BHDD waiver case management standards (SC DDSN) — ID/RD, community supports, and HASCI waivers

South Carolina Department of Disabilities and Special Needs — Waiver Case Management Standards Applicable to: Intellectual Disabilities/Related Disabilities (ID/RD) Waiver; Community Supports (CS) Waiver; Head and Spinal Cord Injury (HASCI) Waiver Revised: 1/1/2022

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I. STAFF QUALIFICATIONS AND PROVIDER REQUIREMENTS

1. Waiver Case Management services must be rendered by qualified staff. Waiver Case Management Supervisors must meet the minimum requirements for a Waiver Case Manager and possess the skills and experience needed to provide oversight. Waiver Case Managers must possess a bachelor's degree from an accredited college or university, or licensure from the South Carolina Department of Labor, Licensing and Regulation Board as a Registered Nurse, and have at least one (1) year of experience working with people with disabilities or one (1) year of Case Management experience. Any functions, tasks or activities performed by a Waiver Case Manager or Waiver Case Management Supervisor who does not meet the qualifications stated herein are not reportable. No exceptions to these qualifications can be made. A Waiver Case Manager cannot provide Waiver Case Management to a family member.

2. Each Waiver Case Manager or Waiver Case Management Supervisor must be an employee of the South Carolina Department of Disabilities and Special Needs (DDSN), a Disabilities and Special Needs (DSN) Board, or a DDSN-qualified Waiver Case Management provider.

3. Each Waiver Case Management provider must maintain:

   • A current list of staff members;
   • A signature sheet for Waiver Case Managers and Waiver Case Management supervisors which includes all signatures and initial variations used by those staff; and
   • A credentials folder for each staff member which includes: a. Resume'/Equivalent Application; b. Official copies of transcripts from an accredited university or college; c. Training records; d. Job description; e. Documentation of minimal background checks and screenings.

4. Waiver Case Management staff must have the following background checks and screenings prior to employment:

   • National federal fingerprint-based criminal background check if prospective employee cannot establish South Carolina residency for the 12 months preceding the date of the employment application and/or prospective employee will work with children under the age of 18;
   • South Carolina Law Enforcement Division (SLED);
   • DSS Child Abuse and Neglect Central Registry;
   • Medicaid Exclusion List;
   • Proof of current licensure as a SC Registered Nurse, if applicable;
   • Nurse Registry, if applicable;
   • Sex Offender Registry;
   • Tuberculosis screening;
   • Validation of a driver's license

   For any Case Manager delivering services to Waiver participants on or before June 30, 2019 who does not meet the minimum initial background check requirements, the initial (prior to employment) checks and screenings must be completed by July 1, 2020. After the initial completion of checks and screenings, the requirements for re-checks and re-screening stated herein must be applied.

   If a National federal fingerprint-based criminal background check is performed, then a SLED background check is not also required.Waiver Case Management staff may be employed by the provider agency prior to completion of Tuberculosis screening; however, staff cannot have any direct contact with any Waiver participant until the screening is complete.

5. Waiver Case Management staff must have the following background re-checks and re-screenings performed at least every five (5) years:

   • National federal fingerprint-based criminal background check if prospective employee cannot establish South Carolina residency for the 12 months preceding the date of the employment application and/or prospective employee will work with children under the age of 18;
   • South Carolina Law Enforcement Division (SLED);
   • Child Abuse and Neglect Central Registry;
   • Medicaid Exclusion List;
   • Proof of current licensure as a SC Registered Nurse, if applicable;
   • Nurse Registry, if applicable;
   • Sex Offender Registry.

   The 5-year clock for re-checks will begin on the date of initial check or date of last re-check for each screening. For employees who have been employed for more than 5 years on June 30, 2019, all background re-checks and screenings must be less than 5 years old or must be performed by July 1, 2020.

