*This self-check list has been developed for the CM’s to use as guide to ensure that all tabs of the Member Record are complete prior to submission of the plan to Supervisor Review. This check list does not need to be submitted to MSU.

• Diagnosis Tab

  • Diagnosis status updated to Complete.

    *Note the status must be updated from “Pending” to “Complete” to allow claims submission.

    **Only the Primary and Secondary Dx is required. These will be populated from the DHS Nurse UCAT on all new cases post 8/27/2018 with the status in Pending. The CM will only update or change the Dx if a non-billable code such as an ICD9 code is received in

    error or the physician returns the “Request for Physician Validation of Member Diagnosis Code” document with indication of a different Primary or Secondary Diagnosis.

• Payers Tab

  • All insurance sources that the Member has in addition to Medicaid should be added. Example: Medicare, Commercial Insurance, VA Benefits, Indian Health Services, Etc.

    *Medicaid record will populate when the case is certified by the DHS Nurse.

    
    

• Medications Tab

  • All Medications Updated or Added. This includes over the counter or self-prescribed.

    *Medications from the DHS UCAT will be populated on all new cases. Any that populate with a Medication listed as “Medication not found” will need to be opened and updated appropriately. In this scenario the Medication name that was entered by the DHS Nurse will be populated in the ELDERS Med section of the Medication record.

    
    

• Relations Tab

  • All contacts for the Members case will need to be added here. Examples: Physician information, Emergency Contact, Next of Kin, Etc.

  • If Member has a POA or Legal Guardian that information is required in this section.

    *This Tab will be blank on all new cases. Contact information from the DHS Nurse will be located on the UCAT I under the Documents Tab in Harmony.

    
    

• Demographics Tab

  • Updated as needed to include the following:

    • Correct Home Address

    • Correct Phone Numbers

    • Preferred Name if differs from listed First/Last Name

    • Box checked for Companion plan if any other household Members are receiving ADvantage or SPPC services.

      
      

• Division Tab

  • Division Status updated from “New” to “Open”

• Provider Enrollments Tab

  • Enrollments with Member Status to Provider = New added for all agencies associated to case. Example: DME, Home Delivered Meals, ADH, Etc.

  • Case Processor should be listed for each Provider Agency.

    *The specific agency will update the status from New to Open once they begin providing services.

    
    

• Documents Tab

  *The following documents are required on all case submissions:

  • ADv – Back-Up Plan

  • ADv – High Risk Indicator & Mitigation Assessment

  • ADv – Long Term Goal

  • ADv – Service Team Release of Information (should be signed and uploaded to a Note)

  • ADv/SPPC – Monitoring/Progress Note

  • ADv/SPPC - Nurse Evaluation – Completed by Home Care RN

  • Uniform Comprehensive Assessment III – Copied version of DHS UCAT with any updates to the UCAT that are discovered at the time of the IDT. MSQ section scores should be reentered to populate correctly on the matrix at the end of the document. This copied version will be required to push to plan as a completed document cannot be used to push to plan.

    
    

• Plans Tab

• Plan Information Sub-Tab

  • Plan Status updated to Supervisor Review

    
    

• Identified Needs Sub-Tab

  • All identified needs marked active, duplicate or deferred as appropriate.

  • All active identified needs should have a minimum of 1 anticipated outcome

  • All active anticipated outcomes should have a minimum of 1 action step

  • All needs, anticipated outcomes, action steps should be Member specific and edited as needed to add personalization.

    
    

• Planned Services Sub-Tab

  • Case Management T1016 auth line will be updated from 40 units to actual units by MSU upon authorization, no CM activity required.

  • RN Assessment T1002 updated from 5 initial units, to actual annual units by MSU upon authorization, no CM activity required.

  • All additional services added as appropriate. This will include all non-Medicaid services such as Informal Supports.

    
    

• Plan Notes Sub–Tab

  • Note to Case Manager Supervisor as notification that case is ready for review. *This note is the only way in the system that the CMS will be notified of the request for review.

  • Signed Signature Page attached to Note with Note Type = Documentation and Note Sub Type = Signature Page.

  • If Member has a DNR, Advanced Directive, Power of Attorney or Legal Guardian the documentation should be attached to a note with Note Type = Documentation and Note Sub-Type as appropriate depending on the document.

  • Signed Service Team Release attached to Note with Note Type = Documentation and Note Sub-Type = Service Team Release

  • Reminder to add all orientation signature page(s) for Member using the Type = Orientation and Subtype = Orientation Signature Page.

**Notes created under the Plan Notes Sub-Tab will also show on the Notes Tab of the Member record.

*This document contains information required on all ADvantage cases regardless of services requested. See the Job Sheet titled “Appendix: Documents Required for Specific ADvantage Services” to make sure all information is included on the case per the service request.