(1) These requirements are in addition to those contained in rule and statutory provisions generally applicable to medicaid providers.

(2) To be qualified as a provider of case management services for children with special health care needs, an entity must:

(a) be a provider of public health nursing or social work services;

(b) be approved by the department's health policy and services division;

(c) have knowledge and experience in the delivery of home and community services to children with special health care needs;

(d) demonstrate an understanding of service coordination for young children up to 18 years of age;

(e) have developed collaborative working relationships with health care and other providers in the area to be served;

(f) have access to multi-disciplinary providers; and

(g) have on file with the department's health policy and services division, a signed collaborative agreement with community providers of services for children with special health care needs that includes at a minimum:

(i) public health nursing;

(ii) social work;

(iii) nutrition;

(iv) primary care providers;

(v) subspecialty providers;

(vi) dental providers;

(vii) Part H early intervention providers;

(viii) paraprofessional home visitor program; and

(ix) others deemed appropriate by the contractor.

(3) Requirements for professional public health providers include:

(a) for a registered nurse: a minimum of a bachelor's degree in nursing including course work in public health; and

(b) for a social worker: a master's or bachelor's degree in behavioral sciences or related field with one year experience in community social services or public health.

(4) The case management provider must be able to directly provide services of at least one of the professional disciplines listed in (3) of this rule.

(5) A case management provider must:

(a) deliver care coordination services appropriate to the child and caregiver's level of need;

(b) respond promptly to requests and referrals of children for targeted case management;

(c) perform assessments and develop care plans for the appropriate level of care and document the services provided;

(d) schedule services to accommodate the child's situation;

(e) inform a child and the child's caregivers regarding whom and when to call for health care emergencies;

(f) assure ongoing communication and coordination of the child's care occurs within the case management team and among the child's care providers;

(g) provide services primarily in the home setting and additionally in office or clinic settings with telephone contacts as appropriate. Home visiting, particularly by the public health nurse, is an integral part of targeted case management for children with special health care needs. To accommodate unusual circumstances or the safety of home visitors, exceptions to home visiting as the primary location of service delivery may be allowed and should be documented in the child's case record;

(h) have a system for handling grievances; and

(i) maintain an adequate and confidential client record system. All services provided must be documented in this system.

(6) A case manager must have knowledge of:

(a) federal, state and local programs for children such as WIC, immunizations, perinatal health care, children's special health care needs, family planning, genetic services, hepatitis B screening, EPSDT, DDFESS, and other health care related programs in Montana;

(b) individual health care systems, plan development, and evaluation;

(c) community health care systems and resources; and

(d) nationally recognized early childhood health care and well child health supervision standards.

(7) A case manager must have the ability to:

(a) interpret medical findings;

(b) develop or participate in the development of an individual case management plan based on assessment of a child's health, nutritional and psychosocial status, and personal and community resources;

(c) inform a child and the child's caregivers regarding health conditions and implications of risk factors;

(d) foster the ability of a child's caregivers to assume responsibility for the child's health care;

(e) assist the child and the child's caregivers to establish linkages among service providers;

(f) coordinate access to multiple provider services to benefit the child and the child's caregivers; and

(g) evaluate a child and the child's caregivers success in obtaining appropriate medical care and other needed services.