(1) These requirements are in addition to those requirements contained in rule and statutory provisions generally applicable to Medicaid providers.
(2) To be qualified as a provider of targeted case management services for high risk pregnant women, an enrolled Montana Medicaid provider must:
(a) be approved by the department;
(b) meet the requirements in (3) through (8);
(c) have knowledge and experience in the delivery of home and community services to high risk pregnant women;
(d) demonstrate an understanding of the concept of prenatal care coordination services; and
(e) have developed collaborative working relationships with health care and other agencies in the area to be served.
(3) A targeted case management provider must use an interdisciplinary team that includes members from the professions of nursing, social work, and nutrition.
(a) The professional requirements are the following:
(i) nursing must be provided by a registered nurse who has a current Montana license and is either:
(A) a registered nurse whose education includes course work in public health; or
(B) a certified nurse practitioner;
(ii) social work must be provided by one of the following:
(A) a clinical social worker with a master's in social work (MSW), who has a current Montana license;
(B) a master's level counselor (LCPC), who has a current Montana license; or
(C) a bachelor's in social work (BSW) with two years' experience in community social services or public health; and
(iii) nutrition services must be provided by a registered dietitian who is licensed as a nutritionist in Montana and has one year experience in public health and/or maternal-child health.
(b) The department must be notified within 30 days regarding any staff changes or updates.
(c) To accommodate special agency and geographic needs and circumstances, exceptions to the staffing requirements, including the use of paraprofessionals, may be allowed if approved by the department. If the targeted case management team includes a paraprofessional, that individual must have a minimum of an associate's degree in behavioral sciences or a related field with two years of closely related work experience, and complete a state-sponsored training for paraprofessional targeted case managers. Qualifying experience may be substituted, year for year, for education.
(4) The targeted case management provider must be able to provide the services of at least one of the professional disciplines listed in (3) directly. The other disciplines may be provided through subcontracts. Where services are provided through a subcontractor, the subcontract must be submitted to the department or designee for review and approval.
(5) A targeted case management provider must:
(a) conduct activities to inform the target population and health care and social service providers in the geographic area to be served of its prenatal care coordination services;
(b) deliver prenatal care coordination services appropriate to the individual member's level of need;
(c) respond promptly to requests and referrals for targeted case management members;
(d) perform assessments and develop care plans for the appropriate level of care and document services provided;
(e) schedule services to accommodate the member's situation;
(f) inform members regarding whom and when to call for pregnancy emergencies;
(g) establish working relationships with medical providers, community agencies, and other appropriate organizations;
(h) assure that ongoing communication and coordination of member care occurs within the targeted case management team and with the member's medical prenatal care provider at least quarterly or at the time of any medical referrals;
(i) provide services in a home, office, or clinic setting, with telephone contacts as appropriate;
(j) have a system for handling member grievances; and
(k) maintain an adequate and confidential records system. All services provided directly or through a subcontractor must be documented in this system.
(6) A case manager providing services for a targeted case management provider must have knowledge of:
(a) federal, state, and local programs for children and pregnant women such as WIC, immunizations, perinatal health care, family planning, genetic services, hepatitis B screening, and other healthcare related programs in Montana;
(b) individual health care plan development and evaluation;
(c) community health care systems and resources; and
(d) nationally recognized perinatal and child health care standards.
(7) A case manager providing services for a targeted case management provider must have the ability to:
(a) develop an individual care plan based on an assessment of a member's health, nutritional and psychosocial status, and personal and community resources;
(b) inform a member regarding health conditions and implications of risk factors;
(c) encourage a member's responsibility for health care;
(d) establish linkages with service providers.
(e) coordinate access to multiple agency services to the benefit of the member; and
(f) evaluate a member's progress in obtaining appropriate medical care and other needed services.
(8) Providers must maintain case records that meet the maintenance of records and auditing guidelines set forth in ARM 37.85.414 and that document for all members receiving targeted case management the following:
(a) the name of the member;
(b) the dates of the targeted case management services;
(c) the name of the provider agency and the person providing the services;
(d) the nature, content, and units of the targeted case management services received and whether goals specified in the care plan have been achieved;
(e) whether the member has declined services in the care plan;
(f) the need for, occurrences of, and coordination with other targeted case managers;
(g) a timeline for obtaining needed services; and
(h) a timeline for reevaluation of the plan.