Free ForwardHealth Case Management Agency Self-Audit Checklist, F-00023 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-00023 (02/09)

STATE OF WISCONSIN

FORWARDHEALTH

CASE MANAGEMENT AGENCY SELF-AUDIT CHECKLIST
This form is a self-audit checklist for case management policies only. Refer to the ForwardHealth Online Handbook for additional provider requirements. Use of this form is strictly voluntary. Name -- Member Name -- Agency SECTION I -- AGENCY REQUIREMENTS The agency has accurately designated the target population(s) it will be serving. Written procedures are in place for determining and documenting a case manager's qualifications. Agency is in compliance with the Provider Rights and Ongoing Responsibilities sections of the Online Handbook. A signature page is in the member's file, if initials are used in the documentation. SECTION II -- MEMBER INFORMATION The member is enrolled in BadgerCare Plus or Medicaid and meets the definition of one or more of the target populations the agency has elected to serve. The person is not receiving covered hospital or nursing home services at the time the case management services are being provided, except when institutional discharge planning services are provided. For severely emotionally disturbed (SED) persons under age 21, there is documentation of the three-member team's (including a psychiatrist or psychologist) SED finding or the evidence that the child has been admitted to an integrated services project under s. 46.56, Wis. Stats. SECTION III -- ASSESSMENT The following information, as appropriate, is completed and in the member's case file: a. b. c. d. e. f. g. h. i. Member identifying information (for example, the "Face Sheet"). Record of physical and mental health assessments and consideration of potential for rehabilitation. A review of the member's performance in carrying out activities of daily living, such as mobility levels, personal care, household chores, personal business, and the amount of assistance required. Social interactive skills and activities. Record of psychiatric symptomatology and mental and emotional status. Identification of social relationships and support (informal caregivers, i.e., family, friends, volunteers; formal service providers; significant issues in relationships; social environments). A description of the member's physical environment, especially regarding in-home mobility and accessibility. In-depth financial resource analysis, including identification of, and coordination with, insurance, veteran's benefits, and other sources of financial assistance. Vocational and educational status and daily structure, if appropriate (prognosis for employment; educational/vocational needs; appropriateness and availability of educational, rehabilitative, and vocational programs). Legal status, if appropriate (guardian relationships, involvement with the legal system). For any member under age 21 identified as SED, a record of the multi-disciplinary team evaluation required under s. 49.45(25), Wis. Stats. The member's need for housing, residential support, adaptive equipment, and assistance with decision making. Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No Yes Yes Yes No No No Yes Yes Yes Yes No No No No Date Form Completed Name -- Person Completing Checklist

j. k. l.

Yes Yes Yes Yes

No No No No Continued

m. Assessment of substance abuse and/or alcohol use and misuse for members indicating possible alcohol and substance abuse dependency.

CASE MANAGEMENT AGENCY SELF-AUDIT CHECKLIST F-00023 (02/09)

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SECTION III -- ASSESSMENT (Continued) n. o. p. q. Accessibility to community resources that the member needs or wants. For families with children at risk, an assessment of other family members, as appropriate. For families with children at risk, an assessment of family functioning For families with children at risk, identification of other case managers working with the family and their responsibilities. Yes Yes Yes Yes No No No No

SECTION IV -- CASE PLAN DEVELOPMENT The member's file contains a written case plan identifying the short-term and long-term goals and includes the following information (for families with children at risk, the plan should address the child enrolled in BadgerCare Plus or Medicaid and services to other family members enrolled in BadgerCare Plus or Medicaid): a. b. c. d. e. f. g. h. i. j. Problems identified during the assessment. Goals to be achieved. Identification of formal services to be arranged for the member, including names of the service providers and costs. Development of a support system, including a description of the member's informal support system. Identification of individuals who participated in developing of plan of care. Schedule of initiation and frequency of various services arranged. Documentation of unmet needs and gaps in service. For families with children at risk, identification of how services will be coordinated by multiple case managers working with the family (if applicable). Frequency of monitoring by the case manager. The case plan is signed and dated. Each update to the case plan must be signed and dated. Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No

