Policy #: / 1.6013 / UM Approval Date: / 1/29/2015
Date Issued: / 1/24/2008 / DT Approval Date: / 2/15/2015
Document Owner: / K. Lubinski/K. Miller / State Approval Date: / 1/5/2015
Contract Reference: / Next Review Date: / 1/1/2017
Title: QXP 1.6013 - Provider Reporting Policy
Policy: Western Wisconsin Cares requires periodic written progress reviews and/or
statements/records from Providers. The frequency and content of progress reviews are based on the type of service provided. See the e-link below titled “2014-1203 Notice to providers change in progress reporting” for details regarding providers and frequencies. Purchase of Service Contract Appendix e-link below for these details.
Purpose: Western Wisconsin Cares authorizes services to provide care and treatment and to promote independence for our members. In order to evaluate the effectiveness of service provision and the attainment of preferred outcomes for members, WWC requires reporting based upon the individualized care plans for each member. This policy shall clarify the frequency and content of reports required by each service area. The areas to be addressed in the specific report may include: Safety, Medical/Dental, Psychological, Behavioral, Assistive Devices, Daily Living Skills, Community Integration, Economics, Vocational, Natural Supports and Transportation.
Definitions:
Outcome: The member’s preference in what they choose to achieve in a
particular of daily living.
Provider Service Expectations (PSE): Documents that outline the
responsibilities for both the provider and WWC related to the scope of services that the provider is contracted for. Provider Service Expectation documents will be developed for each service category in the benefit package with the exception of Medicaid Services which are covered under State and Federal regulations. These documents will be included as an appendix with the Provider Contract. Provider Service Expectations communicate service specific details regarding expectations of the Provider with delivering the service. Categories addressed in the Provider Service Expectations include the following:
· Communication and Reporting
· Documentation
· Expected Outcomes for Participants
· Quality Assurance Requirements
· Quality Indicators
· Service Definition
· Service Descriptions – include SPC and Descriptions
· Staff Qualifications
· Staff Training
· Standards of Service: e.g., Medicaid Waiver standards, Medicaid certification, Medicare certification, etc.
· Supervision and Staff Adequacy
· Units of Service and Reimbursement Guidelines
Reference Documents:
· Member Absence and Change in Condition (CIC) Notification form - this form is to be utilized by Nursing Homes, Traditional and Corporate Adult Family Homes, Community Based Residential Facilities (CBRF) and Residential Care Apartment Complexes. This form is available at the WWC website, www.wwcares.org. These forms may also be requested via email at . This form is e-linked into this document.
· Provider Reporting Requirements for Individualized Plans (page 3 of this document).
· Provider Service Expectations (PSE): These documents are listed on the iCenter/Provider Network/Provider Service expectations.
· Service Progress Report Templates. These form templates are available on the WWC website www.wwcares.org. These forms may also be requested via email at . These templates are e-linked into this document.
Procedure:
1.0 Service Provider Requirements
1.1 Providers shall refer to Attachments for clarification of reporting specifics and frequency of reports.
1.2 Upon service authorization by WWC, the WWC team will complete the Service Referral and Authorization form for the specified services, using member/ legal representative input to develop the goals and outcomes of the service.
1.3 The service provider shall utilize the referral form and input from the interdisciplinary team (the member, guardian, or P.O.A. if applicable, and WWC team) to develop an individualized plan for that member, including measureable goals from the referral.
1.4 The provider will include methodology to teach or to support goals that are member specific. Such methods may include teaching techniques and proactive approaches that best fit the member’s learning style and support needs. For goals which involve teaching/training, the provider shall gather data on member progress which will be used for the required written progress report on WWC reporting form.
1.5 The provider will collaborate with the interdisciplinary team when presented with significant barriers to goal attainment to identify new methods or revise the goal.
1.6 The Provider is responsible for providing a written progress report, at the request of the member, legal representative, and WWC team. Providers who are required to submit regular member progress reports and data to WWC will submit these reports by email or fax. All interdisciplinary team members will offer input to goals, with the strengths and preferences, and Long Term Outcome with the member in mind, through the referral form. Lack of progress on a goal should result in a revision to the goal or the methodology to achieve it through team collaboration. Lack of progress may also result in a request to change the authorized service to a more appropriate service that can support the member’s outcomes on an ongoing basis.
2.0 Internal Quality Control
2.1 Reports will be reviewed by WWC Care Managers. These reports will be forwarded to the electronic file or scanning basket per the established process.
2.2 If WWC teams are not receiving reports from the listed providers they are to work with the provider to attempt to resolve the reporting issue and enter and complete an Incident Report.
2.3 The WWC Quality Department will complete a random chart sample of WWC members receiving services for which provider reports are required.
2.4 Quality Staff will send results of the random chart sample to Provider Network Staff for appropriate follow up.
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