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WVDHHR/BPH/OMCFH/DPWH/WVHVP/October 2017

Right From the Start Policy & Procedures Manual

Policy and Procedures Manual October 2017

Empowering families for healthy beginnings

Mission Statement: Provide professional, individualized and comprehensive care that empowers families to achieve the healthiest possible outcomes during pregnancy and infancy.

Vision Statement: Become a sustainable program that empowers participants

to choose lifestyles resulting in healthy families.

West Virginia Department of Health & Human Resources Bureau for Public Health

Office of Maternal, Child & Family Health Division of Perinatal & Women’s Health West Virginia Home Visitation Program

350 Capitol Street, Room 427 Charleston, WV 25301

(304) 558-5388 Toll Free in WV (800) 642-8522 Fax# (304) 558-7164 www.wvdhhr.org/rfts

WVDHHR/BPH/OMCFH/DPWH/WVHVP/October 2017 Right From the Start Policy & Procedures Manual

Table of Contents

1.0 General Administration

1.1 Introduction ............................................................................................................................. 4

2.0 Eligibility 2.1 Eligibility for Women ............................................................................................................... 6 2.2 Eligibility for Infants ................................................................................................................. 6 2.3 Retroactive Medicaid Eligibility for Newborn Children Under Age One.................................. 7

3.0 Program Components

3.1 Rights and Responsibilities .................................................................................................... 8 3.2 Initial Assessment ................................................................................................................... 8 3.3 Service Care Plan ................................................................................................................... 8 3.4 Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) ................................ 8 3.5 Edinburgh Postpartum Depression Screening (EPDS) .......................................................... 8 3.6 “HITS” Violence Screening for Domestic Violence.................................................................8 3.7 Ages and Stages Developmental Screening Tool (ASQ-3).……………………......................8 3.8 Ages and Stages Social-Emotional Screening Tool (ASQ-SE)..…………………...................9 3.9 Client Tracking Sheet and/or Progress Notes ........................................................................ 9 3.10 External Referral ..................................................................................................................... 9 3.11 High Birth Score Referral and Tracking Form ........................................................................ 9 3.12 Number of Client Contacts ..................................................................................................... 9

4.0 Referral Process

4.1 WV Prenatal Risk Screening Instrument (PRSI) .................................................................. 10 4.2 RFTS Referral Form ............................................................................................................. 10 4.3 High Birth Score Referral ...................................................................................................... 10

5.0 Enrollment

5.1 Care Coordination ................................................................................................................ 11 5.2 Enhanced Prenatal Care Services ....................................................................................... 14 5.3 Enhanced Prenatal Care Services Components .................................................................. 15 5.4 Enhanced Services Only (Prenatal Clients Who Refuse Care Coordination) ...................... 18 5.5 Enhanced Services Education Report .................................................................................. 18

6.0 Case Closure 6.1 Outcome Measures Form ..................................................................................................... 19 6.2 Physician Letter – Case Closure .......................................................................................... 19

7.0 Client Record Maintenance

7.1 Record Management ............................................................................................................ 19 7.2 Record Storage .................................................................................................................... 20 7.3 Confidentiality of Records ..................................................................................................... 20 7.4 Client Review of Record ....................................................................................................... 20 7.5 Client Request for Copy of Record ....................................................................................... 20 7.6 Client Record Release .......................................................................................................... 20 7.7 Routine Record Copying ...................................................................................................... 20 7.8 Record Identification ............................................................................................................. 21 7.9 Record Retention .................................................................................................................. 21 7.10 Referral for Services ............................................................................................................. 21

8.0 Collaboration with Child Protective Services (CPS) .................................................... 21 9.0 Responsibility to the Client’s Medical Provider ........................................................... 21


10.0 Referral to the WV Birth To Three Program .................................................................. 22

11.0 Adoption Policy 11.1 Policy on Conflict of Interest for Designated Care Coordination Agencies .......................... 22

12.0 Perinatal Programs State Office 12.1 Responsibilities of the RFTS State Office ............................................................................ 23 12.2 Development of Policies and Procedures ............................................................................ 23 12.3 Technical Assistance ............................................................................................................ 23 12.4 Training ................................................................................................................................. 23 12.5 Program Maintenance .......................................................................................................... 23 12.6 Community Outreach ............................................................................................................ 23 12.7 Confidentiality of Records ..................................................................................................... 24 12.8 Quality Assurance ................................................................................................................ 24 12.9 RFTS Forms ......................................................................................................................... 24 12.10 Data Collection System ........................................................................................................ 24 12.11 OMCFH Program Collaboration ........................................................................................... 24 12.12 Quality Assurance Monitoring Team (QAMT) ...................................................................... 24 12.13 Corrective Action Plans ........................................................................................................ 25 12.14 Regional Lead Agency Corrective Action Plan ..................................................................... 25 12.15 Designated Care Coordination Corrective Action Plan ........................................................ 25 12.16 Designated Care Coordination Responsibilities ................................................................... 25

13.0 Regional Lead Agency (RLA)

13.1 Description/Qualification ....................................................................................................... 25 13.2 Regional Care Coordinator Job Responsibilities .................................................................. 26 13.3 Regional Care Coordinator Codes and Activities ................................................................. 27 13.4 Regional Secretary/Clerk Job Description ............................................................................ 28 13.5 Regional Secretary/Clerk Codes and Activities .................................................................... 29

14.0 Designated Care Coordinator (DCC) Provider Agency

14.1 Provider Eligibility Criteria ..................................................................................................... 30 14.2 DCC Provider Agency Requirements ................................................................................... 30 14.3 Enhanced Services Only Providers ...................................................................................... 31 14.4 DCC Provider Agency Enrollment – Letter of Agreement Procedure .................................. 31 14.5 Designated Care Coordinator Job Responsibilities .............................................................. 32 14.6 Documentation Requirements for DCC ................................................................................ 34 14.7 DCC Billing and Reimbursement .......................................................................................... 34

15.0 Guidelines For Claims

15.1 Medicaid ............................................................................................................................... 35 15.2 Targeted Case Management & Enhanced Prenatal Care Services ..................................... 36

Appendix A Maternity Services

Appendix B Access to Rural Transportation (ART)

Appendix C Forms

Appendix D Glossary Appendix E OB Fee Schedule


RIGHT FROM THE START

1.0 GENERAL ADMINISTRATION

1.1 INTRODUCTION Ensuring access to health care for low-income women and children has been an ongoing concern for state and federal officials. The Bureau for Medical Services (Medicaid) and the Office of Maternal, Child and Family Health (OMCFH) have worked collaboratively to develop special initiatives that extend support services to women and infants at-risk of adverse health outcomes. This partnership has not only expanded the State’s capacity to finance health care for women and children, but has also strengthened the delivery of care by establishing care protocols, recruiting medical providers and developing supportive services such as case management and nutrition counseling which contribute to improved client well-being. Medicaid and OMCFH have worked collaboratively to develop a systematic approach to deal with the problems of access to prenatal care. The Right From The Start (RFTS) Program was implemented in response to the mandates of West Virginia State Code §9-5-12. RFTS is a home visitation program which provides comprehensive services for Medicaid pregnant women and infants, including care coordination and/or provision of enhanced prenatal care services. RFTS utilizes a standardized curriculum, Partners for a Healthy Baby (PHB), to provide services to enrolled clients, based upon needs identified in the Initial Assessment and Service Care Plan. PHB is a research-based, practice-informed curriculum used in evidence-based programs that have achieved positive outcomes as documented in numerous studies. The curriculum was developed by a multi-disciplinary faculty team at Florida State University and targets topics such as improved prenatal health, positive parenting, enhanced child health and development, infant mental health, economic self-sufficiency, family stability, healthy lifestyles, and well-being. All services are provided by professional staff that must be either a:

• Registered nurse licensed to practice by the West Virginia Board of Examiners for Registered Professional Nurses. Graduate nurses with temporary West Virginia licenses must pass the West Virginia State Board Examination to continue to provide RFTS services; or

• Social worker licensed to practice by the West Virginia Board of Social Work Examiners or social workers with temporary licensure status (certain criteria apply – visit www.wvsocialworkboard.org for details). A bachelor social worker (BSW) or master social worker (MSW) is preferred. In regions where licensed social worker (LSW) shortages exist and agencies have documented a hardship in recruitment of a BSW or MSW for Designated Care Coordinator (DCC) positions, the agency may submit documentation to the State RFTS office for waiver considerations. All non-BSW/MSW applications and credentials are to be reviewed by the Regional Care Coordinator (RCC) and Director of the West Virginia Home Visitation Program (WVHVP) prior to approval as a DCC; this includes non-BSW/MSWs under temporary licensure.

RFTS is a comprehensive statewide initiative for government sponsored pregnant women, whose incomes are at or below 185% of the federal poverty level, and for Medicaid-eligible at-risk infants up to the age of one year (see Definitions). A major component of the Program is to provide in-home care coordination services whereby registered nurses and licensed social workers visit eligible prenatal clients in their homes throughout the pregnancy and eligible infants up to the age of one year. The purpose of the home visit is to assess educational, social, nutritional and medical needs, and to facilitate access to appropriate service providers. Coordination components include a personalized in-home assessment to identify barriers to health care, an individually designed


care plan to meet the client’s needs, community referrals as necessary, follow-up, and monitoring. All pregnant Medicaid and RFTS Maternity Services cardholders are eligible for educational activities designed to improve their health (i.e., childbirth education, smoking cessation counseling, parenting, and nutrition). Consistent with the provisions of West Virginia State Code §9-5-12, the Department of Health and Human Resources (DHHR) uses Medicaid (Title XIX) funds to provide financing for most RFTS activities. OMCFH uses Federal Maternal and Child Health Block Grant (Title V) funds and State Appropriations to provide a limited health benefit package to pregnant women whose income make them ineligible for Medicaid. Funds available to OMCFH are also used to defray portions of the administrative costs of RFTS. Administration of RFTS is accomplished with both WVHVP staff within OMCFH and regional staff consisting of eight RCCs and many DCCs employed by various community, social, and health care agencies throughout the State. RFTS providers follow Standards of Care established by the American College of Obstetricians and Gynecologists (ACOG) for enrolled clients. Program services focus on the mother’s personal health, quality of care giving and life-course development. Providers are dedicated to the public health function of assisting with access to early and adequate prenatal health care. ACOG provides updated Practice Bulletins regarding Standards of Care. Practice Bulletins provide obstetricians and gynecologists with current information on established techniques and clinical management guidelines. ACOG continuously surveys the field for advances to be incorporated in these series and monitors existing bulletins to ensure they are current. Individual bulletins are withdrawn from and added to the series on a continuing basis and reaffirmed periodically. For more information on ACOG and/or to view publications such as Committee Opinions, Technology Assessments, Patient Safety Checklists and Practice Bulletins visit the website at www.acog.org. This manual contains policies and procedures of RFTS and serves as an operational reference for participating in the Program. It is expected that all providers will conform to the policies and procedures contained in this manual and all future revisions. This manual is reflective of RFTS’ dedication to improving the health and well-being of West Virginia’s families. Staff must be familiar with the Program policies and procedures in order to deliver quality care to participants. Questions relative to RFTS, including operational policies and procedures, should be directed to: West Virginia Department of Health and Human Resources Bureau for Public Health Office of Maternal, Child and Family Health Right From The Start Program 350 Capitol Street, Room 427 Charleston, West Virginia 25301-3714 Phone: 1 (800) 642-8522 or (304) 558-5388

www.wvdhhr.org/rfts Questions regarding Medicaid eligibility, provider enrollment, status of claims or other billing questions, call Molina at 1 (888) 483-0793 or (304) 348-3360.


2.0 ELIGIBILITY

RFTS serves Medicaid/Maternity Services eligible pregnant women and Medicaid eligible infants up to the age of one year. The category “women” includes adolescent females. A RFTS client is defined as an eligible woman/infant who receives care coordination and/or an eligible woman who receives enhanced services paid under RFTS billing codes. 2.1 ELIGIBILITY FOR WOMEN

A. CRITERIA FOR RFTS SERVICES ELIGIBILITY To be eligible for RFTS Care Coordination and/or Enhanced Prenatal Care Services

throughout her pregnancy, the month she delivers, and through last day of 2nd postpartum month:

• Be a West Virginia resident;

• Have either a valid Medicaid card or RFTS Maternity Services card; and

• Have had a Referral Form completed to RFTS.

Pregnant teens ages 19 and under are eligible for RFTS services regardless of family income, if uninsured, for maternity care. The pregnant teen must first make an application for Medicaid coverage at the local DHHR office and be denied coverage. DHHR forwards the Medicaid denial information to OMCFH for eligibility coverage assessment for pregnancy service. Pregnant clients under the age of 18 can provide consent for RFTS services.

WV Children’s Health Insurance Program (CHIP) does not cover pregnancy/labor or delivery charges; pregnant CHIP participants will be referred to OMCFH for care coordination including securing financial support to pay for a portion of their pregnancy care.

B. PROGRAM ACCESS A referral to RFTS may be made in one of the following procedures:

• WV Prenatal Risk Screening Instrument (PRSI) completed by a medical provider;

• Completion and submission of a Referral Form to RFTS;

• Medical provider or other agency supplying a list to the RCC of newly diagnosed pregnant clients;

• Director of WVHVP forwarding referrals received by OMCFH to the appropriate RCC;

• Direct contact by prenatal, family member, friend, etc. to OMCFH, RCC or DCC; and/or

• Completion of a Referral Form.

2.2 ELIGIBILITY FOR INFANTS To be eligible to receive Care Coordination up to the age of one year, an infant must: (For example…….. last day of their birth month)

• Be a West Virginia resident;

• Be up to the age of one year;

• Have a valid DHHR Medicaid card; and

• Have had a Referral Form to RFTS completed.

Infants are not eligible for enhanced services.


Medicaid eligible infants may be referred to RFTS by a physician, nurse practitioner, nurse, social worker, other individual, or parent/guardian because of medical, social and/or environmental factors.

Examples:

• Parent exhibits a knowledge deficit in, or expresses a desire to improve parenting skills;

• Family has inadequate resources;

• Infant has low birth weight;

• Infant is technology dependent;

• Infant has had frequent hospitalizations;

• Infant is diagnosed as failure to thrive, etc.; and/or

• Family involved with Child Protective Services (CPS).

Infants identified by Project WATCH as high birth score Medicaid eligible are referred for RFTS services and must be given priority enrollment status.

2.3 RETROACTIVE MEDICAID ELIGIBILITY FOR NEWBORN CHILDREN UP TO THE AGE OF ONE YEAR If an infant is born and is underinsured or uninsured, the infant’s parent, legal guardian or caretaker must be referred to the local DHHR office to file a Medicaid application. The DCC will advise the mother to request retroactive coverage to the date of the infant’s birth. The infant’s Medicaid coverage may be backdated up to three months from the month of application or to the month of birth (whichever one is closest to the month of application) only if verification of information required deems the infant eligible for Medicaid coverage for the month for which coverage is needed. Otherwise, coverage begins the month in which eligibility is established.

A. NEWBORN COVERAGE: MEDICAID

Clients presenting the DHHR Medicaid card are entitled to receive the full-range of services covered under the Title XIX State Plan.

B. NEWBORN OF A MINOR MOTHER Newborns of Medicaid-eligible women (including minors) qualify for Medicaid until 12 months of age as long as the child resides continuously with the mother. The minor mother that is not Medicaid-eligible and whose income is 150% or below the federal poverty level (FPL), must apply for Medicaid coverage for the newborn as soon as possible after the delivery. If the mother’s income is 150-300% of the FPL, the newborn may qualify for West Virginia Children’s Health Insurance Program (WV CHIP) and must make the application before the end of the infant’s birth month. If the mother would like to apply for WV CHIP coverage for the infant they will need to call the Department of Health and Human Resources, Customer Service Center (DHHR CSC) at 1-877-716-1212. All claims related to the infant will be placed on hold by WV CHIP until a social security number has been reported to the DHHR CSC for the child being born. A minor parent can sign consent for services for her infant.


3.0 PROGRAM COMPONENTS

The following are required components for all clients participating in RFTS. 3.1 RIGHTS AND RESPONSIBILITIES To ensure an individual’s rights are protected, the DCC will explain to the client or guardian of the infant their “Rights and Responsibilities” (R&R), confirm with verbal understanding, and obtain client signature for consent. Documentation must be completed using the R&R Form before care coordination can begin.

3.2 INITIAL ASSESSMENT In conjunction with the client or guardian of the infant, a comprehensive assessment of conditions/causes for risk and/or identify other factors that may adversely affect the client’s outcome must be completed. Documentation must be completed using the Initial Client Assessment Form (R036A or R036B) which must be signed and dated.

3.3 SERVICE CARE PLAN Based on areas identified in the Initial Assessment, this individualized plan is developed with the client or guardian of the infant. The Service Care Plan designates the goals and objectives of the client. The client’s individualized Service Care plan guides the services that the client receives during RFTS participation. Care coordination can begin only after the Service Care Plan has been completed and signed by the client or guardian of the infant.

3.4 SMOKING CESSATION AND REDUCTION IN PREGNANCY TREATMENT (SCRIPT) An initial smoking assessment of all prenatal/postpartum clients’ smoking status and exposure to environmental smoke exposure (ETS) must be completed at enrollment. Documentation must be completed using the Tobacco Screening/SCRIPT Form. Clients interested in smoking cessation or reductions are offered a SCRIPT intervention following the 5 “A” protocol (Ask, Assess, Advise, Assist & Arrange). Additional follow up on tobacco usage throughout the case is documented on a Tracking form.

3.5 EDINBURGH POSTPARTUM DEPRESSION SCREENING (EPDS) The EPDS must be completed with all prenatal/postpartum clients to assess depression during the prenatal and postpartum periods. DCCs are required to make necessary referral when indicated by the client’s EPDS score. However, screening is not limited and may be administered at any time. 3.6 DOMESTIC VIOLENCE SCREENING TOOL FOR DOMESTIC VIOLENCE & PARTNER

VIOLENCE (HITS) The HITS must be completed within the first four visits with all prenatal and caregivers of all infant clients to assess the possibility of domestic violence or partner violence occurring in the home. If the DCC feels that it is not safe or suitable to administer the domestic violence (DV) screening at the visit, the DCC can make note of that on the Progress Note and attempt to complete the screening at the next visit. If a client screens positive a referral should be made for the appropriate DV services when the clients consent. The National Domestic Violence Hotline is 1 (800) 799-7233. DV Wallet cards can be provided to client when appropriate. 3.7 AGES AND STAGES DEVELOPMENTAL SCREENING TOOL (ASQ-3) The ASQ-3 screening system is a questionnaire designed to be completed by parents or other primary caregivers at any point for a child between one month and five and a half years of age on all infant clients. These questionnaires can identify accurately infants or young children who are in need of further assessment to determine whether they are eligible for early intervention or early childhood special education services. This screening tool is to be completed by the primary caregiver when the infant is nine and 12 months of age. The score of the last ASQ administered


will need to be recorded on the Infant Outcomes Measures at case closure. If the score is below the referral cutoff then the child must be referred to Birth To Three (BTT). When a family is dismissed from RFTS, a referral should be made to Help Me Grow (HMG) or an appropriate home visitation program to ensure a continuum of service for the child through the age of five if family wishes continued services. **ASQ3 is not required if an infant client is enrolled with BTT. Documentation of the BTT enrollment should be included in the Progress Note. 3.8 AGES AND STAGES SOCIAL-EMOTIONAL SCREENING TOOL (ASQ-SE) The ASQ-SE screening system is a questionnaire designed to be completed by parents or other primary caregivers for children ranging in age from two months to five and a half years of age. This tool was developed to complement the ASQ-3 by providing information specifically addressing the social and emotional behavior of children. This screening tool is to be completed by the primary caregiver when the infant is six months of age for all infant clients. If the score is above the cutoff a referral needs to be made for diagnostic social-emotional or a mental health assessment. **ASQ3 is not required if an infant client is enrolled with BTT. Documentation of the BTT enrollment should be included in the Progress Note. 3.9 CLIENT TRACKING SHEET AND/OR PROGRESS NOTES Notation of client services and DCC billing codes are documented. The client/guardian of the infant must sign the Client Tracking Sheet on all face to face visits. Individual DCC Agency tracking logs cannot be used for RFTS Program documentation. Preparation time, travel time, and distance are recorded on the Client Tracking Sheet for each visit. DCCs must respond to all questions on the Tracking Sheet as appropriate. 3.10 EXTERNAL REFERRAL The External Referral Form is used to track all referrals made for each client, including how the referral was made and any known outcome. The form can also be used to refer individuals who are not eligible for RFTS services to other home visitation programs or community agencies that can meet their needs. 3.12 NUMBER OF CLIENT CONTACTS All RFTS clients are designated as intensive, requiring monthly contacts for both prenatal and infant clients. The main focus of the RFTS Program continues to be home visitation; therefore, client contact should primarily be conducted through home visits. If a home visit is unable to be completed, the DCC must clearly document the rationale in the client chart.

