CurrentBlue Cross Blue Shield - North DakotaPolicy N/A
1915(i) Care Coordination
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Governs responsibilities, processes, and requirements for care coordinators and care coordination agencies providing 1915(i) services to eligible members, including onboarding, assessment, plan of care development, monitoring, and avoiding service duplication.
Policy Summary
PayerBlue Cross Blue Shield - North Dakota
Policy1915(i) Care Coordination
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionSubmit the Plan of Care in Therap for 1915(i) staff approval prior to services being rendered; treat no provider response within two business days as denial and document.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
7distinct care coordinator service areas summarized
quarterlyminimum service provision frequency
monthlymonitoring documentation frequency
Theraprequired POC system
5 business daysinitiate services timeline
1915(i) Coverage Criteria and Requirements
1915(i) Care Coordination Criteria and Requirements
Criteria and responsibilities for provision and continuation of 1915(i) care coordination services.
Care coordination is required for all 1915(i) members.
ALL of the following
- Obtain signature on the BCBSND Medicaid Expansion 1915(i) Member Rights and Responsibilities form and document in the record.
- Arrange supports for member-directed POC meetings and engage people chosen by the member to participate in person-centered planning.
- Identify other services and systems involved to prevent duplication prior to adding services to the POC.
- Only the 1915(i) care coordinator may bill Medicaid Expansion for onboarding/POC meeting time if other providers or case managers attend.
ALL of the following
- Complete or use WHODAS and/or DLA and other assessments as needed to understand needs, preferences and to inform the POC.
- Collect collateral information from family, medical providers, social workers, educators and others to form a complete assessment initially and ongoing.
- Assess social determinants of health and overall safety/risk including suicide risk and conduct risk assessments as needed.
- Develop an initial crisis plan and update/monitor it ongoing.
- Verify and document HCBS setting compliance initially and ongoing.
ALL of the following
- Care coordinator is responsible for developing a person-centered POC with the member using the Therap POC template; alternate templates are not permitted.
- Goals in the POC must be person-centered and follow SMART criteria (specific, measurable, achievable, relevant, timely) and be linked to assessed needs.
- Document progress toward goals and obtain required signatures from attendees and the member/guardian as applicable.
ALL of the following
- Member must need at least one 1915(i) service documented in the person-centered POC.
- The documented 1915(i) service must be provided at least quarterly, with monthly monitoring documented in Therap case notes.
ALL of the following
- Care coordinators must meet face-to-face with the member at least every 90 days to review satisfaction, necessity, delivery and progress; revise goals and POC as needed.
- If services are no longer necessary, update the POC and discontinue services; if eligibility is in question, initiate redetermination including a new WHODAS or DLA.
- Service providers must document all services rendered or attempted in Therap case notes to allow care coordinator review.
ALL of the following
- 1915(i) services cannot duplicate another service that is the same in nature and scope regardless of funding source; care coordinators must check other systems (e.g., MMIS, waiver enrollments) before adding services to the POC.
- When multiple case managers are involved, they must coordinate which provider will bill because Medicaid reimburses only one provider for the same service/date/time.
ALL of the following
- Initial POC meeting must assess strengths and preferences and document goals, supports and crisis planning; document signatures and Members Rights and Responsibilities form.
- Complete member self-assessment and functional reassessments as part of the initial and annual reevaluation process.
ALL of the following
- Goals must follow SMART criteria and be linked to assessed needs; use examples and iterative refinement to ensure goals are measurable and achievable.
Operational coverage and service criteria
Reasonable indication of need and ongoing review requirements for 1915(i) services include:
Member must need at least one 1915(i) service as documented in the person-centered service plan.
The documented service must be provided at least quarterly, with monthly monitoring documented in the member's POC (Therap case notes).
Care coordinators must verify HCBS setting compliance to ensure services are delivered in non-institutional, home-and-community-based settings.
