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Ongoing Care Coordination and Monitoring
Health Education and Nutrition Counseling
Reduction or Termination of Ongoing Care Coordination Services
This chapter outlines Medicaid-covered services, conditions, and limitations for prenatal care coordination (PNCC) services. Prenatal care coordination services include all of the following:
Note: Providers should be prepared to offer all five components of the PNCC benefit - not just the initial assessment - to eligible recipients.
Refer to the Medicaid Guidelines and Performance Measurements for Prenatal Care Coordination (Appendix 7 of this handbook) for detailed information about the benefit’s operational standards and performance measurements. Providers are encouraged to use the guidelines to help ensure that quality services are provided and activities are directed toward the program’s objectives and goal as stated in the General Information chapter of this handbook.
Wisconsin Medicaid also uses the guidelines to monitor the administration of the benefit.
Outreach involves identifying eligible, low-income pregnant women, who may be unaware of or not have access to PNCC services, and informing them about the benefit. Providers may use a variety of strategies to market and promote PNCC services in the community, such as informational brochures or community presentations.
Providers are not reimbursed separately for outreach activities. Wisconsin Medicaid includes the reimbursement for outreach activities in the reimbursement for the initial assessment.
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Providers are required to administer an initial, comprehensive risk assessment to all recipients. The purpose of this assessment is to determine the needs and strengths of the recipients. The Department of Health and Family Services’ (DHFS)-approved tool for the initial assessment is the Pregnancy Questionnaire (Appendix 8 [PDF, 119 KB]of this handbook).
Complete every section on the Pregnancy Questionnaire unless the recipient objects to a particular section. Refer to Appendix 9 of this handbook for instructions on completing the Pregnancy Questionnaire (PDF, 119 KB). Providers may also consult the Guidance Manual for Administering the Prenatal Care Coordination Pregnancy Questionnaire for additional information on administering the questionnaire. Refer to Appendix 16 of this handbook for information on obtaining the Guidance Manual for Administering the Prenatal Care Coordination Pregnancy Questionnaire.
The Pregnancy Questionnaire must be:
The person administering the Pregnancy Questionnaire (PDF, 119 KB) must be an employee of the Medicaid-certified PNCC agency or an employee of an agency under contract to the PNCC agency.
Refer to Appendix 18 of this handbook for a list of types of qualified professionals who can administer or review the Pregnancy Questionnaire. Qualified professionals are required to review and initial all Pregnancy Questionnaires completed by paraprofessional staff.
Wisconsin Medicaid reimburses for the administration of the Pregnancy Questionnaire regardless of the recipient’s score. Recipients may be reassessed at any time, but providers need only readminister the entire Pregnancy Questionnaire (PDF, 119 KB) if the recipient’s situation changes significantly.
Wisconsin Medicaid will reimburse only one comprehensive assessment per recipient, per pregnancy, per provider.
Providers may obtain copies of the Pregnancy Questionnaire at no cost by writing to:
Division of Health Care FinancingWhen requesting the Pregnancy Questionnaire (PDF, 119 KB), note the form number HCF 1105 on the request.
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Wisconsin Medicaid will reimburse care planning as a PNCC service when provided by qualified staff. Care planning includes developing and implementing the care plan. Wisconsin Medicaid will reimburse the development of a care plan for recipients who score 40 or more points on the Pregnancy Questionnaire (PDF, 119 KB). A completed questionnaire must predate the care plan.
Wisconsin Medicaid reimburses for the development of one care plan for each recipient, per pregnancy. (Wisconsin Medicaid reimburses for updates to the care plan under the ongoing care coordination and monitoring procedure code.)
The care coordinator is required to develop an individualized care plan for each eligible recipient. Medicaid does not require a specific care plan format, but the care plan must be:
Note: Providers should note in the care plan if the recipient does not want to address issues identified in the Pregnancy Questionnaire (PDF, 119 KB).
Refer to Appendix 13 (PDF) of this handbook for a blank model of a care plan. Providers are not required to use the sample.
To ensure the recipient’s needs are met, the care plan must:
Refer to Appendix 10 (PDF) of this handbook for a model of a Pregnancy Questionnaire Summary. Providers may use the Pregnancy Questionnaire Summary as an aid in identifying the recipient’s unmet needs.