6. All Waiver Case Management staff must successfully complete the South Carolina Department of Health and Human Services (SCDHHS) Waiver Case Management curriculum before delivering Waiver Case Management services. Waiver Case Management staff must, at a minimum, successfully complete the following training annually:

   • Procedures for Reporting Abuse, Neglect or Exploitation of People (DDSN Directive 534-02-DD);
   • Confidentiality of Personal Information (DDSN Directive 167-06-DD);
   • Person-centered planning;
   • Level of Care;
   • Assessments and Plans of Support;
   • Programmatic changes (as required);
   • One topic of the provider's choosing.

   Any Case Manager delivering services to Waiver participants on or before June 30, 2019, must complete the SCDHHS Waiver Case Management curriculum no later than December 31, 2019. Any Waiver Case Manager hired after July 1, 2019 must complete the SCDHHS Waiver Case Management curriculum before delivering Waiver Case Management services. Beginning January 1, 2020 and thereafter, no Case Manager may deliver Waiver Case Management services until the SCDHHS Waiver Case Management curriculum is completed.

   Documentation must be available and reflect that information presented in training was understood by the Waiver Case Manager. To ensure competency, training beyond the minimum established by these standards is encouraged. Training in a classroom setting is not required. Other venues for training may be used such as:

   • Shadowing an experienced Waiver Case Manager or other professional staff;
   • One on one instruction (not routine supervision) by a supervisor or other designated staff;
   • Site visits to disability programs and services of other community service providers for the purpose of understanding the disability community and its service provider network.

   Refer to DDSN Directive 534-02-DD: Procedures for Preventing and Reporting Abuse, Neglect, or Exploitation of People Receiving Services from DDSN or a Contracted Provider Agency.

7. Waiver Case Management providers must be accessible to people served and must have a system in place which allows people served to receive assistance with any crisis situation 24 hours a day, 7 days a week. A back-up on-call system may be implemented which allows immediate accessibility for people receiving services. People receiving services and providers should be encouraged to call 911 in the event of a medical or police emergency; however, Waiver Case Management providers must still be accessible to provide assistance as needed. It is acceptable to have a general on-call number (outside of normal business hours) provided there is a response to crisis calls within two (2) hours.

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II. SERVICE DESCRIPTION

1. When delivered, Waiver Case Management services must conform to the definition of the service.

   Definition - Waiver Case Management: Services that assist participants in gaining access to needed waiver, State plan and other services, regardless of the funding sources for the services to which access is gained. Waiver case managers are responsible for initiating and/or conducting the process to evaluate and/or re-evaluate the participant's level of care as specified in waiver policy. Waiver case managers are responsible for conducting assessments and planning as specified in waiver policy. This includes the ongoing monitoring of the provision of services included in the participant's "Case Management Support Plan." Waiver case managers are responsible for the ongoing monitoring of the participant's health and welfare, which may include crisis intervention, and referral to non-waiver services.

2. Waiver Case Management services will be provided in accordance with all applicable DDSN policies and procedures. Please refer to: https://www.ddsn.sc.gov/providers/directives-and-standards

3. ASSESSMENT

The "Case Management Annual Assessment" must:

• Be completed within 60 days of Waiver enrollment;
• Be completed prior to the initiation of the "Case Management Support Plan;"
• Include a face-to-face contact in the participant's residence to gather information;
• Be completed prior to the provision of any Waiver-funded services except Waiver Case Management;
• Be re-completed in conjunction with a face-to-face contact in the participant's residence.

Assessment and periodic reassessment, in accordance with person-centered planning principles, is conducted to determine the participant's need for any medical, educational, social, or other services. Such assessment activities include the following:

• Identifying the needs and goals of the participant and completing related documentation;
• Gathering information from other sources such as family members, medical providers, social workers, and educators, if necessary, to form a complete assessment of the participant.

When the information in the most recently completed "Case Management Annual Assessment" changes or is no longer current, the updated information should be documented in case notes. Assessment and the planning can be conducted on the same day.

"Face-to-face" means an in-person contact between the Waiver Case Manager and the Waiver participant. A face-to-face contact in the participant's natural environment is permissible in lieu of the contact in the residence / residential setting under the following circumstances:

• The participant is homeless;
• The participant or homeowner refuses to allow access to the home;
• There is documented evidence of criminal activity, violence, or isolation that places the Waiver Case Manager in danger.