Care coordinators must meet face-to-face with the member at least every 90 days for quarterly reviews to assess satisfaction, necessity, delivery, progress and any conflict-of-interest exemptions.
Quarterly reviews must be documented via the Individual Plan Agenda in Therap and result in an updated POC submitted for 1915(i) program staff approval.
A crisis plan must be developed and documented in the POC within 30 days of enrollment and the POC updated by day 60 to reflect connected services; weekly or more frequent check-ins may be required during initial stabilization.
If services are no longer necessary, the POC must be updated and services discontinued; if eligibility is in question, the care coordinator will initiate an eligibility redetermination including obtaining a new WHODAS or DLA assessment.
Care coordinator must prevent duplication by checking MMIS and coordinating with waiver case managers; verify whether similar 1915(c) waiver services exist before adding 1915(i) services.
Referral process: send referrals via Therap or SComm and include signed release, POC copy and units/frequency/duration; treat no provider response within two business days as a denial with documentation.
Accepting provider must initiate services within five business days of the Anticipated Admissions Date or be considered to have denied the referral.
Coverage criteria and exclusions
Coverage stance, exclusions, and duplication rules for 1915(i) care coordination
ALL of the following
- Redetermination application must be submitted within 45 days of eligibility expiration with no lapse; use SFN 741 1915(i) Eligibility Application and upload redetermination documents into Therap by 1915(i) state team.
- Providers may not bill for time spent helping complete a new application after an eligibility lapse that caused a gap in coverage.
ALL of the following
- Daily limit: services limited to 8 hours per day (32 units).
- Telehealth limit: up to 75% of services per calendar month may be provided via telehealth; at least 25% of services must be in-person each calendar month.
- At least one face-to-face contact is required each quarter.
ALL of the following
- POC must be created and maintained in Therap using the required template.
- Care Coordination Case Note in Therap is required for meetings not documented elsewhere beginning Jan. 6, 2025.
- See Provider Requirements and DHHS 1915(i) webpages for additional resources and guidance.
ALL of the following
- Services duplicative of care coordination or other HCBS waiver services addressing the same goal are non-covered.
- Services exceeding established limits without approved authorization are non-covered.
- Services provided in non-HCBS compliant settings are non-covered.
- Activities outside the scope of care coordination (e.g., checking eligibility), services by non-qualified providers, social-only interactions, texting/electronic messaging as telehealth, and providing other 1915(i) service types instead of coordinating (except short-term stabilization within first 60 days) are non-covered.
ALL of the following
- Care coordination providers generally cannot also be direct service providers for the same member; see the Conflict-of-Interest policy for exemptions and documentation requirements.
ALL of the following
- Medicaid will reimburse only one provider delivering the same service on the same date and time to the same member; targeted case management cannot be billed for the same date/time as 1915(i) care coordination.
Duplication and eligibility rules
Rules governing when 1915(i) services are considered duplicative and thus not eligible for concurrent provision or reimbursement:
ALL of the following
- Medicaid will not reimburse more than one provider delivering the same service at the same date and time to the same member; case managers must decide which provider will bill.
ALL of the following
- Members who previously or currently receive community transition services through the DD or HCBS waivers, TDPP (ND Transition and Diversion Services Pilot Project) or Money Follows the Person (MFP) are not eligible to receive community transition services through 1915(i).
ALL of the following
- 1915(i) housing support (Age 21+) is duplicative with certain HCBS waiver community transition services and other listed community transition services; these services cannot be provided at the same time.
- ND Rent Help and Housing Stabilization services end when a member is connected to a 1915(i) housing supports provider; 1915(i) housing support may begin after other housing services end.
ALL of the following
- 1915(i) offers non-medical transportation (Age 0+) and supported employment (Age 21+); providers must check for duplication with HCBS waiver transportation and employment services before adding these 1915(i) services.
ALL of the following
- If services are available via a student's IEP under IDEA, 1915(i) may not provide duplicative services; the care coordinator must coordinate with the IEP team and document justification that services are not otherwise available via the IEP prior to adding services to the POC.
