Compliance requirements

Case Management Policies and Rules

You are required to be familiar with the Case Management for Children and Pregnant Women Rules and Policies and administer case management services accordingly.

• Rules are contained in the Texas Administrative Code or TAC.
• Policies are contained in the Texas Medicaid Provider Procedures Manual (TMPPM).
• These rules provide standards for case management services.
• Policies provide the procedures for compliance with the program rules and other state laws.

When you have a case management-related question, the policies should be the first place you look for answers. It is your responsibility to ensure that all case management services are provided in compliance with program rules and policies.

Provider and Case Manager Responsibilities

• Agree to comply with program and Medicaid rules, policies and procedures by signing the Medicaid Provider Agreement as part of the Medicaid Provider Application and HHSC CM Application.
• Maintain confidentiality of protected client information. Not use or disclose the protected health information of patients except as permitted by Health Insurance and Portability Accountability Act (HIPAA) and state law.
• Implement appropriate safeguards to prevent unauthorized use or disclosure of the protected health information of patients.
• Share protected health information of patients, as permitted by HIPAA and state law, with other pertinent health, social, and case management providers so that the appropriate referral and tracking may occur.
• Ensure conflicts of interest do not occur.
• Comply with licensing board rules and regulations.
• Use translators or interpreters when necessary.
• Develop and implement a system for reviewing the quality of services.
• Inform TMHP of provider changes by updating the Provider Enrollment Management System (PEMS)
• Ensure client choice for case management services and referrals are given.

Conflicts of Interest (COI)

• Providers and case managers who have dual employment may have conflicts of interest, which include, but are not limited to, referring clients from their primary employment to their case management agency. Any activities which provide monetary benefits may be a conflict of interest.
• Providers and case managers who work for Medicaid MCOs will not be approved to provide case management.
• Case managers who change to dual employment or change their employer must submit notice to TMHP.

Accessibility

You have many responsibilities as a case management provider, including:

• You must ensure that you are accessible for calls or emails. Clients, HHSC CM, DSHS staff, a referral source or a third party must be able to reach you.
• You must answer the phone with your name or name of your business.
• If you work from home, the phone should not be answered by a family member unless the name of your business is identified.
• Your telephone recordings must include your business name and hours of operation and must be in both English and Spanish.
• You must reply to all messages promptly.
• You are also required to respond to all inquiries from HHSC CM and DSHS promptly. Inquiries include phone calls, faxes, e-mail correspondence and letters.

Provider Changes

Significant provider changes must be submitted by the provider to inform TMHP and the client’s MCO of the following:

• Change in demographics or contact person.
• Change in status (Active, Inactive or Closure).
• Request to change service area coverage.
• Request to add or delete a case manager.

HHSC CM and DSHS Program Oversight

HHSC CM and DSHS Regional Liaisons work together to ensure providers are trained and provided technical assistance (TA) for the first year of operation. This assistance is offered quarterly and is optional for the provider to participate in.

TA is conducted by HHSC CM and DSHS Regional Liaisons via phone, email or in-person with the provider to inform and educate the provider.

Examples:

• Provide policy clarifications.
• Assist with coordination of enrollment with TMHP and MCOs.
• Review outreach and marketing materials.

Providers must ensure they maintain client records and an internal quality management system. Quality Assurance (QA) reviews are conducted by MCOs and will typically include a review of a provider’s client records, quality management system, outreach materials, Conflict of Interest (COI) statements, and case manager licensure to ensure compliance with the Department’s rules and policies. After the QA review, providers should receive a summary of the QA review, including any required actions.

Investigations

HHSC CM may receive a complaint that may lead to an investigation if there are concerns about policy noncompliance, unprofessional conduct or suspected Medicaid fraud.

Depending on the issue and factors related to the issue, HHSC CM may take one of the following action steps and will provide written notification:

• Provide technical assistance.
• Depending on the issue and factors related to the issue, HHSC CM may make a referral to the Ombudsman or MCO as appropriate.

Internal Quality Management System

You are required to develop and maintain an internal quality management system. The purpose of this system is to show you are providing quality services.

You must develop a written plan that includes the following:

• A system for logging all clients referred for case management, which may be called a Referral Log.
• Procedures for conducting internal client record reviews.
• Procedures for conducting internal program review.

Referral Log

You must keep a referral log of all persons referred for case management. Providers may use the QMS Client Referral Log (CM-18).

Internal Client Record Review

The procedures must indicate:

• The name of the individual conducting the review. Must be an approved case manager. Case managers may perform a self-review.
• The frequency of the reviews.
• The number or percentage of records to be reviewed.

Providers may use the CM-16 for record reviews.

Internal Program Review

Providers may use the Provider System Review Tool (CM-15). The internal procedure must include:

• Items on the CM-15.
• The frequency of the review.