To the maximum extent possible, include the recipient in the development and any subsequent revisions of the care plan. Include family members and other supportive persons as appropriate. The recipient and care coordinator who developed the care plan are required to sign and date the plan.
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Ongoing care coordination and monitoring activities must be based on the recipient’s written care plan. Wisconsin Medicaid will not cover ongoing care coordination and monitoring services that are not based on the recipient’s care plan.
Ongoing care coordination and monitoring is a covered PNCC service for recipients who score 40 or more points on the Pregnancy Questionnaire (PDF, 119 KB). Except in urgent care situations, providers are required to complete the Pregnancy Questionnaire and a care plan for each recipient prior to providing ongoing care coordination and monitoring services. Providers may offer ongoing care coordination services on the same date they completed the Pregnancy Questionnaire and care plan.
Covered activities include the following:
Recipient contacts may be face-to-face, by telephone, or in writing, as appropriate. Except for health education and nutrition counseling, Wisconsin Medicaid does not cover recipient contacts for the direct provision of services. Wisconsin Medicaid reimburses for the provision of many medical services under other Medicaid benefits.
Wisconsin Medicaid does not limit the number of contacts providers may have with a recipient. However, reimbursement for the benefit is limited to a maximum amount per pregnancy, per recipient, per provider. Refer to Appendix 19 of this handbook for more information on reimbursement limitations.
A collateral is anyone who has direct supportive contact with the recipient, such as a family member, friend, service provider, guardian, housemate, or school official. Since the purpose of contacts with a collateral is to mobilize services and support on behalf of the recipient, the provider is required to identify the role of the collateral in the recipient’s care plan.
Collateral contacts also include time spent on client-specific meetings and formal case consultations with other professionals or supervisors. Do not include time spent discussing or meeting on non-client-specific issues or time spent on general program issues.
Wisconsin Medicaid will not reimburse collateral contacts if there is no recipient contact during the month for which the provider is billing.
Information and referral means providing recipients with current information about available resources and programs to help recipients gain access to needed services. Providers are required to ensure follow up on all referrals within two weeks, unless otherwise stated. Wisconsin Medicaid reimburses information and referral under ongoing care coordination and monitoring.
Wisconsin Medicaid does not cover care coordination services on behalf of family members who are not Medicaid eligible. However, providers may assist non-Medicaid-eligible family members in accessing services needed to best meet the eligible recipient’s needs.
Refer to Appendix 11 (PDF) of this handbook for a model of a Referral Form.
Appendix 16 of this handbook includes a list of resources that providers and recipients may consult.
Transportation Resources for Recipients
Although Wisconsin Medicaid does not cover transportation services as part of the PNCC benefit, providers often assist recipients in making transportation arrangements. Appendix 17 of this handbook provides information for assisting recipients with transportation arrangements.
Providers may update the Pregnancy Questionnaire (PDF, 119 KB) and care plan, and administer other assessment tools, when necessary. Wisconsin Medicaid reimburses these activities as ongoing care coordination and monitoring services.
Assessment Updates
Providers may update the Pregnancy Questionnaire as frequently as needed. Providers may also administer other assessment instruments periodically, if appropriate, to determine the recipient’s progress toward meeting established goals.
Use the ongoing care coordination and monitoring procedure code (W7092) when billing for updates to the Pregnancy Questionnaire and/or administration of other assessments.
Care Plan Updates
Providers are required to review and update the care plan at least every 60 days, or earlier if the recipient’s needs change. The provider and the recipient are required to sign and date all updates to the care plan. The provider may initial updates to the care plan if a signature page is included in the recipient’s file. Providers are required to keep signed copies of the updates in the recipient’s file.
Use the ongoing care coordination and monitoring procedure code (W7092) when billing for updates to the care plan.
Wisconsin Medicaid considers recordkeeping a reimbursable ongoing care coordination and monitoring activity. Reimbursable recordkeeping activities include time spent on the following:
Wisconsin Medicaid reimburses for recordkeeping only if a recipient contact occurred during the month for which the provider is billing.
If a recipient or collateral contact occurs on the last day of the month, the provider may bill Medicaid for the documentation of the contact in the following month (e.g., if the contact occurred on June 30, the provider may bill for the contact with the July contacts). Wisconsin Medicaid will only allow this exception if the provider documents the contact no later than the next business day.