ALL of the following
- If services are available through the Rehabilitation Act or Vocational Rehabilitation, 1915(i) may not provide duplicative services; coordinate with Vocational Rehabilitation and document justification that services are not otherwise available prior to adding them to the POC.
Billing and Coding
Covered CPT/HCPCS CodesHCPCSCovered
| H2015 | Care Coordination (per 15 minutes) |
Service frequency threshold for continued eligibility
Continued eligibility frequencyMember must receive at least one 1915(i) service documented in the person-centered service plan and the service must be provided at least quarterly.
Monitoring documentationMonthly monitoring of service provision must be documented in case notes in Therap.
POC linkageService provision must be documented in the member's person-centered service plan (POC) to count toward eligibility.
Minimum billable minutes per unit
Minimum billable minutes per 15‑minute unitProviders may bill one 15-minute unit for services greater than or equal to 8 minutes (minutes from same day/POS/member can be combined to reach 8 minutes).
Billing incrementsUnit increments follow 15-minute blocks (e.g., 1 unit = 8–22 minutes, 2 units = 23–37 minutes, etc.).
Do not bill under thresholdServices performed for less than 8 minutes should not be billed as a 15-minute unit.
Provider Responsibilities and Operational Steps
Billing Rule
Only 1915(i) coordinator may bill onboarding meeting
Only the 1915(i) care coordinator may bill Medicaid Expansion for the onboarding meeting time when other providers or case managers attend the meeting.
Documentation Required
Submit POC in Therap; referrals via Therap/SComm and responsiveness timelines
Submit the Plan of Care (POC) in Therap for 1915(i) staff approval prior to services being rendered; send referrals via Therap or SComm and, if a provider does not respond within two full business days, treat the lack of response as a denial and document the SComm/referral as proof. The accepting provider must initiate services within five business days of the Anticipated Admissions Date or the agency’s non-initiation will be considered a denial.
- Include signed release of information and a copy of the POC when sending referrals.
- If a provider is not already serving the member, send the referral through Therap; if they are, send via SComm with units/frequency/duration and desired start date.
- Date of POC submission is the Therap submission date; all POCs must be approved by 1915(i) staff prior to the service being rendered.
Prior Authorization
Submit CCRR for redetermination; initiate exceed-limit requests via care coordinator
For eligibility redetermination submit a Care Coordination Request Report (CCRR) selecting 1915(i)-eligibility renewal; redetermination applications must be submitted within 45 days of eligibility expiration with no lapse. Requests to exceed service limits that are necessary to prevent imminent institutionalization, hospitalization, or out-of-home placement must be initiated with the care coordinator and will be reviewed by Medicaid Expansion.
- After redetermination, the 1915(i) state team will upload redetermination documents into Therap.
- Applications submitted after eligibility span ends are treated as new applications; care coordinators cannot bill for time spent helping complete an application after an eligibility lapse.
Billing Rule
Case managers must decide which provider will bill for the same service/time
When multiple case managers/care coordinators are involved, they must determine among themselves which provider will bill because Medicaid reimburses only one provider for the same service on the same date and time.
- Example: targeted case management cannot be billed for the same date and time as 1915(i) care coordination.
Prior Authorization
Members receiving specified community transition services are ineligible for 1915(i) community transition/housing support
Members who previously or are currently receiving community transition services through the DD or HCBS waivers, the TDPP (formerly ADRL), or Money Follows the Person (MFP) are not eligible to receive community transition services through 1915(i); 1915(i) housing support is duplicative with certain waiver community transition services and listed supports and cannot be rendered at the same time.
- Duplicative housing-related services listed include housing facilitation, MFP Community Transition Service, TDPP Community Transition Service, and HCBS (Aging) Community Transition Service.
- ND Rent Help and Housing Stabilization supportive services end once a member is connected to a 1915(i) housing supports provider; 1915(i) housing support may begin after other housing services end.
