Care Coordination Delegation
Guidelines for Community
Members
Secure Blue—MSHO
(Minnesota Senior Health Options)
2012—September Updates
Table of Contents
RESOURCES …………………………..……………………………………………………….3
INTAKE PROCESS
Delegate Responsibilities upon Notification of Enrollment ………………………………….…..4
Blue Plus Members living in a Veterans Administration Nursing Home (added Sept 2012)…….4
Contacting the Member and determining Health Risk Assessment (HRA) tasks (Updated
January 2012)……………………………………...…………………………………...…….……5
CARE COORDINATION ASSESSMENT AND CARE PLAN RESPONSIBILITIES
Contact Requirements—Member ………………..……………………………….………………6
Contact Requirements—Physician (Updated January 2012)……………………………………...6
Health Risk Assessment for members with an HRA not done within 12 months (Updated
January 2012)……………………………………………………………………………...………6
Health Risk Assessment for members with an HRA done within 12 months……………...…..…6
Health Risk Assessment for members on Disability Waivers or residing in an ICF/DD facility
or DD member living in the community (Updated January 2012 & Sept updates in purple)…… 7
In-Home Assessment (Updated January 2012 & Sept updates in purple)………………….……..8
Entry of LTC Screening document (Updated January 2012).………………………...….…….....8
Comprehensive Care Plan (Updated January 2012)……………………………………….….…11
Consumer Directed Community Supports (CDCS) (Added September 2012)………….…...….11
Authorization of Home Care Services (Updated January 2012) ………… ……………...….….12
PCA Assessment Process (Updated January 2012)……...…………………………………..….14
Customized Living Process (Updated January 2012)……….………….…………………..…...16
EW Authorization, Service Agreements and Claims Processing (Updated January 2012)
(April 2012 updates in blue)……………………………………………………………….…....17
Reassessment Requirements (Updated January 2012)………………………………….…….....20
Reassessment LTC Screening Document entry (Updated January 2012)…………………….....21
ON-GOING CARE COORDINATION RESPONSIBILITIES
Primary Care Clinic Change ………………………………………………………..……...……21
Transitions of Care (Updated January 2012 & Sept updates in purple)………..……………..…22
Transfers of Care Coordination to another Delegate (Updated January 2012 & Sept updates
in purple)…...…………………………………………………………………….…………...…23
Transfers of Care Coordination within same agency (Updated January 2012 & Sept updates
in purple)………….................................................................................................................…..25
Case Closure Care Coordination Responsibilities…...…………………………………….….…25
Special Status/Notification of Change Needed……………………………………………..……25
Coordination of Potential Denials, Terminations, and Reduction of Services……………...…...26
Grievances/Complaint Policy and Procedure ……………………………………………..….....26
EW Conversion/Request to Exceed case mix cap (Updated January 2012)(April 2012 updates
in blue).................................................................................................................................…….28
Interpreter Services (Added September 2012)………………………………………………..…30
Care Coordination Delegation Guidelines for Blue Plus MSHO Community Members
Page 1
(Table of Contents continued on Page 2)
OTHER CARE COORDINATION RESPONSIBILITIES
PIPs, Fraud, Waste and Abuse Training, general Care Coordination documentation, member
rights, coordinating with local agency case managers (Updated January 2012)…………...……30
Network Providers (Elderly Waiver and Blue Plus Network)……………………………..…….31
Out of Country Care (new for 2012)……………………………………………………………..31
Audit Process………………………………………………………………………….…………32
Records Retention Policy (April 2012 updates in blue)……………………..………....…..……32
Care Coordination Services Overview………………………………………………………...…32
Care Plan Service and Guidelines………………………………………………………………..33
Care Coordination Delegation Guidelines for Blue Plus MSHO Community Members
Page 2
These guidelines and all forms, letters and resources are available to our Care
Coordination Delegates at:
www.bluecrossmn.com/carecoordination
For Home Care/PCA Authorization questions contact:
IHM Intake/Support at:
1-800-711-9868 or 651-662-5540
Fax: 651-662-6054 or 866-800-1665
Enrollment questions contact: SecureBlue_enrollment@bluecrossmn.com
For Other Member-Specific issues contact:
Clinical Guide Resource Team at: 1-866-518-8447 or
Clinical_Guide_Resource_Team@bluecrossmn.com
For EW Claims Processing and Service Agreement questions contact Bridgeview
Company (formerly First Solutions):
www.bridgeviewcompany.com
1-800-584-9488
Or e-mail:
Serviceagreements@bridgeviewco.com
EWProviders@bridgeviewco.com
General Process questions contact Government Programs Partner Relations Team:
Melody Bialke, Manager
651-662-6420
1-888-878-0139 ext. 26420
Kathy Everson
651-662-7424
1-888-878-0139 ext. 27424
Kim Flom-Brooks
651-662-9647
1-888-878-0139 ext. 29647
Karla Kosel
651-662-4166
1-888-878-0139 ext. 24166
Katie Gumtow
651-662-2297
1-888-878-0139 ext. 22297
Care Coordination Delegation Guidelines for Blue Plus MSHO Community Members
Page 3
Definitions:
Care Coordination is defined as the assignment of an individual who coordinates the provision
of all Medicare and Medicaid health and long-term care services for MSHO enrollees, and
who coordinates services to an MSHO enrollee among different health and social service
professionals and across settings of care.
Delegate is defined as the agency, such as counties, private agencies and clinics, that are
contracted to provide Care Coordination services for Blue Plus.
Required Caseload per worker for Community Well, Nursing Facility, and Elderly Waiver is
as follows: Elderly Waiver/Community Well mix = 50-80, Nursing Facility only = 100-130,
and Community Well only = 100-125.
INTAKE PROCESS
Delegate Responsibilities upon Notification of Enrollment—Blue Plus is notified by
Department of Human Services (DHS) twice a month via enrollment tape then notifies the
Delegate via secure e-mail. Upon notification the Delegate:
1. Assigns a Care Coordinator per Delegate’s policy
2. Informs the member of the name, number, and availability of the Care Coordinator
within 10 days of notification of enrollment
3. Notifies BluePlus’ Integrated Health Management-Government Programs (IHM-GP)
of the Care Coordinator assigned using form 6.07 Notification of Care Coordinator
Assigned.
4. Documents any delays of enrollment notification in case notes
5. Uses the following optional checklist: 6.12 CW EW Checklist SB
6. The Delegate is responsible to verify member’s eligibility prior to delivering Care
Coordination services.
Blue Plus members living in a Veteran Administration Home (Nursing Home) (Added
September 2012)
For MSHO members living in a Veteran’s Administration Nursing Home, the care coordinator
should follow the processes and timelines outlined in the Care Coordination Guidelines for
Members in the Nursing Home.
Note: Please be aware that these members are designated by DHS as a Rate Cell A (Community
Well) and thus will show up as a Rate Cell A on your enrollment reports. In other words, they
will not show up on your enrollment lists as a Rate Cell D like other members in the nursing
home. The Delegate should be aware of this and proceed as they would other Rate Cell D
nursing home members.
Care Coordination Delegation Guidelines for Blue Plus MSHO Community Members
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Contacting the Member and determining Health Risk Assessment (HRA) tasks
1. Welcome call/letter (8.22 Intro Letter) to member within 30 days after notification of
enrollment
2. Explanation of Care Coordinator’s role. Optional resource: 6.01 Welcome Call
Talking Points.
3. Explanation of Additional 2 Routine Podiatry Visits and Safety Benefit discussed
with member using the resource 6.26 Explanation of Additional Benefits for 2012.
Additional Safety Benefit should be used as a last resort payer, after Medicare, MA,
EW and any other third party payer.
4. Per DHS requirements, a Health Risk Assessment must be completed for all members
within 30 calendar days of notification of enrollment. The Care Coordinator will
make a determination about whether an on-site HRA is needed, and, if so, schedules
the meeting and uses the DHS assessment tool, Long Term Care Consultation
(LTCC). See pages 4 and 5 for Health Risk Assessment requirements.
An on-site HRA LTCC should be done for members who:
 Have not had an LTCC within 12 months of enrollment.
 Have had an LTCC completed within 12 months of enrollment but are
experiencing a signification change.
