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Part 101      TARGETED CASE MANAGEMENT SERVICES FOR PERSONS WITH MENTAL RETARDATION AND/OR RELATED CONDITIONS

317:30-5-1010.Eligible providers

[Revised 06-25-09]
(a) Eligible providers. Services are provided by Oklahoma Department of Human Services (OKDHS) Developmental Disabilities Services Division (DDSD) case managers.
(1) Certification requirements. SoonerCare Developmental Disabilities Services Division Targeted Case Management (DDSDTCM) services must be made available to all eligible members and must be delivered on a statewide basis with procedures that assure 24 hour availability, the protection and safety of members, continuity of services without duplication, and compliance with federal and State mandates and regulations related to servicing the targeted population are met in a uniform and consistent manner. A DDSDTCM case manager must:
(A) be employed by the OKDHS, DDSD. 
(B) possess knowledge of:
(i) case management methods, principles and techniques;
(ii) types of developmental disabilities represented within the caseload;
(iii) types of providers and services available for members;
(iv) the behavioral sciences and allied disciplines involved in the evaluation, care and training of persons with developmental disabilities;
(v) interviewing principles and techniques;
(vi) counseling principles and techniques; and
(vii) adaptive communication techniques and non-verbal communication.
(C) possess skill in:
(i) managing a caseload;
(ii) effectively intervening in crisis situations;
(iii) working cooperatively and effectively with other professionals in a team situation;
(iv) collecting and analyzing information;
(v) making decisions relating to services provided to members;
(vi) developing a logical and practical plan of treatment for members with developmental disabilities;
(vii) evaluating the progress of members and the quality of their habilitation programs;
(viii) communicating effectively; and
(ix) mediating with providers and agencies to resolve problems.
(b) Provider agreement. A Provider Agreement between the Oklahoma Health Care Authority and the provider for DDSDTCM services must be in effect before reimbursement can be made for compensable services.
(c) Provider selection. Target group consists of eligible members with developmental disabilities. Providers are limited to providers of case management services capable of ensuring that members with developmental disabilities receive needed services.

 

317:30-5-1010.1.Scope of service

[Revised 06-25-09]
(a) Description of targeted case management services.
(1) Case management services are services furnished to assist members, eligible under the Medicaid State Plan, in gaining access to needed medical, social, educational and other services. Case management includes the following assistance:
(A) assessment of a member to determine the need for medical, educational, social, or other services. Assessment activities include:
(i) taking member history;
(ii) identifying the member's needs and completing related documentation; and
(iii) gathering information from other sources such as family members, medical providers, social workers, and educators to form a complete assessment of the member.
(B) development of an individual plan and a specific plan of care that:
(i) are based on the information collected through the assessment;
(ii) specify the goals and actions to address medical, social, educational, and other services needed by the member;
(iii) include activities such as ensuring the active participation of the eligible member; and work with the member or member's authorized health care decision maker, and others to develop the goals; and
(iv) identify a course of action to respond to the assessed needs of the eligible member.
(C) referral and related activities to help an eligible member obtain needed services including activities that help link a member with:
(i) medical, social, educational providers; or
(ii) other programs and services capable of providing needed services, such as making referrals to providers for needed services and scheduling appointments for the member.
(D) monitoring and follow-up activities include activities and contact necessary to ensure the individual plan and the plan of care are implemented and adequately address the member's needs. Activities and contact may be with the member, his or her family members, providers, other entities or individuals, and may be conducted as frequently as necessary including at least one annual monitoring to assure the following conditions are met:
(i) services are being furnished in accordance with the member's plan of care;
(ii) services in the plan of care are adequate; and
(iii) if there are changes in the needs or status of the member, necessary adjustments are made to the plan of care, and to service arrangements with providers.
(2) Case management may include contact with individuals who are directly related to identifying the needs and supports for helping the eligible member to access services.
(b) Targeted Case Management Service Requirements. DDSD assures that:
(1) case management services are provided in a manner consistent with the best interest of members and are not used to restrict a member's access to other services under the plan;
(2) members are not compelled to receive case management services, condition receipt of case management services on the receipt of other SoonerCare services, or condition receipt of other SoonerCare services on receipt of case management services;
(3) case management conducts activities to ensure the health and welfare of HCBS waiver members. For members who refuse case management services, these activities are completed as follows:
(A) the member develops an Individual Plan (IP) per OAC 340:100-5-50 through 340:100-5-58.
(B) the member develops a plan of care requesting authorization for services and submits it with the IP to the Developmental Disabilities Services Division (DDSD) plan of care reviewer for review and approval per OAC 340:100-3-33 and OAC 340:100-3-33.1.
(C) monthly progress reports, incident reports, OKDHS form 06HM005E, OKDHS form 06HM006E, and other documentation required to be submitted to case management are submitted to the DDSD state office program manager for case management for monitoring and follow-up per OAC 340:100-3-27.
(D) monitoring visits required by OAC 340:100-3-27 are conducted by DDSD Quality Assurance staff.
(E) the DDSD state office program manager assigns staff responsibility for maintaining the record in Client Contact Manager (CCM), obtaining necessary documents from the member and others for continuing service eligibility, providing information regarding available HCBS Waiver providers, making referrals to other programs and identifying training available to assist the member in completing the required tasks.
(4) providers of case management services do not exercise the agency's authority to authorize or deny the provision of other services under the plan.
(c) Non-Duplication of services. To the extent any eligible members in the identified target population are receiving case management services from another provider agency as a result of being members of other covered target groups, the provider assures that case management activities are coordinated to avoid unnecessary duplication of service.