Documentation Required
Coordinate with IEP and Vocational Rehabilitation and document non-duplication before adding services
Care coordinators must coordinate with a student's IEP team and with the Vocational Rehabilitation Agency and document justification that services are not otherwise available through the IEP or Rehabilitation Act before adding duplicative services to the 1915(i) POC.
- For IDEA: document in the member’s record that services identified in the IEP are not otherwise available before entering services like Supported Education, Supported Employment, or Prevocational Services on the 1915(i) POC.
- For the Rehabilitation Act: coordinate with Vocational Rehabilitation and document justification that services are not available under Section 110 before adding services such as Benefits Planning, Supported Employment, or Prevocational services.
Key Definitions
Care coordinator
DefinitionCare coordinator means the professional responsible for plan of care development and coordinating access to needed services.
Primary responsibilitiesDevelop the POC, verify service setting compliance, prevent duplication, and coordinate referrals and provider responses.
System roleDocument and submit the POC in Therap and oversee crisis plan development and monitoring.
Crisis
DefinitionCrisis means a time of intense difficulty, trouble or danger.
Crisis response roleCare coordinators collaborate with providers, social workers and relevant professionals to arrange crisis care services and stabilize members.
DocumentationCrisis situations and responses are documented in the POC and crisis plan in Therap.
Home and Community Based Setting (HCBS)
DefinitionHome and Community Based Setting (HCBS) means a member's private residence or community location rather than an institution or other isolated setting.
Compliance verificationCare coordinators must verify services are rendered in non-institutional HCBS settings and refer to the Home and Community-Based Setting Policy for other settings.
Institution examplesInstitutional settings include nursing facilities, ICF/IID, QRTPs, PRTFs, hospitals and jails/prisons.
Initial contact
DefinitionInitial contact means the first call or contact between the member or the member's guardian and the care coordination agency.
Onboarding tie-inInitial contact begins the onboarding process which includes obtaining signatures on member rights and responsibilities and scheduling POC meetings.
DocumentationInitial contact and related onboarding activities should be documented per agency procedures and in Therap when part of POC creation.
Person-centered planning
DefinitionPerson-centered planning means a planning technique emphasizing member preferences, strengths and choices and providing an opportunity to fully participate in the process.
POC integrationPerson-centered planning drives development of the POC and SMART goals tied to assessed needs and member preferences.
ParticipationCare coordinators must engage members (and guardians where applicable) and document signatures from attendees on the POC and related forms.
Plan of care (POC)
DefinitionPlan of care (POC) means a document that identifies the supports and services provided to a member to address their needs.
POC requirementsPOC must be created in Therap using the required template, include SMART goals, the crisis plan, and be submitted for 1915(i) staff approval.
Updates and timingPOC must be updated within 60 days to reflect services the member is connected to and whenever services are no longer necessary.
Telehealth
DefinitionTelehealth means the use of telecommunications and information technology to provide access to physical, mental and behavioral health care across distances; services must occur in real-time with the member present.
Service constraintsTelehealth must be real-time with the member present and follow applicable telehealth limits in the policy (e.g., monthly/telehealth percentage limits where applicable).
DocumentationTelehealth encounters should be documented in member records and case notes consistent with Therap requirements.
SMART goal (example)
SMART goal exampleMember and peer support specialist will identify one community activity per week; member will leave the house, attend the activity, and speak with at least one person while there, repeated for one month; progress reviewed after one month.
Components explainedSpecific: defines 'leave the house' as attending a community activity; Measurable: one activity and one social interaction per week; Time-bound: one month; Achievable/Relevance: tailored to member capacity and transportation barriers.
Use in POCSMART goals must be documented in the POC and linked to assessed needs; revise as member progresses.
Duplication of services
DefinitionDuplication of services occurs when 1915(i) services are the same in nature and scope as another service regardless of funding source.