 Have no current EW services and requests an LTCC. This assessment
should be completed within 15 calendar days of the request using the
LTCC form and criteria.
A Transitional Health Risk Assessment can be used for situations where an on-site
HRA is not applicable (See page 6).
HRA requirements for members on other waivers (CAC, CADI, DD, BI) and
Members in an ICF\DD or DD case managed (See page 7).
5. Discuss In-Home Assessment Program. (See page 8 for details on this program)
6. Confirm the correct Primary Care Clinic (PCC). The PCC is listed on the
enrollment list received from Blue Plus. A PCC may have been chosen by the
member or auto-assigned if one was not indicated at the time of enrollment. A
member, family member, or Care Coordinator may request the change by contacting
member services at 651-662-6013 or 888-740-6013. The requestor must provide the
member’s name, Blue Plus identification number, name of new PCC clinic, clinic
location (town), and effective date. The effective date must be on the first of a
month. If this PCC change will create a change in Care Coordination delegate for the
member, the process for Transfers of Care Coordination to Another Delegate, as
outlined on page 18, must be followed.
Care Coordination Delegation Guidelines for Blue Plus MSHO Community Members
Page 5
CARE COORDINATION ASSESSMENT AND CARE PLAN RESPONSIBILITIES
Contact Requirements—Member
1. Community Well—One face-to-face visit & one 6 month phone contact, at minimum,
per year
2. Elderly Waiver—Two face-to-face visits per year at minimum
3. As needed per significant change in member’s health status
Contact Requirements—Physician. The Care Coordinator must communicate with the
member’s primary care physician:
1. Within 90 days of enrollment the Care Coordinator shall mail 8.28 Intro to Doctor
Letter even if unable to contact the member.
2. Annually, the Care Coordinator will complete and mail 8.29 Care Plan Summary
Letter to Doctor or send a copy of the care plan.
3. As needed for Transitions of Care (See page 22), assessment, and care planning
Health Risk Assessment for newly enrolled members who have not had an LTCC within
twelve months from date of enrollment. (For members on other disability waivers, in an
ICF/DD or DD member living in the community without DD waivered services, see section
on Page 5)
1. The Care Coordinator will thoroughly complete all sections of the Minnesota Long
Term Care Consultation Services Assessment Form (LTCC) [DHS-3428] (also Form
6.25 on the web-portal) within 30 days of receiving notification of a member’s
enrollment.
2. Include Falls Risk Assessment. If the member is determined to be at risk of falls
based on the LTCC assessment outcome (answering yes to any of the 3 falls risk
questions), the Care Coordinator will make a referral for a home Physical Therapy
(PT) evaluation. The PT may provide education or other support based upon the
results of the assessment.
3. Include a discussion regarding the In-Home Assessment Program (see page 8)
4. Document any delays in scheduling of the assessment
Health Risk Assessment for newly enrolled members who have had an LTCC within twelve
months of enrollment and who have not experienced a significant change.
1. The Care Coordinator is still responsible for completing a HRA within 30 days of
notification of enrollment. The Care Coordinator can meet this requirement without
conducting a new LTCC by reviewing the current LTCC and care plan/community
support plan/collaborative care plan from the member’s previous Health Plan or
county.
2. The Care Coordinator should review the LTCC and care plan with the member, either
telephonically or in person, to ensure that the assessment information hasn’t change
and that the care plan is addressing the member’s needs.
3. The Care Coordinator documents these activities by completing the 6.28 Transitional
Health Risk Assessment Form.
Care Coordination Delegation Guidelines for Blue Plus MSHO Community Members
Page 6
4. Include a discussion regarding the In-Home Assessment Program (see page 8).
Health Risk Assessment and care planning for members on Disability Waivers such as
Developmental Disabilities, Brain Injury, or Community Alternatives for Disabled
Individuals (DD, BI, CAC or CADI) or are living in an ICF/DD or a DD member living in
the community (September 2012 updates in purple).
These members already benefit from intensive case management by the HCBS waiver case
manager or the DD case manager for a member on the DD Waiver, in the community without
DD waivered service, or in an ICF/DD. While the SecureBlue (MSHO) Care Coordinator can
provide additional support, the primary case management responsibility will remain with the
HCBS waiver case manager or the DD case manager for a member in an ICF/DD.
All MSHO/MSC+ Care Coordination responsibilities such as contacts with member and
physician, health risk assessments, care planning, and all other responsibilities and timeframes
outlined in the Care Coordination Guidelines continue to be required.
However, to avoid duplication with the case manager, the CC may complete some of the health
risk assessment and care planning requirements in conjunction with the case manager’s current
assessments and care plans, if available, and if completed within the past 12 months. Thus, the
Care Coordinator can review the current assessment and plan of care following the process
below.
Note: If there is no other assessment and care plan available to review, or the other assessment
and care plan is older than 12 months, then an LTCC and Collaborative Care Plan must be done
within 30 days of notification of enrollment.
1. Health Risk Assessment— The Care Coordinator is responsible for completing a Health
Risk Assessment within 30 days of notification of enrollment. The Care Coordinator can
meet the HRA requirement by reviewing the member’s current assessment and care plan
and completing the 6.17 ICF/DD and HCBS Disability Waiver Health Risk Assessment
and Care Plan Supplement. A copy of the current assessment and care plan reviewed
should be placed in the member’s MSHO case file.
2. Care Plan— Health related goals must be entered onto this form. Preventive care should
be discussed and documented. The Care Coordinator must sign and date and send a copy
to the other Case Manager (if different than the Care Coordinator) and a care plan
summary should be sent to the physician.
3. The Care Coordinator should never enter a Screening Document in MMIS. This task is
completed by the disability case manager only.
4. Be sure to document your attempts to obtain the assessment and care plan documentation
from the other case manager and document any delays in completing your HRA and care
planning requirements in your case notes.
Care Coordination Delegation Guidelines for Blue Plus MSHO Community Members
Page 7
5. Include a discussion regarding the In-home Assessment (formerly MedAssurant)
Program (see below).
In-Home Assessment Program (Administered for Blue Plus by Inovalon formerly known as
MedAssurant) (Excludes Essentia and North Clinics) September 2012 updates in purple.
During the Health Risk Assessment the Care Coordinator will introduce the In-Home
Assessment program and give the member a copy of an informational flyer, form 6.30 InHome Assessment Program—Member Information. This program has two components:
1. In-Home Assessment. All newly enrolled MSHO members shall be offered a noninvasive in-home assessment by a Nurse Practitioner or Physician from Univita, a new
sub-contracted agency replacing Inspiris, contracted with Inovalon. Care Coordinators
will explain who Inovalon and Univita are and inform the member of the phone call they
will receive offering a non-invasive in-home assessment. The purpose of the assessment
is to insure the member’s health care needs are identified early and this information is
shared with the member’s primary care physician.
 Inovalon staff will call newly enrolled members no sooner than 45 days of
enrollment to schedule the in-home assessment.
 A copy of the 3-4 page assessment results will be left with the member and sent to
the primary care physician.
 For questions, the member, or the Care Coordinator on the member’s behalf, can
contact Inovalon at 866-359-1626
2. Throughout the year, MSHO members will be identified, according to Blue Plus claims
data, with what appears to be undocumented chronic conditions and follow up with
either:
 A letter encouraging members to visit their primary care physician with a
corresponding letter to their primary care physician identifying the conditions, or
 A letter and a phone call encouraging the member to visit their primary care
physician with a corresponding letter to their primary care physician identifying
the conditions, or
 An offer of an in-home non-invasive assessment by a Nurse Practitioner or a
Physician from Univita, an agency contracted with Inovalon. A copy of the
results of the assessment are left with the member and sent to the primary care
physician for follow-up as deemed necessary by primary care physician.
Entry of LTC Screening Document information into MMIS If no Screening Document in
MMIS, then enter full LTC Screening Document into MMIS by cut-off dates listed below.
MSHO-CW Screening Documents must be entered within 45 days of enrollment date.
CW-members who cannot be found or refuse to have an assessment should have a SD entry
using the Refusal code in MMIS.