317:30-5-1011.Coverage by category
[Revised 06-25-12]
Payment is made for targeted case management service as set forth in this Section.
(1) Adults. Payment is made for services to persons with an intellectual disability and/or related conditions as follows:
(A) The target group for Developmental Disabilities Services Division Targeted Case Management (DDSDTCM) services are Medicaid eligible individuals:
(i) served by the Home and Community Based Waivers operated by the Department of Human Services/Developmental Disabilities Services Division (DHS/DDSD); or
(ii) residing in institutions who:
(I) have requested Home and Community Based Waiver services operated by DHS/DDSD, and
(II) receive targeted case management services during a transition period not to exceed 180 consecutive days immediately prior to entering the Waiver; or
(iii) who are being assessed for admission to the Home and Community Based Waiver operated by DHS/DDSD.
(B) Targeted case management services may be provided when the client, the client's family as appropriate, the client's legal representative and case manager have worked together to achieve a plan.
(2) Children. Services for children are the same as for adults.
(3) Individuals eligible for Part B of Medicare. Case Management Services provided to Medicare eligible recipients are filed directly with the fiscal agent.
317:30-5-1012.Reimbursement
[Revised 06-25-12]
(a) Reimbursement for DDSDTCM services is a unit rate based on the weekly cost per case for documented DDSDTCM services. The cost base consists of the annualized cost of case management staff including all applicable overhead and indirect service cost in accordance with the approved DHS cost allocation plan. A first year interim rate is computed by dividing the annual cost base by the projected number of units. Subsequent annual rates will include an adjustment based on previous years cost versus total billable amount. A unit of service is defined as one calendar week of targeted case management, provided that a minimum of one contact which meets the description of a targeted case management activity with or on behalf of the member has been documented during the week claimed. Payment is made on the basis of claims submitted for payment. The provider bills at the weekly unit rate for a documented unit of SoonerCare DDSDTCM services provided to each SoonerCare eligible member during the calendar week.
(b) Only one unit of DDSDTCM services may be billed for each SoonerCare eligible member per week while the member is receiving services under a DHS/DDSD HCBS Waiver or is in the transition process to receive those services. No more than twenty-six units of DDSDTCM may be provided and billed for each eligible SoonerCare member during their transition period from the institution. DHS/DDSD must provide documentation of all such transitional DDSDTCM services provided, indicating the date performed for each unit billed. In no case may DHS/DDSD bill for transitional and regular DDSDTCM services provided during the same week (i.e., if DDSD bills transitional DDSDTCM for the third week in June and the member is deinstitutionalized into the particular Waiver during the third week in June, DDSD cannot also bill for regular DDSDTCM for the third week in June). If DDSDTCM has been provided to an individual during such a transitional period but that individual dies before the placement into the community is made, decides to refuse the placement or the placement falls through, reimbursement is available.
(c) the billing week for DDSDTCM is Monday through Sunday.
317:30-5-1013.Billing
[Issued 8-01-97]
Billing for case management services is on Form HCFA1500. Claims should not be submitted until Medicaid eligibility of the individual has been determined. However, a claim must be received by OHCA within 12 months of the date of service. If the eligibility of the individual has not been determined after ten months from the date of service, a claim must be submitted in order to assure that the claim is timely filed and reimbursement from Title XIX funds can be made should the individual be determined eligible at a later date.

317:30-5-1014.Documentation of records
[Revised 06-25-12]
All case management services rendered must be reflected by documentation in the records. All units of SoonerCare DDSDTCM services provided are documented by the case manager weekly in Client Contact Manager. The following conditions must be met in order for case management services to reimbursed under SoonerCare.
(1) The case manager must conduct a face-to-face interview with the member in order to determine member needs and develop approaches to meet these needs.
(2) The case manager with a team including the member or member's representative, must develop a plan of care which is documented in the case record.
(3) The case manager must reassess the plan of care when necessary but at a minimum annually.
(4) The case manager must provide documentation to supplement the plan of care which includes:
(A) information supporting the selection of outcomes;
(B) information supporting the approaches selected;
(C) information supporting case management decisions and actions;
(D) documentation of communication with the member and, as appropriate, his/her representative;
(E) documentation of linkages with resources;
(F) documentation of follow-up and monitoring of the plan; and
(G) other factual information relevant to the case.

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.