Assignment of Risk Levels Sample Clauses
The Assignment of Risk Levels clause establishes a framework for categorizing various activities, assets, or obligations according to their associated risk. In practice, this clause outlines criteria or processes for determining risk levels—such as low, medium, or high—and may specify who is responsible for making these assessments. By clearly defining how risks are classified and managed, the clause helps ensure that appropriate controls and responses are applied, thereby promoting effective risk management and reducing uncertainty for all parties involved.
Assignment of Risk Levels. The Contractor shall develop a Care Management program that addresses the varying needs and differing levels of Care Management needs for Members. Based on the Health Risk Screening, the Contractor’s Care Management program must provide for the completion of a detailed health risk assessment for Members, which includes an assessment of and assignment to risk stratification levels (e.g., low, medium, high) which determine the intensity of interventions and follow-up care that is required for each Member. The Contractor shall prioritize and assign Members to low, medium, or high levels based on the identified risk and level of need. Members who have high costs or potentially high costs or otherwise qualify, include but are not limited to pregnant women under twenty-one (21), high risk pregnancies, serious and persistent behavioral health conditions, and infants and toddlers with established risk for developmental delays, shall be assigned to the medium or high risk level and receive Care Management services. Members with less intensive needs will be assigned to the low risk level and shall have access to Care Management teams. The Care Manager must contact the Member via telephone or face-to-face interview to assess the Member’s Care Management needs. This detailed health risk assessment must evaluate the Member’s medical condition(s), including physical, behavioral, social and psychological needs. The goal of this assessment is to confirm the Member’s need for Care Management, identify the Member’s existing and /or potential health care needs, determine the types of services needed by the Member and begin the development of the treatment plan. The Contractor will determine the need for an onsite visit at the Member’s residence to complete this assessment. This detailed health risk assessment must occur within thirty (30) calendar days for Members newly assigned to the High or Medium risk levels as a result of the Health Risk Screening, referral and/or predictive modeling. The detailed health risk assessment must be reviewed by a qualified health professional appropriate for the Member’s health condition. The detailed health risk assessment shall address the following, at a minimum:
a. Identification of the severity of the Member’s conditions/disease state;
b. Evaluation of co-morbidities, or multiple complex health care conditions;
c. Demographic information (including ethnicity, education, living situation/housing, legal status, employment status; and
d. T...