The following are the essential components of Case Management for Children and Pregnant Women services and explanation of billable components.

(1) Intake--A case manager's contact with the client/family/guardian that includes the collection of demographic, health, and other information relevant to the determination of the client's potential eligibility.

(2) Comprehensive visit--A case manager's face-to-face meeting with the client/family/guardian that includes the development of a: (A) Family Needs Assessment. A comprehensive face-to-face assessment of client needs to determine the need for any medical, educational, social, or other services required to address short- and long-term health and well-being of the client. These assessment activities must be documented on a Family Needs Assessment form and must include: (i) taking a client's history; (ii) identifying the client's needs, assessing and addressing family issues that impact the client's health condition/risk or high-risk condition and completing related documentation; and (iii) gathering information from other sources, such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the client. (B) Service Plan. A document developed with the client that determines a planned course of action based upon the information collected through the assessment. The Service Plan must be documented on a Service Plan form and must: (i) include activities and goals that are developed in consultation with the client, involve the participation of the client, and address the medical, social, educational, and other services needed by the client; (ii) identify a course of action to respond to the assessed needs of the client, including identifying the individual responsible for contacting the appropriate health and human service providers, and designating the time frame within which the client should access services; and (iii) include a Service Plan Addendum if there are revisions or if additional needs have been identified following the initial Service Plan development. The Service Plan Addendum shall be completed and documented during a follow-up visit.

(3) Referral and related activities to help the client obtain needed services, including activities that help link the client with: (A) medical, social, and educational providers; and (B) other programs and services that can provide needed services, such as making referrals to providers for needed services and scheduling appointments for the client.

(4) Follow-up contacts by a case manager necessary to ensure the service plan is implemented and adequately addresses the client's needs. (A) Follow-up contacts shall be conducted as frequently as necessary to determine whether the following conditions are met: (i) services are being furnished in accordance with the client's service plan; (ii) services in the service plan are adequate; and (iii) the service plan and service arrangement are modified when the client's needs or status change. (B) Follow-up contacts by case manager for clients who are pregnant women with a high-risk condition shall occur as needed through the 59th day postpartum.

(5) Case management may include collateral contacts with non-eligible individuals that are directly related to identifying the needs and supports for helping the client access services and managing the client's care.

(6) The case management components that are eligible for Medicaid reimbursement are the comprehensive visit and each follow-up contact performed in accordance with this section.

(7) Case management services are not reimbursable if they: (A) are provided to clients who do not meet the definition for client eligibility in §27.5 of this title (relating to Client Eligibility); (B) are not prior-authorized in accordance with §27.13 of this title (relating to Prior Authorization); or (C) are provided to a client who has already received another case management service on the same day from the same billing provider.

Source Note: The provisions of this §27.11 adopted to be effective June 30, 2013, 38 TexReg 3985