When these circumstances exist, the assessment and "Case Management Support Plan" should address safety issues or housing concerns for the participant. Waiver Case Management services can be delivered prior to the initial assessment. The results of the "Abbreviated Case Management Assessment" cannot be used to complete the "Case Management Support Plan" for Waiver participants.

4. SUPPORT PLAN

The "Case Management Support Plan" (Plan), must:

• Be completed or updated within 60 calendar days of the participant's enrollment in the Waiver;
• Be completed prior to the provision of any Waiver-funded services except Waiver Case Management;
• Be re-completed annually;
• Reflect consideration of the need to contact the Waiver participant more frequently than minimally required herein;
• Include information about what is important to the participant.
• Include information about the participant's plan for responding to emergencies.
• Address the Waiver participant's identified health and safety needs when residing in a DDSN-sponsored residential settings.
• Include the following:
  • A statement of need(s);
  • The service or intervention to address the need(s);
  • Type of provider to which the participant will be referred;
  • The funding source;
  • The amount, frequency and duration of the service;
• Be signed, titled, and dated by a qualified Waiver Case Manager;
• Be signed by the participant, his/her representative if available within three (3) months of Plan completion;
• Be updated as needed using the "Plan Change Request" form and remain current at all times;
• Be provided, by copy, to the participant or his/her representative within three (3) months of completion.

The case record must document the participant's/representative's participation in the planning process.

Planning includes the development and periodic revision of a plan ("Case Management Support Plan") which is based on the information collected through assessment ("Case Management Annual Assessment" and specific Waiver service assessments). The plan documents the participant's needs/goals and documents the Waiver-funded services, State Plan-funded services and the medical, social, educational and/or other services, regardless of the funding sources which are required to address the needs/goals of the participant.

Notes:

• A Plan is "completed", "updated" or "re-completed" when approved by the DDSN Waiver Administration Division. The Plan date is assigned by the DDSN Waiver Administration Division based on the date of approval.
• Prior to the delivery of Waiver-funded services, if a Plan was completed for the provision of Medicaid Targeted Case Management or State Funded Case Management services and developed based on the results of the "Case Management Annual Assessment," that Plan can be updated and used for the Waiver participant. The Plan must be updated within 60 calendar days of Waiver enrollment and prior to the delivery of all Waiver services except Waiver Case Management.
• A Plan developed based on the results of the "Abbreviated Case Management Assessment" cannot be used as the Support Plan for Waiver participants.
• "Annually" means every 365 calendar days from the completion date of the last plan. To allow adequate time for approval by the Waiver Administration Division, it is strongly recommended that the annual re-completion of Plans be performed at least 30 days prior to expiration date of the last plan.
• Waiver Case Management must be included as a service on the Plan.
• The Plan must be signed, titled, and dated by the Waiver Case Manager; this signature, title, and date are generated within Therap.
• The signature of the participant or his/her representative can be obtained on a printed copy of the Plan or a separate form indicating the participant's/representative's agreement with the Plan.
• The Plan must be updated when problems or concerns are noted and/or when there are changes in family circumstances, participant strengths/needs/goals, risk factors, resources, and the support network. Updates to the Plan must be made using the "Plan Change Request" form in Therap.
• A copy of the completed Plan must be provided to the participant/representative within three months of Plan approval. This must be documented in the case notes.
• The Waiver Case Manager must document that the participant/representative participated in the planning process. Evidence of participation may be in the form of a plan meeting sign-in sheet when the participant was present and/or a specific description of his/her participation documented in case notes.

"Within three (3) months of completion" means by the last day of the third month following the Plan completion date. For example, if a Plan is dated January 13, 2019, the due date would be April 30, 2019. Payment for any services (except Waiver Case Management) delivered in the absence of a current/valid Plan may result in sanctions/recoupment when identified through quality assurance reviews, Medicaid audits, or other means.