1. Prenatal clients must receive a minimum of:

• A face-to-face contact for Initial Assessment and Service Care Plan development;

• Monthly face-to-face contacts at the client’s home or other agreed upon location. Visits based on a calendar month; and

• A face-to-face contact within two weeks after hospital discharge following delivery.

2. Infants will receive a minimum of:

• A face-to-face contact for Initial Assessment and Service Care Plan development;

• Monthly face-to-face contacts at the client’s home or other agreed upon location. Visits based on a calendar month; and

• A face-to-face contact within 30 days prior to infant’s first birthday (can be counted as case closure).


TABLE 1 - CLIENT CONTACT SUMMARY

1. Initial Assessment and Service Care Plan In home or other agreed upon location.

2. Face-to-Face contacts monthly through delivery of infant In home or other agreed upon location.

3. Post Hospital Discharge within two weeks In home or other agreed upon location.

4. Prenatal Case Closure contact within last two weeks of eligibility

In home or other agreed upon location or via phone call.

5. Infant Case Closure contact within 30 days prior to first birthday

In home or other agreed upon location.

4.0 REFERRAL PROCESS

4.1 WEST VIRGINIA PRENATAL RISK SCREENING INSTRUMENT (PRSI) Uniform Maternal Screening Act – WV Code §16-4E-1, et seq., effective January 1, 2011, states all health care providers offering maternity services shall be required to utilize the uniform maternal risk screening tool (which is the PRSI) in their examinations of any pregnant woman. Additionally, they shall notify the woman of any high-risk condition which they identify along with any necessary referral and report the results to the Bureau for Public Health, Office of Maternal, Child and Family Health in the manner provided in the legislative rule. The completed PRSI is faxed to OMCFH at (304) 957-0176 where it will be entered into a web-based data system. When a PRSI is received by OMCFH and the pregnant woman is eligible for RFTS, the referral is submitted to the RFTS Regional Lead Agency (RLA). The RLA staff will then attempt to contact the potential client to establish whether or not the client would like to enroll in RFTS. If the client states that she would like to receive RFTS services the referral is assigned to an agency or DCC. The DCC must make contact with the pregnant woman within ten working days from receipt of the referral to schedule a home visit for enrollment into RFTS. If the RLA office is unable to establish contact, the referral will be closed. 4.2 RFTS REFERRAL FORM Prenatal or infant clients may be referred to RFTS using the RFTS Referral Form. The RFTS Referral Form may be completed by anyone who desires to make a referral to RFTS including medical providers, DCCs, WIC staff, DHHR staff, community individuals, etc.

Upon five working days of receipt of the RFTS Referral Form by the RCC the case will be assigned to the appropriate DCC. If the client states that she would like to receive RFTS services the referral is assigned to an agency or DCC. The DCC must make contact with the pregnant woman within ten working days from receipt of the referral to schedule a home visit for enrollment into RFTS. 4.3 HIGH BIRTH SCORE REFERRAL The Project WATCH Office will send referrals to RFTS electronically for all infants identified as having a high birth score and being Medicaid eligible. These referrals will be processed the same as all other referrals. NOTE: A minimum of three attempts (telephone and/or letter) must be made for client

enrollment and all attempts must be documented in the Progress Notes.


5.0 ENROLLMENT

5.1 CARE COORDINATION A. Initial Client Assessment

• Complete at the first visit for both infant and prenatal clients;

• Identify needs and areas of risk;

• Use Initial Client Assessment to create the Service Care Plan;

• Complete accurately, thoroughly, and legibly with the client or guardian of infant;

• DCC must sign, date, and forward a copy to the RCC within five working days; and

• One assessment per client (per pregnancy); updates and changes may be made if needed. All changes must be initialed and dated by DCC and copied to RCC within five working days.

B. Rights and Responsibilities


• Explain Rights and Responsibilities to client or guardian of infant;

• Document verbal acknowledgement of understanding;

• Complete, sign, and date by the client or guardian of infant client and DCC at the first visit;

• Must be completed and signed prior to initiation of any services. Copy provided to the client; and

• Forward copy to RCC and medical provider within five working days. C. Service Care Plan Development


• Address needs identified on the Initial Client Assessment by client or guardian of infant, medical provider, or DCC;

• Goals and objectives for the individualized Service Care Plan must be developed in conjunction with the client or guardian of infant;

• Discuss with the client or guardian of infant how, when and where referral, coordination, and follow-up will occur;

• Ensure the Service Care Plan is signed and dated by the DCC and the client or guardian of infant. A copy of the Service Care Plan is to be given to the client or guardian of the infant on the date the Initial Client Assessment is completed. Copies are to be sent to the RCC and medical provider within five working days;

• Make referrals as specified in the client’s Service Care Plan and provide appropriate follow-up;

• Act as advocate for resolution of problems that may arise in implementing the Service Care Plan;

• Client or guardian of infant contact must be completed at least monthly to ensure identified goals and objectives are met/pursued;

• Periodic review and revision of the Service Care Plan should be done to ensure appropriate quality, quantity, and effectiveness of services. Revisions to the Service Care Plan must be completed as indicated (significant junctures in client care/status); and

• All revisions/changes made to the Service Care Plan must be signed and dated by the DCC and client on the revision line. The DCC must forward revised Service Care Plans to the RCC and medical provider within five working days.

D. Client Tracking Sheet

• Complete at each contact for both infant and prenatal clients starting with the Initial Client Assessment (i.e., home visits, telephone calls, client advocacy, face-


to-face contacts, etc.);

• Must be completed accurately, thoroughly, and legibly;

• Complete Safe Sleep, Period of Purple Crying, and Smoking questions;

• Submit appropriate copies to: ❖ RCC: Must accompany Initial Client Assessment, Progress Note, Service

Care Plan, Rights and Responsibilities, and Tobacco Screening/SCRIPT Form within five working days of signature; and

❖ DCC Billing Department: Within five working days of service date.

• Must include client or guardian of infant signature on all face to face visits;

• Must include client’s social security number. If unavailable at previous encounters, social security number must be included on final Client Tracking Sheet at case closure.

NOTE: DCC Agency Signature Logs cannot be used to document the client signature. The RFTS Program will only accept client signature on the Client Tracking Sheet.

E. Progress Notes

• May be submitted for both infant and prenatal clients.

• Include the date and time the referral was received by the DCC.

• Must describe all events, in accurate detail, that occurred during the contact;

• Must include the time (in and out) and date of the contact/attempted contact; and

• Must include DCC signature at the conclusion of each Progress Note.

• Must be completed and submitted with each billable Client Tracking Sheet.

F. Physician’s Letter It serves as notification to the medical provider of RFTS eligibility and enrollment.

• Complete for both infant and prenatal clients; and

• Submit to medical provider within five working days with Service Care Plan and Rights and Responsibilities.

G. SCRIPT Form

• Complete on all prenatal and post-partum clients, including non-smokers, during initial visit. Complete only one Tobacco Screening/SCRIPT Form per pregnancy.

NOTE: A client may refuse the education. If so, document as “refused” on Tobacco Screening

Form and offer again later.

NOTE: Clients who report they have quit since they became pregnant are at high-risk for relapse.

If smoker, provide clear message about risks of smoking to mother/fetus; provide clear, strong, and personal advice to quit; and document education on the Tobacco Screening Form.

• Carbon Monoxide (CO) screens on all self-reported smokers should be completed. Non-smokers can be CO tested if they request. The Tobacco Screening Form must include documentation of CO level, client refusal, or equipment problem;

• If smoker, provide A Pregnant Woman’s Guide to Quit Smoking to the client;

• Provide brief counseling by reviewing cessation skills in the Commit to Quit DVD and Guide;

• Provide a copy of the SCRIPT Form to the client at the time of completion;

• If the client smokes, provide the client with information for the WV Tobacco Quitline. Complete Quitline referral form if client requests Quitline services; and

• Submit the SCRIPT Form to RCC and medical provider within five working days.


NOTE: The Commit to Quit Smoking During and After Pregnancy DVD is for DCC use in smoking cessation education which is to be done with the client. However, if the DCC feels the client will benefit, the DCC may loan the DVD for a short period of time, but is responsible to obtain the DVD at the next home visit. Additional information from Smokefreemom (smokefree.gov) on texts, tools, and resources can be provided.

Assess client smoking status by self-report;

• CO test all clients except the ones who state they have never been a smoker. Non-smokers can be CO tested if they request. CO testing should be used at visits where a smoking change has occurred. This should be approached as a teaching tool for families to see the impact on the baby. Minimum CO testing must be at enrollment, during a third trimester visit, post-partum, and with any smoking status change and documented. The Client Tracking Form must include documentation of CO level, client refusal, or equipment problems.

H. Edinburgh Postnatal Depression Scale

• The EPDS Scale is used to monitor clients for early warning signs of depression issues throughout the course of care coordination;

• The EPDS must be administered face-to-face during the third trimester and postpartum on perinatal clients. If during the Initial Assessment, the client indicates a history of depression or mental health concerns, it is recommended to screen at that time. Screening is not limited and may be administered at any time;

• Instructions for Users: 1. The mother is asked to underline the response which comes closest to how

she has been feeling in the previous seven days; 2. All ten items must be completed; 3. Care should be taken to avoid the possibility of the mother discussing her

answers with others; and 4. The mother should complete the scale herself, unless she has limited

English or has difficulty with reading and/or writing.

• Scoring: Response categories are scored 0, 1, 2, and 3 according to increased severity of the symptoms. Items marked with an asterisk (*) are reverse scored (i.e. 3, 2, 1, 0). The total score is calculated by adding together the scores for each of the ten items.

• Interpretation: 1. Women who score above the threshold of 12-13 are likely experiencing an

episode of depression and must be referred to a physician or mental health care provider. If evidence of suicidal tendencies/hopelessness exists, establish a safety plan with client/family and arrange urgent (24-48 hrs.) or emergency evaluation at a Mental Health Center or Emergency Room based on the DCC assessment;

2. A score of 9-11 might indicate depression therefore a referral should be made to the client’s medical provider. A careful assessment should be carried out to confirm the results of the screen and in certain cases it may be useful to repeat the EPDS after two weeks (earlier if indicated);

3. A score of 0-8 may indicate minimal/mild depression. The client should be carefully assessed and the RFTS individualized Service Care Plan followed. If questions or concerns arise, the screen should be repeated; and

4. Submit copies to the RCC and Medical Provider within five working days of completion.


NOTE: Users may reproduce the scale without further permission providing they respect copyright by quoting the names of the authors, the title and the source of the paper in all reproduced copies. 1

I. Ages and Stages Developmental Screening Tool (ASQ-3)

• Complete for all infants at 9 and 12 months of age;

• The primary caregiver is to complete the questionnaires;

• The most recent age appropriate screen score is to be used on the Infant Outcome Measures;

• If the score is below the referral cutoff, a referral to Birth To Three must be made;

• Submit copies to the RLA to future steps; and

• RLA submits the ASQ, along with a form letter from the RCC to the medical provider.

J. Ages and Stages Social-Emotional Screening Tool (ASQ-SE)

• Complete for all infants at 6 months of age;

• The primary caregiver is to complete the questionnaire;

• If the score is above the referral cutoff a referral needs to be made for diagnostic social-emotional or mental health assessment;

• Submit copies to the RLA to future steps;

• RLA submits the ASQ, along with a form letter from the RCC to the medical provider.

K. External Referral

• Form started at enrollment and should be completed for all prenatal and infant clients;

• DCC to update throughout case as referrals are made and note the Referral Code and Outcome Status.

• External Referral Form is to be used to document referrals and follow-up to referrals;

• Submit copies to the RLA office within five working days of completion of closure; and

• Original to be kept in client’s chart.

L. Domestic Violence Screening

• Complete for all prenatal and guardians of infant clients within first four visits;

• If DCC suspects that the client or the DCC is in danger, the DCC will need to document that screening was not completed;

• If client scores positive based upon the screening score of >10, the DCC will need to make the appropriate referral using the RFTS External Referral Form; and

• Submit copies to the RLA office within five working days of completion. 5.2 ENHANCED PRENATAL CARE SERVICES RFTS offers Enhanced Prenatal Care Services which must be rendered in accordance with established Program criteria. Client encounters for Enhanced Prenatal Care Services are called sessions. Each category of Enhanced Prenatal Care Services has a limited number of sessions for which reimbursement will be made. All Enhanced Prenatal Care Services are to be provided face-to-face with the client using the educational components in the PHB curriculum. Enhanced Prenatal Care Services may be provided to clients who are participating in full case management during face-to-face encounters.

1 Reprint with permission from: Cox, J. L., Holder, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782 - 786.


Providers who choose not to provide case management services may provide Enhanced Prenatal Care Services as face-to-face sessions such as Childbirth Education, Parenting Classes, etc. to women who are pregnant or fall within the 60 day postpartum period. The education provided by Enhanced Services Only providers should follow the PHB curriculum.

A. REFERRAL CRITERIA 1. Referral for RFTS Enhanced Prenatal Care Services is based on:

• Referral of Medicaid client from RCC;

• Physician’s treatment plan established for the client; or

• Client’s request (self-referral).

2. Referral from RFTS Enhanced Prenatal Care Services must come from the RCC through the Regional Lead Agency (RLA). A DCC cannot begin enhanced services until services are approved by the RCC.

3. DCCs will offer RFTS care coordination to all Enhanced Prenatal Care Services clients.

B. ELIGIBILITY CRITERIA A pregnant woman is eligible for Enhanced Prenatal Care Services if she:

• Has a valid West Virginia DHHR Medicaid card or RFTS Maternity Services card for a current pregnancy; and

• All RFTS clients are eligible for Enhanced Prenatal Care Services, even if they choose not to participate in care coordination.

5.3 ENHANCED PRENATAL CARE SERVICES COMPONENTS A. Parenting Education One session per day with service limit of 32 sessions during the prenatal period and up to the last day of the second post-partum month. Topics covered in Parenting Education

should include but not be limited to topics such as:

• Feeding, bathing, dressing of infant;

• Recognition of preventive health needs;

• Recognition of acute care needs;

• Newborn/child development;

• Child safety;

• Sibling issues; and

• Smoke free environment. Instruction must be rendered by Medicaid certified providers who have appropriate education, license or certification. A DCC cannot provide and bill for both Parenting and Childbirth Education services simultaneously unless there is a documented need. This exception would be parents who need additional Parenting Education after the “Parenting Component” of Childbirth Education has been completed and parents need additional parenting skills enhancement. The services need to be well documented in Progress Notes and units split per service. The PHB curriculum must be used to base and guide Parenting Education sessions for women enrolled in care coordination.

B. Childbirth Education Instruction must be rendered by a Medicaid certified provider who is a certified childbirth educator or a registered nurse. A DCC can provide one session per day with a service limit of seven sessions within nine months (total of 14 hours) during the prenatal period. Sessions should include, but not be limited to topics such as:


• Maternal and fetal development;

• Nutrition, fitness and drugs;

• Physiology of labor and delivery;

• Relaxation and breathing techniques for labor;

• Postpartum care and family planning; and

• Newborn care and feeding. C. Preventive Self-Care

Instruction during the prenatal period and through last day of 2nd postpartum month - one session per day with a service limit of 32 sessions. Topics should include, but not be limited to:

• Physical and emotional changes during pregnancy and postpartum;

• Warning signs of pregnancy complications; and

• Healthful behaviors.

Instruction must be rendered by Medicaid certified providers who have appropriate education, license or certification. The PHB curriculum must be used to base and guide Preventive Self-Care sessions for women enrolled in care coordination.

D. Nutrition Education Certain medically-related dietary concerns will require specialized nutrition services that are extensive, that is, highly complicated and/or intensive. These cases will be referred to a registered dietitian for comprehensive nutrition evaluation, care plan, and counseling.

The following non-comprehensive list identifies medical conditions requiring specialized nutrition services by a registered dietitian: Pregnant Women:

• Pregnancy-induced hypertension/pre-eclampsia

• Multiple gestation

• Metabolic condition, chronic disease or disability which complicates present pregnancy, impairs dietary intake, or requires a special diet such as: Chronic pulmonary disease; Chronic hypertensive disease; Gestational diabetes; Diabetes mellitus; Renal disease; Hypolipoproteinemia; Chronic cardiac disease; Cystic fibrosis; Phenylketonuria; Other inborn errors of metabolism*; Anorexia nervosa/bulimia; Maternal gastrointestinal diseases; malabsorption syndromes; Conditions requiring an elemental diet, enteral (specialized formula feeding by mouth or feeding tube), or total parenteral nutrition

• Adolescent pregnancy (i.e., < 15 years of age or < 2 years since onset of menses)

• Intrauterine growth retardation

• Anemia of pregnancy (i.e., iron and/or Focalin - Hgb < 10 g, Hct < 30%, Focalin < 3 mg/ml)

• Hyperemesis gravida rum

• Maternal protein deficiency: Severe hypoalbuminemia < 2 g/dl; Persistent ketosis; Hypercholesterolemia; Negative nitrogen balance; Lymphocytopenia

• Low pre-pregnancy weight (i.e., < 85% standard weight for height)

• Inadequate weight gain (i.e., < 2 pounds per month during last 2 trimesters of pregnancy or unsatisfactory pattern of weight gain per weight gain grids)

• Significant weight loss in the first trimester due to nausea/vomiting (i.e., > 5% of body weight [120 lb. woman would lose 6 lbs.])


*Referral should be made, if not done previously, to: West Virginia University – Department of Pediatrics, Robert C. Byrd Health Sciences Center, Genetic/Metabolism Section, Post Office Box 9214, Morgantown, West Virginia 26506 - Telephone: (304) 293-7331.

Postpartum Women (through end of 2nd postpartum month) whose infants have the following conditions:

• Low birth weight < 2273 grams or 5 lbs.

• Congenital anomaly affecting ability to feed or requiring special feeding techniques such as: Cleft lip/palate; Cerebral palsy; Esophageal strictures

• Chronic diseases and/or conditions requiring a therapeutic formula (i.e., renal, hepatic or cardiac disease, bronchopulmonary dysplasia)

• Cystic fibrosis

• Metabolic disorders such as:* Diabetes mellitus; Phenylketonuria (PKU); Other inborn errors of metabolism

• Medical diagnosis of failure to thrive

• Developmental delay with associated feeding problems (i.e., ineffective sucking, frequent regurgitation, persistent vomiting, etc.)

• Infant gastrointestinal diseases, malabsorption syndromes, such as necrotizing Enterocolitis, short gut, etc.

• Conditions requiring an elemental diet, enteral (specialized formula feeding by mouth or feeding tube) or total parenteral nutrition

• Weight for length < 5th percentile (based on National Center for Health Statistics [NCHS] growth chart)

• Weight for length > 95th percentile (based on National Center for Health Statistics [NCHS] growth chart)

• Gastroenteritis and/or chronic diarrhea

• Failure to gain weight

*Referral should be made, if not done previously, to: West Virginia University – Department of Pediatrics, Robert C. Byrd Health Sciences Center, Genetic/Metabolism Section, Post Office Box 9214, Morgantown, West Virginia 26506 - Telephone: (304) 293-7331.

To provide specialized nutrition education and counseling for highly complicated medically related conditions, one session of evaluation and counseling services can be provided. This must be during the prenatal period and through 60 days postpartum with a service limit of 32 sessions. Qualified provider of these specialized nutrition services must be a registered dietitian (RD) in accordance with the Commission on Dietetic Registration.

Responsibility of Nutrition Education Enhanced services provider:

• Receive a copy of the physician’s order before providing the services;

• Complete a nutritional assessment/develop nutritional plan;

• Provide counseling and discharge when appropriate; and

• Send required copies of physician’s order and tracking information to the RCC for RFTS clients (Enhanced Services Education Report – R060) within five working days of completion.


5.4 ENHANCED SERVICES ONLY (PRENATAL CLIENTS WHO REFUSE CARE COORDINATION)

For those Enhanced Services clients who do not choose to participate in care coordination services, the Enhanced Services Education Report (R060) should be completed for the prenatal client’s entry into RFTS Enhanced Services Only. If, upon initial contact for Enhanced Services Only, the client chooses to enter into RFTS care coordination services, the Enhanced Services Only provider should forward a copy of the Enhanced Services Education Report to the RCC within five working days to advise the RCC of the client’s Program participation. The Enhanced Services provider should check the “YES” box at the bottom of the Enhanced Service Education Report to notify the RCC that the client desires entry into RFTS care coordination services. The RCC will then complete a Referral Form for the client and refer the case to a DCC for entry into RFTS care coordination services. Copies of all subsequent Client Tracking Sheets will be sent to the RCC by the Enhanced Services Only DCC within five working days.

Upon receipt of the Enhanced Services Only client referral from the RCC, the DCC will contact the client to offer full RFTS care coordination services and schedule a home visit within five working days. At the home visit the DCC will complete the, Initial Client Assessment and Service Care Plan. The DCC will then proceed with full care coordination services and all associated RFTS components according to protocol. Closure of Enhanced Services Only: This category is for clients who choose to participate in Enhanced Services Only. NOTE: 1. All records must be closed in accordance with specified time frames and reasons for closure.

