Care Coordination
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Governs AllCare Health CCO's care coordination program requirements, processes, and staff responsibilities for Medicaid members, including prioritized populations such as those receiving LTSS, children in DHS custody, and members with behavioral health needs.
No material clinical or coverage changes in this revision.
Coverage Criteria
Intensive Care Coordination (ICC) eligibility
Covered when ALL of the following are met for Intensive Care Coordination (ICC) prioritized populations
AllCare automatically assesses prioritized populations for ICC
Referrals for members with long-term care or LTSS from DHS will receive ICC within 30 days or sooner if clinically required
Reassessment and follow-up criteria
Reassessment-triggered contact requirements
Full list of triggers enumerated in policy
Reassessment and program revision occur as needed
Access and rights
Member rights and access
Includes prioritized populations given direct access per OAR definitions and POP-CCO-009
The policy clarifies that certain services will be provided to members regardless of coverage or billing status. Specifically, ICC and behavioral health services are provided to children and adolescents in DHS custody and other identified prioritized populations per the contract and program exhibits, without limiting provision based on whether the services are billed to the plan.
Parts of the document do not list explicit coverage exclusions. The policy notes oversight and monitoring procedures but contains no discrete exclusion lists in the referenced sections, so providers should follow the stated eligibility and reassessment rules rather than seek additional exclusions here.
This section does not enumerate explicit ‘not medically necessary’ conditions. Instead, the policy focuses on eligibility for Intensive Care Coordination for prioritized populations and reassessment triggers rather than defining services that are not medically necessary.
No statements in these oversight and related sections explicitly label services as not medically necessary. The document emphasizes monitoring, audits, and staff policy review without providing negative coverage determinations in these paragraphs.
Coding and Triggering Conditions
| Z codes (primary Z code) | Reference to two or more billable primary Z code diagnoses within one month as a triggering event |
Provider Actions and Responsibilities
Specialist access and second opinions (no referral PA specified)
Members retain direct access to specialists for covered care and have the right to a second opinion from a network or out-of-network provider at no cost; the policy does not impose prior authorization requirements for referrals in this section.
Operational reports referenced for care coordination
Operational reports are used routinely to support care coordination activities and should be referenced when completing authorizations or internal workflows.
- Daily reports: HRA, Nurse Help Line, ED report, hospital discharge and admit reports (multiple HL7 and Asante-Providence logs)
- Weekly reports: Medical Management listings (e.g., Auths E0466, ED Utilization, Essette Case Management)
- Specific daily listings include hospice, admit/discharge, ER logs, hospital SNF reports, and auths Date of Death listing
General provider actions for ICC delivery
Providers must follow the policy's stated provider actions for care coordination (see documentation, reporting, reassessment, and engagement requirements) when delivering ICC and related services.
- Use evidence-based engagement strategies (motivational interviewing, culturally and linguistically appropriate approaches, trauma-informed care)
- Conduct universal assessment for ICC triggers and follow reassessment/contact timelines
Required operational provider responsibilities
Providers are required to implement the program procedures and engagement strategies described in policy, including the multiple-attempt outreach sequence and collaboration with member care teams.
- Make multiple attempts to engage members, including contacting external resources to obtain current contact information
- Collaborate with primary care, specialists, behavioral health agencies, APD, and community providers when creating care plans
Required EHR documentation
Staff must document member consent, program engagement, assessments, individualized care plans, and all contact attempts and attachments in the EHR as specified by policy.
- Record member consent and mail Program Welcome Letter identifying the member's case owner
- Document any decline of participation and provide plan website information
- Document fax confirmations (number, date, time) and attach external documents to the EHR
- Use secure Outlook messaging for sending member PHI; report non-secure information per Secure Messenger Usage Policy
Maintain internal reporting records (daily & weekly)
Maintain and make available internal daily and weekly operational reports and logs to support care coordination activities and oversight.
- Keep daily HRA, Nurse Help Line, ED, discharge, admit, hospice, and auths listings (HL7 and Asante-Providence logs)
- Keep weekly Medical Management reports (Auths listings, ED Utilization, Essette Case Management) and collective SNF admission/discharge notifications
Noncompliance risk for missed ICC assessments
Failure to conduct required assessments or to provide Intensive Care Coordination (ICC) for prioritized populations (as identified in POP-CCO-009) may constitute noncompliance with contract requirements.
- Ensure universal assessment processes are completed for members with special needs and prioritized groups to avoid contract noncompliance
Audit-identified noncompliance may lead to corrective actions
Noncompliance discovered during regular case audits by the Care Coordination Supervisor could trigger corrective actions or denial of internal approval processes.
- Maintain required documentation and follow procedures to avoid audit findings
- Be prepared to provide internal reports and EHR records during audits
Level of Care Criteria
Outpatient / Intensive Care Coordination (ICC) — level-of-care criteria
AllCare automatically assesses prioritized populations
Case owner to update continuous care plan every 90 days or as needed
Care Coordination Engagement and Support Services
Care coordination engagement and support services
Document contact attempts and use secure messaging and EHR attachments for sent/received documents
Visit Limits and Contact Frequency
Definitions
Background
Care coordination is described as an organized, team-based approach that addresses a member’s interrelated medical, behavioral, social, and support needs. A Care Coordinator serves as a single, consistent individual responsible for following the member through transitions of care, ensuring services are unduplicated and aligned with the member’s strengths and needs, and coordinating between the member and other participants to improve outcomes and reduce duplication of services.
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