Common use of Level of Service Clause in Contracts

Level of Service. Complex case management with member focus involves the active coordination of care and services with the member and between providers while navigating the extensive systems and resources required for the member. It includes comprehensive assessment, determination of available benefits, development and implementation of a complex case management plan directed at the member’s chronic health conditions. Complex case management targets members with two (2) or more disease states who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition or members who have had an inpatient hospital stay in the last ninety (90) days or members with high dollar claims of over fifty thousand $50,000 thousand dollars (>$50,000) in six (6) months. The focus is on working with the providers to meet the needs of the individual through communication with the member, PMP (if applicable), other providers, and the member’s natural support system. The member’s active involvement will help EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE members gain optimum health or improved functional capability, in the right setting and in a cost-effective manner. At a minimum, the Contractor must provide complex case management services for members discharged from an inpatient psychiatric or substance abuse hospitalization, for no fewer than ninety (90) calendar days following that inpatient hospitalization. The Contractor must also provide complex case management services for any member at risk for inpatient psychiatric, drug overdose, or substance abuse re-hospitalization. Care managers must contact members during an inpatient hospitalization, or as soon as practicable upon receiving notification of a member’s inpatient behavioral health hospitalization. The care manager must work with the hospital discharge planner, behavioral health provider case manager and/or natural supports (i.e. family) to ensure that an outpatient follow-up appointment is scheduled to occur no later than seven (7) calendar days following the inpatient behavioral health hospitalization discharge. The Contractor must ensure that lack of transportation is not a barrier to the member attending the appointment. Complex case management includes all of the services and benefits from disease management and care management. The Contractor shall use community health workers, to physically make contact when members cannot be reached via telephone within a predetermined, State approved timeframe. Should such attempts fail, the Contractor shall develop a plan for how to reach members (including outreach to providers, repeated physical outreach, etc.). All members in complex case management with member focus must receive materials no less than monthly. Avoidance of unnecessary Emergency department and inpatient hospitalizations and increased use of preventive health care are goals for complex case management.

Level of Service. Complex case management with member focus involves the active coordination of care and services with the member and between providers while navigating the extensive systems and resources required for the member. It includes comprehensive assessment, determination of available benefits, development and implementation of a complex case management plan directed at the member’s chronic health conditions. Complex case management targets members with two (2) or more disease states who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition or members who have had an inpatient hospital stay in the last ninety (90) days or members with high dollar claims of over fifty thousand $50,000 thousand dollars (>$50,000) in six (6) months. The focus is on working with the providers to meet the needs of the individual through communication with the member, PMP (if applicable), other providers, and the member’s natural support system. The member’s active involvement will help EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE members gain optimum health or improved functional capability, in the right setting and in a cost-effective manner. At a minimum, the Contractor must provide complex case management services for members discharged from an inpatient psychiatric or substance abuse hospitalization, for no fewer than ninety (90) calendar days following that inpatient hospitalization. The Contractor must also provide complex case management services for any member at risk for inpatient psychiatric, drug overdose, or substance abuse re-hospitalization. Care managers must contact members during an inpatient hospitalization, or as soon as practicable upon receiving notification of a member’s inpatient behavioral health hospitalization. The care manager must work with the hospital discharge planner, behavioral health provider case manager and/or natural supports (i.e. family) to ensure that an outpatient follow-up appointment is scheduled to occur no later than seven (7) calendar days following the inpatient behavioral health hospitalization discharge. The Contractor must ensure that lack of transportation is not a barrier to the member attending the appointment. Complex case management includes all of the services and benefits from disease management and care management. The Contractor shall use community health workers, to physically make contact when members cannot be reached via telephone within a predetermined, State approved timeframe. Should such attempts fail, the Contractor shall develop a plan for how to reach members (including outreach to providers, repeated physical outreach, etc.). All members in complex case management with member focus must receive materials no less than monthly. Avoidance of unnecessary Emergency department and inpatient hospitalizations and increased use of preventive health care are goals for complex case management. EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE Complex Case Management (Provider Focus) Level of Service Complex case management with a provider focus is appropriate for members who either choose not to be actively involved or are unable to actively participate in their health care. Complex case management targets members with two (2) or more disease states who need assistance with care coordination, making preventive care appointments, or accessing care to address the members’ chronic health conditions or members who have had an inpatient hospital stay in the last ninety (90) days or members with high dollar claims of over fifty thousand dollars (>$50,000) in six (6) months. The focus is on working with the providers to meet the needs of the individual through communication with the PMP (if applicable), other providers, and the member’s natural support system. The goal is to help members gain optimum health or improved functional capability, in the right setting and in a cost -effective manner. Complex case management with provider focus is the active coordination by the Contractor of care and services between providers while navigating the extensive systems and resources required for the member. It involves comprehensive assessment, determination of available benefits, development and implementation of a complex case management plan directed at the chronic health conditions. At a minimum, the Contractor must provide complex case management services for members discharged from an inpatient psychiatric, drug overdose, or substance abuse hospitalization, for no fewer than ninety (90) calendar days following that inpatient hospitalization discharge. The Contractor must also provide complex case management services for any member at risk for inpatient psychiatric or substance abuse re-hospitalization. Care managers must contact members during an inpatient hospitalization or as soon as practicable upon receiving notification of a member’s inpatient behavioral health hospitalization. The care manager must work with the hospital discharge planner, provider case manager and/or natural supports (i.e. family) to ensure that an outpatient follow-up appointment is scheduled to occur no later than seven (7) calendar days following the inpatient behavioral health hospitalization discharge and transportation is not a barrier to attending the appointment. Complex case management with provider focus includes all of the services and benefits from disease management and care management. In addition, all members receiving provider focused complex case management services must receive materials no less than six (6) times a year. Avoidance of unnecessary Emergency department and inpatient hospitalizations and increased use of preventive health care are goals for complex case management.