2. All closures will be accurately recorded on the Enhanced Services Education Report.

3. Closure of a record by a DCC will include:

• A copy of the Enhanced Services Education Report forwarded to the RCC within five working days of the closure; and

• The original maintained at the DCC agency. 5.5 ENHANCED SERVICES EDUCATION REPORT Complete on prenatal clients who choose not to participate in care coordination. Send copy to RCC within five working days of initial contact. Within five working days of termination of services, send copy of the Enhanced Services Education Report to RCC and medical provider: 6.0 CASE CLOSURE

Tracking Form At case closure the appropriate case closure reason is marked on the Tracking form;

• Refused Further Services – Client indicates to DCC that she does not want to continue receiving services for herself/infant;

• Lost to Follow-up – Contact has been made with client, but then DCC is unable to make contact again;

• Induced Abortion – Client chooses to have an abortion;

• Spontaneous Abortion – Client has a spontaneous abortion or miscarriage (grief support is applicable with permission from RLA);

• Moved Out-of-State – Client moves out of state;


• Death – Prenatal client or infant of mother dies (grief support is applicable with permission from RLA); and

• Transferred (with date) – Client moves into another region and the case must be transferred in order to continue services.

A copy of the Service Care Plan must be submitted with the closure date written in appropriate box. Also, if client is closed prior to the end of eligibility, the reason for closure (from list on Tracking Form) must also be written in the appropriate box on the form. 6.1 OUTCOME MEASURES FORM Complete for both prenatal and infant clients who have had an Initial Client Assessment and Service Care Plan completed and are closing at the end of their eligibility. If prenatal client closes after delivery but before the end of eligibility, complete as much of the Outcomes Measures Form as possible. For the infant complete as much of the outcome measures form as possible upon closure. NOTE: If a client transfers within the same region or to a different region, do not complete the

Outcome Measures Form and do not close the case. Client Tracking Sheet should be coded as transferred and submitted to the RCC immediately. A copy of the client’s entire record must be forwarded to the RCC for reassignment.

Date, reason for closure, and DCC’s signature will be recorded on the Service Care Plan, Client Tracking Sheet as well as Progress Note. Submit Outcome Measures Form to RCC and medical provider within five working days of case closure. 6.2 PHYSICIAN LETTER – CASE CLOSURE Use to notify medical provider of case closure specifying reason for closure. Complete for both prenatal and infant clients. Submit to RCC and medical provider within five working days of case closure.

7.0 CLIENT RECORD MAINTENANCE

7.1 RECORD MANAGEMENT Upon receiving a client referral, the RCC will assign the referral to a DCC agency/DCC and send a copy of the approved referral to the DCC agency/DCC with all pertinent information about the client to the DCC; Upon completion of client opening:

• The RCC will send a copy of the Referral Form and/or any other pertinent information about the client to the DCC;

• The original documents used in the client assessment and development of the Service Care Plan and all other documents used in the revision of care coordination services will remain in the agency of the DCC. A copy of the Initial Client Assessment, Service Care, Plan, Client Tracking Sheets, and any other document required for the provision of services will be forwarded to the RCC; and

• Original case records will be maintained through timely and accurate scheduling and documentation (must use policies and procedures, forms, and record formats approved by RFTS).


7.2 RECORD STORAGE All record keeping and storage of records must assure client confidentiality as indicated below:

• Original client records will be maintained in a locked storage cabinet or drawer nightly and during weekends. Original records are not to be kept in staff vehicles or residences, but are to be kept at the agency of employment;

• Only duly-authorized Program personnel are permitted access to case records;

• All RFTS providers must comply with the American Health Insurance Portability and Accountability Act of 1996 (HIPAA). (The Individually Identifiable Health Information [Privacy Rule] effective on April 14, 2003.); and

• For those providers who work from their homes instead of out of their agency of employment, original client records must be maintained at the employing agency. Sections of client records containing information needed for DCC use in service provision may be copied. Original client records, as well as copied records, must be maintained in accordance with HIPAA guidelines to protect the privacy of individually identifiable health information. (Examples: client files must not be accessible for viewing by unauthorized individuals, computers must be secure, telephone discussions with or about clients must not be overheard, etc.) All original client records must be kept current at the employing agency.

7.3 CONFIDENTIALITY OF RECORDS Care should be exercised to ensure client privacy at all times to include:

• Recording in the client’s file;

• Telephoning the client;

• Seeking information about the client;

• Providing consultation;

• Referring the client; and/or

• Correspondence by email, social media or text. 7.4 CLIENT REVIEW OF RECORD The prenatal client or the guardian of an infant may review their record at a reasonable, scheduled appointment date and time. The following procedure must be adhered to:

• Client must sign and date a Client Request for Record Release Form before the record is reviewed; and

• A private area must be made available for record review. 7.5 CLIENT REQUEST FOR COPY OF RECORD The prenatal client or guardian of an infant must sign and date the Client Request for Record Release Form before the record is copied.

• Upon request, the record may be mailed to the place of residence by registered mail with return receipt requested; or

• The record may be obtained from the RLA or the DCC’s office. 7.6 CLIENT RECORD RELEASE During the Initial Assessment, the client or guardian of infant should sign and date the Rights and Responsibilities Form, which includes the Client Release/Exchange of Information to/from medical providers and agencies participating in care. Copies should be forwarded to the RCC. 7.7 ROUTINE RECORD COPYING Copying of a case record will be for the following purposes:

• Referrals for care coordination and other needed services as appropriate;

• Client moves out of region;

• Client moves within region but not in working area of DCC;

• Case closure by DCC;


• Request by RLA or state office for utilization of review and monitoring;

• Submission of monthly tracking sheets to RCC; and

• Sections of client charts containing information needed for DCC to make a home visit. 7.8 RECORD IDENTIFICATION Infants or non-citizens who do not have a Social Security Number (e.g., NICU infants that are low-birth weight, preterm, and who are automatically eligible for SSI) will be assigned a computer generated Social Security Number. Refer family of infant to the local Social Security Office to obtain a social security number. When the infant’s Social Security Number has been obtained, records must be changed to use the infant’s true Social Security Number. All clients are assigned a computer-generated ID number when entered into the RFTS Data System. The Medicaid/RFTS Maternity Services eligibility number will be included in the record. 7.9 RECORD RETENTION All active and closed records must be kept for seven years or three years after the completion of the Federal audit, at which time the records may be destroyed. 7.10 CLIENT REFERRALS MADE BY DCC’s FOR OTHER SERVICES All external referrals made by DCCs shall comply with standards for protection of client confidentiality and be documented on the RFTS External Referral Form.

8.0 COLLABORATION WITH CHILD PROTECTIVE SERVICES (CPS)

As registered nurses and licensed social workers under WV Law (WV Code 49-6A-2), it is the responsibility of the RFTS DCC to report suspected or apparent child abuse and/or neglect to Child Protective Services (CPS). Detailed reporting information is available on the Bureau for Children and Families website at www.wvdhhr.org/bcf. After the information is reported by the DCC, it is the responsibility of CPS staff to determine what further action will be taken. Observation to determine further action is not within the role of the DCC, but is the responsibility of CPS staff.

• DHHR must notify any person mandated to report suspected child abuse and neglect according to WV Law (WV Code 49-6A-2a), as to whether an investigation has been initiated and when the investigation is complete;

• Any contact/collaboration between the RFTS DCC and CPS staff must be documented in detail in the client’s file;

• Client information may not be released to CPS staff without written permission from the client or guardian of infant; and

• In the event CPS opens services, the role of the RFTS workforce does not change. RFTS workforce does not replace the CPS workers’ visitation and direct observation of the child at risk.

9.0 RESPONSIBILITY TO THE CLIENT’S MEDICAL PROVIDER

The DCC will provide an update of client status to the client’s medical provider as changes occur. The update may contain:

• Notification of case closure, reason for closure and/or referral to another agency for additional services using Physician Case Closure Letter; and

• A copy of any changes in the Service Care Plan or any other significant change in the client’s status (i.e. loss of housing, family dysfunction including abuse or neglect).


10.0 REFERRAL TO THE WV BIRTH TO THREE (BTT) PROGRAM

The WV Birth To Three Program (BTT) assist children from birth to 36 months of age who have a diagnosis of hearing loss, a developmental delay(s), or a condition known to lead to developmental delay(s). Referrals are made during the RFTS Initial Assessment or at any time deemed necessary during enrollment in RFTS. The DCC will:

• Explain the BTT to the parent/guardian and ask if a referral is desired;

• Submit the referral, if indicated, to BTT serving the county of client’s residence and notify the primary medical provider that the referral has been made. Document all referral information on the RFTS External Referral Form and in the Progress Notes; and

• Inform the primary medical provider if the parent/guardian refuses the referral. NOTE: BTT referrals can be made by calling the WV Statewide Toll-Free referral line at (866) 321-4728. Information and electronic referral forms are available on the BTT

website at www.wvdhhr.org/birth23/. 11.0 ADOPTION POLICY

11.1 POLICY ON CONFLICT OF INTEREST FOR DESIGNATED CARE COORDINATION AGENCIES OMCFH requires agencies providing RFTS and adoptive counseling services to provide separate staff for the performance of the two services. The RFTS DCC agency goal is to provide quality services to high-risk pregnant women, infants, and their families through care coordination services and accessing needed medical, health, educational, psychosocial, and nutritional services. These services are intended to preserve families and give those families the best possible foundation for successful parenting. The agency expects staff to be assertive in ensuring that clients’ needs are met, that they are protected from harm, and that their legal rights are not violated. To avoid actual or perceived conflict of interest, any RFTS provider (RCC, DCC, clerical staff, etc.) will under no circumstances adopt a RFTS infant, recommend, or advocate for adoption. Note the following role clarifications:

ROLE OF DCC ROLE OF ADOPTIVE

AGENCY

• Provide client with names of licensed adoption agencies.

• Emphasize client’s right to choose adoption agency;

• Clarify DCC’s role as defined in RFTS Manual and explain adoption planning is not included or discussed;

• Outline client’s options such as foster care placement, adoption, or pregnancy termination;

• Provide referral information if requested by client;

• Adhere to rules of confidentiality and provide no written or verbal information to adoption staff without the written consent of the client;

• When working with adoption agencies whose program staff wish to provide total birth parent counseling services, contact the RCC to determine if the RFTS client’s care coordination services will be closed and transferred to the adoption agency staff; and

• When working with adoption agencies whose program staff does

• Inform client of legal rights, responsibilities, and obligations; and

• Provide adoption planning.


not wish to provide total care coordination, DCC will continue RFTS care coordination services.

12.0 HOME VISITATION PROGRAMS STATE OFFICE

12.1 RESPONSIBILITIES OF THE STATE HOME VISITATION PROGRAMS OFFICE

REGARDING THE RFTS PROGRAM A signed Grant Agreement between OMCFH and the West Virginia Department of Health and Human Resources/Bureau for Medical Services designates the State Home Visitation Programs Office to administer and be responsible for the operation of the RFTS Program. The State Home Visitation Programs Office subcontracts with other healthcare agencies and service providers to operate the RFTS Program.

12.2 DEVELOPMENT OF POLICIES AND PROCEDURES Home Visitation Programs is responsible for the development, revision and implementation the RFTS Policy and Procedures Manual.

12.3 TECHNICAL ASSISTANCE Be available to RLAs and service providers by phone, email or on-site.

12.4 TRAINING

• Make available training necessary to meet standards and procedures set forth in RFTS Policy and Procedures Manual. (RLAs and provider agencies’ staff are encouraged to participate in training opportunities); and

• Review, select and provide RCC training on standardized, best practice home visitation curriculum and supporting resources.

12.5 PROGRAM MAINTENANCE Home Visitation Programs is responsible for maintaining the following in order to assure client access to early and adequate prenatal and infant health care: State Office:

• Provider list updates;

• Data collection and tracking system;

• DCC Equipment Assignment list;

• NHS client data;

• WV Birthing Facility list;

• OMCFH Provider Number list; and

• Website updates.

Regional Lead Agency:

• Yearly Grant Agreement;

• Monthly/Quarterly Reports;

• Quarterly Training Minutes;

• Monthly Timesheets and Invoices; and

• Correspondence.

Designated Care Coordinator:

• Initial Letter of Agreement;

• Annual Agreement Renewal; and

• DCC addition/deletion – Part A.

Medical Provider:

• Initial Letter of Agreement;

• Annual Agreement Renewal; and

• Medical Provider addition/deletion.

12.6 COMMUNITY OUTREACH


Work cooperatively with RCCs and community resources to enhance RFTS objectives, such as strengthening linkages and collaboration. 12.7 CONFIDENTIALITY OF RECORDS

• In conjunction with RLAs and provider agencies, will adhere to those conditions outlined in their respective agreement and the RFTS Policy and Procedures Manual regarding the safe keeping of client information; and

• Maintain compliance with the American Health Insurance Portability and Accountability Act (HIPAA) enacted 1996.

12.8 QUALITY ASSURANCE Quality Assurance review for RLAs and DCC provider agencies will be managed by the OMCFH Quality Assurance Monitoring Team per the guidelines outlined in the Right From The Start Policy and Procedures Manual. The Director of the WVHVP or RFTS Program Coordinator will review and respond to Program monitoring reviews. Quality Assurance:

• DCCs will participate in RFTS quality assurance review and monitoring activities.

• The DCC will use the Quality Assurance Report for RFTS to audit both prenatal and infant charts. At least ten prenatal and ten infant charts must be audited each quarter, documented, and retained by the DCC provider agency, and sent to the RCC. The DCC may select either open or closed charts for audit.

12.9 RFTS FORMS Develop, provide and approve Program forms and letters to be used by RLAs and DCC provider agencies for the provision of RFTS services.

12.10 WEB-BASED DATA COLLECTION SYSTEM Maintain and monitor a web-based data entry system for the Program.

12.11 OMCFH PROGRAM COLLABORATION The OMCFH programs and staff functions identified in the RFTS Policy and Procedures Manual are an integral part of the total system design. The Director of the WVHVP is to be contacted if problems occur related to RFTS collaboration with other OMCFH programs. 12.12 QUALITY ASSURANCE MONITORING TEAM (QAMT) The OMCFH QAMT performs quality assurance activities for OMCFH programs using a standardized process to review and document services rendered. Reviews are conducted with all RFTS providers. Responsibilities:

• Contact RLA or service provider to schedule the monitoring according to protocol;

• Notify the RCCs of monitoring activity in their regions;

• Conduct an on-site monitoring to verify by observation and documentation provider compliance with RFTS policies and procedures; and to review the conditions surrounding services rendered;

• Conduct an on-site annual monitoring of RLA data entry using client files selected from the RFTS data system; and

• Randomly select twenty charts representing the active and closed caseload of pregnant women and infants of the entity or person being reviewed.


12.13 CORRECTIVE ACTION PLANS Within two weeks upon receipt of a Monitoring Report, the Director of the WVHVP or RFTS Program Coordinator will review the report, make recommendations to improve compliance, identify needs for in-service programs, and send the recommendations to the RCC. 12.14 REGIONAL LEAD AGENCY (RLA) CORRECTIVE ACTION PLAN

• Within three weeks following receipt of the Monitoring Report, the RCC will submit a written correction plan to the RFTS Program Coordinator addressing each item of concern noted in the recommendations;

• Inform the Director of the WVHVP or the RFTS Program Coordinator of any progress or delays in implementing the plan; and

• Director of the WVHVP or the RFTS Program Coordinator will make site visits to RLA or schedule a conference call to discuss report and corrective action plan.

12.15 DESIGNATED CARE COORDINATING CORRECTIVE ACTION PLAN

• RCC will send a copy of the Director of the WVHVP or RFTS Program Coordinator recommendations to the service provider within one week of receipt;

• RCC will meet face-to-face with the DCC to develop a Corrective Action Plan and include time tables for compliance;

• RCC will review, approve and submit the written service providers Corrective Action Plan to the Director of the WVHVP and RFTS Program Coordinator addressing each item of concern noted in the recommendations within four weeks following receipt of the Monitoring Report; and

• RCC will inform the Director of the WVHVP and RFTS Program Coordinator of any progress or delays in implementing the plan.

12.16 DESIGNATED CARE COORDINATING AGENCY RESPONSIBILITIES

• Work with the RCC to develop a Corrective Action Plan to be submitted to the Director of the WVHVP and RFTS Program Coordinator within four weeks following the RCCs receipt of the Monitoring Report and recommendations;

• Inform the RCC of any progress or delays in implementing the plan; and

• Implement activities identified in Corrective Action Plan to obtain DCC agency compliance with RFTS protocol.

13.0 REGIONAL LEAD AGENCY (RLA)

13.1 DESCRIPTION/QUALIFICATION An agency designated as a RLA, under Grant Agreement with the Bureau for Public Health, OMCFH, must meet specific agency criteria to provide for the administration of RFTS at the community level in accordance with RFTS policies and procedures. The RLA must:

• Demonstrate capacity to provide core administrative and managerial support of RFTS at the regional level;

• Demonstrate experience in coordination and linkage of available community agencies meeting RFTS service provider status;

• Demonstrate experience with the target population to be served under RFTS;

• Demonstrate administrative capacity to ensure quality services in accordance with RFTS policies and procedures and with State and Federal regulations;

• Provide one full time Registered Nurse for the position of RCC and a sufficient number of clerical staff meeting RFTS administrative qualifications;

• Provide a capable financial management system that will provide documentation of Program administrative services and costs;

• Demonstrate capacity to document and maintain client records in accordance with RFTS policies and procedures and State and Federal regulations;


NOTE: In case the RLA is no longer the service provider, all original client files will be

maintained by the former RLA. Copies of active client files will be forwarded to the new RLA or to the State Perinatal Programs RFTS Administrative office.

• Provide and document ongoing RFTS in-service training for provider staff (DCCs, clerks). Report in-services and documentation of staff meetings and/or training sessions to the Director of the WVHVP to include dates, speakers, topics and attendees; and

• Provide the RCC with a copy of the signed and dated RLA contract upon receipt from OMCFH.

13.2 REGIONAL CARE COORDINATOR JOB RESPONSIBILITIES Qualifications:

• Registered Nurse, BSN, licensed in the State of West Virginia with at least three years of community nursing experience as a registered nurse;

• Previous supervision and administrative experience: basic computer/internet, and data entry skills; skills in monthly report preparation and recordkeeping; and

NOTE: In regions where nursing shortages exist and agencies have documented that a BSN and/or three years of community health experience presents a hardship in recruitment for the RCC position, the agency may submit documentation of the nursing shortage and a description of unsuccessful recruitment efforts for approval to the Director of the WVHVP. In these circumstances in place of community health experience a registered nurse with an Associate in Nursing with community health background and/or a DCC with one year experience can be substituted with approval from the Director of the West WVHVP.

• Qualifications must be submitted and approved by the Director of the WVHVP before assuming RCC position.

Job Objectives:

• Comply with RFTS guidelines to administer a regional system for eligible pregnant women and infants;

• Provide training and technical support to medical providers and other professionals to facilitate delivery of timely services to eligible clients;

• Maintain information systems for risk assessment and client tracking;

• Provide technical assistance and support for individuals or agencies that provide direct RFTS services; and

• Network and foster collaborative relationships with community agencies/programs.

Authority Lines:

• Responsible to: RLA and OMCFH WVHVP; and

• Responsible for: RFTS Secretary and/or Clerk; and DCC and other service providers in

provision of care coordination and enhanced services in compliance with RFTS policy and

procedures.

Chief Responsibilities Include:

• Participate in required RFTS curriculum training;

• Technical assistance to new DCC agencies for Medicaid/MCO enrollment process;

• Referral to other home visitation agencies if ineligible for RFTS;

• Maintenance of standardized RFTS display;

• Recruitment of providers (DCC and OB);


• Provider training;

• Client tracking;

• Community outreach;

• Attendance at required meetings;

• Communication with DCCs and DCC agencies within region;

• Oversight of RFTS data system at the regional level;

• Accurate documentation and timely reporting procedures; and

• RLA staff time spent in the provision of RFTS administrative services will be documented on OMCFH time sheets by approved service codes. Time sheets are to be given to the RCC to be submitted to the RFTS Program Coordinator no later than 35 days following the end of the month (A copy should be kept at the RLA for auditing purposes). RCCs are expected to spend 100% of their time for the provision of RFTS RLA functions.

13.3 REGIONAL CARE COORDINATOR CODES AND ACTIVITIES

CODE ACTIVITY

001

PROGRAM ELIGIBILITY Activities performed for potentially eligible pregnant women and infants to help obtain Medicaid or medical appointments:

• Identifying potential Medicaid and/or RFTS Maternity Services eligibility for pregnant women and infants.

• Processing referrals.

• Notifying non-Program eligible clients of ineligibility and making referral to appropriate resource(s); and

• Referring of Program eligible clients for service care plan development and care coordination.

002

OVERSIGHT OF DCC SERVICES Oversight of DCC services to ensure:

• Service Care Plan met the needs identified in assessment.

• Service Care Plan documented in chart.

• Referrals are completed.

• Medical provider notified of clients participation in Program.

• Use of CO monitor for all smokers and former smokers.

