Comprehensive Case Management Including Coordination of Care Services. Contractor shall ensure the provision of Comprehensive Medical Case Management to each Member. Contractor shall maintain procedures for monitoring the coordination of care provided to Members, including but not limited to all Medically Necessary services delivered both within and outside the Contractor's provider network. These services are provided through either basic or complex case management activities based on the medical needs of the member.
A. Basic Case Management Services are provided by the Primary Care Provider, in collaboration with the Contractor, and shall include:
1) Initial Health Assessment (IHA);
2) Individual Health Education Behavioral Assessment (IHEBA);
3) Identification of appropriate providers and facilities (such as medical, rehabilitation, and support services) to meet Member care needs;
4) Direct communication between the provider and Member/family;
5) Member and family education, including healthy lifestyle changes when warranted; and
6) Coordination of carved out and linked services, and referral to appropriate community resources and other agencies.
B. Complex Case Management Services are provided by the Contractor, in collaboration with the Primary Care Provider, and shall include, at a minimum:
1) Basic Case Management Services
2) Management of acute or chronic illness, including emotional and social support issues by a multidisciplinary case management team
3) Intense coordination of resources to ensure member regains optimal health or improved functionality
4) With Member and PCP input, development of care plans specific to individual needs, and updating of these plans at least annually
C. Contractor shall develop methods to identify Members who may benefit from complex case management services, using utilization data, the Health Information Form (HIF)/Member Evaluation Tool (MET), clinical data, and any other available data, as well as self and physician referrals. Complex case management services for SPD beneficiaries must include the concepts of Person-Centered Planning.
