Comprehensive Visit and Documentation

(includes Family Needs Assessment and Service Plan)

Once you have received approval for the Prior Authorization Request, you need to schedule an in-person or synchronous audiovisual Comprehensive Visit with the client, parent or guardian.

During the Comprehensive Visit, you are asking the client, parent or guardian questions about the child, the family or the pregnant woman. Gaining this information will help you and the client, parent or guardian determine the strengths and needs to develop a Service Plan.

This information will be documented on the Family Needs Assessment (FNA) and Service Plan (SP). The following forms are used to document the Comprehensive Visit:

• Family Needs Assessment (FNA) CM-02
• Service Plan (SP) CM-03
• Service Plan Consent Form CM-03 CON
• Migrant Information Form CM-02A, if required

Comprehensive Visit Policy Highlights

• If the client has urgent needs, the Comprehensive Visit must be completed within two business day of approval of the Prior Authorization Request.
• If the client is unable to meet with you within seven business days, you must document your efforts to schedule a visit.
• The Comprehensive Visit cannot be completed or billed while the client is receiving care at an inpatient hospital, facility or another treatment facility.

Family Needs Assessment (FNA) CM-02

• Evaluates all issues affecting the health and well-being of the client and family.
• Must clearly reflect eligibility by documenting at least one medically necessary medical, social, educational, developmental or other need to address the short-term or long-term health and well-being of the client.
• Reflects a client-centered, family-focused approach to service delivery.
• Addresses all needs identified in the Intake and Initial Prior Authorization Request.
• In each section, document all issues and how they are being addressed based upon the information provided by the client, parent or guardian.
• If there are needs, the “Check If Needs Assistance” box must be marked.
• All sections of the FNA must be completed and paint a clear picture of the client’s current health and well-being. The FNA should also include family status.

Service Plan (SP) CM-03

• Identifies all client’s needs from the completed FNA. (If the “Check If Needs Assistance” box is marked, the need must be noted on the SP).
• Document one need per box under “Service Need.”
  • Only one to three needs per SP form should be documented.
  • Additional SP forms may be used if there are more than three needs.
  • Number the pages on the SP form.
• Document the detailed action steps for addressing each need under “Action Plan.”
• Identify and document who is responsible for completing each action under “By Whom.” This may include more than one person.
  • Example: case manager and parent
  • Example: parent and client
• Establish timeframes for addressing each action step. Timeframes must be specific and individualized to address the need under “By When.”
  • Example: within two days
  • Example: within two weeks
• The case manager must provide a copy of the Service Plan to the client, parent or guardian by the first follow-up visit.
• If the SP is translated for the client, parent or guardian in their preferred language, only the English version of it must be maintained in the client’s record.

Service Plan (SP) Consent Form CM-03CON

• Must obtain written/verbal consent by the client, parent or guardian after the Service Plan has been completed. (Document the client, parent or guardian’s name, date of verbal consent, and signature of the case manager on the CM-03CON).
• Serves as a release of client information for agencies documented on the Service Plan.
• Is required for submitting a claim for the Comprehensive Visit.
• Reminds the case manager to educate families about the Texas Health Steps Complaint Number. (This includes complaints and concerns about any Medicaid services, including doctors, dentists and case management providers.)
• Document the date or timeframe for the next follow-up visit with the client, parent or guardian.
• If the client, parent or guardian language of preference is not English and the SP was interpreted, the interpreter must provide written/verbal verification of services provided on the CM-03CON. (Document the interpreter’s name, date of verbal verification and signature of the case manager on the CM-03CON.)
• The SP Consent form should be completed and dated at the same time as the FNA.

Migrant Information Form CM-02A

A migrant worker is a person who either migrates within their home country or outside it to pursue employment.

• Identify whether anyone in the family is a migrant worker.
• If yes, complete the form.
• Information on the form is used to coordinate and expedite services when the family is moving to another location.
• If the family is not able to provide sufficient information to complete the form, the Service Plan should include gathering necessary information as a need.

Activity: FNA

Review the Case Scenario below.

Reminder: The FNA should paint a clear picture of Adam, his needs and any family needs.

Case Scenario

Adam
5 years

Case Manager Cindy Wall met with Adam’s mom, Sarah Smith, on 11/08/22 to conduct the Comprehensive Visit. Cindy asked Sarah questions to document the FNA.

Adam, age 5, lives with Sarah, who is 30. Adam is newly enrolled to Medicaid and currently has FFS.

Adam’s PCP is Dr. Charlie Brown, whom he saw last month for an ear infection. Dr. Brown told Sarah to schedule another appointment to discuss his developmental concerns. Adam is not on any medications currently and doesn’t require any medical equipment or supplies. Adam is not receiving any other medical services, but Sarah thinks he needs speech therapy.

Sarah was not familiar with any of the Medicaid waiver wait lists. The case manager provided some information about them and Sarah was interested in him going on the wait list. She also was not familiar with SSI and would like more information on how to apply.

Adam has not been diagnosed or ever evaluated. He is unable to say complete sentences and says only a few words. He bangs his head on the floor or wall when upset. He rocks his body back and forth when watching his iPad. His teacher calls his mom when he bangs his head on the desk and ask her to pick him up. This is Adam’s first year in a school setting.

Adam is unable to hold crayons or pencils well. He can walk and run, but his mother says he seems uncoordinated and falls a lot. He can feed himself and dress himself with his mother’s assistance.

Sarah reported no concerns with vision or hearing.

Adam attends Spring Elementary and is in kindergarten. He has not been referred to Special Education. His mother reported that she is not aware of what services the school should provide. She wants the school to stop calling her to pick him up when he bangs his head and to try to find a way to calm him down. CM informed Sarah that Adam needs an evaluation for Speech, Occupational and Physical therapies. Sarah has the option to use private therapies through home health or be evaluated through the school. She says she would like Adam to be evaluated by the school. The CM also informed her that she could help her ask for these evaluations and attend school meetings with her. Sarah was informed that a behavioral plan could be developed by the school so that when Adam starts banging his head, the school staff can implement the plan to calm him down instead of calling her.

Family information was gathered from the parent by the CM. See the FNA completed section.

Review the FNA and SP completed by the case manager.

Adam Smith FNA

Adam Smith SP