• Completion of Edinburgh Postnatal Depression Scale per Program protocol; and

• Technical Assistance: DCC/RFTS service provider on-site and/or telephone assistance.

003

PROGRAM DEVELOPMENT Time spent working with State Program staff in formal work committees to assess and plan or project activities that meet Program goals and objectives:

• Training: Instruction on Program policies and procedures to prepare RCCs to train providers; professional training of DCC/medical personnel to enhance or up-date professional skills; and attendance at monthly state RCC meetings or other required training; and

• Meeting with agency administrators, retreats, etc.

004

REGIONAL LEAD AGENCY OVERSIGHT

• Supervising computer input of Client Tracking and/or written recording of client information for Program effectiveness and evaluation of client outcome.

• Working with State Office for technical assistance with RFTS Electronic Data System; and

• Work with DCCs, clerical support, and State Office on electronic tracking of assessments, screenings, closures and other required RFTS activities.


CODE ACTIVITY

005

COMMUNITY ACTIVITIES

• Preparing for community outreach activities such as participation on locally-based committees, public speaking engagements, or baby showers that promote Program goals and objectives; and

• Travelling to events and activities.

006

REPORTS/SURVEYS/BUDGET PREPARATION/BILLING Time spent preparing required Program specific reports and conducting surveys to include but not limited to:

• Projecting/reporting monthly caseload of service providers.

• Projecting yearly regional lead agency budgets; and

• Preparing monthly invoices.

• Reporting change in service provider agency or RLA agency staffing.

• Completing monthly RCC activity reports; and

• Preparing of new agency agreements and or Parts A.

• Completing reports.

007

OUTREACH/CERTIFICATION OF SERVICE PROVIDERS/PROVIDER RECRUITMENT Includes time spent with the service provider in readjusting caseload assignments during a given period and time expended in processing service provider agreements to the RFTS State Office.

• Agency qualifications.

• Agency staff qualifications.

• Assistance with projecting service provider caseload.

• Execution of service provider agreements.

• DCC and OB Provider recruitment; and

• DCC case reassignment.

008

TIME OFF Annual leave, sick leave, lunch breaks (if applicable), or other leave approved by the RLA.

009 MISCELLANEOUS (Must include explanation of activities)

13.4 REGIONAL SECRETARY/CLERK JOB DESCRIPTION Definition: Direct office support to RCC; typing and general office duties, including computer data entry, minor administrative tasks, and office functions, limited participation in organization and Program matters based on policies and procedures.

Qualifications: A Regional Secretary/Clerk must possess a high school diploma or GED, basic computer/data entry skills, and organizational skills.

Authority Lines: Regional Secretary/Clerks are responsible to RLA under direct supervision of the RCC and OMCFH. Chief Responsibilities:

• Support to RCC in daily administration of RLA RFTS;

• Routine office functions and coordination of Program activities that include assisting clients and/or service providers with routine inquiries;

• Preparation of routine correspondence/form letters for RCC signature;


• Timely data entry of client and Program information;

• Daily maintenance of regional office files and records;

• Schedule meetings and set up RCC appointments;

• Regional RFTS staff (RCC and clerical staff) will maintain an individual time sheet for the administration of RFTS activities; and

• Any clerical support staff time spent in activities other than RFTS administration must be documented on the time sheet and deducted from the total amount of hours the RLA will be invoicing.

13.5 REGIONAL SECRETARY/CLERK CODES AND ACTIVITIES

CODE ACTIVITY

100 COMPUTER INPUT Entering Program data into RFTS data system as forms are received, completing data transfer, or retrieving data for RCC.

101

TECHNICAL ASSISTANCE

• Assisting RCC, relaying information to the RCC.

• Scheduling RCC appointments.

• Assisting with RFTS DCC training.

102

CLERICAL SUPPORT

• Preparing letters/memos, routine correspondence, and form letters for Program.

• Preparing information to forward to DCC for case assignments and trainings.

• Maintaining files and records.

• Filing.

• Assessing Client Tracking Sheets, Service Care Plans, and other RFTS forms for completion.

103

OUTREACH WORKER

• Contacting local provider offices, including medical, social service, and others to promote RFTS services and referrals. This may include telephone contact to inquire about new referrals, mailing brochures, or other requested information and providing information about related events, services, etc.

• Placing brochures and other relevant information (such as posters, event flyers, etc.) in traditional and non-traditional sites.

• Contacting referrals to the program that have not yet engaged in services/agreed to enrollment, coordinated with the RFTS DCCs. This may include additional telephone contact, encouraging medical provider to participate in referral/enrollment process, establishing contact with referral through other agencies such as WIC, DHHR, Early Head Start, etc.

104 REPORTS Compiling information and preparation of reports.

105

BILLING

• Compiling information on invoicing for lead agency and completion of monthly invoices.

• Purchasing.

106 TRAINING Receiving training on Program policies and procedures, use of computer systems.

107 TIME OFF Taking time off for annual leave, sick leave, lunch (if applicable), or other leave approved by the RLA.

108 MISCELLANEOUS Include explanation of activities, such as unexpected community crisis assistance.


14.0 DESIGNATED CARE COORDINATOR (DCC) PROVIDER AGENCY

14.1 PROVIDER ELIGIBILITY CRITERIA All RFTS provider agencies must meet the following criteria: Provider must be:

• A local health department as created in West Virginia Public Health Law, Chapter 16-2-1, 16-2-3, and 16-2A of the West Virginia Code;

• A health center as defined by U.S. Public Health Service Act 330; or

• Other federally qualifying health or community services facility as defined by 42 U.S.C. § 1396a (1) (2) (B).

Provider must:

• Demonstrate capacity to provide core elements of defined services as grouped below:

I. Prenatal Clients II. Infant Clients III. Enhanced Only

Prenatal Clients

• Assessment • Service Plan Development • Care Coordination & Referral • Follow-up and Monitoring • Enhanced Services

• Assessment • Service Plan Development • Care Coordination & Referral • Follow-up and Monitoring

• Enhanced Services Education

• Provide sufficient number of qualified staff to meet core elements of the defined service(s) categories;

• Provide administrative capacity to ensure quality of services in accordance with State and Federal requirements;

• Conduct quality assurance activities within each agency for the chart audit on ten prenatal cases and ten infant cases per quarter. (Quality Assurance Report);

• Provide financial management capacity and a system that documents services and costs; and

• Demonstrate capacity to document and maintain individual case records in accordance with state and federal requirements (seven years or three years after a federal audit at which time the case records may be disposed/destroyed).

14.2 DCC PROVIDER AGENCY REQUIREMENTS Service Provider Staff Licensure: The licensure of the DCC must be validated by the RCC at the time of Letter of Agreement (LOA) initiation, renewals, and prior to care coordination services being initiated. The RCC must maintain a list of license numbers and names of licensees on file at the RLA. Any new DCCs added by the provider agency must follow the same protocol. Since licenses expire at different times throughout the year, verification is required at the end of the fiscal year (June 30) or at the discretion of the RCC.

Agency DCC changes must be submitted by the RCC to the Director of the WVHVP on Part A of the LOA within five working days of receipt. Attendance at Meetings: Requirements of DCC participation:

• At least one DCC and/or Enhanced Services provider from each DCC agency must attend the regional quarterly training. The DCC/Enhanced Services provider attending the regional quarterly training will be responsible for updating their site with information reviewed/obtained at that training. If this requirement is not met, the DCC agency must


notify, in writing, the RCC for approved absence at least one week in advance;

• All DCC provider staff must complete all RFTS Program training, in its entirety, prior to providing client services or receiving program educational equipment and materials. It is the discretion of the RCC as to whether the DCC is ready to receive referrals and provide services;

• If a DCC provides RFTS services in two different regions, the DCC must attend a quarterly training in at least one region. The DCC must notify the RCC, in writing, of training attendance and obtain updates. It is also a must that the DCC communicate with each RCC for each region that they provide services in on a regular basis and attend quarterly trainings in each region during different quarterly sessions; and

• DCCs will attend on-site meetings, group technical assistance, or continued education trainings offered by RFTS or the RCC.

Research: DCCs will participate in research and evaluation activities that address the RFTS target population. Activities will be designed by OMCFH/RFTS research personnel in conjunction with State and local RFTS personnel. 14.3 ENHANCED SERVICES ONLY PROVIDERS Enhanced prenatal care services will be rendered by certified providers using the PHB curriculum who have appropriate education, licensure or certification such as, but not limited to:

• Registered Nurse

• Childbirth Educator

• Health Educator

• Social Worker

• Registered Dietician

NOTE: The license or certification will be validated by the same protocol used for the DCCs. 14.4 DCC PROVIDER AGENCY ENROLLMENT - LETTER OF AGREEMENT PROCEDURE 1. To be eligible for participation and reimbursement for services provided to Medicaid members,

all providers shall:

• Meet applicable licensing, accreditation, and certification requirements;

• Have a valid signed provider enrollment application/agreement on file with BMS; and

• Meet and maintain all BMS provider enrollment requirements. 2. The RCC will contact the State RFTS staff with the name and address of the interested

agency. 3. State RFTS Office sends LOA to the appropriate RCC who will forward it to the potential DCC

agency for review and signatures. 4. Agency completes Part A, the Caseload Projections and signs Agreement (DCC licensing,

titles and counties covered must be entered on Part A). 5. LOA is submitted to the appropriate RCC for certification of Part A. The RCC will submit the

original certified LOA to the OMCFH, Director of the WVHVP for approval. After the LOA has been submitted to OMCFH, the RCC may start training the DCC(s). Training must be provided on the PHB curriculum and documented on the DCC Training Checklist.

6. Upon approval of the LOA, OMCFH will submit a copy of the LOA to Molina for assignment of a Medicaid Provider number for billing purposes. OMCFH will retain the original LOA and will forward a signed copy to the RCC, DCC agency Administrator and the DCC(s).

• Molina will send the DCC agency the application for a provider number. Agency completes application and returns to Molina. Molina will process completed application within ten working days, notify the agency, and the Director of the WVHVP of the assigned number.

NOTE: Providers may not participate in RFTS until certification is completed and a RFTS

Medicaid billing number has been assigned. RCC is not to make referrals or assign


RFTS curriculum or equipment prior to receiving notification of the agency’s Medicaid Provider number, effective date, and completion of DCC training.

• The provider number assigned by Molina is to be used ONLY for the purpose of billing RFTS Care Coordination/Enhanced Services to Molina or the appropriate MCO. This number is not to be confused or exchanged with the ten-digit provider number assigned by the OMCFH for the sole purpose of ordering materials (literature, forms, etc.) from OMCFH Materials Management.

7. In the event the provider wishes to modify the caseload volume or enhanced services offered during the contract year, the following process must be followed:

• A revised Part A (Attachment I of LOA - Appendix E) must be submitted to the RCC with requests for modification of services.

❖ The RCC will: Certify the provider has the personnel needed to modify the caseload/service volume; Verify that there is a demonstrated need for modification of services in the designated area; and send in revised Part A and Caseload Projection Worksheet to the Director of the WVHVP.

8. Parts A of the agreement and caseload projections must be submitted annually. All RFTS

providers must submit Part A to the RCC by June 1st. The RCC should forward originals to the State Office annually, no later than June 15th.

9. In the event of cancellation of a DCC LOA, OMCFH will notify Molina of the cancellation and the effective date. Agency must provide RCC and OMCFH with a letter of termination giving 30 days’ notice according to the LOA. If any RFTS billing is submitted by this DCC agency with a service date after the end date of the LOA, the claim will be denied for payment by Molina/HMO. The agency has 60 days following LOA cancellation to submit billing.

10. The potential DCC agency must also secure contracts with each WV Managed Care Organization (MCO).

14.5 DESIGNATED CARE COORDINATOR JOB RESPONSIBILITIES Objectives:

• Coordinate the health, education and nutritional care for Medicaid-eligible or RFTS Maternity Services pregnant/postpartum women and infants with providers, professional specialists, and community resources;

• Improve the pregnant woman/infant’s and the family’s knowledge regarding the importance of quality health care;

• Use appropriate referral and follow-up procedures to access necessary resources for the primary needs of the family. This includes, but is not limited to food, shelter, safety, crisis intervention, mental health, transportation assistance, and child care; and

• Empower the pregnant woman/family to have the knowledge and ability to access necessary resources following case closure.

Authority Lines: The DCCs are responsible to:

• The RCC for care coordination/enhanced services activities and all RFTS training;

• The employing agency for human resource related activities; and

• Service providers for coordination, reporting, and communication related to services provided.

Chief Responsibilities: A. Coordinates the health, education, and nutritional care for the RFTS eligible

pregnant/postpartum woman and infant.


• Receives referrals from RCC;

• Provides follow-up and coordination on referrals and offers RFTS care coordination to eligible infants;

• Completes assessment and Referral Form, if necessary, to identify barriers to a healthy outcome;

• Develops care plan with the client or guardian of the infant using RFTS Service Care Plan and does periodic evaluation for each objective included on the Service Care Plan;

• Arranges for interventions which meet identified needs;

• Makes home visits and client contacts according to policy;

• Follows a standardized recording system for documenting client care;

• Reassesses and revises Service Care Plan as needed;

• Updates medical provider of client’s progress/change in Service Care Plan as needed;

• Sends required information to RCC;

• Arranges for and/or participates in interdisciplinary and/or interagency problem/service care plan meetings for multi-problem clients to determine the appropriate agency to serve as primary case manager and to assign service care plan responsibilities;

• Coordinates with other programs providing case management or home visiting services to infants such as the BTT and/or Children with Special Health Care Needs;

• Refers client or guardian of infant into appropriate case management system at time of closure or as risks are determined; and

• At or near case closure, completes Outcome Measures form and forwards copies to RCC and medical provider.

B. Increases the pregnant woman/infant’s family’s knowledge regarding the importance of

quality health care.

• Communicates with the client or guardian of infant and the family concerning the value of self-care;

• Plans with the client or guardian of the infant for medical perinatal and/or pediatric care;

• Plans with the client for participation in Women, Infants & Children (WIC) for nutritional needs, counseling, and food supplements;

• Models and teaches problem-solving skills;

• Plans with the client for receiving a postpartum exam and family planning services;

• Plans with the client or guardian of infant for support systems;

• Plans with the client or guardian of infant for receiving well child visits and immunization services;

• Encourages and promotes routine oral health care; and

• Uses guidelines and appropriate client handouts included in the PHB curriculum.

C. Advocates for the primary needs of the family, including, but not limited to, food, shelter, safety, crisis intervention, transportation assistance, and child care.

D. Uses appropriate referral and follow-up procedures to acquire necessary resources for

the client or guardian of infant.

• Establishes cooperative agreements and contacts for referral on the local level;

• Coordinates services from all disciplines;

• Communicates with medical care providers;

• Refers parent or guardian of very low birth weight, preterm infants to SSI (if not referred by hospital at birth). SSI approval provides Medicaid eligibility; and

• Monitors receipt of services.


E. Participates in all training provided by the RCC or OMCFH, including mandatory training on the PHB curriculum.

F. Safely maintain all state supplied, assigned equipment, and return to RCC upon

termination of agreement or DCC. G. Wear state supplied identification when providing all RFTS services. 14.6 DOCUMENTATION REQUIREMENTS FOR DCC The DCC must:

• Maintain a separate individual case record for each RFTS referred client, including refusals;

• Open a new record for each client who has a subsequent pregnancy;

• Maintain a record for each client who receives Enhanced Services Only;

• Have all appropriate client information relative to the case and document immediately upon completion of a service unit. If unable to complete documentation immediately, documentation must be completed as soon as possible (no longer than five working days) following service delivery. Delay of documentation will be considered noncompliance and repeated offenses will risk termination of an agency’s agreement to continue RFTS service provision;

• With all RFTS forms, documentation must accurately reflect the services provided. This includes, but is not limited to:

❖ Number of units provided for care coordination services on the Client Tracking Sheet.

❖ DCC signature after each entry in Progress Notes. ❖ Client or guardian of infant must sign Client Tracking Sheet for all face

to face visits. ❖ Documentation of the geographical location in which the service was

rendered. The name of the town will be sufficient for a clinic site in a multi-clinic agency or provider’s office. For services performed in the client’s home, the address need not be repeated.

❖ Include reference to handouts provided to client from the PHB curriculum on the Client Tracking Sheet

• Include copies of email correspondence in all RFTS records for those clients who are

hearing impaired; and

• Make appropriate corrections on original client record and return, along with copy of

Corrections Request Form, to RCC within five working days after receipt. Maintain copy

of in the client file.

14.7 DCC BILLING AND REIMBURSEMENT Covered Services: Covered services and procedure codes for targeted case management are outlined on Page 36. Units of service for care coordination reimbursement represent the time spent in the actual service activity. A unit of service is defined as 15 minutes. Partial units are to be rounded up or down to the nearest whole unit. For example, if less than 7 minutes rounded down and 8 minutes or more rounded up)

Enhanced Services are provided as sessions for prenatal clients only. These are limited to reimbursement for one session per code per day and must adhere to the specific service limits designated for each code according to Program guidelines. A session is not billed by a certain amount of minutes but is billed by the educational component. To ensure quality service to the client a session must not be less than 15 minutes.


All service providers will adhere to the allowable units/sessions of service established by the Program for reimbursable covered services. There is no provision for extension or approval of units of service beyond the approved number.

NOTE: Care Coordination can be billed prior to completion of assessment and Service Care

Plan contingent on RCC approval. Only in extreme or emergency cases can this be done (example: attempts to provide follow-up of infants with a high birth score).

Non-Covered Services:

• Services provided by non-Medicaid certified provider personnel, regardless of supervision. Persons rendering services must be approved during the provider agency certification process and must meet the qualification criteria for the categories of service they will be rendering;

• Telephone calls for Enhanced Services. Enhanced Services can only be provided face-to-face with the prenatal/postpartum client;

• Time spent seeking clarification on Program procedures/policies;

• Time used to train service providers or time used by service providers to acquire training;

• Time spent in the preparation of reports;

• Time spent preparing letters or literature to send to clients;

• Mileage reimbursement for travel by DCCs to render services;

• Added time that it takes to get to or from a client;

• Added time for documentation after seeing, visiting, or talking with a client;

• Picking up supplies (diapers, food, etc.) and delivering to a client. A DCC can only charge for the actual time spent with the client;

• A home visit if the client (prenatal or infant) is not home.

• An infant client visit if the guardian of infant is not home (exception: caregiver permission form signed by parent/guardian);

• The initial contact (phone call, letter);

• Enhanced Services on an infant case;

• RFTS case management if coaching the prenatal client during labor;

• In cases where the client has refused RFTS services, DCCs cannot bill for a Service Care Plan and Initial Client Assessment if the client has not signed the Service Care Plan;

• Billing for Initial Client Assessment by a DCC/agency after the first one has already been billed; and

• Calls made specifically to schedule (or verify) face-to-face visits. 15.0 GUIDELINES FOR CLAIMS

15.1 MEDICAID RFTS claims processing for Medicaid clients will accommodate the national version of the Center for Medicare and Medicaid Services-1500 Health Insurance Claim Form. Federal regulations require that the recipient exhaust all benefits available to meet the costs of care prior to use of Medicaid benefits. Medicaid is the payer of last resort. For questions regarding billing issues, call Molina at 1-800-483-0793 or log on to www.wvdhhr.org/bms and choose the Molina link. For questions regarding a specific Health Maintenance Organization (HMO), Molina will provide appropriate contact information.


15.2 RIGHT FROM THE START PROGRAM PROCEDURE CODES TARGETED CASE MANAGEMENT AND ENHANCED PRENATAL CARE SERVICES

PROCEDURE CODE

PROCEDURE DESCRIPTION UNIT(S)

SERVICE SERVICE LIMIT

S5190HD $96.00

Service Care Plan Assessment/Wellness Assessment (Prenatal Clients Only) Based on medical Prenatal Risk Screening Instrument, assessment of the client’s situation, identification of needed services, and development of an individualized Service Care Plan.

1 session 1 per case

T1016HD $12.78

Care Coordination/Case Management Based on the individualized Service Care Plan, care coordination, and referral for resources and services; follow-up and monitoring; Service Care Plan update.

15 minutes None

T1016HDU1 $12.78

Care Coordination/Case Management Second place of service on same day

15 minutes None

S9444HD $16.00

Health Education – Parenting Classes; non physician provider Client education for infant care; recognition of preventive and acute health care needs; child development and child safety. Should include but not be limited to topics such as: 1) Feeding, bathing, dressing of infant; 2) Recognition of preventive health needs; 3) Recognition of acute care needs; 4) Newborn/child development; and 5) Child safety.

1 session per day

32-15 minute sessions during the prenatal period and up to 60 days postpartum

S9445HD $12.00

Health Education – Preventive Self-Care; not otherwise classified; non physician provider; individual Intervention education for pregnant/postpartum women to include but not be limited to such topics as: 1) Physical/emotional changes during pregnancy and postpartum; 2) Warning signs of pregnancy complications; and 3) Healthful behaviors.