5. REFERRAL AND LINKAGE

Following the completion, update, or re-completion of the Plan, the Waiver Case Manager will implement/follow the Plan. Prior to referring/linking to planned services and annually thereafter, the Waiver Case Manager must offer the participant or his/her representative choice of available providers. The offering of choice must be documented. Authorization(s) for all Waiver-funded services must be issued prior to service delivery. Annually, written information about abuse, neglect and exploitation and how to report it is provided to the participant or his/her representative.

Referral includes making actual referrals, issuing authorizations, and activities related to making referrals/issuing authorization (such as scheduling appointments) that help the participant obtain needed services. Linkage includes activities that help link the participant with medical, social and educational providers and/or other programs and services that could provide services to address identified needs and achieve goals specified in the Plan. For each intervention in the Plan, the Waiver Case Manager will either make an initial referral for services or confirm services are still needed.

Notes:

• The participant/representative must be given the opportunity to select each service provider from all qualified providers of the service. Choice should be offered: annually during plan development; any time the participant/representative requests a change; or when an intervention/service to address a new need is identified.
• The offering of choice must be documented in case notes along with the choice made by the participant or his/her representative. If only one potential provider is available, the participant or his/her representative must be informed and the Waiver Case Manager must document this discussion in a case note.
• Waiver Case Managers should be responsive to preferences of the participant/representative including a request for a change in any service provider. When a change is requested, documentation must reflect that choice was offered.
• Authorization for Waiver-funded services must be issued prior to service delivery except for the following services which do not require the issuance of authorization: Waiver Case Management (ID/RD, CS, and HASCI Waivers); Adult Dental (ID/RD Waiver); Adult Vision (ID/RD Waiver).
• When electronic authorizations are issued in Therap, Waiver Case Managers must issue or re-issue authorizations for all services requiring authorization each Plan year. Authorizations corresponding to services in the new Plan must be issued prior to the end date of the previous Plan and no later than ten (10) business days from the approval date of the new Plan.

6. MONITORING AND FOLLOW UP

Monitoring and follow-up must be conducted as frequently as necessary in order to ensure:

• The health, safety and well-being of the participant;
• The Plan is being effectively implemented;
• Services adequately address the needs of the participant;
• Services are being furnished by the chosen provider in accordance with the authorization, relevant policies and quality expectations;
• The participant/representative is satisfied with their chosen providers;
• At least two (2) Waiver services have been received by the participant monthly;
• The participant will continue to receive at least two (2) waiver services monthly.

The frequency of Waiver Case Management contact must be determined based on the participant's needs. At a minimum, the following contacts with the participant/representative must be provided:

• A contact at least monthly;
• A face-to-face contact at least once every three (3) months;
• A face-to-face contact in the participant's residence/residential setting every six (6) months.

Notes:

• A "Waiver Case Management contact" is defined as a meaningful communication exchange with the participant or his representative to provide one or more Waiver Case Management activities. Methods of contact include both face to face conversations and telephone calls, text messages, email messages, or written correspondence that are not face-to-face. The use of social media (e.g., Snapchat, Instagram, Twitter) is not allowed.
• For the purposes of monthly contact, a face-to-face contact is not required. Also for the purpose of monthly contact, contact with a "representative" is allowed. A "representative" is a person who knows the needs of the participant. It is preferred that this representative live with the participant and/or has daily contact with the participant (such as a parent, other family member or residential staff member).
• When exceptional circumstances prevent the completion of a required face-to-face contact, a contact that is not face-to-face may be made in lieu of the required face-to-face contact. Documentation must include details describing the nature of the circumstances preventing a face-to-face encounter.
• A face-to-face contact in the participant's natural environment that is not his/her residence is permissible in lieu of the contact in the participant's residence under the following circumstances: the participant is homeless; participant or homeowner refuses to allow access to the home; there is documented evidence of criminal activity, violence, or isolation in the residence that places the Case Manager in danger. When these circumstances exist, the assessment and the Plan should address safety issues or housing concerns for the participant. During the face-to-face contact, the Case Management Monitoring Tool must be completed to meet assurances as outlined in the waiver document.
• If the participant/representative cannot be reached for the purposes of a non-face-to-face contact after three (3) documented attempts on different days and varying times, it is acceptable for the case manager to conduct the non-face-to-face contact with a "knowledgeable resource" previously identified by the participant/representative. In order to utilize a knowledgeable resource, prior to contact, the Waiver Case Manager must obtain written consent from the participant/representative identifying the person(s) who will be designated as a knowledgeable resource(s) and consenting for the Waiver Case Manager to discuss the participant with the designated person(s). The consent must remain in the participant record. Contact with a knowledgeable resource is expected to be rare and is not allowed for consecutive monthly contacts.
• Regarding contact requirements: "Monthly" means once each calendar month (Ex: any date in July, any date in August, etc.); "Quarterly" means once every three (3) calendar months (Ex: any day in July, any day in October); "Every six (6) months" means once every six (6) calendar months (Ex: any day in July, any date in January).

