Care Coordination Delegation Guidelines for Members in a 护理协调代表团成员在指南.docVIP

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Care Coordination Delegation Guidelines for Members in a 护理协调代表团成员在指南.doc

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Care Coordination Delegation Guidelines for Members in a 护理协调代表团成员在指南

Table of Contents RESOURCES ………...……………………………………………….…………………………2 DEFINITIONS (January updates)………………………………………………………...……3 INTAKE PROCESS Delegate Responsibilities Upon Notification of Monthly Enrollment (September updates)……4 Blue Plus Members living in a Veterans Administration Nursing Home ……………………..….4 Contacting the Member (January updates)……..……………………………….………………5 CARE COORDINATION ASSESSMENT AND CARE PLAN RESPONSIBILITIES Scheduling an Assessment /Care Plan Review of the Member (January updates) (September updates)…………………………………………………………………………………….……..5 Contact Requirements—Member ……...…………………………………………………………5 Contact Requirements—Physician………………………………………………………………..6 Comprehensive Assessment (January updates)………………………………………………6 Care Planning (January updates) ………………………………………...…………….………..6 In-Home Assessment Program (Inovalon) (January updates).…7 Reassessment (January updates)………………………………………….………………...…...8 ON-GOING CARE COORDINATION RESPONSIBILITIES Primary Care Clinic (PCC) Change……………………………………………………..8 Transitions of Care (September updates)………………………………………………..……9 Communications from Utilization Management (UM) (added September)……………………11 Transfers of Care Coordination to another Delegate(September updates) …………………11 Transfers of Care Coordination within same agency …………………..…………….………13 Special Status/Notification of Change Needed……………………………………………..……13 Grievances ……….…………………………………………………….……………………...…13 Discharge Planning (added in September)……………………………………………………..15 Moving Home Minnesota (added in September)………………………………………………15 Interpreter Services ………………………………………...……………………………………16 Nursing Home Tracking of Assessments………………………………………………………...17 OTHER CARE COORDINATION RESPONSIBILITIES Out of Country Care...……………………….………………………………….…………..…17 Audit Process…………………………………………………………………………………….17 Records Retention Policy ……………………………………………………………..….…...17 Other Care Coordination Responsibilities …………………………………………….…..…….18 Care Plan Services and Guidelines……………………………