1 session per day

32-15 minute sessions during the prenatal period and up to 60 days postpartum

S9442HD $12.00

Health Education – Childbirth Classes; non physician provider; group classes or individual sessions Education during the prenatal period to include but not limited to topics such as:

1) Maternal and fetal development; 2) Nutrition, fitness and drugs; 3) Physiology of labor and delivery; 4) Relaxation and breathing techniques for labor; 5) Postpartum care and family planning; and 6) Newborn care and feeding.

1 session per day

7/9 months (total 14 hours)

S9452HD $18.00

Nutritional Assessment/Counseling; non physician provider To provide specialized nutrition education and counseling for highly complicated medically related conditions occurring during pregnancy, postpartum or to the infant. Qualified provider of these specialized nutrition services must be a registered dietician (R.D.) in accordance with the Commission on Dietetic Registration.

1 session per day

32-15 minute sessions during the prenatal period and 32-15 minute sessions up to 60 days postpartum



Appendix A – Maternity Services Page 1

Appendix A MATERNITY SERVICES

One of Home Visitation Programs component activities is limited funding of prenatal, delivery, postpartum, and routine newborn hospital care for low-income, medically-indigent pregnant women who are determined to be ineligible for Medicaid, have no insurance to cover obstetrical care, and have a monthly income below 185% of the Federal Poverty Level. Because there is a need to identify these women for billing and reporting purposes, they are often referred to as RFTS Maternity Services clients. Care for this population is paid for using federal (Title V) monies in conjunction with State appropriations to increase access for the targeted population. RFTS Maternity Services supports comprehensive prenatal care as outlined in the American College of Obstetricians and Gynecologists (ACOG) guidelines. This helps to ensure West Virginia women have the benefit of appropriate health care during the course of their pregnancy. The purpose of this section is to explain the policies regarding medical coverage for pregnant women by RFTS Maternity Services.

I. ELIGIBILITY A. CRITERIA

1. West Virginia residency; 2. Application denied for Medicaid coverage for pregnancy; 3. Gross income of 185% of the Federal Poverty Level (FPL); and 4. No insurance or insurance will not cover pregnancy.

NOTE: Eligibility determination is made by the Director of West Virginia Home

Visitation Programs using income information supplied by the WV Department of Health and Human Resources (DHHR). The client is notified by mail of the outcome of the eligibility review. Eligible clients will receive a card for identification as a covered RFTS Maternity Services client.

B. CATEGORIES 1. Code MM - Minors (Pregnant teens age 19 years and under regardless of family

income) NOTE: If a RFTS Maternity Services client turns 18 during the pregnancy,

coverage continues. However, these clients are encouraged to apply for Medicaid because of the additional benefit to them and their child(ren). Once a minor turns 18, their parents’ income is no longer deemed to them.

2. Code MX - Income eligible and medically indigent pregnant clients age 20 years or older NOTE: Should the family income decrease during the pregnancy, these

clients should be encouraged to reapply for Medicaid coverage because of the additional benefits to them and their child(ren).

3. Code MA - Income eligible non-citizens




NOTE: In keeping with its role as payer of last resort, RFTS Maternity

Services covers prenatal care only for these clients. Non-citizens must apply for Emergency Medical care at their local DHHR office within thirty days of their delivery. The Emergency Medical application also allows the DHHR to assess Medicaid eligibility for the newborn.

NOTE: Examples of the explanation of benefit letters for all of the above categories, both approved and denied, are located at the end of this section.

II. PRESUMPTIVE ELIGIBILITY RFTS Maternity Services recognizes the importance of early prenatal care. If clients are unable to pay for care and have no third party resource (insurance, Medicaid), they are less likely to seek prenatal care, and providers may be hesitant to render services. To overcome this obstacle and assure access to early prenatal care, RFTS Maternity Services acts as a guarantor of payment for initial prenatal exams, and associated laboratory/diagnostic tests. However, RFTS Maternity Services is the payer of last resort. If the client is approved for Medicaid or another third party source, the practitioner is paid by that source. There are two categories of presumptive eligibility that may be assigned by RFTS Maternity Services:

A. Code PM

If the client has not applied for Medicaid or eligibility has not been determined, the client may feel she cannot seek prenatal care because she has no means of payment. To surmount this obstacle to care, RFTS Maternity Services agrees to pay for the initial prenatal visit, the associated laboratory diagnostic testing, and the initial ultrasound (if indicated). The PM number does NOT cover any other diagnostic tests or services, or any additional prenatal visits. The presumption is that the client will be approved for Medicaid by the time the invoice is presented for payment or the client will be eligible for RFTS Maternity Services coverage.

B. Code SM The client has been approved for Medicaid coverage, but coverage was not backdated to cover the initial prenatal visit, and associated laboratory diagnostic assessments. RFTS Maternity Services may pay for the services incurred before the effective date of Medicaid coverage, if the client was income eligible.

III. COVERED SERVICES RFTS Maternity Services covers only routine pregnancy related care and treatment listed on the RFTS website in the “Provider Only” section (user name and password required). Within the limitations stated below, RFTS Maternity Services normally pays for the following types of service for sponsored clients at established RFTS Maternity Services rates:

• Routine prenatal care;

• Laboratory and diagnostic assessments in accordance with ACOG standards; NOTE: HIV screening should be included in the routine panel of prenatal screening

tests for all pregnant women and is a covered service under RFTS Maternity Services.




• Ultrasound and radiologic examinations;

• Delivery charges (vaginal and c-section), hospital supplies, laboratory work, (Limited to one thousand dollars [$1,000.00]);

• Anesthesia (at time of delivery);

• One postpartum examination to include routine laboratory, diagnostic tests;

• Routine newborn care rendered during the mother’s hospitalization for delivery includes newborn examination, circumcision, and discharge; and

• RFTS Program services comparable to those provided Medicaid recipients. NOTE: Prenatal vitamins and iron tablets are supplied by the OMCFH to

participating prenatal providers or local health departments for their pregnant clients covered under RFTS Maternity Services.

IV. NON-COVERED SERVICES The following is a partial list of services not covered by RFTS Maternity Services for payment:

• Hospitalization at any time other than for delivery;

• Observation status at the hospital;

• Intermediate or intensive care for the mother or newborn;

• Any service/care that is not pregnancy related;

• Emergency room charges/care;

• Ambulance services;

• Family planning services/postpartum sterilization (woman must be referred to the OMCFH Family Planning Program);

• Infant care rendered after discharge from the hospital; and

• Infant care other than routine newborn care specified in Section 3, page 2.

V. BILLING PROCEDURES • Practitioners and health care facilities are to bill RFTS Maternity Services using the

CMS 1500 billing form or the UB 92 billing form with attached itemization;

• Only standard CPT codes and service descriptions used by Medicaid and approved by RFTS Maternity Services will be eligible for reimbursement. A list of covered RFTS Maternity Services codes may be obtained by calling 1-800-642-8522 or by accessing the “Provider Only” section of RFTS website;

• The client’s assigned RFTS Maternity Services ID number must be included on the billing form to receive reimbursement;

• Payment of an invoice by RFTS Maternity Services constitutes payment in full. The client must not be billed the balance after payment is received from RFTS Maternity Services. RFTS Maternity Services will pay for services provided to pregnant women at the established RFTS Maternity Services rate; and

• Invoices should be submitted within sixty (60) days from the date of service to:

WVDHHR Office of Maternal, Child and Family Health

RFTS Maternity Services 350 Capitol Street, Room 427 Charleston, West Virginia 25301-3714




VI. GENERAL NOTES • In addition to these services, RFTS Maternity Services supplies prenatal vitamins, iron

and literature to contracted obstetrical providers for distribution to participating clients. The policy of RFTS Maternity Services for the distribution of vitamins/iron is as follows: Give one bottle at the time of positive pregnancy determination or first OB visit to: 1) minors (19 years of age and under); 2) non-citizens; 3) clients who have not yet applied for or been approved for Medicaid; and/or 4) clients denied Medicaid and not yet approved for RFTS Maternity Services. As soon as a client is enrolled in:

❖ Medicaid - provide her with a prescription for future vitamin/iron needs; and/or

❖ RFTS Maternity Services - provide her with two (2) additional bottles of vitamins.

• Clients may use non-contracted practitioners; however, contracted providers must accept RFTS Maternity Services rates as payment in full for services rendered. They must also abide by RFTS Maternity Services policies and procedures; and

• RFTS Maternity Services clients wishing to have a sterilization must apply to the OMCFH Family Planning Program.

STATE OF WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES

Jim Justice

Governor

Tuesday, October 31, 2017

Bill J. Crouch

Cabinet Secretary

Dear

Improving access to health care for pregnant women has been a longstanding goal of state government. Since the 1980's, the Office of Maternal, Child and Family Health (OMCFH) has paid for prenatal care and delivery for women who are uninsured/underinsured and have low income. You are not eligible for the WV Home Visitation Programs' Maternity Services/OMCFH coverage because you:

have pregnancy-related insurance coverage, OR are over the income guidelines, OR did not provide insurance verification.

If your income decreases, you will need to reapply for Medicaid at your local Department of Health and Human Resources office.

If you have any questions, please call the OMCFH at (304) 558-5388 or toll-free in West Virginia, 1-800- 642-8522 or 1-800-642-9704 between the hours of 8:30 a.m. and 5:00 p.m., Monday through Friday.

Sincerely,

WV Home Visitation Program

II/ii

cc: Maternity Services Client File

WWDHHR/BPH/OMCFH/DPWH/WVHVP 2017

STATE OF WEST VIRGINIADEPARTMENT OF HEALTH AND HUMAN RESOURCES

Jim Justice

Governor

Bill J. Crouch

Cabinet SecretaryTuesday, October 31, 2017

Dear

The Office of Maternal, Child and Family Health (OMCFH), Home Visitation Program has been notified that you were

denied Medicaid coverage. You are approved to receive prenatal care coverage through the OMCFH/HVP Maternity

Services Program

for the following services as long as you are a West Virginia resident, for this pregnancy only:

Your identification card for prenatal medical coverage is enclosed.

Please NOTE: The OMCFH coverage does not include hospitalization, emergency room, pharmacy or

ambulance coverage.

If you have any questions concerning your coverage, or how to access Family Planning services, please call (304)

Division of Perinatal and Women's Health

Home Visitation Program

Enclosures

cc: Maternity Services Client File MA

This program will pay

Prenatal care.

Office of Maternal, Child and Family Health

*

Routine prenatal laboratory and diagnostic assessments; and*

RFTS Care Coordination and enhanced education services.*

Patient ID Number:

Effective Date:

0

The OMCFH will not pay for any services associated with your delivery, your care after delivery, or the care of

your baby. This coverage MAY be available to you and your baby by contacting the local Department of Health

and Human Resources (DHHR) office in your county of residence. You MUST apply to the local DHHR office

for Emergency Medical Services for yourself and your babywithin 30 days of delivery in order to receive

help with medical bills.

When you visit your health care provider to receive prenatal care, be sure to show him/her your WVHVP Maternity

Services identification card to assure that OMCFH is billed for your care. Be sure that he/she knows that OMCFH

reimbursement is to be considered as "payment in full" for covered services. If you have not selected a provider,

please call us at 1-800-642-8522 and we will give you the names of providers in your area contracting with

OMCFH.

558-5388 or toll-free in West Virginia at 1-800-642-8522.

WVDHHR/BPH/OMCFH/DPWH/HVP 2017

Jim Justice

Governor

STATE OF WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES

Tuesday, October 31, 2017

Bill J. Crouch

Cabinet Secretary

Patient ID Number: 0

Effective Date:

Dear The Office of Maternal, Child and Family Health (OMCFH), Home Visitation Program has been notified that

you were denied Medicaid coverage. You are approved to receive prenatal care coverage paid for by the

OMCFH/HVP. Your identification card for prenatal medical coverage is enclose. The Program will

pay for the following services as long as you are a West Virginia resident, for this pregnancy only:

* Routine prenatal care and delivery.

* Routine prenatal laboratory and diagnostic assessments.

* $1,000 payment for hospitalization at time of delivery ONLY. (Patient is responsible for

any additional charges); and

* Please note the OMCFH coverage does not include emergency room visits, emergency

hospital admissions, ambulance coverage, or pharmacy.

When you visit your prenatal care provider:

* Be sure to show him/her your HVP Maternity Services identification card to assure that

OMCFH is billed for your prenatal care; and

* Be sure that he/she knows that OMCFH reimbursement is to be considered as "payment

in full" for covered services. If you have not selected a provider, please call us at 1-800-

642-8522 and we will give you the names of providers in your area contracting with

OMCFH. Please apply at your local Department of Health and Human Resources Office for a Medicaid card

for your baby within 30 days of delivery. If you have any questions concerning your coverage, please call (304) 558-5388 or toll-free in West

Virginia at 1-800-642-8522. Office of Maternal, Child and Family Health

Division of Perinatal and Women's Health

Home Visitation Program Enclosures

cc: Maternity Services Client File MM MX

WWDHHR/BPH/OMCFH/DPWH/HVP 2017

#Type!

Effective Date:

BUREAU FOR PUBLIC HEALTH

Office of Maternal, Child and

Family Health

Home Visitation Program(HVP)/Maternity Services

(Non-Medicaid Eligibles)

Patient ID Number:

Category Code:

Card ID Number0

The Home Visitation Program/Maternity Services is a government funded program for uninsured,

If you have any questions about the billing process or client coverage, please call 1-800-642-8522.

Approved by: Date:

Category Code: MM - Minor (age of 19 and under)

MX - Income Eligible (under 185% of Federal Poverty Level)

Category Code: MA - Non-Citizen

apply for Medicaid coverage for the infant within 30 days after delivery.

delivery, emergency room visits, ambulance fees, prescriptions and sterilizations.

Prenatal Vitamins, Iron Tablets - may be obtained from your prenatal care provider, or your

local health department.

low-income pregnant women. Payment for services will be made according to the OMCFH/HVP

fee schedule for non-Medicaid enrolles and should be considered payment in full. Billing for the Maternity

Services Program is to be submitted on a CMS-1500 or UB-92 within 60 days of date of service.

Invoices should be mailed to:

Home Visitation Program/MATERNITY SERVICES

350 CAPITOL STREET, ROOM 427

CHARLESTON, WEST VIRGINIA 25301-3714

Covered Services: Prenatal visits, basic prenatal lab work, ultrasounds, non-stress test, and amniocentesis

a flat fee of $1,000.00 for inpatient hospitalization at the time of the delivery only (patient is

responsible for remaining balance). Be sure to apply for Medicaid for the infant within 30 days after

the delivery.

Non-covered services include are not limited to: inpatient hospitalization except at time of

delivery, emergency room visits, ambulance fees, prescriptions and sterilizations.

Covered Services: Prenatal visits, basic prenatal lab work, ultrasounds, non-stress test, and

amniocentesis. Client must apply for Emergency Medical Services to pay for delivery and inpatient

hospitalization at their local DHHR county office within 30 days after delivery. The client must also

Non-covered services include, but are not limited to: inpatient hospitalization at any time including

WVDHHR/BPH/OMCFH/DPWH/HVP 2017


Right From the Start Policy & Procedures Manual Page 1

Appendix B – ART Policy & Procedures

Appendix B ACCESS TO RURAL TRANSPORTATION (ART)

I. INTRODUCTION

Access to Rural Transportation (ART) provides payment for transportation of RFTS eligible clients to medical or other predetermined medical care appointments (i.e. childbirth classes). The provision of transportation assistance is important to the goal of improving pregnancy outcomes and to the wellness of women and infants in West Virginia. RFTS Maternity Services clients receive transportation assistance via the ART system while Medicaid eligible clients receive transportation via the Non-Emergency Medical Transportation (NEMT) system through the NEMT Broker.

II. RFTS ART PROVIDER FUNDING When enrolling as an ART Provider, the DCC Agency must contact the secretary for the West Virginia Home Visitation Program (WVHVP) to request funds to have them available for reimbursement of travel for RFTS Maternity Services clients. If the DCC agency has a substantial need for funds for RFTS Maternity Services clients and are in danger of having funds depleted, please contact the WVHVP at 1-800-642-8522 or 1-800-642-9704 to request additional funding.

III. ART/NEMT FORMS

A. OIM-ART-1 (NON-MEDICAID CLIENTS)

1. To be eligible for ART benefits, the client must:

• Be enrolled as a prenatal Right From The Start participant;

• For clients enrolled in care coordination, eligibility for ART benefits will begin the date the service plan is signed;

• For clients receiving only enhanced services, eligibility for ART benefits will begin when the client is identified as receiving RFTS services through tracking procedures;

• Have a planned appointment for medical care, educational or other services that are covered by the RFTS Program, and are a Medicaid allowable expense; and

• Have received pre-authorization from the DCC ART agency for the benefits being requested.

NOTE: A planned appointment is defined as an arrangement made on behalf of the client for a medical and/or other Medicaid approved service.

2. RFTS Maternity Services card holders are to use OIM-ART-1 form for approved

medical appointments for reimbursement of travel. Reimbursement can be provided two ways:

• Advanced financial assistance; and/or

• Reimbursement after the appointment has been kept. It is the decision of the ART provider which method is to be used.

3. It is important that the form be completed correctly and signed by the medical provider or designated representative. The client is responsible for making sure


Right From the Start Policy & Procedures Manual Page 2

Appendix B – ART Policy & Procedures

this is done. The form is void if this area is not completed and reimbursement will not be provided.

4. The completed form must be returned to the ART provider within sixty (60) days of the medical visit if reimbursement is to be made. If advanced payment was made and the client fails to verify the appointment was kept within 60 days, advanced payment will not be given to the client in the future.

B. MEDICAID CLIENTS 1. The NEMT Broker is to be contacted by RFTS clients who are WV Medicaid

recipients five business days before the medical appointment in order to arrange transportation or to pre-authorize mileage reimbursement. The broker’s trip form is to be completed with verification of the approved visit by signature of the provider or designated representative.

2. This form must be submitted to the RFTS DCC for review before being forwarded to the NEMT Broker for processing within 60 days.

3. Reimbursement after the approved visit is the only option of payment provided through the DHHR NEMT process since advanced payment/financial assistance is not an option for Medicaid recipients. Checks are generated on a regular payment schedule by the broker when submitted in a timely manner.

IV. APPROVED APPOINTMENTS

ART recipients only receive payment for travel to medical appointments, one round trip per day for eligible family members. If more than one family member has appointments on the same day, only one visit will be approved. NEMT recipients may receive reimbursement for a variety of approved services. These services include, but are not limited to, medical appointments, one round trip for medically necessary hospital visits for parent to visit infant in NICU, and approved out of state medical appointments. For more information on NEMT services and processing of the applications please contact the NEMT Broker at 1-844-549-8353 or refer to the WV Chapter 524. It is important to check the website periodically for changes and to access the broker’s trip form. For more information see the following websites:

• http://www.wvdhhr.org/bms/Pages/Chapter-524-Transporation.aspx; and/or

• http://www.mtm-inc.net/west-virginia/.

http://www.wvdhhr.org/bms/Pages/Chapter-524-Transporation.aspx

http://www.mtm-inc.net/west-virginia/

West Virginia Department of Health and Human Resources Perinatal Programs’ Maternity Services Project Access to Rural Transportation (ART) FORM

(See reverse side for Section IV, Provider Information) WVDHHR/BPH/OMCFH/DPWH/PP/MS – R082 Revised: 11/2016

Verification of Attendance/Application

SECTION I: IDENTIFYING INFORMATION

Case Name:

Social Security Number:

Address:

Case Number:

ART Office:

Patient’s Name(s):

The person listed above has indicated to Access Rural Transportation Service (ART) that she or a member of her family has

a continuing need for medical services and that she needs assistance in securing funds for transportation to a medical or

other facility.

SECTION II: VERIFICATION OF ATTENDANCE

In order for ART to provide these transportation funds, it is necessary to certify the patient’s attendance at your facility

through completion of this form.

Name of Facility:

Date Patient Attended:

Signature of Facility Representative: Date:

SECTION III: PATIENT’S RESPONSIBILITIES:

To the Patient:

Who will provide transportation? (Circle one) You, Family, Friend, Volunteer, Foster Parent, AFC Provider, other.

Please request the Facility Representative to complete Section II above.

After the form is completed it must be returned as instructed below to:

(ART Office)

(Street Address)

(City) (State) (Zip Code)

Please return this completed form to the ART Office at the above address no later than 60 days from the date of the

trip(s) for which you are requesting benefits verified in Section II above. Failure to return this form within the

deadline date will result in a denial of benefits.

Payment may be made only when preauthorization or approval is received from the office of ART Services and when

Section IV on the reverse side of this form is completed by the provider.

Patient’s Signature Date

Authorized by Date

WVDHHR/BPH/OMCFH/DPWH/PP/MS – R082 Revised: 11/2016

SECTION IV: IDENTIFYING INFORMATION

Provider’s Name:

Provider Number

Address:

Date of Travel

Telephone No:

Destination of Trip

Mileage & Travel Trip Route

Odometer Reading

Ending:

Beginning:

Total Mileage:

Other expenses:

(Attach Verification if required)

Amount $

Reason: Total Payment Due: $

I certify that the information provided above is true and correct to the best of my knowledge and as a transportation provider

for the Department of Health and Human Resources, I agree to carry on my vehicle liability insurance required by state law

of West Virginia and that I have special seats in my vehicle for the safe containment of children as required by state law.