EW Screening Documents (SD) must be entered by the cut-off dates listed below:
Care Coordination Delegation Guidelines for Blue Plus MSHO Community Members
Page 8
When the First Month of
the Eligibility Span is:
January
February
March
April
May
June
July
August
September
October
November
December
January 2012
Last Day to Enter Screening
Document timely is:
12/19/11
1/19/12
2/16/12
3/20/12
4/18/12
5/20/12
6/19/12
7/19/12
8/21/12
9/18/12
10/21/12
11/18/12
12/18/12
The delegate is responsible for updating LTC Screening Documents into MMIS for either
Community Nursing Home Certifiable (EW) or Community Well (CW) populations when the
member:
 moves from another Health Plan to Blue Plus
 switches products within Blue Plus (i.e., MSC+ to SecureBlue (MSHO))
 moves from FFS to Blue Plus
The care coordinator must also update the Screening document when there is a change in care
coordinator.
Care Coordination Delegation Guidelines for Blue Plus MSHO Community Members
Page 9
The table below outlines what information should be updated:
INSTRUCTIONS for MMIS ENTRY
Move from FFS
or another
health plan to
Blue Plus or
switch of Blue
Plus product
Community
Non-EW
Move from FFS
or another
health plan to
Blue Plus or
switch of Blue
Plus product
Nursing Home
Certifiable
EW
Transfer of Care
Coordination
Only
Transfer of Care
Coordination
Only
Community
Non-EW
Nursing Home
Certifiable
EW
02
05
02
05
Activity
Date:
Date Transitional
HRA is
completed
LTCC Site:
Change to BHP
Date
Transitional
HRA is
completed
Change to BHP
Date delegate
assumed Care
Coordination
responsibility
n/a
Date delegate
assumed Care
Coordination
responsibility
n/a
Case
Managers
Name and
UMPI
Number
Use your MCO
UMPI number
Use your MCO
UMPI number
Use your MCO
UMPI number
Use your MCO
UMPI number
Assessment
Result:
03 - remain in
community
without waiver
services
98 - other
03 - remain in
community
without waiver
services
98 - other
Effective
Date:
Date of HRA is
completed (the
SD does not reset
the ReAssessment date)
Date of HRA is
completed
(this will not
effect the elig
span when using
Activity type 05)
Date delegate
assumed Care
Coordination
responsibility (the
SD does not reset
the ReAssessment date)
Date delegate
assumed Care
Coordination
responsibility (this
will not effect the
elig span when
using Activity type
05)
LTCC
Screening
Document
Fields
Activity
Type:
Care Coordination Delegation Guidelines for Blue Plus MSHO Community Members
Page 10
*Refer to the Screening Document manual for complete detailed information.
Comprehensive Care Plan—Care Coordinators shall develop a comprehensive care plan in
collaboration with the member, caregiver, and/or other interested persons, as appropriate within
30 days of the LTCC assessment using 6.02.01 Collaborative Care Plan. (For members on
other disability waivers, in an ICF/DD or DD member living in the community, see section
on Page 5) Instructions for the Collaborative Care Plan are available as form 6.02.02. The Care
Plan must include:
1. Case mix/caps
2. Collaborative input
3. Assessed needs
4. Member requested services
5. Formal and informal supports
6. Person-centered goals, target dates, on-going monitoring
7. Preventive focused
8. Emergency back-up plans
9. Risk plan for services refused
10. Health Management discussion. BluePlus offers telephonic programs to address
members’ current health concerns. Members or their caregivers have access to a
dedicated clinician to receive education and support for their health concerns.
Dedicated Clinicians are available to provide disease management services for
members with asthma, coronary artery disease, congestive heart failure, or diabetes.
Dedicated Clinicians may also provide short-term case management services in
complex situations involving catastrophic illness/injury due to accident, high cost
medical situations, frequent hospitalizations, out-of-state providers, or when
additional education or support is requested by a member’s caregiver. Refer to these
programs using 6.09 Health Management Referral form.
11. Advanced Directives discussions. The care coordinator can also use the resource 9.19
BCBSMN Advance Directive
12. Care Coordinators can consult with Blue Plus Health Plan resources if needed
13. Educate and communicate to enrollee about good health care practices and behaviors
which prevent putting their health at risk.
Important: The member must sign the Collaborative Care Plan. A copy of the care plan,
including the budget worksheet and the Member Bill of Rights, Form 6.02.03, must be
given to the member.
Consumer Directed Community Supports (CDCS) (Added September 2012)
CDCS is a service option available under the Elderly Waiver which gives members more
flexibility and responsibility for directing their services and supports including hiring and
managing direct care staff. Refer to the Department of Human Services website
(http://mn.gov/dhs) for additional information regarding CDCS.
Care Coordination Delegation Guidelines for Blue Plus MSHO Community Members
Page 11
Choosing CDCS does not change the Care Coordinator’s responsibilities under the health plan.
The Care Coordinator remains responsible for the completion of the Health Risk Assessment
(LTCC) and collaborative care plan within the required timeframes. The collaborative care plan
should coordinate with the community support plan created by the member or their
representative.
The Bridgeview Service Agreement web-tool contains two fields specific to CDCS: CDCS
Eligible and CDCS Monthly Amount. Please refer to the web tool user guide for details
regarding these fields and contact Bridgeview directly with questions.
Authorization of Home Care Services
Medicare billable skilled home care services do not require a review. The home care agency will
determine whether the member qualifies for Medicare home care services. If Blue Plus is
notified of Medicare eligible home care services, Blue Plus will advise the home care agency to
contact the Care Coordinator to assure continuity of services.
BluePlus will review Medical Assistance State Plan home care requests and determine the
number of visits based upon medical necessity and state plan guidelines. Per statute,
authorization is based upon medical necessity and cost-effectiveness when compared with other
care options.
Home care services include Skilled Nurse visits, Home Health Aide visits, Private Duty Nursing,
Physical, Occupational, Respiratory, and Speech Therapy. This relates to all members receiving
Medical Assistance home care services including those on a home and community based service
waiver.
If a member switches from Fee-For-Service or another health plan to Blue Plus, Blue Plus will
honor the current authorization until the authorization end date or a new review occurs. Blue
Plus reserves the right to review these requests for medical necessity. The member then will be
reassessed at their normal assessment period following the process below.
Reminder: For MSHO/SecureBlue, MSC+/Blue Advantage members on EW, extended home
care services may be authorized by the Care Coordinator. To be eligible for extended home care
services, the member must first be accessing home care under the medical benefits. If the
medical benefits alone do not meet the member’s care needs, extended home care services may
be authorized by the Care Coordinator. The Care Coordinator should assess for appropriateness
of extended home care. The Care Coordinator may only review for the same services already
authorized under the medical benefit (i.e., Home Health Aide is approved under the medical
benefit, then the EW extended home care service must also be Home Health Aide. Blue Plus
does not need to review these services as extended home care services under EW, are not subject
to Medical Necessity guidelines.
Notes related to billing of state plan and extended home care services:
Care Coordination Delegation Guidelines for Blue Plus MSHO Community Members
Page 12




Extended home care services and state plan home care services count towards
CAP if member is on EW
Extended home care services and state plan home care services need to be
included on the Service Agreement to Bridgeview Company.
Extended home care claims should be submitted to Bridgeview Company.
State Plan home care claims should be submitted to Blue Plus
The Care Coordinator shall follow the process outlined below and fax in home care requests
prior to services starting using either of the following forms:
For members who are on disability waivers such as CADI, CAC, BI, or DD use form
6.04.01 Recommendation for Auth of MA Home Care (DHS 5841-ENG 0611)
For members on EW or Community Well members not on waivers listed above use form
6.04.03 MA Home Care Services Recommendation/Non-disability form
1. Prior to the services starting, or upon annual reassessment, the Care Coordinator will fax
in the 6.04.01 Recommendation for Authorization of MA Home Care Services form for
members open to a home and community based disability (after consulting with the
disability waiver case manager) or the form 6.04.03 Home Care Services
Recommendation-Non Disability to request BluePlus to review the services. Be sure to
include a copy of the current authorization if previously on FFS or another Health Plan.
