2021-350-EMS-E-WellCare Health Plans of NC Inc-Medicaid managed care

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Page 36 of 48 i) Ensuring that a care manager is assigned to manage the transition ii) Facilitating clinical handoffs; iii) Obtaining a copy of the discharge plan/summary; iv) Conducting medication reconciliation; v) Following-up by the assigned care manager rapidly following discharge; vi) Ensuring that a follow-up outpatient, home visit or face to face encounter occurs; and vii) Developing a protocol for determining the appropriate timing and format of such outreach. 15.13.5. Tier 3 AMH practices must use electronic data to promote care management. (a) The Tier 3 AMH practice must receive claims data feeds (directly or via a CIN) and meet state-designated security standards for their storage and use. 16. Care Management for High-Risk Pregnancy. To the extent Participating Provider is a Local Health Department (“LHD”) offering care management for high-risk pregnancy, this Section applies. Care Management for High-Risk Pregnancy refers to care management services provided to a subset of high -risk pregnant women by LHDs (Section VII, M(4)). 16.1 General Contracting Requirement. Participating Provider shall accept referrals from WellCare for Care Management for High-Risk Pregnancy Services. Participating Provider shall comply with the requirements NC DHHS’ Care Management for High-Risk Pregnancy Policy. 16.2 Care Management for High-Risk Pregnancy: Outreach. Participating Provider shall refer potentially Medicaid-eligible pregnant women for prenatal care and Medicaid eligibility determination, including promoting the use of presumptive eligibility determination and other strategies to facilitate early access to Medicaid coverage during pregnancy. Participating Provider shall contact patients identified as having a priority risk factor through claims data (Emergency Department utilization, antepartum hospitalization, utilization of Labor & Delivery triage unit) for referral to prenatal care and to engage in care management. 16.3 Care Management for High-Risk Pregnancy: Population Identification and Engagement. Participating Provider shall review and enter all pregnancy risk screenings received from Pregnancy Ma nagement Program providers covered by the pregnancy care managers into the designated care management documentation system within five (5) calendar days of receipt of risk screening forms. Participating Provider shall utilize risk screening data, patient self-report information and provider referrals to develop strategies to meet the needs of those patients at highest risk for poor pregnancy outcome. Participating Provider shall accept pregnancy care management referrals from non-Pregnancy Management Program prenatal care providers, community referral sources (such as Department of Social Services or WIC programs), patient self-referral, and provide appropriate assessment and follow up to those patients based on the level of need. Participating Provider shall review available WellCare data reports identifying additional pregnancy risk status data, including regular, routine use of the Obstetric Admission, Discharge and Transfer (OB ADT) report, to the extent the OB ADT report remains available to Participa ting Provider. Participating Provider shall collaborate with out-of-county Pregnancy Management Program providers and Care Management for High-Risk Pregnancy teams to facilitate cross-county partnerships to ensure coordination of care and appropriate care management assessment and services for all patients in the target population. 16.4 Care Management for High-Risk Pregnancy: Assessment and Risk Stratification. Participating Provider shall conduct a prompt, thorough assessment by review of claims history and medical record, patient interview, case review with prenatal care provider and other methods, on all patients with one or more priority risk factors on pregnancy risk screenings and all patients directly referred for care management for level of need for care management support. Participating Provider shall utilize assessment findings, including those conducted by WellCare to determine level of need for care management support. Participating Provider shall document assessment findings in the care management documentation system. Participating Provider shall ensure that assessment DocuSign Envelope ID: 2EC1F0FD-FAF9-4B42-B52E-D419F55A6210