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III. RECORD KEEPING AND DOCUMENTATION

1. A primary case record will be maintained for each participant. Case records (paper and electronic records) maintained by the Waiver Case Manager are considered to be the participant's primary case record with DDSN.

2. The primary case record must be organized in accordance with a File Index determined by the provider agency. Primary case records should be logically and consistently organized. Waiver Case Management providers may use the filing system of their choosing (i.e., six-section divided files, three-ring binders, etc.). Primary case record organization should permit someone unfamiliar with the participant to quickly acquire knowledge sufficient to provide Waiver Case Management, or to review/audit the record. Purged contents of the primary case record should also be maintained according to the provider agency's File Index and in close proximity to the primary case record. HASCI Waiver recipients' files must follow the HASCI Waiver index (refer to the HASCI Waiver Manual).

   Primary case records and backup records for former Waiver participants whose DDSN case has been closed will also be retained according to the provider's primary case record index. Primary case records for closed cases must be retained for a period of no less than six years after the end of the annual contract period. If any litigation, claims or other actions involving the records are initiated prior to the expiration of the six-year period, the records must be retained until completion of the actions and resolution of all issues which arise from it, or until the end of the required period whichever is later. (For more detailed information regarding record retention, please refer to DDSN Directive 368-01-DD: Individual Service Delivery Records Management.)

3. The primary case record must identify records or documents that are maintained electronically.

4. At a minimum, Waiver Case Management providers must maintain the following documentation/information for all participants:

   • The name of the participant;
   • The dates of the Waiver Case Management services;
   • The name of the Waiver Case Management provider agency and the staff members providing the service;
   • The nature, content and units of the services received;
   • If the participant has declined services in the Plan;
   • The need for, and occurrences of, coordination with other case managers;
   • Assessment information;
   • Plan/planning documents;
   • Case notes;
   • All attempts to contact the participant/representative, including date, time, and method;
   • All correspondence by the Waiver Case Manager for which Medicaid reimbursement was claimed;
   • Medical information;
   • Psychological assessments/psychiatric reports, if applicable;
   • Individualized Education Plans (IEPs) and Individual Family Service Plans (IFSPs), as appropriate and/or available;
   • Information from other service agencies providing services to the participant.

5. The participant's primary case record contains the Waiver forms required by the applicable Waiver manual. Therap and/or the Consumer Data Support System (CDSS) are considered the electronic portion of the primary case record. Any form completed in the electronic system is considered a part of the primary case record and should not be printed for inclusion in a paper file.

   • Community Supports Waiver: https://www.ddsn.sc.gov/resources/medicaid-home-and-community-based-waiver-services-programs/community-supports-waiver
   • Head and Spinal Cord Injury Waiver: https://www.ddsn.sc.gov/resources/medicaid-home-and-community-based-waiver-services-programs/head-and-spinal-cord-injury
   • Intellectual Disability/Related Disabilities Waiver: https://www.ddsn.sc.gov/resources/medicaid-home-and-community-based-waiver-services-programs/intellectual-disability-and

6. The primary case record (paper and electronic records) must be securely and confidentially maintained/kept. Refer to DDSN Directives:

   • 167-06-DD: Confidentiality of Personal Information;
   • 368-01-DD: Individual Service Delivery Records Management;
   • 367-12-DD: Computer Data Security.

