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GUIDELINES, DOCUMENTATION, AND BILLING
P R E S E N T E D BY:
T H E D E PA R T M E N T O F H E A LT H C A R E P O L I C Y A N D F I N A N C I N G
A N D T H E D I V I S I O N F O R D E V E L O P M E N TA L D I S A B I L I T I E S
Targeted Case Management
Background
Case Management in Colorado Administrative Case Management Case Management as a Waiver Service Targeted Case Management
Designated by Waiver
Overview
State Plan Benefit Entitlement Benefit
Targeted Population Persons with Developmental Disabilities; and Enrolled HCBS-DD, SLS, or CES; or Enrolled in Early Intervention Services; and Medicaid Eligible
CMS Assurances
The State Assures that: Clients will have free choice of providers Case management services will be provided in a
manner consistent with the client’s best interest Case management services will not be used to restrict
a client’s access to other services Clients will not be compelled to receive case
management services Case managers cannot authorize or deny other State
Plan services
Qualified Providers
Community Centered Boards Only legally authorized agencies to provide TCM to
individuals with DD in community settings
Case Managers Appropriate qualifications to provide TCM
Bachelor’s Degree, Five years experience in the field of developmental
disabilities, OR Some combination of education and experience
Purpose
Facilitate Enrollment
Service Plan Development
Service Monitoring Effective Efficient
Coordination of Services/Benefits Educational Mental Health Emotional Social Medical
Ensure Non Duplication of Services
Reimbursement
15 Minute IncrementsCMS CompliantHSRI FindingsAuditsBilling Codes
Reimbursement
Specifically Defined Activity and Purposeful Outcome
Example: Telephone contact to schedule IDT Meeting
Bill in 15 minute increments 1-15 minutes = 15 minutes
Continuous Activity with Separate tasks
Example: Record Review, Telephone Contact, Service Plan Revision Bill Total Time Spent
State of
Colorado
Reimbursement
Multiple Client Contact Example: Monitoring Visit with
4 Clients at the same Group Home Estimate time/unit per individual
Multiple Contacts – One Day Example: Client calls 10 times in
one day Professional Judgment Number of units billed should not exceed total
amount of time worked.
State of
Colorado
General Contacts
Direct Contacts Face-to-Face Email Correspondence
Indirect Contacts Consultation with supervisor for the purpose to plan
or coordinate need services Documentation of TCM Activities Documentation and Review of Documentation for the
purpose of the individual record Review and distribution of records for planning,
coordinating, assessing, and referral to services.
Billable Activities
Comprehensive Assessment and Periodic Reassessment
Determine need for: Medical, Educational, Social, Other Services
Examples: Client History Assist in accessing benefits e.g., Social Security and/or
Medicaid re-determination Obtain and review any relevant and/or required
assessments needed for service planning
Billable Activities
Service Plan Development Based on information collected through
assessment Specifies goals for meeting all service needs
Medical Social Educational Other Services
Activities to ensure client participation Work with individual and others to develop goals Identifies course of action
Billable Activities
Service and Support Coordination Coordination of the services being provided in the
Service Plan to ensure continuity of service provision
Referral and Related Activities Help individual obtain needed services and activities
and link them to the appropriate provider: Medical Social Educational Other Programs
Billable Activities
Monitoring and Follow Up Activities Services are:
Implemented and delivered according to Service Plan
Adequately meeting the individual’s need
Monitor changes in need
Make necessary changes/revisions Provide Notification
Billable Activities
Monitoring and Follow Up Activities cont.
Health & safety needs are met
Rights are respected
Client Satisfaction
Administrative Activities
Intake and Eligibility DeterminationReporting and Aggregating Data
Critical Incidents Complaints
Agency Meetings Case Management/Staff Training Professional Developmental
Utilization Review ULTC 100.2 SIS
Documentation
Benefits Utilization System
If it didn’t happen on the BUS, it didn’t happen . . .
Documentation
Reimbursement based on BUS Documentation Log notes document units Reports generated by the BUS
Support claims paid
Benefits Utilization System
If it didn’t happen on the BUS, it didn’t happen . . .
Documentation
Date The BUS will generate a date and time of entry CM should reflect within the log note the
date/time of the activity notedTime
Record when appropriate Pertinent to the activity
Units Drop Down Menu 15 Minute Increments Record Units up to 32 Units (8 Hours)
Documentation
Activity TCM activity that is being
performed Multiple related activities or activities
performed within a single day may be entered into a single log note
Must be a billable activity Type of contact
Direct Indirect
Documentation
Finding The observations, assessments, or
outcomes of the activity.
Follow Up Action The actions to be taken with the
information obtained from the activity When appropriate
Considerations
Ethical and Professional Reporting
AppropriationBudget Neutrality
Questions?