Level of Service. Complex case management with member a provider focus involves the active coordination of care and services with the member and between providers while navigating the extensive systems and resources required is appropriate for the member. It includes comprehensive assessment, determination of available benefits, development and implementation of a complex case management plan directed at the member’s chronic members who either choose not to be actively involved or are unable to actively participate in their health conditionscare. Complex case management targets members with two (2) or more disease states who need assistance with care coordination, making preventive care appointments appointments, or accessing care to address the members’ chronic health condition conditions or members who have had an inpatient hospital stay in the last ninety (90) days or members with high dollar claims of over fifty thousand $50,000 thousand dollars (>$50,000) in six (6) months. The focus is on working with the providers to meet the needs of the individual through communication with the member, PMP (if applicable), other providers, and the member’s natural support system. The member’s active involvement will goal is to help members gain EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE members gain optimum health or improved functional capability, in the right setting and in a cost-effective manner. Complex case management with provider focus is the active coordination by the Contractor of care and services between providers while navigating the extensive systems and resources required for the member. It involves comprehensive assessment, determination of available benefits, development and implementation of a complex case management plan directed at the chronic health conditions. At a minimum, the Contractor must provide complex case management services for members discharged from an inpatient psychiatric psychiatric, drug overdose, or substance abuse hospitalization, for no fewer than ninety (90) calendar days following that inpatient hospitalizationhospitalization discharge. The Contractor must also provide complex case management services for any member at risk for inpatient psychiatric, drug overdose, psychiatric or substance abuse re-hospitalization. Care managers must contact members during an inpatient hospitalization, hospitalization or as soon as practicable upon receiving notification of a member’s inpatient behavioral health hospitalization. The care manager must work with the hospital discharge planner, behavioral health provider case manager and/or natural supports (i.e. family) to ensure that an outpatient follow-up appointment is scheduled to occur no later than seven (7) calendar days following the inpatient behavioral health hospitalization discharge. The Contractor must ensure that lack of discharge and transportation is not a barrier to the member attending the appointment. Complex case management with provider focus includes all of the services and benefits from disease management and care management. The Contractor shall use community health workersIn addition, to physically make contact when all members cannot be reached via telephone within a predetermined, State approved timeframe. Should such attempts fail, the Contractor shall develop a plan for how to reach members (including outreach to providers, repeated physical outreach, etc.). All members in receiving provider focused complex case management with member focus services must receive materials no less than monthlysix (6) times a year. Avoidance of unnecessary Emergency department and inpatient hospitalizations and increased use of preventive health care are goals for complex case management.

Level of Service. Complex case management with member focus involves the active coordination of care and services with the member and between providers while navigating the extensive systems and resources required for the member. It includes comprehensive assessment, determination of available benefits, development and implementation of a complex case management plan directed at the member’s chronic health conditions. Complex case management targets members with two (2) or more disease states who need assistance with care coordination, making preventive care appointments or accessing care to address the members’ chronic health condition or members who have had an inpatient hospital stay in the last ninety (90) days or members with high dollar claims of over fifty thousand $50,000 thousand dollars (>$50,000) in six (6) months. The focus is on working with the providers to meet the needs of the individual through communication with the member, PMP (if applicable), other providers, and the member’s natural support system. The member’s active involvement will help EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE members gain optimum health or improved functional capability, in the right setting and in a cost-effective manner. At a minimum, the Contractor must provide complex case management services for members discharged from an inpatient psychiatric or substance abuse hospitalization, for no fewer than ninety (90) calendar days following that inpatient hospitalization. The Contractor must also provide complex case management services for any member at risk for inpatient psychiatric, drug overdose, or substance abuse re-hospitalization. Care managers must contact members during an inpatient hospitalization, or as soon as practicable upon receiving notification of a member’s inpatient behavioral health hospitalization. The care manager must work with the hospital discharge planner, behavioral health provider case manager and/or natural supports (i.e. family) to ensure that an outpatient follow-up appointment is scheduled to occur no later than seven (7) calendar days following the inpatient behavioral health hospitalization discharge. The Contractor must ensure that lack of transportation is not a barrier to the member attending the appointment. Complex case management includes all of the services and benefits from disease management and care management. The Contractor shall use community health workers, to physically make contact when members cannot be reached via telephone within a predetermined, State approved timeframe. Should such attempts fail, the Contractor shall develop a plan for how to reach members (including outreach to providers, repeated physical outreach, etc.). All members in complex case management with member focus must receive materials no less than monthly. Avoidance of unnecessary Emergency department and inpatient hospitalizations and increased use of preventive health care are goals for complex case management.