Care coordinator responsibilityThe care coordinator must check for similar services (including 1915(c) waivers) and ensure the POC does not include duplicative services; use MMIS to verify waiver enrollment and coordinate with waiver case managers.
Effect on provisionIf a member has access to similar services elsewhere, they should not receive duplicative 1915(i) services; overlapping scopes (e.g., community transition) cannot be rendered concurrently.
Crisis plan
DefinitionCrisis plan is a plan developed, implemented and monitored by the care coordination agency and documented in the POC to stabilize the member during the initial enrollment period.
TimingCrisis plan must be documented in the POC and submitted to the state within 30 days of enrollment; the POC must be updated by day 60 to reflect connected services and stabilization efforts.
MonitoringProgress is measured by completion of the crisis plan in Therap within 30 days, documented referrals and provider responses, and weekly (or more frequent) check-ins as needed.
Eligibility redetermination
Process summaryEligibility redetermination occurs when a current 1915(i) member reapplies within 45 days of eligibility expiration with no lapse; redetermination triggers submission of a CCRR selecting 1915(i)-eligibility renewal and upload of redetermination documents into Therap by the state team.
Application timingApplications submitted after a member's eligibility span ends are new applications (not redeterminations); care coordinators cannot bill for time spent helping complete an application after a lapse.
Required formA completed SFN 741 1915(i) Eligibility Application must be submitted for eligibility redetermination and POC updated and submitted for approval.
HCBS setting compliance verification
Verification dutyCare coordinators must verify that services are provided in home and community-based, non-institutional settings and ensure HCBS Settings Rule compliance.
Referral to HCBS policyFor service settings other than a member's private residence or community-based nonresidential setting, care coordinators should refer to the Home and Community-Based Setting Policy to determine compliance.
DocumentationVerification should be documented in the POC and member record as part of routine assessments and monitoring.
Care Coordination / Case Management overlap
Availability by ageCare coordination (1915(i)) is a State Plan service available for Ages 0+.
Overlap with other case managementMay overlap with targeted case management and other waiver case management services; however, Medicaid reimburses only one provider for the same service/date/time and case managers must decide who bills.
Multiple systemsMembers may receive specialized case management from multiple systems, but duplication for the same date/time is not reimbursable.
Community Transition / Housing Support duplications
Service agesCommunity transition is offered Age 0+; housing support is offered Age 21+ under 1915(i).
Duplication ruleMembers previously or currently receiving community transition through DD or HCBS waivers, TDPP, or MFP are not eligible to receive 1915(i) community transition; 1915(i) housing support is duplicative with certain waiver community transition services and cannot be rendered at the same time.
Sequencing optionND Rent Help/Housing Stabilization services end once a member connects to a 1915(i) housing supports provider; 1915(i) housing support may begin after other housing services end.
IDEA duplication rule
RestrictionIf services are available to a student through IDEA (IEP), 1915(i) may not provide duplicative services (42 CFR 441.720(a)(7)).
Coordination requirementCare coordinator must coordinate with the student's IEP team before entering services on the 1915(i) POC.
Documentation requirementJustification that services are not otherwise available through the IEP must be documented in the member's record and kept on file prior to adding duplicative services to the POC.
Rehabilitation Act duplication rule
RestrictionIf services are available under the Rehabilitation Act or via Vocational Rehabilitation, 1915(i) may not provide duplicative services (42 CFR 441.720(a)(7)).
Coordination requirementCare coordinator must coordinate efforts with the Vocational Rehabilitation Agency before adding services to the 1915(i) POC.
Documentation requirementJustification that services are not otherwise available under Section 110 of the Rehabilitation Act must be documented in the member's record and kept on file.
Policy Summary
PayerBlue Cross Blue Shield - North Dakota
Policy1915(i) Care Coordination
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionSubmit the Plan of Care in Therap for 1915(i) staff approval prior to services being rendered; treat no provider response within two business days as denial and document.
SourceLink
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