Also, if member is residing in a Residential setting such as Customized Living Facility or
Adult Foster Care, please include this information in the Summary section. If a member
resides in Customized Living and you are requesting home care service, please fax a
copy of the Individualized EW Customized Living Plan along with your request.
2. BluePlus will obtain necessary medical information from the home care agency including
a medical records request. Sending in this documentation is the responsibility of the
home care agency. Blue Plus may contact the care coordinator for additional
information.
3. BluePlus will instruct home care agencies to contact the member’s Care Coordinator for
consultation regarding the member’s plan of care and to assure services fit under CAP.
4. BluePlus will review the information submitted and make a coverage determination
within 10 calendar days of receipt of the request. Requests are reviewed based on the
individual’s medical needs and therefore the number of visits and date span authorized
may vary.
5. Blue Plus understands that, at times, a member may require an immediate evaluation due
to a significant change in medical condition; thus Blue Plus would never deny an
evaluation.
6. For an acute change in a member’s medical condition, where the services requested are
not Medicare eligible, the care coordinator should fax in the request form as soon as they
Care Coordination Delegation Guidelines for Blue Plus MSHO Community Members
Page 13
are aware of the home care needs. Up to ten visits of skilled home care services such as
PT/OT/ST, RN, or Home Health Aide will be approved immediately to assure patient
medical needs are met.
Note: For members with chronic conditions, the care coordinator need only fax in one
request. Blue Plus may approve 2-3 months at a time. It is the responsibility of the home
care agency to send in supporting documentation when the authorization comes to an end.
Blue Plus will keep the Care Coordinator informed with each subsequent authorization
for management of cap. Care Coordinators do need to fax in the home care request with
each annual assessment.
7. After a determination is made, BluePlus will notify the member and the home care
provider of the outcome via a letter.
8. Blue Plus will fax the determination back to the Care Coordinator for their records, EW
case mix cap management, and disability waiver budget management. The Care
Coordinator must communicate with the other waivered case manager, if any.
9. Denials, Terminations or Reduction (DTR) of MA State Plan Home Care services will be
processed by Blue Plus for home care denials, reductions or terminations.
Note: Fluctuations in a member’s plan of care is not a DTR.
See page 26 for detailed instructions on the process for Potential Denial Termination
Reduction of Services that are initiated by the Care Coordinator.
PCA Authorization Process
Blue Plus will review all PCA requests for medical necessity. A member is entitled to up to two
PCA evaluations per year. Care Coordinators should contact Blue Plus if additional evaluations
are needed.
All Secure Blue (MSHO) and MSC+ members receiving or requesting PCA services will be
required to be assessed using the DHS tool, Personal Care Assistance (PCA) Assessment and
Service Plan (DHS-3244-ENG), or if on any HCBS Waiver, use the DHS tool Supplemental
Waiver Personal Care Assistance (PCA) Assessment and Service Plan (DHS-3428D-ENG).
Blue Plus will review all PCA requests to determine the number of units the member is eligible
for under state plan services. Assessors may be a Care Coordinator or a PHN but they must
attend DHS training before qualifying to perform PCA assessments.
1. Upon completion of the PCA assessment, the assessor (PHN or Care Coordinator) is
responsible for providing a copy of the Completed PCA Assessment and Service
Plan to the member and PCA provider within 10 days.
Care Coordination Delegation Guidelines for Blue Plus MSHO Community Members
Page 14
2. The assessor must also fax the PCA assessment, prior to services starting, to Blue
Plus for a coverage determination and authorization at 866-800-1665 or 651-6624022.
Note: Blue Plus will not accept LTCC Assessment tool for determination of PCA
services
3. If Blue Plus has questions regarding an assessment, we may contact the Care
Coordinator or the PHN assessor to discuss.
4. As a reminder, reduction or termination in services requires a 30 day notice.
5. BluePlus will send any letters (approval or denial) to the member and agency via mail
and the care coordinator via fax.
Requests for PCA Temporary starts or increases:
 All temporary PCA starts or temporary increases may be approved on an as
needed basis. The Care Coordinator should complete section, PCA
Temporary Start/Temporary Increase, on the form 6.04.03 MA Home Care
Services Recommendation-Non Disability and fax it to BluePlus for entry.
 PCA temporary starts and temporary increases are only valid for up to 45
days and must include the reason for the temporary start/increase.
On-going PCA Services:
 If services are reduced, the current authorization will be extended to
accommodate the 30 day notification period.
 A new authorization will be entered for services beyond the 30 days with the new
number of units approved.
 If services are an increase, the increase will start the day of the BluePlus
determination.
 If the Care Coordinator is requesting a future start date, please indicate the start
date on your request (see first case example below).
Case Examples:
Mildred, a MSHO/SecureBlue member is currently receiving 3 hours per day.
The new PCA assessment indicated that the member now qualifies for 4 hours per
day. Her current authorization does not expire until 1/31/12. The member’s
waiver date span does not end until 1/31/12 and the member does not have room
in her CAP for an increase until that time. Blue Plus received the PCA
assessment and makes a determination that the increased hours are appropriate.
The decision is made on 12/4/11. The new authorization for 4 hours per day will
start on 2/1/12.
Henry, a MSHO/SecureBlue member is currently receiving 4 hours per day. At
his annual assessment the PCA assessment indicates that he only qualifies for 2
Care Coordination Delegation Guidelines for Blue Plus MSHO Community Members
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hours per day now. His current authorization was up on 12/31/10. BluePlus
receives the PCA assessment and makes a determination to decrease the hours
to 2 hours per day. The decision is made on 12/30/10. Henry’s current
authorization for 4 hours per day will be extended until 1/29/11 to accommodate
the 30 day notification period. A new authorization is entered for 2 hours per day
effective 1/30/11 through 12/31/11.
Extended PCA Requests for members on EW:
For MSHO/SecureBlue and MSC+/Blue Advantage members on EW, extended PCA
hours may be authorized by the Care Coordinator. Extended PCA services cannot be
a “stand-alone” PCA service. To be eligible for extended PCA, the member must
first be accessing PCA services under the medical benefits. If the medical benefits
alone do not meet the member’s care needs, extended PCA services may be
authorized by the Care Coordinator. The Care Coordinator should assess for
appropriateness of extended PCA. Blue Plus does not need to review as extended
PCA is not based on medical necessity criteria.
Notes related to billing of state plan and extended PCA services:
 Extended PCA services and state plan PCA services count towards CAP if
member is on EW
 Extended PCA services and state plan PCA services need to be included on the
Service Agreement to First Solutions.
 Extended PCA claims should be submitted to First Solutions.
 State Plan PCA claims should be submitted to Blue Plus
PCA Reassessment—Per DHS, the PCA assessment is valid for 12 months from the
assessment date. Statute for reference: 256B.0659, subd.3(a) and 4.
Customized Living Process
Blue Plus uses the approved DHS EW Customized Living Tool Kit which is available for
download from the DHS website at: http://www.dhs.state.mn.us/dhs16_143983. Care
Coordinators authorizing Customized Living Services need to complete the full tool kit which
includes four separate documents. Upon completion, the entire tool kit is to be submitted to
DHS through the use of MNITS. If you have questions please refer to the “Instructions for Use
of the Customized Living Tools- Individual Care Plan,” which can also be found at the DHS
website. For recent changes to the CL Tool or process updates, please refer to the EW
Customized Living Tool Newsletter that is sent out to Care Coordinators from DHS.
The Care Coordinator will assist members who are moving to a registered Housing with
Services establishment to obtain or recover a verification code from the Senior Linkage
Line.
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Note: Please follow the new Customized Living standards per DHS Bulletins and 8/19/11
Communiqué.
Elderly Waiver Authorizations, Service Agreements and Claims Processing
Bridgeview Company (formerly FirstSolutions), a third party administrator, processes
most Elderly Waiver provider claims and Service Agreements for MSHO/SecureBlue and
MSC+/Blue Advantage.
When authorizing an EW service, the Care Coordinator is expected to be compliant with
all EW program rules, follow all appropriate bulletins related to MSHO/EW, and follow
directions found in the Provider Manual Chapter 26A: Elderly Waiver and Alternative
Care. Care Coordinators will submit Service Agreements directly to Bridgeview Company
through their web-based tool and are responsible to become familiar with this web-tool and
its accompanying manual. Care Coordinators are also responsible for EW Provider
inquiries related to their Service Agreement entries.

