CARE COORDINATION AND CASE MANAGEMENT Clause Samples
The Care Coordination and Case Management clause outlines the responsibilities and processes for organizing and managing a patient's healthcare services across different providers and settings. Typically, this clause requires one party—often a healthcare provider or insurer—to ensure that patient care is efficiently coordinated, including arranging referrals, sharing relevant medical information, and monitoring treatment progress. By establishing clear procedures for communication and oversight, this clause helps prevent gaps in care, reduces duplication of services, and improves overall patient outcomes.
CARE COORDINATION AND CASE MANAGEMENT. 5.1 General Care Coordination and Case Management Requirements As part of the Care Coordination and Case Management System, the CONTRACTOR shall be responsible for the management, coordination, and Continuity of Care for all its Members and shall develop and maintain Policies and Procedures to address this responsibility. The CONTRACTOR’s Care Coordination activities and Case Management Program shall be based on sound evidence and conform to the requirements and industry standards stipulated in the NCQA requirements for Complex Case Management and by the Standards of Practice of Case Management released by the Case Management Society of America (CMSA). The CONTRACTOR shall:
5.1.1 Make a best effort to conduct an initial screen of each Enrollee’s needs, within ninety (90) Days of the effective date of Enrollment for all new Enrollees, including subsequent attempts if the initial attempt to contact the Enrollee is unsuccessful. (42 CFR § 438.208(b)(3))
CARE COORDINATION AND CASE MANAGEMENT. 4.11.7.1 The Contractor shall be responsible for the Care Coordination/Case Management of all Members and shall make special effort to identify Members who have the greatest need for Care Coordination, including those who have catastrophic, or other high-cost or high-risk Conditions.
4.11.7.2 The Contractor’s Care Coordination system shall emphasize prevention, continuity of care, and coordination of care. The system will advocate for, and link Members to, services as necessary across Providers and settings. Care Coordination functions include:
4.11.7.2.1 Early identification of Members who have or may have special needs;
4.11.7.2.2 Assessment of a Member’s risk factors;
4.11.7.2.3 Development of a plan of care;
4.11.7.2.4 Referrals and assistance to ensure timely access to Providers;
4.11.7.2.5 Coordination of care actively linking the Member to Providers, medical services, residential, social and other support services where needed;
4.11.7.2.6 Monitoring;
4.11.7.2.7 Continuity of care; and
CARE COORDINATION AND CASE MANAGEMENT. 4.11.7.1 The Contractor shall be responsible for the Care Coordination/Case Management of all Members and shall make special effort to identify Members who have the greatest need for Care Coordination, including those who have catastrophic, or other high-cost or high-risk Conditions.
4.11.7.2 The Contractor’s Care Coordination system shall emphasize prevention, continuity of care, and coordination of care. The system will advocate for, and link Members to, services as necessary across Providers and settings. Care Coordination functions include:
4.11.7.2.1 Early identification of Members who have or may have special needs;
4.11.7.2.2 Assessment of a Member’s risk factors;
4.11.7.2.3 Development of a plan of care;
4.11.7.2.4 Referrals and assistance to ensure timely access to Providers;
4.11.7.2.5 Coordination of care actively linking the Member to Providers, medical services, residential, social and other support services where needed;
4.11.7.2.6 Monitoring;
4.11.7.2.7 Continuity of care; and
4.11.7.2.8 Follow-up and documentation.
4.11.7.3 The Contractor shall develop and implement a Care Coordination and case management system to ensure:
4.11.7.3.1 Timely access and delivery of Health Care and services required by Members;
4.11.7.3.2 Continuity of Members’ care; and
4.11.7.3.3 Coordination and integration of Members’ care.
4.11.7.4 These policies shall include, at a minimum, the following elements:
4.11.7.4.1 The provision of an individual needs assessment and diagnostic assessment; the development of an individual treatment plan, as necessary, based on the needs assessment; the establishment of treatment objectives; the monitoring of outcomes; and a process to ensure that treatment plans are revised as necessary. These procedures must be designed to accommodate the specific cultural and linguistic needs of the Contractor’s Members;
4.11.7.4.2 A strategy to ensure that all Members and/or authorized family members or guardians are involved in treatment planning;
4.11.7.4.3 Procedures and criteria for making Referrals to specialists and subspecialists;
4.11.7.4.4 Procedures and criteria for maintaining care plans and Referral Services when the Member changes PCPs; and
4.11.7.4.5 Capacity to implement, when indicated, case management functions such as individual needs assessment, including establishing treatment objectives, treatment follow-up, monitoring of outcomes, or revision of treatment plan.
4.11.7.5 The Contractor shall submit the Care Coordination a...
CARE COORDINATION AND CASE MANAGEMENT. 5.1 General Care Coordination and Case Management Requirements As part of the Care Coordination and Case Management System, the CONTRACTOR shall be responsible for the management, coordination, and Continuity of Care for all its Membership and shall develop and maintain Policies and Procedures to address this responsibility. The CONTRACTOR’s Care Coordination activities and Case Management Program shall be based on sound evidence and conform to the requirements and industry standards stipulated in the NCQA requirements for Complex Case Management and by the Standards of Practice of Case Management released by the Case Management Society of America (CMSA). The CONTRACTOR shall:
5.1.1 Make a best effort to conduct an initial screen of each Enrollee’s needs, within ninety (90) Days of the effective date of Enrollment for all new Enrollees, including subsequent attempts if the initial attempt to contact the Enrollee is unsuccessful.
5.1.2 Utilize appropriate assessment tools and Health Care Professionals in assessing a members physical and Behavioral Health care needs.
5.1.3 Develop Programmatic-Level Policies and Procedures for Care Coordination and Case Management services.
5.1.4 Use Care Coordination and Case Management as a continuous process for:
5.1.4.1 The assessment of a Member’s physical health, Behavioral Health and social support service and assistance needs,
5.1.4.2 Identification of persons who need LTSS services or persons with special health care needs,
5.1.4.3 The Plan must annually provide, for Department approval, its procedures related to contacting and assessing the needs for LTSS services or other special health care needs
5.1.4.4 The identification of physical health services, Behavioral Health Services, LTSS, special needs and other social support services and assistance necessary to meet identified needs, and
5.1.4.5 The assurance of timely access to and provision, coordination and monitoring of the identified services associated with physical health, Behavioral Health, LTSS, special needs, and social support services and assistance to help the member maintain or improve his or her health status including coordinating access to services not covered by the plan.
5.2 Member Risk Stratification Requirements The CONTRACTOR shall stratify its Members based on risk.