Signature Date

WVDHHR/BPH/OMCFH/DPWH/WVHVP/October 2017 Right From the Start Policy & Procedures Manual Appendix C – Right From The Start Forms

Appendix C RIGHT FROM THE START FORMS INDEX

Initial Client Assessment - Perinatal……………………………………………………….. Initial Client Assessment – Infant ............................................................................…. Client Rights and Responsibilities ..........................................................................…. Client Request for Record Release .........................................................................…. Service Care Plan .................................................................................................…. Client Tracking Sheet ..............................................................................................…. Progress Notes .......................................................................................................…. Provider Enrollment Letter ......................................................................................…. Tobacco Screening Form .......................................................................................…. Edinburgh Postnatal Depression Scale (EPSD) ....................................................... … Referral Form……………………………………………………………………………..….. External Referral........................................................................................................... “HITS” Form ............................................................................................................…. Enhanced Services Education Report ....................................................................…. Outcome Measures at Case Closure – Perinatal.......................................................... Outcome Measures at Case Closure – Infant............................................................... Provider Letter (at Case Closure) ............................................................................….

OFFICE OF MATERNAL, CHILD AND FAMILY HEALTH RIGHT FROM THE START PROGRAM

INITIAL CLIENT ASSESSMENT – PRENATAL

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS/R036A Page 1

Revised: 09/2017

Last First MI Name:

Date of Birth: (mm/dd/yyyy)

Age: SSN:

Street City State Zip Code Address:

County of Residence: Telephone #: Alternative #:

Current Address: (if not staying at home) Street City State Zip Code

Directions to Home:

Race:

White Check all that apply

Asian

Hawaiian/Pacific Islander

Black/African American Ethnicity:

Hispanic/Latino

Not Hispanic/Latino

U.S. Citizen

Yes

No

Marital Status:

Single

Married

Separated

Widow

Divorced

Employed:

Yes

No If yes,

F/T

P/T

Medicaid/RFTS Maternity Services/MCO Name:

Medicaid/RFTS Maternity Services/MCO Number:

OB Provider Name: Telephone #:

Emergency Contact: Telephone #: Relationship to Client:

Street City State Zip Code Address:

PREGNANCY HISTORY:

Gravida

Para # Abortions (Insert # in box) # Living Children Past Deliveries (insert # in the box)

Spontaneous:

Induced: Vaginal: VBAC: C-Section:

Reason for C-Section:

Complications with Past Deliveries:

CURRENT PREGNANCY

Estimated Date of Delivery (EDD):

Trimester for initial prenatal visit: 1st 2nd 3rd

If none, then was referral made? Yes No Referral Date:

Present Illness (non-pregnancy related):

Current Medications (prescription or OTC):

MEDICAL HISTORY

Illness/Disease Yes No Assistance Needed/Comments Referred To

Has/Had Diabetes?

Has/Had Gestational Diabetes?

Has/Had History of Gestational Diabetes?

Has/Had Heart Disease/Defect?

Has/Had Birth Defect?

Has/Had Physical Impairment/Disability?

Has/Had STDs?

Has/Had High/Low Blood Pressure?

Had Past Surgery(ies)?

Have/Had Seizures?

Received Tdap Vaccine for Current Pregnancy?

Received Flu Shot in Past 12 Months?

Has/Had Intellectual Impairment/Disability?

Has/Had History or Risk of Depression?

Has/Had History of Postpartum Depression?

Has/Had History of Psychiatric Illness?

Past Date: Diagnosis:

Present Date: Diagnosis:

Therapist:

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS/R036A Page 2 Revised: 09/2017

SUBSTANCE USE

Illness/Disease Yes No Assistance Needed/Comments Referred To

Do you have a family history of substance use?

Does your partner have a history of substance use?

Did you use substance(s) before you knew you were pregnant?

If yes, what substance(s)? (Check all that apply)

Alcohol Marijuana Stimulants (cocaine, methamphetamines) Hallucinogens (ecstasy)

Opioids (hydrocodone, codeine, buprenorphine, oxycodone, morphine, heroin Other drugs (cold/flu medicines, ketamine, inhalants)

Have you used substance(s) after you knew you were pregnant?




Are you currently using substance(s)?




Are you currently in treatment for substance use?

If yes, what type of treatment? (Check all that apply)

Behavioral Health Medication Assisted Treatment Other, explain:

Is infant substance affected/substance exposed?

Did the infant receive neonatal abstinence syndrome treatment?

TOBACCO USAGE

Currently using tobacco? Yes No If yes: cigarettes smokeless tobacco e-cigs/vaping (Please check all that apply.)

If so, how often? Please provide answer below:

1-5 usages per day 5–10 usages per day 10–15 usages per day 15–20 usages per day 25-30 usages per day

More than 30 usages per day

Are you exposed to: second hand smoke Yes No third hand smoke Yes No

MATERNAL LEGAL HISTORY

Issue Yes No Assistance Needed/Comments Referred To

Is client a minor? If yes, who is the legal guardian/custodian?

CPS Involvement? If yes,

Past Current Self Child(ren)

Describe:

Involvement with criminal justice system? If yes,

Past Current Self Partner Other

Describe (charges, dates, findings. incarcerations, probations):

EDUCATION


Currently in School?

Name of School: Purpose:

Years completed (list numbers in boxes 1-12) 12+

Degreed Obtained: GED High School Diploma

Certification College Degree

Illiteracy (self) yes no to a degree of comprehension

Do you have future education plans?

SUPPORT SYSTEM

Last First MI Age

Other parent of infant: Living with client

Other household members:

Name Age Relationship to client

Other support:

Children living outside the home:



(Continued) Children living outside the home: Age Relationship to client

LIVING ARRANGEMENT

Where Client Lives √ Other Financial Assistance √ Referred To

House SNAP

With other family members WV Works

Apartment WIC

Public housing Emergency Assistance/Uutilities

Foster home LIEAP

Parent’s home Child Support

Friend’s home NEMT

Shelter Disability

Homeless Other

Motel

Other

Do you have difficulties meeting your monthly bills/obligations? Yes No

NUTRITION ASSESSMENT

Issues Yes No Assistance Needed/Comments Referred To

Have adequate food?

Have medical condition require dietary medication?

Have nausea/vomiting?

Have non-food craving: (If yes, list below)

List:

Frequently skips meals/fasts/binges?

Have bulimia/anorexia or history?

Have food allergy or intolerance?

Have prior nutritional counseling?

ORAL HEALTH


History of oral health problems?

Painful aching in mouth in past year?

Do you have a dental home?

Do you have a toothbrush and toothpaste/floss?

PREVENTIVE SELF CARE/CHILDBIRTH EDUCATION


Poor previous pregnancy experience?

Significant apprehension/anxiety?

Poor pregnancy information?

Lack of knowledge of risk factors?

Lack of knowledge of prescribed treatments?

Non-compliance with prescribed treatments?

Desires parenting/infant care education?

Desires information on infant development?

Desires childbirth education?

HOME/FAMILY NEEDS ASSESSEMENT


Have concerns about your housing?

Have adequate heating/cooling?

Exposed to environmental tobacco smoke?

In home In car Other

Parent has CPT education?

Have concerns about unsafe water? (If yes, list below)

List:

Have safe crib?

Bed sharing with infants/children?

Need baby care items?

Have working fire extinguishers?

Have working smoke detectors?

Have working carbon monoxide detectors?


Have emergency plan?

Have pets (explain danger of cat litter)?

Are there other in-home providers? If yes, please list below.

List:

Recent loss of a partner?

Abandonment

Separation/Divorce

Death Other

Current conflict in the home?

Parent(s)

Partner

Other

Abuse in past year?

Physical Verbal

Sexual Other

Religious/ethnic/cultural factors affecting pregnancy outcomes?

Family member(s) with disabilities?

OTHER REFERRALS/NOTES

DCC Signature:

Title:

Agency:

Region:

Date:

Both sides of each sheet, signed, original to DCC Agency and copy to RCC.


INITIAL CLIENT ASSESSMENT – INFANT

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS/R036B Page 1

Revised 09/2017

Last First MI

Name: Date of Birth : (mm/dd/yyyy)

Male

Female

SSN:

Street City State Zip Code

Address: County of Residence: Phone #: Alternative #:

Current Address (if not living at home): Street City State Zip Code

Directions to Home:

Medicaid/MCO Name: Medicaid/MCO#:

Birth Score: High Low Unknown Race: White (Check all that apply)

Black/African American

Asian

American Indian/Alaska Native

Native American/Pacific Islander

Ethnicity: Hispanic/Latino

Not Hispanic/Latino

Birth Weight (specify unit):

Gestational Age (# weeks):

Birth Facility:

Last First MI

Parent(s)/Guardian(s): Relationship to Infant: Parent(s)/Guardian(s) SSN:

Is/was mother of infant enrolled in The Right From The Start Program? Yes No

Pediatrician: Phone #:

Name of Emergency Contact: Telephone #: Relationship to Client:

Street City State Zip Code

Address:

SUPPORT SYSTEM Last First MI Age Other parent of infant: Living with client

Other household members:


Other Support:

Children Living Outside the Home


MEDICAL HISTORY

Illnesses/Conditions:

Issue Yes No Assistant Needed/Comments Referred To

Has/Had Respiratory Distress?

Has/Had Hyperbilirubinemia?

Has/Had Seizures?

Has/Had Intraventricular Hemorrhage?

Has/Had Visual Impairment?

Has/Had Herpes?

Has/Had Chlamydia?

Has/Had Hepatitis?

Has/Had HIV?

Has/Had Sickle Cell?

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS/R036A Page 2 Revised 092017

MEDICAL HISTORY

Illnesses/Conditions


Has/Had Down Syndrome?

Has/Had Cystic Fibrosis?

Has/Had Genetic Disorder?

Has/Had Cardiac Problems?

Is Drug Affected/Drug Exposed

Has/Had Neonatal Abstinence Syndrome?

Past Surgery(ies)?

NICU Stay? Number of days_________?

Has/Had Risk Clinic?

Need for Specialty Physician(s)?

History Psychiatric Illness (mother/father)?

Has Diarrhea/Constipation?

Current Medications?

Type: How Often:

Is Technology Dependent?

Type: Started:

ORAL HEALTH


Has family oral health issues?

Baby has teeth?

Has fluoride exposure?

Has sugary foods or drinks?

Has knowledge of age 1 dental visit?

FEEDING/NUTRITION


Has feeding problems?

Has started solid foods? Type: Started:

Has started other beverages? Type: Started:

Is or has enrolled in WIC?

Exclusively breastfeeding/pump? (breastmilk only, including pumped)

Breast and formula feeding?

Formula feeding?

Formula changes?

NEWBORN SCREENING

Issue Yes

No

Unknown

Assistance Needed/ Comments Referred To

Received heel stick before enrolling in RFTS?

Is yes, was screen abnormal or normal? Abnormal Normal

Received pulse oximetry before enrolling in RFTS?

Yes

No

Unknown

If yes, was screen abnormal or normal? Abnormal Normal

Newborn Hearing Screening done? Yes

No

Unknown

Date L Passed Referred R Passed Referred

Rescreen Date L Passed Referred R Passed Referred

If failed rescreen, date referred:

Audiologist WVSBD (Date): WVH&V (Date):

BTT (Date): CSHCN (Date):


LIVING ARRANGMENTS FINANCIAL

Where Client Lives √ Other Financial Assistance √

Parents’ house SNAP With other family members WV Works Apartment WIC Public housing Emergency Assistance/Utilities Foster home LIEAP Friend’s home Child Specialist Shelter NEMT Homeless Disability Motel/Hotel Other Other


Do you have difficulties meeting your monthly bills/obligations?

Caregiver currently working?

Caregiver currently in school?

HOME/FAMILY NEEDS ASSESSMENT


Have concerns about your housing?

Have adequate heating/cooling?

Exposed to environmental tobacco smoke?

Home Car Other__________________

Parent(s) have CPR education?

Have transportation?

Have concerns about unsafe water? (If so list below):

List Concerns:

Need baby care items?

Have safety seat?

Have working fire extinguishers?

Have working smoke detectors?

Have working carbon monoxide detectors?

Have emergency plan?

Have refrigerator?

Have telephone access?

Have pets?

Have a child care plan? (If no, refer)

Have adequate support system?

Other service providers in home? (If yes, list below)

List providers:

Have CPS involvement (Parent/Guardian) Past Present If yes, describe in Progress Notes.

Caregiver feeling about baby: Nervous Overwhelmed Comfortable

Parent’s recent loss of partner Abandonment Separation/divorce

Death Other

Current conflict in home Parent(s)/Guardian(s) Partner of parent

Grandparents

Other

Abuse in past year (mother of infant) Physical Verbal

Sexual Other

Have religious/ethnic/cultural factors affecting access to healthcare?


HOME/FAMILY NEEDS ASSESSMENT


Family member(s) with disabilities?

Have illiteracy (parent/guardian)?

Parent/guardian alcohol use?

If yes enrolled in treatment?

List treatment plan and describe:

Parent/guardian drug use?

If yes, enrolled in treatment?

List treatment plan and describe:

Have special healthcare needs?

Have adequate food for family?

Parent/guardian has significant apprehension/anxiety?

Have lack of knowledge for prescribed tx?

Is non-compliant with prescribed tx?

Desires parenting/infant education?

Desires information on infant development?

Are you or your baby exposed to: Second hand smoke? Third hand smoke?

SAFE SLEEP


Has a safe sleep environment?

Does infant have a crib, bassinet, or Pack & Play to sleep in?

Does infant always sleep and nap alone in a crib, bassinet, or Pack & Play?

Is it free of soft bedding including bumper pads, heavy or loose blankets, pillows, toys or other objects?

Does caretaker ever share a bed with the infant?

Does caretaker share a room with the infant?

Does infant always get placed to sleep and nap on his/her back until infant rolls over?

Did someone discuss infant safe sleep practices with the caretaker and give them materials prior to leaving the hospital?

Did someone discuss the Period of Purple Crying educational materials with caregiver and give them materials about coping with crying prior to leaving the hospital?

OTHER REFERRALS/NOTES

DCC Signature:

Title: Agency: Region: Date:

Both sides of each sheet, signed, original to DCC Agency and copy to RCC.

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS - R004 White: DCC Revised 08/2016 Yellow: RCC

Pink: Client

Goldenrod: Medical Provider

West Virginia Department of Health and Human Resources

RIGHT FROM THE START PROGRAM CLIENT RIGHTS AND RESPONSIBILITIES

NAME: ________________________________________ SSN: ______________________________________________ (Last) (First) (MI)

RIGHTS RESPONSIBILITIES

• To receive professional treatment and consideration.

• To participate in development of the care plan and selection of services.

• To choose the agency which will provide services agreed upon.

• To question any planned action.

• To decline any or all services offered.

• To withdraw from care coordination at any time without penalty or loss of any other program eligibility.

• To review or receive a copy of your RFTS records.

• To participate in RFTS any time during the eligibility period even if services have previously been refused.

• To keep all medical appointments.

• To keep all appointments for other services identified in the care plan and agreed upon by the client.

• To obtain all medically-ordered laboratory procedures.

• To report any change in address or telephone number.

• To report any changes in health condition.

• To report any changes in home environment which affect health condition.

• To provide Care Coordinator with a safe environment for visits.

TO REPORT ANY PROBLEMS OR CHANGES, PLEASE CALL: _________________________________________________

If you believe you have been denied any of the above rights, you may contact the Right From The Start Program by phone at 1-800-642-8522 or mail at 350 Capitol Street, Room 427, Charleston, West Virginia 25301-3714.

CLIENT: I have read and understand my responsibilities and rights and do hereby give permission for my/my infant’s RFTS record to be

released by the Care Coordinator to agencies participating in my care. I also give my permission for agencies participating in

my/my infant’s care to release information to the RFTS staff.

______________________________________________________________________________________________________(Signature) (Date) DESIGNATED CARE COORDINATOR: I have reviewed the rights and responsibilities with this client.

______________________________________________________________________________________________________ (Signature) (Date)

CAREGIVER PERMISSION

I, ___________________________________________Parent/Guardian of _________________________________________

(Infant) give permission to ____________________________________________ to discuss and plan care for my infant in my absence (Designated Care Coordinator) with _________________________________________________. (Caregiver) ________________________________________________________________________________________ (Parent/Guardian Signature) (Date) ________________________________________________________________________________________ (Designated Care Coordinator Signature) (Date)

COMMENTS:___________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

*Please identify additional person/persons who may be caregivers.

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS - R003 Original: DCC Revised: 08/2016 Copy: RCC Copy: Client

WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES BUREAU FOR PUBLIC HEALTH


350 Capitol Street, Room 427 Charleston, West Virginia 25301-3714

Toll Free in WV: 800-642-8522

CLIENT REQUEST FOR RECORD RELEASE

I, __________________________________________________________________ do hereby

request: (Client’s Name)

To review my Right From The Start Program case record.

A copy of my Right From The Start Program case record.

A copy of my Right From The Start Program case record be released to:

____________________________________________________________________________ (To Whom Records will be released)

____________________________________________________________________________ (Signature of Client) (Date)

____________________________________________________________________________ (Witness Signature) (Date)

____________________________________________________________________________ (Title/Agency)

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS - R011A White: DCC Revised: 08/2016 Pink: RCC Yellow Client Goldenrod: Provider

Service Care Plan Revision Line


SERVICE CARE PLAN

CLIENT NAME SSN CLOSURE DATE

UNABLE TO COMPLETE CARE PLAN

(Use code from Client Tracking Sheet)

Last First MI

IDENTIFIED NEEDS

Prenatal Infant

Childbirth education Parenting education

Obstetrical care Pediatric care

Parenting education Nutrition

WIC Safety

Oral health Safe sleep environment

Safety DCC/Client trusting relationship

DCC/Client trusting relationship Coordination of services

Coordination of services Transportation needs

Transportation needs Infant care items

Choose method of infant feeding Oral health

Infant care items Please list others:

Please list others:

GOALS TO BE COMPLETED TO MEET IDENTIFIED NEEDS

Prenatal Infant

To have a full term, healthy pregnancy To promote optimal infant health to age one year

To choose a family planning method To ensure safety

To provide parenting education To educate on coping skills

To obtain postpartum care To educate about signs/symptoms of maternal depression

To assist with locating resources To provide parenting education

To provide benefits of breast vs. bottle feeding To assist with locating resources

To educate about signs/symptoms of maternal depression To educate about family planning/spacing of pregnancies

To establish trusting DCC/client relationship To establish trusting DCC/guardian relationship

Please list others: Please list others:

ACTIVITIES TO BE COMPLETED TO MEET GOALS

Prenatal Infant

Client will: Client will:

Keep all doctor appointments Choose a doctor and keep appointments

Keep all WIC appointments Keep all WIC appointments

Eat a nutritious diet recommended for pregnancy Keep Medicaid/MCO card current

Remain tobacco, alcohol and drug free Get all immunizations according to schedule

Maintain a smoke and substance free environment Maintain diet recommended for age

Recognize signs/symptoms of pre-term labor Provide a smoke and substance free environment

Maintain a safe environment Practice safe sleep

Report any health concerns to physician and then to DCC Provide safe care during feeding, changing and transportation

Keep Medicaid/MCO card current Bond with infant and provide adequate stimulation for growth and development

Be up-to-date with immunizations Recognize signs/symptoms of illness and seek medical care DCC will:

Report any health concerns to physician and then to DCC

Screen for depression and help client recognize signs/symptoms Complete developmental and social screenings for infant

Promote oral health DCC will:

Teach about components of adequate prenatal care Promote oral health

Provide education on labor and delivery Promote mother/infant bonding

Provide education on family planning choices Provide safe sleep education

Provide safe sleep education Complete domestic violence screening

Complete domestic violence screening Make referrals as needed

Make referrals as needed Establish trusting DCC/client relationship

Establish trusting DCC/client relationship Please list others:

Educate about immunizations during pregnancy

Please list others:

Copy of completed, signed and dated Service Care Plan to be given to client on the date client signs the plan. / / / / Client Signature Date DCC Signature Date / / / / Client Signature Date DCC Signature Date

OMCFH/RFTS/R001A White: DCC Revised: 07/2017 Yellow: RCC

Pink: Billing


CLIENT TRACKING SHEET

Prenatal Name: Last, First and MI

SSN: _________________________ DOB: ________________________

EDC: / /

Change in EDC: / /

Delivery Date: / /

County:

Infant Name: Last, First and MI SSN: _________________________ DOB:

County:

Guardian’s Name:

Guardian’s SS#:

Infant Height (specify unit):

Infant Weight (specify unit):

For Prenatal or Infant

Date of Last Medical Visit: Total Prep Time: Hours: Minutes:

Name Change: Travel Time: Hours: Minutes:

Contact Status: Attempted Cancelled Completed Travel Distance: Miles:

Medicaid #: RFTS Maternity Services #:

MCO Name: MCO #:

Date of Service: ______________________________________________

Place: Home Office Clinic

Other: ____________________________________________________

Face-to-Face: Yes No

Closed Case Lost to Follow-up

Refused Further Services Spontaneous Abortion

Induced Abortion Death Closed by Regional Care Coordinator

Moved Out-of-State Transferred

DATE: / / S5190HD ASSESSMENT/SERVICE CARE PLAN _________________

(Prenatal Only - 1 Per Case)

T1016HD T1016HDU1 Care Coordination __________ (15 Min. Units)

ENHANCED SERVICES – PRENATALS ONLY – 1 SESSION PER DAY

S9442HD HEALTH EDUCATION/CHILDBIRTH CLASSES

Maternal/Fetal Development Relaxation/Breathing Tech.

