IEP Date:______

Service Record – Targeted Case Management

Medicaid Number / Last Name / First Name
WVEIS Number / Date of Birth / Diagnosis Code / School
County / Teacher Name (Print) / Month Service Provided / Procedure Code
T1017
Definition: T1017 = 15 minute unit. Services which assist Medicaid eligible recipients to gain access to the needed medical, behavioral, health, social and educational needs, etc.
Types of Contact: 1. Face to Face 2. Correspondence 3. Telephone Contact
Targeted Case Management Activities
A / Assessment: The case manager ensures an on-going formal and informal process to collect and interpret information about student’s strengths, needs, resources and life goals. This process is used in the development of an individualized education program (IEP)/Service Plan.
B / IEP/Service Planning: The case manager ensures and facilitates the development of a comprehensive, IEP/Service Plan.
C / Linkage/Referral: The case manager ensures linkage to all internal and external services and supports identified in student’s IEP/Service Plan related to medically necessary service (PT, OT, ST, Health Care Plan, Behavior Intervention Plan).
D / Advocacy: The case manager’s advocacy refers to the actions undertaken on behalf of the student in order to ensure continuity of services, system flexibility, integrated services, proper utilization of facilities, and resources and accessibility to services.
E / Crisis Response Planning: The case manager must ensure that adequate and appropriate crisis response procedure(s) and accessibility are available to the student and identified in the IEP/Service Plan.
F / IEP Evaluation: The case manager continually evaluates the appropriateness of the student’s IEP/Service Plan and makes appropriate modifications, establish new linkages, or engage in other dispositions as necessary related to medically necessary service (PT, OT, ST, Health Care Plan, Behavior Intervention Plan).
G / Monitoring and Follow Up: The case manager monitors and follows up on one of the above stated components.

Enter the TCM activity letter under the appropriate dates during this calendar month.

Date / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15 / 16 / 17 / 18 / 19 / 20 / 21 / 22 / 23 / 24 / 25 / 26 / 27 / 28 / 29 / 30 / 31
TCM
TCM
TCM
Units

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Signature Date

WV-BMS-SBHS-02 Effective Date: September 14, 2014