Extended home care services are to be authorized through the Bridgeview Company
web tool with the appropriate HCPCS service code. These services are billed to
Bridgeview Company.
State Plan Home Care Services, Care Coordination and other services included in Case
Mix Cap but Billed to Blue Plus

Care Coordinators must calculate the monetary total of state plan home care
services (X5609-PCA, HHA, SN, PDN), care coordination (T1016 UC, T1016 TF
UC), adult day bath (S5100 TF), and CDCS case management (T2041) services that
are being rendered to the member during the waiver span and are counted against
the member’s monthly case mix service cap. This total amount must be placed in
the Bridgeview Company web tool under the LTCC/Case Mix section. These
services are not billed to Bridgeview Company; they are billed to BluePlus.
Extended Supplies and Equipment (T2029)
1. To assist with the authorization the Care Coordinator shall use the resource
Extended Supplies and Equipment (T2029) Grid. This tool is to be used as a
resource for EW eligibility and/or proper first payer. This document is not all
inclusive and will be updated regularly. It is available on the Bridgeview Company
web site: www.bridgeviewcompany.com
2. If an item is listed on the Extended Supplies and Equipment resource as not Elderly
Waiver Eligible, the Care Coordinator should not authorize it. If an item has not
been included on the resource list and the Care Coordinator is uncertain if it meets
the EW Service Criteria as outlined in the MHCP Manual, contact the Clinical
Guide team at 1-866-518-8447 or
Clinical_Guide_Resource_Team@bluecrossmn.com.
Note: Telemonitoring is not an eligible service under EW.
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When completing the Service Agreement, each Extended Supply and Equipment item
authorized should be listed on a separate line with a narrative description of what is being
authorized, the number of units, and the specific rate per unit. Inquiries related to EW
claims and Service Agreements should be directed to Bridgeview Company:
www.bridgeviewcompany.com
1-800-584-9488
Or e-mail:
ServiceAgreements@bridgeviewco.com
EWProviders@bridgeviewco.com
Prior Authorization Process for Specialized Supplies and Equipment/Items over $500 and
Exceptions to SSE/T2029 Guide (Updated April 2012)
Both delegate Care Coordinators and Blue Plus Utilization Management (UM) now have a role
in authorizing Specialized Supplies and Equipment for members on Elderly Waiver (EW).
Coordination and communication is key.


Delegate Care Coordinators—authorize EW Services
Blue Plus UM—authorize:
o SSE items over $500
o Exceptions to the SSE/T2029 Guide
Process
1. To request a prior authorization for a SSE item over $500 or an Exception to items listed
as ‘no’ for EW eligibility in the SSE/T2029 Guide, the Care Coordinator must fax all of
the following to Blue Plus Utilization Review at 651-662-4022 or 1-866-800-1665:
a. Completed 6.06 Elderly Waiver Prior Authorization Request form which should
include:
b. Extenuating circumstances that warrant an exception to the SSE/T2029 Guide.
c. How the item will prevent institutional placement.
d. Is the item the most cost effective alternative?
e. Description of other alternatives that have been tried and failed or considered
prior to this request.
2. Blue Plus will make a coverage determination within 10 business days and notify the
Care Coordinator and Bridgeview Company via secure e-mail.
a. The Care Coordinator is responsible to notify the member of the approval and
document all approved services on the member’s service agreement and the
budget worksheet.
3. DTR Appeal Notices
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a. If the Over $500 or Exception requested item is denied, Blue Plus UM will issue a
DTR to the member and e-mail a copy to the Care Coordinator.
4. Authorization entry
a. The Delegate Care Coordinator will enter the authorized EW items in the
Bridgeview Company service agreement web-tool. This would include:
 UM approved items over $500
 Approved exceptions to the SSE/T2029 Guide
Note: Do not enter a Service Agreement until the item has been approved.
Prior Authorization Process for Lift Chair and Mechanism
Both delegate Care Coordinators and Blue Plus Utilization Management (UM) now have a role
in authorizing lift chairs for members on EW. Coordination and communication is key.
 Delegate Care Coordinators—authorize EW services
 Blue Plus UM authorizes
o Lift mechanisms under member’s medical benefit (Medicaid/Medicare)
o Prior authorize chairs paid for under EW over $500.
Process
1. To request authorization for a lift chair, the Care Coordinator must fax the following to
Blue Plus Utilization Review at 651-662-4022 or 1-866-800-1665:
a. A completed 6.06 Elderly Waiver Prior Authorization Request form,
b. the Specialized Supplies and Equipment Providers written quote the seperates out:
 the cost of the chair vs. the lift mechanism, and
 includes a description of any specialized chair features
Note: Providers have been notified of the requirement for prior authorization of chair/seat
lift mechanisms.
2. Blue Plus will make a coverage determination within 10 business days and notify the
appropriate parties of the approval determination as follows:
a. Motorized lift portion authorization under Medicare/Medicaid—notification will
be sent to:
 The member
 Specialized Supply and Equipment/Durable Medical Equipment Provder
 Care Coordinator
b. Chair portion over $500 authorization under EW—notification will be sent via
secure e-mail to:
 Care Coordinator
 Bridgeview Company
3. DTR Appeal notices
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a. If the lift portion is determined ineligible under Medicare/Medicaid Blue Plus UM
will not send a DTR; the Care Coordinator will be authorizing the lift under the
EW benefit.
b. If the Over $500 chair is denied, Blue Plus UM will issue a DTR to the member
and a copy the Care Coordinator.
4. Entry of Authorization
a. Blue Plus UM will enter an authorization into the claims payment system for
approved Medicare/Medicaid covered chair lift mechanisms.
b. Delegate Care Coordinators will authorize EW covered items in the Bridgeview
Company service agreement web-tool. This should include:
 Lift mechanisms not covered under Medicare/Medicaid
 Chair portions at or below $500
 UM approved chair portions over $500
Note: Do not enter Service Agreements until an approval is received.
Reassessments
A reassessment must be completed within 12 months of the previous assessment for EW and CW
members. The following steps are to be completed with each reassessment:
1. The Delegate is responsible to verify member’s eligibility prior to delivering Care
Coordination services.
2. The Care Coordinator will thoroughly complete all sections of the Minnesota Long
Term Care Consultation Services Assessment Form (LTCC) [DHS-3428] (also Form
6.25 on the web-portal). (For members on other disability waivers, in an ICF/DD
or DD member living in the community, follow process outlined on Page 7)
a. The same LTCC tool should be used for no more than three assessments.
3. The Care Coordinator shall complete the 6.02.01 Collaborative Care Plan within 30
days of the LTCC (refer to page 11).
a. Document on-going monitoring of goals, interventions, and target dates
b. The member must sign the Collaborative Care Plan. A copy of the care
plan, including the budget worksheet and the Member Bill of Rights, Form
6.02.03, must be given to the member
4. The Care Coordinator will complete 8.29 Care Plan Summary Letter to Doctor or
send a copy of the care plan.
5. If state plan home care services are needed, the Care Coordinator shall fax in the new
request for authorization of home care services as outlined on page 12.
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Entry of Reassessment LTC Screening Documents into MMIS by 4:30 of the cut-off date
listed below.
When the First Month of
the Eligibility Span is:
January
February
March
April
May
June
July
August
September
October
November
December
January 2013
Last Day to Enter Screening
Document timely is:
12/19/11
1/19/12
2/16/12
3/20/12
4/18/12
5/20/12
6/19/12
7/19/12
8/21/12
9/18/12
10/21/12
11/18/12
12/18/12
Note: If a Community Well member refuses an annual assessment, a Screening Document
should be entered in MMIS as a refusal.
ON-GOING CARE COORDINATION RESPONSIBILITIES
The Delegate is responsible for confirming member’s eligibility before providing Care
Coordination Services
Primary Care Clinic (PCC) Change
When a member makes a permanent PCC change, Blue Plus must be notified so our systems are
updated and the member can receive a Blue Plus identification card listing the name of their new
PCC. A member, family member, or Care Coordinator may request the PCC change by
contacting member services at 651-662-6013 or 888-740-6013. The requestor must provide the
member’s name, Blue Plus identification number, name of new PCC clinic, clinic location
(town), and effective date. The effective date must be on the first of a month.