7. Case notes must document all Waiver Case Management activity on behalf of the specific participant represented by the primary case record. Case notes should provide a clear/concise description of the circumstances being recorded. The contents should be current, complete, timely, and meet documentation requirements. Multiple actions which support the same activity and which occurred on the same day may be incorporated into a single case note provided all necessary information is included and is clear to any other readers or reviewers.

8. Case notes will include the following if a reportable activity is being documented:

   • The activity completed and type of contact.
   • Place of contact or activity.
   • Person with whom the contact occurred and relationship to the participant.
   • Purpose of the activity.
   • Outcome(s) of the activity and, if applicable, the next step(s) to be taken.
   • The date of the activity.
   • Signature and title of case manager completing activity and the date of the signature.
   • All efforts to obtain services that are included in the Plan, but are unavailable to a participant.

   In order to determine the rate paid for the activity, each case note must indicate the type of Waiver Case Management activity as: WCM Without Travel; or WCM With Travel. WCM Without Travel should be selected when a case manager provides WCM to a person and does not leave the provider's location to do so. WCM With Travel should be selected when a case manager provides WCM to a person and leaves the provider's location to do so. Signature, title, and date of the signature are electronically created by Therap.

9. All case notes must:

   • Be entered on the Waiver Case Management template in Therap.
   • Must be entered in Therap within seven (7) calendar days of the activity/event being documented.
   • Be completed by a qualified Waiver Case Manager.
   • Properly document any omissions.

   It is strongly recommended and considered a best practice to complete case notes on the day an activity is performed. Case notes in Therap are the electronic documentation of Waiver Case Management activities performed by the Waiver Case Manager. The case note module in Therap is in accordance with the Uniform Electronic Transactions Act (S.C. Code Ann. § 26-6-10 et seq.).

   Only case notes entered for participants on the Waiver Case Management template are reportable. Providers will only be reimbursed for units of Waiver Case Management services reported on the Waiver Case Management template. Case notes entered for participants on any other Therap case note template are not reportable. Providers will not be reimbursed for units of Waiver Case Management services reported on any Therap case note template other than the Waiver Case Management template.

   When a case note for a reportable activity is completed ("Submit" not "Save" is chosen) in the Waiver Case Management template in Therap, it is automatically transmitted to DDSN for possible billing. When a case note is "Saved" ("Submit" not chosen), the note is considered to be in progress (not complete) and will not be transmitted to DDSN for possible billing. In exceptional circumstances, it may be necessary to handle omissions in the documentation. All documentation should be entered into Therap. Case notes completed in Therap should not be printed and placed in the primary case record. Please note that case records in Therap that contain case notes that are "Saved" (i.e., not submitted or complete) will not transfer to another provider. Any "Saved" case notes must be completed ("Submit") or terminated before the transfer can occur.

10. A list of any abbreviations or symbols used in the records must be maintained. This list must be clear as to the meaning of each abbreviation or symbol, and only abbreviations and symbols on this approved list may be used.

11. Any person(s) referenced in case notes or any supporting correspondences must be identified in each entry. Identify person(s) in case notes by their full name and title or relationship to the participant. References in case notes must be done at least one time for each entry/case note.

12. Errors in case notes must be corrected appropriately. When an error is made to a case note in the Waiver Case Management template, the Waiver Case Manager must follow error correction procedures identified in Therap. The history of all case notes is maintained.