SECTION V -- ONGOING MONITORING AND SERVICE COORDINATION a. b. c. d. e. f. For ongoing monitoring and service coordination, there is one, identified individual who serves as the case manager and is known and available to the member. All member collateral contacts, including travel time incurred to provide case management services, are recorded in the case file. All record keeping necessary for case planning, coordination, and service monitoring is recorded in the member's file. There has been at least one documented member or collateral contact, case-specific staffing, or formal case consultation during a month when time was billed for record keeping. The case manager has monitored the member and collaterals according to the frequency identified in the case plan. The case manager has signed (or initialed) and dated all entries in the member's file. Yes Yes Yes Yes Yes Yes No No No No No No

SECTION VI -- DISCHARGE PLANNING a. Discharge-related case management services billed on a member's behalf who has entered a hospital inpatient unit, nursing facility, or intermediate care facility/mentally retarded (ICF/MR) (following an initial assessment or case plan) have been billed using the appropriate modifier. Discharge planning services were provided within 30 days of discharge. Services billed as discharge planning do not duplicate discharge planning services that the institution normally is expected to provide as part of inpatient services. Yes No

b. c.

Yes Yes

No No Continued

CASE MANAGEMENT AGENCY SELF-AUDIT CHECKLIST F-00023 (02/09)

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SECTION VII -- MAINTENANCE OF CASE RECORDS A written record of all monitoring and quality assurance activities is included in the member's file and has the following: a. b. c. d. e. f. g. Name of member. The full name and title of the person who made the contact. If initials are used in the case records, the file includes a signature page showing the full name. The content of the contact. Why the contact was made. How much time was spent. The date the contact was made. Where the contact was made. Yes Yes Yes Yes Yes Yes Yes No No No No No No No

SECTION VIII -- BILLING REQUIREMENTS One of the following activities has been performed prior to billing for targeted case management: a. Face-to-face and telephone contacts with the member: b. To assess or reassess needs. To plan or monitor services. To monitor member satisfaction with care. Yes Yes Yes No No No

Face-to-face and telephone contacts with the member: To mobilize services and support. To educate collateral of the needs, goals, and services identified in the plan. To advocate on behalf of the member. To evaluate / coordinate services in the plan. To monitor collateral satisfaction or participation in member care. Yes Yes Yes Yes Yes No No No No No

SECTION IX -- NONBILLABLE SERVICES Wisconsin Medicaid or BadgerCare Plus do not cover the following as services under case management services: a. b. c. d. e. f. g. h. i. j. k. l. Diagnosis, evaluation, or treatment of a physical, dental, or mental illness. Monitoring of clinical symptoms. Administration of medication. Member education and training. Legal advocacy by an attorney or paralegal. Provision of supportive home care, home health care, or personal care. Information and referral services that are not based on a member's plan of care. Ongoing monitoring to a resident of a Medicaid or BadgerCare Plus-funded hospital, skilled nursing facility, ICF, or ICF-MR, except for the 30 days before discharge. Case management to Medicaid waiver members, except for the first month of waiver enrollment. Duplicative discharge planning from an institution. Services other than case management covered under Wisconsin Medicaid or BadgerCare Plus. For Group A target populations, more than one assessment or case plan per year with no change in county of residence. Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No Continued

m. For Group A target populations, more than two assessments or case plans per year with a change in county of residence. n. For Group B target populations, more than two assessments or case plans per year.

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SECTION IX -- NONBILLABLE SERVICES (Continued) o. p. Costs for more than one case manager (unless there is a qualified temporary replacement.) Services during periods in which the member was not enrolled in Medicaid or BadgerCare Plus, including periods of time when a member is detained by the legal process, is in jail or other secure detention, or when an individual 22 to 64 years of age is in an IMD. Interpreter services. Case management to members enrolled in Family Care, special managed care programs, or a community support program. Any service not specifically listed as covered in the Case Management service area of the Online Handbook. Yes Yes No No

q. r. s.

Yes Yes Yes

No No No

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