Nutrition/Fitness/Drugs Postpartum/Family Planning

Physiology of Labor/Delivery Newborn Care/Breastfeeding

S9444HD HEALTH EDUCATION/PARENTING CLASSES

Infant Care Child Safety Preventive Care Newborn Development S/S Acute Illness

S9445HD HEALTH EDUCATION/PREVENTIVE SELF CARE

Physical/Emotional Changes Breastfeeding

Warning Signs in Pregnancy Contraceptive Care

Healthy Behaviors Smoking Assessment Eating Habits Safety/Domestic Violence Prenatal (PHB Curriculum) Infant (PHB Curriculum)

Months 1-3 Month 7

Month 4 Month 8

Month 5 Month 9

Month 6

Month 1 Month 5 Month 9




S9452HD NUTRITIONAL ASSESSMENT/COUNSELING (Registered Dietitian only)

CO Value _________________ PPM Refused Equipment Problem Explanation in Progress Notes I am currently smoking the following amount of cigarettes per day: I Quit 1 2 3 4 5 6-10 11-15 16-20 More than one pack per day 2 or more packs per day Infant Only Does infant always sleep and nap alone in a crib, bassinet, or Pack & Play? Is it free of soft bedding including bumper pads, heavy or loose blankets, pillows, toys or other objects? Does caretaker ever share a bed with the infant? Does caretaker share a room with the infant? Does infant always get placed to sleep and nap on his/her back until infant rolls over? Exclusively Breastfeeding? Yes No If no, Ever breastfed? Was safe sleep education provided to the caretaker by RFTS? If RFTS provided Period of Purple Crying education, was the caregiver engaged in face-to-face discussion (including Q&A) about the education materials? Yes No

“I received a face-to-face visit by the DCC today.” DCC Signature:

Client Signature: Region : Agency:

Alcohol Dependence

Drug Dependence

Tobacco Dependence

Well Child Care

Acute Care for Infant

Oral Health

Developmental Progress

ASQ

Nutrition

Safe Sleep

Depression Screening

Family Planning

Transportation

Revise Plan/Assessment

Compliance of Care

Domestic Violence

Advocacy

Financial: Utilities

Financial: Infant Care Items

Financial: Access to Phone

Financial: Money Management

Environment: Adequate Housing

Environment: Infant Stimulation

Environment: Safety

Child Abuse Prevention Observation

Other

Yes No Yes No Yes No Yes No Yes No Yes No Yes No

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS/R015 DCC: Original Revised 10/2016 RCC - Copy

West Virginia Department of Health and Human Resources Office of Maternal, Child and Family Health

RIGHT FROM THE START PROGRAM Progress Notes

Prenatal Infant

Name: ________________________________ DCC: _________________________________

Las First MI Title

SSN: _________________________________ Agency: _______________________________

Date Time In/Out Comments

*DCC Signature required for each entry

OFFICE OF MATERNAL, CHILD AND FAMILY HEALTH

Bureau for Public Health

350 Capitol Street, Room 427

Charleston, WV 25301-3714 Phone: (304) 558-5388 Toll-Free (in WV): 1-800-642-8522 or 1-800-642-9704 FAX: (304) 558-7164

Jim Justice

Governor

STATE OF WEST VIRGINIA

DEPARTMENT OF HEALTH AND HUMAN RESOURCES

RIGHT FROM THE START PROGRAM

___________________________________________

(Date)

RE: ____________________________________ (Client Name)

____________________________________

(Social Security Number)

Dear Provider:

The State of West Virginia provides money so that social workers and nurses from local health departments, community health centers and other community agencies can offer pregnant women and their newborns support services to improve well-being. These nurses and social workers are knowledgeable on how to locate community resources, depending on the need, such as WIC, housing assistance, travel reimbursement to doctor appointments, infant care items and the availability of medical care. They offer information on pregnancy discomforts and body changes that occur during pregnancy. They can help the pregnant woman learn to recognize warning signs of complications such as preterm labor and postpartum blues and to understand when to call their doctor. The nurses and social workers also offer parenting support and baby care information on issues such as the “Period of Purple Crying,” dealing with a fever and determining if the baby is sick.

These services, called Right From The Start, are provided at no cost to the family and are offered

in the family’s home or other setting. Pregnant women and new moms who participate in Right From The Start choose which services they want.

The above referenced client has been evaluated and is eligible for Right From The Start services.

With the assistance of the client, a service plan has been developed for management of the client’s needs. Should you wish to recommend any modifications to the service plan at any time, please call me at the number listed below. Sincerely,

Designated Care Coordinator

____________________________________ Phone Number

____________________________________ Agency Name

____________________________________ Address

____________________________________ City, State & Zip

Enclosure WVDHHR/BPH/OMCFH/DPWH/PP/RFTS – August 2016 White: Provider R010 – Dear Dr. Ltr Yellow: DCC

Bill J. Crouch

Cabinet Secretary

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS – TS001 SCRIPT White: RCC Revised: 7/2017 Yellow: DCC

Pink: OB Provider Goldenrod: Client

West Virginia Department of Health and Human Resources RIGHT FROM THE START PROGRAM

Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT)

Prenatal CO VALUE PPM

Postpartum Refused # of weeks: _ Equipment Problem

Date: _ Explanation in Progress Notes MM DD YYYY

DOB:

SSN:

Name: Last Name First Name MI

Region: County:

DCC:

Agency:

1. Which type of tobacco do you use? (Check all that apply.)

I have never smoked cigarettes. (Mark here if you have only tried smoking)

I have stopped smoking - I am not currently smoking. I dip, chew, or use smokeless tobacco.

I use electronic cigarettes/vaping. I currently smoke cigarettes. Per day, I smoke the following amount of cigarettes:

1 2 3 4 5 6-10 11-15 16-20 More than one pack per day 2 packs or more per day

2. How many cigarette smokers live in the same house with you? (choose only one) 0 1 2 or more

3. How is cigarette smoking handled where you live? (choose only one)

No one smokes where I live - they smoke outside. People may only smoke in certain rooms where I live. People may smoke anywhere I live.

4. How many of your family and friends are cigarette smokers? (choose only one) None A few Some Most

If Never Smoked or Quit - STOP HERE. Continue ONLY if Currently Smoking.

5. How soon after you wake up do you usually use tobacco? (choose only one)

5 minutes or less 6 to 30 minutes 31 to 59 minutes 1 to 2 hours Greater than 2 hours

6. Do you want to quit now? (choose only one)

Yes I would like to reduce my cigarette smoking. I would like more information about quitting. No

7. SCRIPT intervention was given? (refer to handout, choose all that apply, summarize counseling in progress notes)

ASK ASSESS ADVISE ASSIST ARRANGE

8. Are any of your family and friends who smoke cigarettes ready to quit with you? (choose only one) Yes No I haven’t talked to any of them about quitting.

9. The SCRIPT Program provided me with: (choose all that apply) Guide Counseling Time Spent (In Minutes)

10. My doctor advised me to quit. Yes No

11. I have been referred to the WV Quitline. Yes No

12. I have used the WV Quitline. Yes No

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS – R065

Revised: 10/2016 White: DCC Yellow: RCC

Pink: OB Provider Goldenrod: Client

West Virginia Department of Health and Human Resources RIGHT FROM THE START PROGRAM

EDINBURGH POSTNATAL DEPRESSION SCALE (EPDS)

*Name: ___________________________________________________________ Last First MI

*Social Security #: _______________________ *DOB: ____________________

*Prenatal

*Pregnancy Due Date: ______________________ *Postpartum *Baby’s DOB: _____________________________

Because you are pregnant or you have recently had a baby, which can often result in mood changes, we would like to know how you are feeling. Please underline the answer which comes closest to how you have felt IN THE PAST SEVEN (7) DAYS, not just how you feel today. Please complete all ten items.

1. I have been able to laugh and see the funny side of things.

• As much as I always could • Not quite so much now • Definitely not so much now • Not at all

_________

Score

2. I have looked forward with enjoyment to things. • As much as I ever did • Rather less than I used to • Definitely less than I used to • Hardly at all

_________

Score

3. I have blamed myself unnecessarily when things went wrong. (*)

• Yes, most of the time • Yes, some of the time • Not very often • No, never

_________

Score

4. I have been anxious or worried for no good reason. • No, not at all • Hardly ever • Yes, sometimes • Yes, very often

_________ Score

5. I have felt scared or panicky for no very good reason. (*)

• Yes, quite a lot • Yes, sometimes • No, not much • No, not at all

_________

Score

6. Things have been getting the best of me. (*) • Yes, most of the time I haven’t been able to

cope at all • Yes, sometimes I haven’t been coping as well

as usual • No, most of the time I have coped quite well • No, I have been coping as well as ever

_________

Score

7. I have been so unhappy that I have had difficulty sleeping. (*)

• Yes, most of the time

• Yes, sometimes • Not very often • No, not at all

_________

Score

8. I have felt sad or miserable. (*) • Yes, most of the time • Yes, quite often

• Not very often • No, not at all

_________

Score

9. I have been so unhappy that I have been crying. (*)

• Yes, most of the time • Yes, quite often • Only occasionally • No, never

_________

Score

10. The thought of harming myself has occurred to me. (*)

• Yes, quite often • Sometimes • Hardly ever • Never

_________

Score

Client’s Signature: ______________________________________________________ Date: ________________________________ DCC Signature: ________________________________________________________ Date: ________________________________ DCC Agency:___________________________________________________________________________________________________ *EPDS Score: *Referred to: Medical Provider *Date: ________________________________ Emergency Room

*Required Field

EDINBURGH POSTNATAL DEPRESSION SCALE (EPDS) J. L. Cox, J.M. Holden R. Sagovsky

From: British Journal of Psychiatry (1987), 150, 782-786.

*SEPARATE FORMS FOR MULTIPLE BIRTHS White:RCC

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS-R019 Yellow:DCC Revised: 08/2016 Pink:HMO

Goldenrod:RCC



REFERRAL OF INFANTS/PRENATALS TO RFTS

Infant Name: Last First MI

SSN:

Hospital of

Delivery:

Date of Birth: / / Sex: Female Male

Mother/Guardian Name:

Address:

Mother/Guardian SSN:

Mother/Guardian DOB: / /

County:

Telephone:

Medicaid #:

Effective Date: / /

Child Mother/Guardian

MCO Plan:

MCO #:

Effective Date: / /

Name & Address of Physician:

__________________________________________________

__________________________________________________

__________________________________________________

Telephone:

Concerns:

Prenatal Name: Last First MI

SSN:

Address:

Telephone:

DOB: / /

EDC: / /

County:

RFTS Maternity Services Medicaid Insurance

RFTS/Medicaid #:

Effective Date: / /

MCO Plan:

MCO #:

Effective Date: / /

Name & Address of Physician:

Telephone:

Concerns:

Child Protective Services Referral:

Case Worker: Telephone:

Referred to RFTS by: ___________________________________________________ Date: / /

Site: _________________________________________________________________ Telephone:

Date Received: ___________________________________________ Date of Approval: / /

Referred to (DCC Agency):

Recommendations:

Signature: _________________________________________________________ Date: / / (Regional Care Coordinator)

OMCFH/RFTS-R013 DCC Use Only Revised 08/2016 Page 1


EXTERNAL REFERRAL

Name: Last First MI

Birthdate: Date: / / Date of first referral

□ Prenatal □ Infant □ Referral Not Necessary

Reason for Referral: □ Alcohol Abuse Treatment □ Domestic Violence □ Neonatal High Risk Follow-up □ Smoking Cessation □ Charitable Services □ Drug Abuse Treatment □ Nutrition Education □ SNAP □ Child Care Referral Services □ Education (or School) □ Nutrition Services □ SSI/Disability □ Child Care Subsidies □ Housing (long term) □ Parenting Education □ Transportation □ Contraception □ Housing/Shelter □ Pediatric Care □ Unemployment Benefits □ CSHCN □ Lactation Support □ Prenatal Care □ Utility Assistance □ Dental Care □ Legal Services □ Preventive Self Care □ WV Works (ex. TANF) □ Developmental Concerns □ Mental Health □ Relationship Counseling □ Other □ Diabetes Counseling

Referred To Date Referral Code Outcome

Status Code

□ Birth To Three

□ Community Agency

□ CPS

□ CSHCN

□ DHHR County Office

□ Domestic Violence

□ Early Head Start

□ Family Planning

□ Genetics

□ HealthCheck

□ Healthy Families America

□ Help Me Grow

□ Housing

□ Law Enforcement

□ Medical Provider

□ MIHOW

□ Newborn Hearing

□ Parents as Teachers

□ Systems Point of Entry

□ WIC

□ WV CHIP

□ WV Quitline

□

□

□

□

OMCFH/RFTS-R013 DCC Use Only Revised 08/2016 Page 2

Referral Code: Outcome Status Code: A: Accompanied to the referral agency 1. Pending B: Arranged for referring agency to call client 2. Ongoing C: Called referral agency on behalf of individual 3. Completed D: Called referral agency together 4. Participant refused or did not take action E: Provided information for the individual to arrange services 5. Participant not eligible for service 6. Service was not accessible to participant

NOTES

DCC Name: Case Closure Date: / / DCC Agency: County: Region:

HITS is copyrighted in 2003 by Kevin Sherin MD, MPH; For permission to use HITS,

email [email protected]; *HITS is used globally in multiple languages 2006

WVDHHR/BPH/OMCFH/PWH/PP/RFTS 08/2016

WEST VIRGINIA DEPARTMENT OF HEALTH & HUMAN RESOURCES Bureau for Public Health

Office of Maternal, Child & Family Health West Virginia Right From the Start

“HITS”

Violence Screening Tool for Domestic Violence & Intimate Partner Violence Client Name: ___________________________ Date of Visit: _________________________ DCC Name: ____________________________ Region: _____________________________ Please read each of the following activities and fill in the circle that best indicates the frequency with which your partner acts in the way depicted.

Each item is scored from 1-5. Thus, scores for this inventory range from 4-20. A score of greater than 10 is

considered positive.

Clinical Research and Methods (Fam Med 1998; 30(7):508-12.)

How often does your partner?

Never Rarely Sometimes Fairly Often

Frequently

1. Physically hurt you

2. Insult or talk down to you

3. Threaten you with harm

4. Scream or curse at you

1 2 3 4 5

mailto:[email protected]

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS-R060 Original: Enhanced Service Provider Revised: 08/2016 Copy: OB (at case closure) Copy: RCC (at initial visit and case closure)


ENHANCED SERVICES EDUCATION REPORT

Last Name:___________________________ First Name:__________________________ MI:

SSN:_________________________________ DOB:______/______/_______ Date: / /

Address: Street

City______________________________________State_____________________Zip

Telephone:_______________________________ EDC:

Medicaid Number: _________________________ MCO:

RFTS Maternity Service Number:

Service Provider:

Verbal Approval Received from RCC on Date: / /

Service Provided Subtypes ES DCC

Initials:

□Health

Education/Childbirth Classes (S9442 HD)

□Maternal/Fetal Development □Relaxation/Breathing Techniques □Nutrition/Fitness/Drugs □Postpartum/Family Planning

□Physiology of Labor and Delivery □Newborn Care/Breastfeeding

□Health

Education/Parenting Classes (S9444 HD)

□Infant Care □Child Safety

□Preventive Care □Newborn Development

□S/S Acute Illness

□Health

Education/Preventive Self Care (S9445 HD)

□Physical/Emotional Changes □Eating Habits

□Warning Signs in Pregnancy □Breastfeeding

□Healthful Behaviors □Contraceptive Care

□Smoking Assessment □Safety/Domestic Violence

□Nutritional

Evaluation/Counseling (S9452 HD)

(For Registered Dietician Only)

Referred for Right From The Start Care Coordination:

□Yes □No □Refused If yes, then date: / /

Use closure code reasons from Client Tracking form:

RCC Name:

RLA Name:

Region: _____________

DCC Signature:

(FOR USE BY AGENCIES THAT ONLY PROVIDE ENHANCED SERVICES EDUCATION)


RIGHT FROM THE START PROGRAM OUTCOME MESAURES AT CASE CLOSURE

PRENATAL

OMCFH/RFTS-R022A DCC Use Only Revised 07/2017 Page 1

_________________________________________________________________________________________________________________________

Name: Last First MI SSN __________ - _____ - __________ Birthdate (mm/dd/yyyy) _______/_______/__________

Infant 1 ; Infant 2 ; Infant 3 ; Infant 4

Did client fulfill all service care plan goals? Yes No

PHYSIOLOGY OF LABOR AND DELIVERY Delivery Date: _____/_____/_______

Were there any maternal complications during labor and delivery? Yes No List: ________________________________________________________________________________________________________.

If yes, did patient deliver at a tertiary care center? Yes No

Vaginal C-Section VBAC Gestational Age__________(weeks) Baby’s weight and length at birth (specify unit): weight: __________ length: __________

Any birth defects present? Yes No

Was a NICU stay required? Yes No If yes, number of days_________________________________

Infant Death Stillbirth What was the age of infant at time of death?

0-24 hours 2 days-2 weeks 3 weeks-4 weeks

5 weeks-6 weeks 7 weeks-8 weeks Reason for death:

Genetic disorder Accident Drugs Alcohol SIDS/SUIDS

Head trauma Unknown

Other (state reason) __________________________________________________________________________________.

MEDICAL CONDITIONS

Did client have any of the following medical condition during her pregnancy? Yes No

Gestational Diabetes Pregnancy Induced Hypertension Urinary Tract Infections

Vitamin/Iron Deficiencies Vaginal Bleeding STDs

Preeclampsia Other

If yes, did client receive treatment? Yes No

Education provided on medical conditions? Yes No How much weight did the client gain during her pregnancy?

0-20lbs 21-40lbs 41-60lbs 61-100lbs greater than 100lbs

POSTPARTUM DEPRESSON

Did client keep postpartum appointment? Yes No

If no, is client scheduled for postpartum appointment? Yes No

Was the Edinburgh Postnatal Depression Scale administered to client? Yes No

Is the client receiving treatment for postpartum depression? Yes No

CONTRACEPTIVE CARE

Did mother begin a method of birth control after delivery? Yes No

If no, was the mother referred to the Family Planning Program? Yes No

Was education on contraception and spacing between children provided to the client? Yes No

SUBSTANCE ABUSE

Was there maternal substance use during pregnancy? Yes No

Maternal substance use treatment? Yes No If yes, what substance(s): (check all that apply)


Opioids (hydrocodone, buprenorphine, oxycodone, morphine, heroin) Other Drugs (inhalants, ketamine)

Is infant drug affected/drug exposed? Yes No

Infant received neonatal abstinence syndrome treatment? Yes No

OMCFH/RFTS-R022A DCC Use Only Revised 07/2017 Page 2

TOBACCO/NICOTINE USE

Never smoked Quit before or after becoming pregnant Current Smoker

Client participated in SCRIPT? Yes No Tobacco/Nicotine used by current user (check all that apply):

Cigarettes Smokeless tobacco E-Cigarettes/Vaping

Client has reduced the number of daily usage? Yes No If client has reduced, what is client’s daily usage:

Less than 1 1-5 5-10 11-15 16-20 more than 20

Client has remained tobacco/nicotine reduced through delivery? Yes No

If client quit while in RFTS, what did client use: SCRIPT WV Quitline Other (specify below) If other, please specify: ________________________________________________________________________________________.

Was there exposure to environmental tobacco smoke at closure? Yes No

If so where: Home Car Other, explain. ______________________________________________________________________.

CO level at time of closure (ppm): _________________ Refused Equipment problem

ORAL HEALTH When was the last time the client visit the dentist?

One year or less than one year More than one year Never

Did client receive oral/dental care during RFTS? Yes No What were the reasons the client did not get the dental care she needed?

Client did not think anything serious was wrong/expected dental problems to go away

Could not afford the cost Was not recommended Medical provider advised against it

No transportation Fear of dentist Other _________________________________________

Does client have a dental home? Yes No

FEEDING/BREASTFEEDING

Did client exclusively breastfeed (breastmilk only) at (choose all that apply): Yes No

Hospital discharge Case closure

Is client receiving breastfeeding support? Yes No If yes, from: __________________________________________________________________________________________________

If no, did client try to breastfeed? Yes No What were the client’s reasons for not breastfeeding?

Sick/taking medication Other children required care Tried but too hard

Too many household duties Did not like breastfeeding Did not want to

Went back to school/work Discouragement from family/friends

Other: ____________________________________________________________________________________________.

