March 04, 2020
We have discussed the various strategies the DD Waiver providers can employ to minimize the time and effort needed to respond to or to try to engage the “Care Coordination” feature of the CCC Plus Health Plans; DMAS has, at our request, worked to streamline the processes and make communication smoother and easier. If there continue to be issues, however, you may have the option described below.
We have been directed to the following section of the COMMONWEALTH COORDINATED CARE PLUS MCO CONTRACT FOR MANAGED LONG TERM SERVICES AND SUPPORTS:
18.104.22.168 HRA When Member Refuses
The Contractor shall oversee and coordinate quality services for the Member, even in the absence of communication with the Member. In order to adequately manage the case and ensure appropriateness of care to the maximum extent possible, a comprehensive care review is needed based on any and all available information. It is the Contractor review of a Member’s existing care that determines what services are needed and if provided appropriately. A full completed HRA is not required in the circumstance that a Member refuses to participate in a HRA.
If a Member refuses to participate in the HRA, the Care Coordinator shall complete a comprehensive care review based on available clinical information from rendering providers or caregivers and information received from transition reports, service authorizations, and claims. Other sources of information may include, but are not limited to, MDS, UAI, early intervention individualized family service plan, etc.
The Contractor shall document internally in the care plan for the Member why the HRA was not completed without the Member’s involvement. The comprehensive care review shall include the sources of information, the Member’s conditions and diagnoses, current needs and services, identified risks, concerns related to non-adherence, access to care and contradictory provider treatment plans and Contractor recommendations. An ICP must be established based on the outcome of the comprehensive care review and updated accordingly. The Department reserves the right to request the Contractor’s comprehensive care review information.