If this PCC change will create a change in Care Coordination delegate for the member, the
process for Transfers of Care Coordination to Another Delegate, as outlined on page 23, must be
followed.
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Requesting a change to a member’s PCC is very important when a member moves to a nursing
facility and their care coordination will be done by a new delegate. It is also vital to ensure
physician communication is sent to the appropriate PCC.
Transitions of Care (September 2012 updates in purple)
1. The Care Coordinator will provide transition of care services for members when they
move from one care setting to another due to a change in health status. The goal of
this process is to reduce incidents related to fragmented or unsafe care and to reduce
readmissions for the same condition. Examples of transitions include: moving from
their usual care setting to a hospital, skilled nursing facility, custodial nursing facility,
regional treatment center or rehabilitation facility. Any movement between sites of
care is a separate transition including the member’s transition back to his/her usual
care setting. Follow up is required regardless of how or when the Care Coordinator
learns of the transition. See 9.23 Transition Training Videoconference Q&A located
on the web-portal for additional information.
2. The Care Coordinator will document transition services on the 6.22 Individual Care
Transitions Log. Use 6.22.01 Individual Care Transitions Log Instructions for
detailed information on the completions of the log. Use one log for each transition.
The Individual Transition Log should be kept in the member’s file along with
additional case note documentation as appropriate.
3. The Care Coordinator must document all care transition contacts in compliance with
the following timelines:
a. For planned transitions, contact the member prior to the admission day to
ensure they have the Care Coordinator’s phone number and understand how
the Care Coordinator will assist during the member’s care transitions
b. Share essential information with the receiving facility (discharge planner,
Social Worker, etc.) within 1 business day of learning of the admission.
Examples of essential information include: services currently being received
by the member and who provides them; the name of the Primary Care
Provider/Specialty Care Provider to use as a resource for current medications,
chronic conditions, and current treatments; the Care Coordinator contact
information and a brief explanation of their role in assisting the member with
care transitions. Work with the discharge planner to ensure continuity in
home care, if needed, upon discharge.
c. Notify the Primary Care Physician and/or Specialty Care Physician of all
transitions including the transition to home, within 1 business day of
learning of the transition, if they were not the admitting physician. Optional
fax form: 6.22.2 Fax Notification of Care Transition is available for this
communication
d. Communicate with the member and/or member’s Rep within 1 business day
of learning of the transition to explain your role and how to contact you during
their stay and after they return home. Talk about what happened, changes in
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health status, what might occur while in the hospital/nursing home, and any
discharge plans leading to or delaying discharge. Communication with the
Customized Living or Nursing Facility does not replace the requirement to
contact the member/member’s representative.
e. Reach out to the member after the return to their usual setting of care no later
than 1 business days from notification to assess the member’s needs.
Suggested topics to review: medication changes/new prescriptions filled,
DME/supply needs, scheduling of follow-up appointments, transportation or
other services needs, changes in functional needs (bathing, eating, dressing,
transfers, etc.), and the member’s understanding of what to do if their
condition worsens.
f. Provide education to the member or the member’s authorized representative
related to prevention of unplanned transitions and/or how to maintain their
health and remain in the least restrictive setting. This education should be
tailored to the member’s specific needs, diagnoses, health issues, etc. and
should be in a format that best works for the member based on their abilities.
Members with chronic conditions who are frequently hospitalized can still
benefit from educational discussions about their conditions, appropriate care,
treatment options and relationship building with the Care Coordinator.
Members in a nursing facility can benefit from an opportunity to reinforce or
develop what is in their nursing facility plan of care.
Educational examples include (but are not limited to):
 Use of written materials related to a member’s medical condition. (These
can be found in the Resource Management section of the Care
Coordination web portal.)
 A referral to Disease Management
 A referral to Medication Therapy Management (Medicare recipients can
receive this through a local pharmacy, or directly from a Blue Plus
Pharmacist – see Key Contact List)
 Falls risk education
 Caregiver support/training
 Discussion with member (or authorized representative) during a nursing
facility care conference
Transfers of Care Coordination to Another Delegate
Enrollment reports are distributed to delegates twice a month. The “Newly Enrolled”
member enrollment report is sent via secure email the first week of each month. A “Full
Detail” report is sent via secure email 3-5 days following the newly enrolled report. The
Full Detail report contains all current members as well as newly reinstated members and
termed members. Blue Plus relies on the financial worker to update the information
timely and due to DHS's report cut off dates, there could be a delay of up to two months
in the information showing up on our report. So, it is important, when a care coordinator
becomes aware that a member has moved from their county, out of the Delegate’s service
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area, the following shall be done to expedite communication to the new delegate and
assist our members with smooth transfer of care coordination services and minimize any
gaps in care:
1. The current Care Coordinator is required, at a minimum, to share assessment and plan
of care information with the new delegated entity when the current Care Coordinator
is made aware of a members move to another county, health plan, etc.
2. Be sure to communicate address changes to your county financial worker for timely
updating of this information to the DHS tapes.
3. If the member is on EW, the current Care Coordinator shall keep the Waiver Span
open in MMIS, as they remain eligible for EW.
4. The Care Coordinator must also notify the county financial worker and Blue Plus
IHM-GP department when a member moves from their county by completing and
faxing a 6.08 Notification of Member Change Needed form. This is the only way
Blue Plus will be notified of the change and thus be able to communicate to the
receiving Delegate in a timely manner.
5. The delegate must also notify Blue Plus when the transfer involves a move from the
community to a nursing home for long term placement or from the nursing home back
to the community and the case needs to be transferred to a Care Coordinator outside
of the current agency. Notify Blue Plus using 6.08 Notification of Member Change
form.
6. If a member enters an in-patient setting such as a hospital, Residential Treatment
Center, etc. outside of the county the member resides in, the Care Coordination
responsibility continues with the current Care Coordinator. Once it is determined the
member will not be returning to the original county, the Care Coordinators should
precede with the Transfer directions in #4 above.
7. Blue Plus will securely e-mail this form to the receiving Delegate as official
notification that the new Delegate is now responsible to follow this member.
8. Receiving delegate has 10 days from the faxed date to assign a Care Coordinator and
notify the member. The 8.30 CM Change Intro letter may be used to notify the
member of a change in Care Coordinator.
9. The Care Coordinator will notify the physician using 8.28 Intro to Doctor Letter.
10. Keep copies of all forms and letters related to the transfer for your records
11. If no current Health Risk Assessment/Care Plan is received, the receiving
Delegate must follow the process for completing the health risk assessment and
care plan.
12. 9.01 Blue Plus Service Area Map 2012 can be used as a resource to determine if
a move will take the member out of our service area. Implications of a move
outside Blue Plus service area should be discussed with the member. Member
questions related to selecting a new plan can be directed to Senior Linkage Line
at 1-800-333-2433.
Important: The current Care Coordinator is responsible for all care coordination
activities until the case is formally transitioned. However, there may be tasks associated
with the transfer that may make sense that one or the other completes and thus it is
expected that the current and receiving Care Coordinators will work together throughout
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the transition. Both Delegates can be reimbursed for their care coordination services
during the overlapping time period.
Transfers of Care Coordination within your agency
If there is a change in Care Coordinator within the Delegate agency, the Care
Coordinator must inform the member of the name, number, and availability of the Care
Coordinator within 10 days of this change. The new Care Coordinator may use the 8.30
CM Change Intro letter for this purpose. The Delegate must also notify Blue Plus of the
change by faxing the 6.07 Notification of Care Coordinator Assigned form.
Case Closure Care Coordination Responsibilities
1. Please refer to the Bridgeview Company manual for requirements related to closure of
current Service Agreements.
2. Inform the County Financial Worker of any permanent moves so that they may update
their systems accordingly.