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IV. SERVICE REPORTING

1. Electronic case notes intended to document Waiver Case Management activities must be sufficient in content to support Medicaid billing. Reportable Waiver Case Management case notes must represent Waiver Case Management activities. SCDHHS will reimburse for no more than 40 units per calendar month per participant of WCM. WCMs must work within the allotted 40 units per month to complete all required WCM activities. In exceptional cases, where medical necessity has been demonstrated, additional hours over the 40-unit limit can be approved through the prior authorization process. Waiver case managers must monitor the usage of WCM services as necessary. Prior authorization should be requested through the Waiver Administration Division when more than 40 units of WCM is needed during a calendar month. Case notes must correspond to reporting in type of activity, length of activity, units of service, and date of delivery.

SUPPORT PLAN: Waiver Case Management activity may be reported only when a participant is enrolled in a DDSN Waiver and a current "Case Management Support Plan" is in place or is in process according to established timeframes. If a Plan is not in place or not in process within established time frames, the activity must be documented as non-reportable.

Activities Reportable when documented in a case note on the Therap Waiver Case Management template:

• Conducting Level of Care reevaluations;
• Re-establishing/re-documenting Freedom of Choice;
• Assessing needs; completing an assessment;
• Assessing a participant's medical and/or mental health needs through review of evaluations completed by other providers of services;
• Assessing physical needs, such as food and clothing;
• Assessing social and/or emotional status;
• Assessing housing, financial and/or environmental needs;
• Assessing family and/or social supports;
• Assessing vocational and/or educational needs;
• Assessing independent living skills and/or abilities;
• Reviewing professional records;
• Developing a Plan that contains waiver services and non-waiver services;
• Providing information on the following topics to participant/representative: self-directed care; abuse, neglect and exploitation; reconsideration process and/or appeal rights;
• Assessing a participant's/representative's eligibility for self-directed care;
• Providing a copy of the completed Plan to participant/representative;
• Working with the participant and others to identify actions to respond to the participant's assessed needs and goals in the Plan;
• Linking participants with medical, social, educational, and other providers, programs, and services;
• Completing service authorizations;
• Ensuring the Plan is implemented effectively and is adequately addressing the needs of the participant;
• Completing contacts; conducting necessary follow-up activities as a result of the contacts;
• Contacting the participant, family members, outside service providers, or other entities to ensure services are being furnished in accordance with participant's Plan;
• Ensuring the adequacy of the services in the Plan, particularly as changes occur in the needs or status of participants;
• Reviewing service provider documentation directly connected to a Waiver or state plan service on the participant's plan (the case note must include the purpose for the record review including any conclusions drawn);
• Reviewing records of those served with supervisors for the purposes of problem solving and/or ensuring participants receive quality services;
• Monitoring access to and receipt of services; addressing and correcting problems identified;
• Determining a participant's other payers and providing this information to providers to ensure TPL guidelines are followed;
• Monitoring participant progress and performing periodic reviews and reassessments (when an assessment indicates the need for medical treatment, referrals or arrangements for such treatment may be included as Waiver Case Management services, but the actual treatment must not be included);
• Arranging and monitoring the participant's access to healthcare providers (may include written correspondence to a healthcare provider which gives a synopsis of the treatment the participant is receiving, follow-up and documentation);
• Contact with the participant in which the case manager helps in the resolution of service issues;
• Contacting the family, representatives of human service agencies, and other providers to form a multidisciplinary team to develop a Plan;
• Preparing a written report that details psychiatric and/or functional status, history, treatment, or progress (other than for legal purposes) for service providers;
• Carrying out activities related to assisting a participant in executing his emergency/evacuation plan or an alternative solution during an emergency;
• Responding to participant's urgent, emergent or unplanned circumstances;
• Carrying out activities related to ensuring a CS Waiver participant does not exceed the individual cost limit and providing information to the participant/representative about the cost limit;
• Suspending services when a participant enters an inpatient facility;
• Preparing for, taking part in, or completing follow-up activities related to Medicaid appeals/hearings on behalf of SCDHHS and/or SCDDSN, acting as an agent of the State;
• Dis-enrolling participants from a waiver;
• Reporting critical incidents;
• Providing Waiver Case Management to participants in the hospital.

Activities NOT reimbursable as Waiver Case Management (guide only, not exhaustive):