When ongoing care coordination services are provided in an urgent situation (e.g., the woman is pregnant and homeless, or pregnant and without food), the provider is required to:
Note: Providers may offer ongoing care coordination services to recipients in urgent situations, but Wisconsin Medicaid will not reimburse for these services when they are provided to recipients who score fewer than 40 points on the Pregnancy Questionnaire.
As part of the care planning process, the provider is required to discuss and document the planned frequency of ongoing contacts and monitoring with the recipient (and the recipient’s collaterals, if appropriate). At a minimum, contacts should occur every thirty days. If possible, schedule more frequent visits during the early months of the pregnancy.
Wisconsin Medicaid covers PNCC services up to 60 days following delivery. Wisconsin Medicaid covers postpartum PNCC services only if the recipient received care coordination services prior to delivery. During the postpartum period, providers are required to:
Refer to Appendix 7 of this handbook for additional information on services provided during the postpartum period.
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Wisconsin Medicaid covers health education and nutrition counseling under the PNCC benefit if all of the following occur:
Health education may include, but is not limited to, the following topics:
Nutrition counseling may include, but is not limited to, the following topics:
Refer to Appendix 7 of this handbook for additional information on the provision of health education and nutrition counseling services.
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According to HFS 106.02(9), Wis. Admin. Code, all providers are required to prepare and maintain truthful, accurate, complete, legible, and concise documentation and records. Providers may keep records in written or electronic formats. If providers keep electronic records, they are required to have hard copies available for review and audit.
As defined in HFS 105.52(5), Wis. Admin. Code, the recipient’s file must include the following information, as appropriate:
The following are general guidelines for documentation of activities:
Please refer to Appendix 14 (PDF) of this handbook for a completed sample time log form.
State and federal laws require that the personal information of all Medicaid recipients be safeguarded. However, when providing care coordination services, providers may need to obtain or release recipient information on behalf of the recipient. To comply with state and federal laws, providers may release recipient-specific information if:
In cases where more stringent laws govern the release of certain personal information, providers are required to comply with those laws. It is the provider’s responsibility to be aware of patient confidentiality laws.
For a model of a release of information form, please consult the Informed Consent to Release/Obtain Health Care Information Form in Appendix 12 of this handbook.
Please refer to HFS 104.01(3), Wis. Admin. Code, or to the Provider Rights and Responsibilities section of the All-Provider Handbook for additional information on maintenance and confidentiality of Medicaid recipient records.
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A recipient should not require PNCC services from more than one provider. Although Medicaid does not deny claims for concurrent services, both providers are notified of the overlap. It is the providers’ responsibility to eliminate the overlap by communicating with the recipient and with each other to determine which provider will continue to provide PNCC services. The recipient’s preferences concerning which care coordinator should provide services must be considered when the care coordinators’ roles overlap.
When multiple family members have care coordinators (case managers), the care plan must identify the role of each care coordinator. Coordinators may not duplicate services. This requirement applies whether or not Medicaid covers the other care coordinator’s services.
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If a provider needs to reduce or terminate care coordination services for any reason, the provider should notify the recipient in advance and document this in the recipient’s record. A decision that services can be reduced or terminated should be mutually agreed upon by the provider and recipient. The recipient’s file must include a statement, signed and dated by the recipient, indicating agreement with the decision to terminate services. Changes in the care plan should always be discussed with the recipient/guardian/parent.
In circumstances when the provider is unable to obtain a signature from the recipient for the termination of services (for example, the recipient consistently misses meetings with the provider and does not follow through on referrals, but indicates she wants to continue receiving PNCC services), the recipient’s file must include documentation of all attempts to contact the recipient through telephone logs and returned or certified mail. The provider is encouraged to provide the recipient with the names and addresses of other PNCC providers.
If a provider terminates ongoing PNCC services for any reason, the recipient’s case is closed. However, there is no limit to the number of times a provider may reopen a recipient’s case. The provider is required to document in the recipient’s record why the case has been closed and reopened.
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The following related limitations apply to PNCC services in addition to the other limitations stated in this handbook:
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The following services are not covered under the Medicaid PNCC benefit:
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