changes, an amendment or new agreement will be provided.

  • Service Management Effective support of in-scope services is a result of maintaining consistent service levels. The following sections provide relevant details on service availability, monitoring of in-scope services and related components.

  • Virus Management DST shall maintain a malware protection program designed to deter malware infections, detect the presence of malware within DST environment.

  • Pharmacy Services The Contractor shall establish a network of pharmacies. The Contractor or its PBM must provide at least two (2) pharmacy providers within thirty (30) miles or thirty (30) minutes from a member’s residence in each county, as well as at least two (2) durable medical equipment providers in each county or contiguous county.

  • Radiation Therapy/Chemotherapy Services This plan covers chemotherapy and radiation services. This plan covers respiratory therapy services. When respiratory services are provided in your home, as part of a home care program, durable medical equipment, supplies, and oxygen are covered as a durable medical equipment service.

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