3. If a SecureBlue/MSHO member has Medicare and loses eligibility for Medical
Assistance, Blue Plus will continue to provide Medicare-covered Plan benefits for up to
three months. If after three months, the member has not regained Medical Assistance,
coverage with Blue Plus will end. The member will need to choose a new Part D plan in
order to continue getting coverage for Medicare covered drugs. If the member needs
assistance, they can call the Senior Linkage Line at 1-866-333-2466. Care Coordination
services continue to be provided during this three month period.
4. Determine the appropriate closing activity for the MSHO member by referring to DHS
Instructions for Completing and Entering the LTC Screening Document into MMIS for
MSHO/MSC+ Programs https://edocs.dhs.state.mn.us/lfserver/Public/DHS-4625-ENG.
 If the EW member is placed in a Nursing Facility for more than 30 days, the
waiver span must be closed
 If the member dies the SD must be updated to reflect the death for EW members
 If the EW member loses eligibility for MA, and therefore loses EW, the waiver
span must be closed
Special Status Notification/Notification of Change Needed
The Delegate must notify Blue Plus about the following by completing and faxing the 6.08
Notification of Member Change Needed to IHM—GP at 651-662-6054 or 1-866-800-1665:



Member moves and requires a change in care coordination.
Date of death
Institution-based services: Fax this form if the member moves from the Community
to a nursing facility for a long term placement (> 180 days) and the case needs to be
transferred to a Nursing Home Care Coordinator outside of your agency.
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Coordination of Potential Denials, Terminations, and Reduction of Services—Blue Plus will
review notifications of Denial, Termination, and Reduction of Services for State Plan and
Elderly Waiver Services.
State Plan Home Care Services
If the Care Coordinator, not the provider, recommends a DTR of State Plan Home Care
Services, the Care Coordinator shall fax in the 6.05 Notification of Potential Denial
Termination or Reduction of Services form to Blue Plus IHM-GP. Blue Plus will review
the request for Medical Necessity and if a DTR is needed will the fax a copy of the DTR
to the Care Coordinator and will mail a copy to the member.
Note: Fluctuations in a member’s plan of care is not a DTR.
Elderly Waiver Services
The care coordinator will evaluate waiver services and if it has been determined that the
members needs can be met with fewer or different waiver services, and the member has
not initiated the reduction or termination, the care coordinator shall fax the 6.05
Notification of Potential Denial, Termination or Reduction of Services form to Blue Plus
within 24 hours of the determination. Blue Plus will review the request to determine if a
DTR should be issued according to Blue Plus’ guidelines. BluePlus may contact the Care
Coordinator with any questions. If a DTR is determined to be appropriate, Blue Plus will
then fax a copy of the DTR to the Care Coordinator and will mail a copy to the member.
Grievances/Complaint Policy and Procedure
Definitions
Grievance
Grievances are verbal or written expressions of dissatisfaction about any matter other
than an Action (see definition below), including but not limited to, the quality of care or
services provided or failure to respect the member’s rights. Some examples of grievances
include: the quality of home delivered meals (food is cold), transportation providers
being late, dislike of a roommate in the nursing home, impolite staff, in ability to access
services appointment, missed or delayed diagnosis, or lack of treatment. Grievances can
be filed either orally or in writing.
Grievant
The grievant is the person that is submitting the grievance for consideration. This may be
a member, any individual acting on behalf of the member, or a provider with the
member’s written consent.
Action
An action is a denial or a limitation of an authorization of a requested service, which
includes:
• The type or level of service,
• the reduction, suspension or termination of a previously approved service
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• the denial, in whole or in part for the payment for a service
• The failure to provide services in a timely manner
• The failure of the health plan to act within the required timeframes for resolution
of appeals and grievances.
• For a resident of a rural area with only one Health Plan, the denial of a Medicaid
member’s request to exercise services outside of the network.
Appeal
An appeal is a request to change a previous decision or action made by the health plan.
Appeals may be filed orally or in writing.
Authorized Representative
An authorized representative is an individual that is authorized by the member, or a
surrogate who is acting in accordance with State law on behalf of the member in order to
obtain an organization determination or deal with any level of the appeals process.
Delegate Responsibilities
The delegate must have a Policy and Procedure and system in place for handling grievances for
MSHO/SecureBlue, and MSC+/Blue Advantage. A copy of written grievances, if submitted to
the Delegate, must also be retained in the member’s file.
A contact person will need to be established by each delegate for grievances. The contact person
will be responsible to obtain any necessary information to resolve written or oral grievances
submitted directly to us. The delegate must be able to retrieve records within two business days.
Required Oral Grievance Member Assistance
Care Coordinators should direct members to report all oral grievances to Blue Plus by calling
member services, seven (7) days a week 8:00 a.m. to 8:00 p.m. Central Time.
Care Coordinators may also call Blue Plus to report an oral grievance on behalf of the member if
the member requires assistance. MSHO/MSC+ Member services number is:
MSHO
(651) 662-6013 or 1-888-740-6013 (Calls to this number are free)
TTY users call: (651) 662-8700 or 1-888-878-0137 (Calls to this number are free)
MSC+
651-662-5545 or 1-888-711-9862 (Calls to this number are free)
TTY users call: (651) 662-8700 or 1-888-878-0137 (Calls to this number are free)
Written Grievances
If a member requests the assistance of the Care Coordinator in filing a written grievance, the
grievance should be transcribed in the member’s words and faxed to Blue Plus Consumer
Service Center within one business day of the receipt of the grievance. Fax: 651-662-9517 or call
651-662-5545 or 1-800-711-9862
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The information faxed to Blue Plus should include both the written grievance and all other
pertinent information or documentation related to the grievance. Blue Plus Consumer Service
Center may contact the delegate for additional information during investigation of the grievance.
Blue Plus 6.11 Grievance Form may be used to document the written grievance. Original
documentation should be maintained on file by the delegate.
EW Conversion/Request to Exceed case mix cap
Conversions: A request for a higher monthly case mix budget cap may be submitted to
Blue Plus for review and consideration if an EW eligible member;




wishes to live in the community and
is a resident of a certified nursing facility and
has lived there for 30 consecutive days or more and
their needs cannot be met within the assessed Case Mix budget Cap:
Please see DHS Bulletin 12-25-01 Elderly Waiver- Conversion Rates and Maintenance
Needs Allowance changes.
Requests to exceed Diversion Case Mix Budget Cap: If a member has a unique set of assessed
needs that require care plan services above their budget cap and there are no other informal
support options, a request for a higher monthly case mix budget cap may be submitted to Blue
Plus for review and consideration
First-time requests must take place prior to the service initiation. A reauthorization request of a
previously approved rate must be made at least 30 days prior to the end of the current
authorization period.
To request a Conversion/Exceed Cap rate, the Care Coordinator must fax the following
information to the attention of EW Review Team, at 651-662-6054 or 1-866-800-1665
following the time frames above:
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Either the DHS EW Conversion Rate Request form (Attachment C of Bulletin 12-2501) or the 6.27 Blue Plus Exceeds the Case Mix Cap form
Copies of member Care Coordination case notes for previous 2 months
A copy of the member’s LTCC assessment completed within the previous 60 days
A copy of the Plan of Care
A description of what other options within the member’s current budget have been
considered and why they are not possible
A copy of Customized Living tool, if appropriate, or a copy of the budget which
differentiates between service costs vs. room and board if moving in or living in a foster
care
Any other supporting documents deemed appropriate
Other documents requested by the EW Review Team
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The Blue Plus Review Team will:
 Review the request within 10 business days/14calendar days, whichever is sooner, of the
receipt of all the required information/documents
 Will confer with the Care Coordinator if the documentation provided does not support the
requested level of service
 Consult with the submitting Care Coordinator to ask for clarification or request further
documentation as needed
 Consult with the IHM-GP Medical Director as needed
 Approve, deny, or recommend a change in the budget rate request
If request is approved, Review Team will:
Determine the length of time for the approval.
