Section 69-10.4 - Case Management

69-10.4 Case Management

(a) "Case management" means functions, including but not limited to:

(1) conducting an initial assessment and periodic reassessments of the enrollee's medical needs;

(2) evaluating the enrollee's strengths, informal support system and environmental factors relevant to his/her care;

(3) reviewing information provided by the enrollee, the enrollee's informal support system, and current providers (including any school related or habilitation services) regarding the services presently being provided to the enrollee and any existing gaps in the services being provided to the enrollee;

(4) establishing a comprehensive, written case management plan to assist the enrollee or the enrollee's caregiver to manage the delivery of all qualifying health care services needed by the enrollee;

(5) assisting an enrollee or the enrollee's caregiver to obtain services set forth in the case management plan for the enrollee through referral to agencies or persons qualified to provide those services;

(6) assisting the enrollee with any forms necessary for the receipt of or payment for services;

(7) assisting with crisis intervention in the event that the enrollee has emergency service needs;

(8) developing and maintaining a list of alternative provider sources that may be available to the enrollee in the event of service disruption, and making that list available upon the request of the enrollee or the enrollee's caregiver; and

(9) monitoring the services provided under the case management plan by:

(i) verifying that the services identified in the case management plan are being received by the enrollee in the amount and frequency specified in the case plan; and

(ii) documenting the case record regarding the enrollee's medical condition and progress made.

If the enrollee already has a case manager in another health related program, the Fund Administrator's case manager shall coordinate the enrollee's care in conjunction with the other case manager.

(b) Case manager qualifications. A case manager shall have significant experience or educational training in health or social services, preferably including work experience or a practicum that involved the performance of assessments and the development of case management plans. Voluntary or part-time experience that can be verified will be accepted on a pro rata basis.

(c) Case manager reassignment. An enrollee or person acting on an enrollee's behalf can request a change in case manager at any time by submitting a written request for reassignment on a form provided by the Fund Administrator. Reassignments will occur as promptly as possible based on case manager availability and existing caseloads.

(d) Responsibilities of an enrollee or enrollee's parent, guardian or legal representative. The enrollee or the enrollee's parent, guardian or legal representative is responsible for participating in an initial case management conference and subsequent, periodic case management conferences on a schedule determined by the needs of the enrollee. The repeated failure of the responsible individual to participate in necessary case management conferences may result in the Fund Administrator not processing any claims or requests until compliance with this requirement occurs.

Effective Date: 
Wednesday, June 18, 2014
Doc Status: 
Complete