 Initial Conversion Rate for members transitioning out of a nursing facility,
authorization will be given for a six month period. This will allow the Care
Coordinator and the EW Review team time to determine if the member is stable in
their new community environment and if services and rates need to be adjusted to
meet any changes in the identified needs of the member
 Reauthorization without Change in Level of Service: If the EW Review team agrees
with the level of services authorized for members who have previously transitioned to
the community using an approved EW conversion budget, Blue Plus will reauthorize
the budget for a twelve month period. This applies to current and newly enrolled
MSC+ /MSHO members
 Reauthorization with Change in Level of Service: If the EW Review Team assesses
the member to need a different level service than what was previously authorized for
a member who has transitioned to the community using an approved EW conversion
budget, the authorization period will be for six months. This will allow the Care
Coordinator and the EW Review Ream time to determine if the member is stable with
the new service levels and if services and rates need to be adjusted to meet any
changes in the identified needs of the member
 Requests to Exceed Case Mix Cap: Requests to exceed the case mix cap approval
period will be determined based on the member needs and reason for exception, not
to exceed a twelve month period
EW Review Team will then:
 Send notification to Bridgeview Company
 Send notification to Care Coordinator
The Care Coordinator must:
Place the full CAP amount (rather than the higher conversion rate/approved amount
that exceeds case mix cap) in the Case Mix/DRG Amount field on the LTC screening
document.
If the request is not approved, the EW Review Team will:
 Advise the Care Coordinator on how to assist the member to look at other options
which may include adjusting the level of service to more appropriately reflect the
documented need and/or explore other provider options
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IHM-GP Clinical Guides will then:
 Issue a Denial, Termination, or Reduction (DTR) letter to the member and Care
Coordinator within 10 business days/14calendar days, whichever is sooner, of the
receipt of all the required information/documents.
Interpreter Services (Added September 2012)
The Blue Plus contract with the Minnesota Department of Human Services requires that persons
with limited English proficiency receive language assistance as necessary. If a Blue Plus member
does not speak English as their primary language and has a limited ability to read, speak, write or
understand English, the Care Coordinator may initiate the use of a Blue Plus contracted
interpreter to assist in assessment, care planning and on-going care coordination. Blue Plus
prefers the use of a formal interpreter over a family member, as best practice. A list of Blue Plus
contracted providers is available in the Blue Cross Blue Shield provider manual, chapter 3. You
can click on the link below or copy and paste this web address into your browser:
http://www.bluecrossmn.com/bc/wcs/groups/bcbsmn/@mbc_bluecrossmn/documents/public/pos
t71a_023249.pdf
To initiate the process for interpreters or for any questions contact our Member Services at 651662-6013 or 1-888-740-6013.
For Face-to-Face Interpreters: The Care Coordinator can also initiate the process by contacting
an in-network provider directly.
For Over-the-Phone Interpreters: The Care Coordinator may contact Via Language or Language
Line as described in the instructions provided by your Partner Relations Consultant.
If the Blue Plus member is requesting information about the use of an interpreter for their
medical appointments (such as a clinic visit), the member should be directed to Member
Services.
OTHER CARE COORDINATION RESPONSIBILITIES
1. PIPs—The Care Coordinator will participate in the on-going performance
improvement projects that are designed to achieve significant favorable health
outcomes for members. These projects incorporate standards and guidelines
outlined by the Centers for Medicare and Medicaid (CMS) with input by the
Minnesota Department of Human Services (DHS).
2. Fraud, Waste, and Abuse Training is required for 2012. Curriculum will be
provided annually.
3. Documentation—The Care Coordinator shall document all activities in the
member’s case notes.
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4. The Care Coordinator shall comply with any applicable Federal and State laws that
pertain to member rights including HIPAA laws and the Minnesota Data Privacy
Act and your organization’s confidentiality policy.
5. The Care Coordinator should be coordinating with local agency case managers
(mental health, developmental disabilities, adult protection, etc), financial workers
and other staff as necessary to meet the member’s needs. This includes using the
Case Manager/Financial Worker Communication Form (DHS # 5181) when:
 A member requests waiver services
 A member receiving waiver services has a change in circumstances
(exits waiver, moves to SNF, expires, etc)
 For more information refer to DHS Bulletin #07-21-09
Out of Network Providers
Elderly Waiver Network—Blue Plus does not contract directly with EW service providers.
1. Vendors within the Delegate’s County Network. If the Care Coordinator determines
that a member needs covered services from a vendor with no current contract, the
Delegate may enter into a one-time service agreement. This one-time contract will
include the procedures needed to reimburse the provider for the services.
2. Vendors Outside of the Delegate’s County. If the Care Coordinator determines that a
member needs covered services from a vendor not in the county’s network, the Care
Coordinator will determine if the requested vendor has a Lead County contract in
another county. The Care Coordinator will contact the Lead County to determine if
services may be authorized under the Lead County contract.
Blue Plus Network
1. Blue Plus members do not have out of network benefits for services that are not
emergent/urgent. (i.e., Our member, Mildred, is visiting her daughter in Missouri and
needs outpatient I.V. therapy. This service is not emergent/urgent and thus would not
be covered)
Note: Questions related to in-network providers and benefit questions should be directed to
Provider Services at 1-800-262-0820 or 651-662-5200.
Out of Country Care—Medicaid. Effective 1/1/12, Medicaid payments, including EW, will
not be made:
1. For services delivered or items supplied outside of the United States; or
2. To a provider, financial institution, or entity located outside of the United States.
United States includes the fifty states, the District of Columbia, the Commonwealth of
Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana
Islands.
Reminder: Any Benefit questions should be directed to Member Services.
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Audit Process—The BluePlus contract with DHS and CMS requires the auditing of care
coordination activities on an annual basis.
Records Retention Policy The Delegate must have policies and procedures to address record
retention in accordance with DHS and Center for Medicare and Medicaid Services rules and
regulations. Files, either in electronic or hard copy format, are to be kept for 10 years from the
date the files are closed. After 10 years the files may be destroyed.
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File information includes: patient identification information, provider information,
clinical information, and approval notification information.
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All documents pertaining to pending litigation or a regulatory matter must be retained
despite general disposal policy until Blue Plus advises that such documents may be
returned to the general disposal policy.
Care Coordination Services Overview
The Care Coordinator will work with the member with support from IHM-GP staff
and/or Government Programs staff to assure that the member has access to the following
services as needed:
1) Rehabilitative Services. These are services that promote the rehabilitation of
members following acute events and for ensuring the smooth transition and
coordination of information between acute, sub acute, rehabilitation, nursing home
and community settings.
2) Range of Choices. The care coordinator is key in ensuring access to an adequate
range of choices for members by helping the member identify formal as well as
informal supports and services, ensuring that the services are culturally sensitive.
Interpreter services are available for all BluePlus members.
3) Coordination with Social Services. The Care Coordinator will collaborate with the
local Social Service Agency when the member may require any of the following
services:
 Pre-petition Screening
 OBRA Level II Screening
 Spousal Impoverishment Assessments
 Adult Foster Care
 Group Residential Housing and Board Payments; or
 Extended Care or Halfway House Services covered by the Consolidated
Chemical Dependency Treatment Fund
 Targeted Mental Health Case Management
 Adult Protection
4) Coordination with Veteran’s Administration (VA). The Care Coordinator shall
coordinate services and supports with those provided by the VA if known and
available to the member.
5) If the Care Coordinator receives notification of a member’s hospital admission,
contact will be made with the hospital social worker/ discharge planner, to assist with
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discharge planning. The Care Coordinator can work with the discharge planner,
member or home care nurse (if appropriate) to complete the following:
 Assess the member’s medical condition;
 Identify any significant health changes;
 Reassess and revise the CSP for the member to meet their new health
needs, if required; and
 Schedule an interdisciplinary team conference, if needed at this time.
6) Identification of Special Needs and Referrals to Specialists. The Care Coordinator
should have the ability to identify special needs that are common geriatric medical
conditions and functional problems such as polypharmacy issues, lack of social
supports, high risk health conditions, cognitive problems, etc. and assist the member
in obtaining specialized services to meet identified needs.
Care Plan Service and Guidelines
Delegate staff use professional judgment interpreting the following guidelines to make decisions
related to the care and treatment of their SecureBlue members:
 MN rules and statutes,
 DHS policies and training,
 County program training and guidelines,
 Provider training and guidelines,
 Medicare coverage criteria,
 Long Term Care Screening Document,
 Disease Management protocols,
 Case mix caps/budget, and
 SecureBlue Certificate of Coverage
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