Does client understand the benefits of exclusively breastfeeding? Yes No

SAFETY/HEALTH

Does baby have a primary care provider? Yes No Did someone discuss infant safe sleep practices with the caretaker and give them materials prior to leaving the hospital?

Yes No

Was safe sleep education provided to the caretaker by RFTS? Yes No Did someone discuss the Period of Purple Crying educational materials with caregiver and give them materials about coping with

crying prior to leaving the hospital? Yes No If RFTS provided Period of Purple Crying education, was the caregiver engaged in face-to-face discussion (including Q&A) about the

education materials? Yes No

Does baby sleep on his/her back? Yes No

Does caretaker use a child safety seat to transport infant? Yes No

Is caretaker aware of current child safety seat laws? Yes No

Flu shot received: Before enrolling in RFTS After enrolling in RFTS None

If none, why: Refused Not aware Other (specify):_____________________________________________________.

Did baby receive Newborn Metabolic Screening (heel stick) during RFTS? Yes No

Did baby receive pulse oximetry screen during RFTS? Yes No

Did mother receive Tdap vaccine during RFTS? N/A Yes No

Did mother receive Tdap vaccine between 27 and 36 weeks of gestation? Unknown Yes No

DCC Signature: _______________________________________________________ Service Date: ____________________________ Region: __________ Agency: ___________________________________________ County: ________________________________ Both sides copied with original sent to DCC Agency and copy to RCC.


OUTCOME MEASURES AT CASE CLOSURE INFANT

OMCFH/RFTS-R022B DCC Use Only Revised 07/2017 Page 1

_______________________________________________________________________________________________________________________________________

Name: Last First MI SSN: ____________ - _________ - __________ Birthdate (mm/dd/yyyy): __________/________/__________ ____________________________________________________________________________________________________________ Caretaker: Last Name Caretaker: First Name Caretaker: MI

Caretaker SSN: ________-_______-________ Did client fulfill service care plan goals? Yes No

INFANT HEALTH Infant’s weight and length at birth (specify units): weight: __________ length: __________ Infant’s weight and length at closure (specify units): weight: __________ length: __________

Does infant have a medical home? Yes No

Has infant kept all 8 well child visits with primary care provider? Yes No

Are infant’s immunizations up-to-date? Yes No

Did caretaker complete Medicaid/WV CHIP/private insurance application for infant’s health insurance? Yes No

Are there any other medical concerns? Yes No If yes, then list: ____________________________________________________________________________________. If infant did not receive Newborn Metabolic Screening (heel stick) prior to enrolling, did infant receive Metabolic Screening while in

RFTS? Yes No

Newborn Hearing Screening passed at birth? Yes No

If no, was the infant rescreened? Yes No

Did the infant pass the rescreen? Yes No

If no, was the infant referred to an audiologist? Yes No

DELIVERY

Vaginal C-Section VBAC

Were there any maternal complications during labor and delivery? Yes No If yes, then list: ___________________________________________________________________________________________.

Was the infant delivered at a tertiary care center? Yes No Gestational age _______________ (weeks)

Any birth defects present? Yes No

Was a NICU stay required? Yes No If yes, number of days__________

ORAL HEALTH In the past 12 months, has the infant’s medical care provider had a conversation with the caretaker about age one (1) dental visit?

Yes No

Does infant have any teeth at closure? . Yes No

Does infant have dental provider? Yes No

Does infant have fluoride exposure via drinking water, supplements, professional applications or toothpaste? Yes No

Does infant drink/eat sugary foods i.e. juice, carbonated or non-carbonated soft drinks, energy drinks? Yes No

Did caretaker receive infant oral health education by RFTS provider? Yes No

Did infant receive oral/dental care during RFTS? Yes No

DEVELOPMENT

Has the caretaker completed an Ages and Stages – 3 (most recent age appropriate) for the infant? N/A Yes No

Did infant receive a score that was in the monitoring zone? Yes No

Did infant receive a score that required a referral for further developmental services? Yes No

OMCFH/RFTS-R022B DCC Use Only Revised 07/2017 Page 2

FEEDING/BREASTFEEDING

Is infant having difficulty feeding (bottle/breastfeed)? Yes No

Was infant ever breastfed (including breastmilk supplemented with formula/food) Yes No

Was infant breastfeeding at 6 months? Yes No

Was infant breastfeeding at 12 months? Yes No

Was infant exclusively breastfed (breastmilk only, including pumped) at 3 months? Yes No

Was infant exclusively breastfed (breastmilk only, including pumped) at 6 months? Yes No

Was mother advised not to breastfeed due to: Medical reasons Substance use No If infant was breastfed, what were the reasons mother stopped (check all that apply):

Infant had difficulty latching or nursing Mother was not producing enough milk or her milk dried up

Breast milk alone did not satisfy the baby Mother had too many other household duties

Infant was not gaining enough weight Mother felt it was the right time to stop breastfeeding

Mother’s nipples got sore, cracked or bleeding Mother became sick and had to stop for medical reasons

It was too hard, painful or too time consuming Mother went back to work or school

Infant was jaundiced Infant was living with another caretaker not mother

Substance abuse

Other ___________________________________________________________________________________.

Was infant fed only formula? Yes No At what age did infant start eating solid foods (includes cereal mixed in bottle)?

0-3 months 4-6 months 7-12 months

INFANT SAFETY

Does infant always sleep and nap in a crib, bassinet, or Pack & Play? Yes No

Is it free of soft bedding including bumper pads, heavy or loose blankets, pillows, toys or other objects? Yes No

Does caretaker ever share a bed with the infant? Yes No

Does caretaker share a room with the infant? Yes No

Does infant always get placed to sleep and nap on his/her back until infant rolls over? Yes No

Does caretaker use a child safety seat to transport infant? Yes No

Is caretaker aware of current child safety seat laws? Yes No

ENVIRONMENT

Maternal substance use? Yes No Maternal substance use treatment?

Yes No

Is infant drug affected/drug exposed? Yes No

Infant received neonatal abstinence syndrome treatment? Yes No

Is infant exposed to environmental tobacco smoke (even if it is outside)? Yes No

Is caretaker currently in school? Yes No

Is caretaker currently working? Yes No

Is caretaker currently receiving financial assistance? Yes No Current living situation for infant (choose all that apply):

Home with parent(s)/guardian(s) Foster care Living with other relative

DCC NOTES: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

DCC Signature:____________________________________________________________ Service Date: ________________________ Region: __________ Agency: ________________________________________________ County: ____________________________ ____________________________________________________________________________________________________________ Copy both sides, original to DCC Agency and copy to RCC.


Bureau for Public Health

350 Capitol Street, Room 427

Charleston, WV 25301-3714 Phone: (304) 558-5388 Toll-Free (in WV): 1-800-642-8522 or 1-800-642-9704 FAX: (304) 558-7164

Jim Justice

Governor

STATE OF WEST VIRGINIA

DEPARTMENT OF HEALTH AND HUMAN RESOURCES


_________________________________ (Date)

Re: ________________________________________ S. S. Number: _______________________________ Dear Provider, This is to inform you that this client's case record is being closed for Right From The Start services as of

_______________________________________. Enclosed is a copy of the final Service Care Plan and, if

applicable, a copy of the Outcome Measures form. Please call or email me if you have any questions.

Sincerely, _____________________________________________ Designated Care Coordinator

_____________________________________________ Agency Name

_____________________________________________ Agency Address

_____________________________________________ Agency Telephone Number

_____________________________________________ Email Address

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS - R039 White: Provider Revised: 08/2016 Yellow: DCC Pink: RCC

Bill J. Crouch

Cabinet Secretary

WVDHHR/BPH/OMCFH/DPWH/WVHVP/October 2017 Right From the Start Policy & Procedures Manual Appendix D – Glossary of Terms Page 1

Appendix D GLOSSARY OF TERMS

TERM DESCRIPTION

REFERRAL FORM Clients who are referred into the RFTS Project in some way other than by the PRSI or the Infant Birth Score Card.

CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)

Provides health care to children 0 - 19 years of age whose family income is at or below 300% of the FPL and do not have health insurance.

DESIGNATED CARE COORDINATOR

Registered nurse licensed to practice by the West Virginia Board of Examiners for Registered Professional Nurses; OR a graduate nurse with temporary licensure pending Board results. Nurse must pass Boards in order to continue as a care coordinator. A Licensed Social Worker (LSW) must be licensed by the West Virginia Board of Social Work Examiners. Temporary Licensed Social Worker (TLSW) must work under supervision of a LSW.

DESIGNATED REGIONS Eight designated regions of the State used for health planning activities.

DISCHARGE Release of the infant from the hospital to the care of the parent(s) or legal guardian.

ENHANCED SERVICES Component of RFTS that provides more comprehensive prenatal and postpartum care services to improve pregnancy outcomes, such as client health education, including preventive self care, childbirth classes, parenting education, nutrition evaluation, and counseling services.

FAMILY PLANNING Family Planning Program supports services that enable clients to plan, space or delay having children. Medical services are provided at either no cost or a very small cost based on the individual's ability to pay.

OMCFH HEALTHCHECK OUTREACH WORKER

OMCFH HealthCheck Outreach Worker is responsible to contact clients, inform them of available services, and assist them in accessing available care.

OMCFH HEALTHCHECK PREVENTION SPECIALIST

OMCFH HealthCheck Prevention Specialists have the responsibility for interfacing with the Medical Home in providing technical assistance to the child’s provider.

OUTREACH The process of assisting potentially eligible clients to apply for health services; developing a strong referral network; and increasing community awareness of care coordination services and benefits. Encouraging clients to enroll in care coordination services. This includes such activities as evaluating eligibility status, explaining care coordination services available to the client, and obtaining the client's consent to work with the care coordinator.

REGIONAL CARE The nurse in each Regional Lead Agency who is responsible


TERM DESCRIPTION

COORDINATOR (RCC) for the administration of the RFTS Program.

REGIONAL LEAD AGENCY An agency in each health planning region responsible for administration of the RFTS Program at the community level.

RFTS MATERNITY SERVICES

OMCFH medical coverage for non-Medicaid eligible pregnant uninsured/underinsured aliens, pregnant women whose income is less than 185% FPL, and all teens age 19 and under regardless of family income.

TITLE XIX

(MEDICAID)

Medicaid Program coverage includes pregnant women and children with family incomes at or below 150% of the current Federal Poverty Level (FPL).

WIC Special Supplemental Food Program for Women, Infants and Children. A federally funded program for eligible pregnant, postpartum, and breastfeeding women, infants, and children up to age 5.

RISK ASSESSMENT FORMS

PROJECT WATCH

(formerly BIRTH SCORE)

A risk assessment completed by all WV birthing facilities and used by the RFTS Project for identification of infants who are at-risk for infant mortality and/or poor health outcome.

PRENATAL RISK SCREENING INSTRUMENT (PRSI)

Universal prenatal risk assessment completed at the first prenatal visit. Can be used for patient referral for other services.

CASE MANAGEMENT

TERM DESCRIPTION

ASSESSMENT Based on the medical treatment plan established by the client's medical provider, the DCC will review and evaluate the client's needs and identify necessary services for management of the client's care.

CARE COORDINATION REFERRAL

The DCC arranges for appropriate services and ensures continuity of care by referring the client to suitable service providers. The DCC assists the client in obtaining and keeping appointments, arranging transportation, and clarifying information/issues for the client.

OBSERVATION Assessing ongoing progress and ensuring that services are delivered; maintaining contact with the service providers and the client to assure that the client keeps appointments, understands, and complies with the service care plan or the requirements of other service providers.

SERVICE CARE PLAN DEVELOPMENT

A mutually agreed upon plan of care developed to describe the services and resources required to meet the client's needs identified through the assessment, including a description of the specific action steps and responsible person necessary to meet each identified need. Based on the client's needs assessment, the DCC and client agree to a plan of care that establishes goals and tasks.


MEDICAID

TERM DESCRIPTION

CASE NUMBER The case number appearing on the client’s Medicaid Card consisting of 10 digits. The case number will be the same for all individuals in a group such as a family.

CLAIM FORM An invoice used to bill for identified services rendered by a provider, giving accurate and required information, and signed by the provider or his/her authorized representative. For Medicaid, the provider is to use the CMS - 1500.

CMS-1500 Centers for Medicaid and Medicare developed form 1500 for filing claims with third party payers, Medicaid, and Medicare.

CPT CODES Current Procedural Terminology Code - A system of terminology and coding developed by the American Medical Association. CPT codes are used for describing medical services and procedures.

F.E.I.N. Federal Employee Identification Number will be used as provider number.

ICD-10-CM The International Classification of Disease 10th Revision Clinical Modification diagnostic codes used in a standardized disease classification for morbidity and mortality coding for statistical data.

IDENTIFICATION CARD 1. Medical Identification Card - An identification card issued annually to each Medicaid eligible client or family unit. Designed to give the provider of medical services the recipient’s identification number for billing purposes.

2. Third Party Payer - Generally provided to identify the covered party or group insurance of the covered employee. It lists the address for billing, number to call for pre-authorization, if required, and policy number. It may state place of employment and type of coverage, whether family or single.

3. Children’s Health Insurance Program (CHIP) - An identification card that lists the names and birthdates of eligible children up to age 21. Claims are paid by Wells Fargo Third Party Administrations, Inc.

4. RFTS Maternity Services Card – An identification card issued by OMCFH to pregnant women who do not qualify for Medicaid and are uninsured/underinsured.

MANAGED CARE ORGANIZATION (MCO)

A prepaid group health insurance plan which entitles members to services of participating physicians, hospitals, and clinics, with emphasis on preventive medicine.

MEDICAID ELIGIBLE An individual with a valid identification card receiving financial and/or medical assistance from the Bureau for Children and Families and the Bureau for Medical Services, and children in foster care under Bureau supervision.

MEDICAID ID NUMBER (MAID#)

The medical identification number appearing on the client’s Medicaid card consisting of eleven digits. It appears on the card in front of the client’s name and begins with 00.

OMCFH ELIGIBLE A pregnant woman who has been denied Medicaid may be eligible for RFTS Maternity Services coverage if income is less than 185% FPL and has no private maternity insurance


TERM DESCRIPTION

coverage. All pregnant teens age 19 and under are eligible regardless of family income.

PAAS Physician Assured Access System. Medicaid system similar to MCOs. Each client is assigned a primary care provider for all treatment.

PLPW An eligible poverty level pregnant woman who initiates a WV KIDS-1 at the local DHHR Office.

PROVIDER

The person or agency that will be providing a service to the individual and billing for services rendered.

PROVIDER NUMBER The 10-digit provider number assigned to an individual/agency by the Bureau for Medical Services that allows them to bill for services rendered to eligible clients.


ABBREVIATIONS

TERM INITIALS

Access to Rural Transportation ART

American College of Obstetricians and Gynecologists ACOG

Bureau for Medical Services BMS

Certified Nurse Midwife CNM

Childbirth Education CBE

Children’s Health Insurance Program CHIP

Department of Health and Human Resources DHHR

Designated Care Coordinator DCC

Federal Financial Participation FFP

Federal Poverty Level FPL

Graduate Nurse GN

Licensed Certified Social Worker LCSW

Neonatal Intensive Care Unit NICU

Non-Emergency Medical Transportation NEMT

Office of Maternal, Child and Family Health OMCFH

Omnibus Budget Reconciliation Act OBRA

Prenatal Risk Screening Instrument PRSI

Regional Care Coordinator RCC

Regional Lead Agency RLA

Registered Dietician RD

Right From The Start RFTS

Social Security Number SSN

Supplemental Security Income SSI

Temporary Assistance to Needy Families TANF

Temporary Licensed Social Worker TLSW

Women, Infants and Children's Supplemental Food Program WIC


ABBREVIATIONS AND TERMS

ϵ Change/Changes

@ At. May also mean about or approximate.

~ Before

6 Leads to or results in

8 Increased or High

9 Decreased or Low

Ab Abortion (spontaneous or induced) e.g., AAb@ means A1 Abortion @)

A/B Apnea and/or Bradycardia

ac Before meals

AGA Average for Gestational Age

ALTE Apparent Life-Threatening Event

Ao Aorta, Aortic

AOP Apnea of Prematurity

ASD Atrial Septal Defect

A/V Canal Atrioventricular Canal

B/L Bilateral

BPD Bronchopulmonary Dysplasia

CHD Congenital Heart Disease

CHF Congestive Heart Failure

CMV Cytomegalovirus

CPS Child Protective Services

c/s Cesarean Section

DHHR Department of Health and Human Resources

DM Diabetes Mellitus

ECG/EKG Electrocardiogram

ECMO Extra-corporeal Membrane Oxygenation

EDC Expected Date of Confinement

EDD Expected Date of Delivery

EEG Electroencephalogram

EGA Estimated Gestational Age

ETOH Ethyl Alcohol (alcoholic beverage)

FAE Fetal Alcohol Effect

FAS Fetal Alcohol Syndrome

FFP Fresh Frozen Plasma

FOB Father of Baby

FOW Family Outreach Worker

G Gravida (e.g., AG2@ means Gravida2”)

GA Gestational Age

GBS Group-B Streptococcus

GER Gastroesophageal Reflux

h.c. Head circumference

HIE Hypoxic Ischemic Event

HMD Hyaline Membrane Disease

HR High Risk

HSV Herpes Simplex Virus

HTN Hypertension

ICH Intracranial Hemorrhage

IDDM Insulin-Dependent Diabetes Mellitus

IDM Infant of Diabetic Mother

IUGR Intra-Uterine Growth Restriction

IVH Intraventricular Hemorrhage


LBW Low Birth Weight (<2500 grams)

LGA Large for Gestational Age

LMD Local Medical Doctor

m Cardiac Murmur

MAS Meconium Aspiration Syndrome

MGF Maternal Grandfather

MGM Maternal Grandmother

NEC Necrotizing Enterocolitis

numberE Number of hours (e.g., Aq3E means every three hours @)

number1 One minute APGAR

number5 Five minutes APGAR

number10 Ten minutes APGAR

p After

P Para (e.g., AP2@ means Apara2”)

PA Banding Pulmonary Artery Banding (for VSD & other cardiac defects)

pc After meals

PDA Patent Ductus Arteriosus

PFC Persistent Fetal Circulation

PFO Patent Foramen Ovale

PGF Paternal Grandfather

PGM Paternal Grandmother

PMD Primary Medical Doctor

PPHN Persistent Pulmonary Hypertension of Newborn

PPS Peripheral Pulmonary Stenosis

RDS Respiratory Distress Syndrome

ROP Retinopathy of prematurity

RSV Respiratory Synclinal Virus

SGA Small for Gestational Age

S/P Status post (after)

S/S Signs and Symptoms

SSI Supplemental Security Income

SVT Supraventricular Tachycardia

TBA To be arranged

TGV Transposition of Great Vessels

TOF Tetralogy of Fallot

TORCH Syndrome

Congenital infection consisting of: Toxoplasmosis; Other; Rubella; CMV; or HSV

TPC Trend pneumocardiogram (also called simply Apneumogram@)

TTN Transient Tachypnea of Newborn

U/S Ultrasound

VHR Very High Risk

VLBW Very Low Birth Weight (<1500 grams)

VPI Velopharyngeal Incompetence

VSD Ventricular Septal Defect

Maternity Services/RFTS/Fee Schedule & Codes 1 Revised 07/1/2017

Office of Maternal, Child and Family Health Right From The Start Program

Maternity Services (Non-Medicaid Enrollees)

Fee Schedule Effective 07/01/2017

(Available at www.wvdhhr.org/rfts - requires username and password available from OMCFH)

Procedure Description Rate

1961 Anesthesia for cesarean delivery only

Base 7 Units $22.70 x 7 = $158.90 (7 base units)

$22.70 x units on bill (Max 8 units) = X $158.90 + X = Total Payment

1965 Anesthesia for missed abortion


$22.70 x units on bill (Max 8 units) = X $90.80 + X = Total Payment

1967

Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor


$22.70 x units on bill (Max 8 units) = X $113.50 + X = Total payment

1968 Anesthesia for cesarean delivery following Neuraxial labor analgesia/anesthesia (list separately in addition to code for primary procedure performed)

Base 2 Units (01967) $22.70 x 5 = $113.50 (5 base units) (10968) $22.70 x 2 = $45.40 (2 base units)

$22.70 x units (01967 & 01968) on bill (Max 8 units) = X $113.50 + $45.40 + X = Total Payment

Procedure Description Facility 1 Non – Facility 1

54150 Circumcision, using clamp or other device; newborn $72.85 $108.10

54160 Circumcision, surgical excision other than clamp, device or dorsal slit; newborn

$105.22 $152.22

59000 Amniocentesis; diagnostic $61.10 $88.77

59020 Fetal Contract Stress Test $49.35 $49.35

59020-TC Fetal Contract Stress Test $21.15 $21.15

59020-26 Fetal Contract Stress Test $27.94 $27.94

59025 Fetal Non-Stress Test $34.20 $34.20

59025-TC Fetal Non-Stress Test $11.49 $11.49

59025-26 Fetal Non-Stress Test $22.45 $22.45

59120 Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring

salpingectomy and/or oophorectomy, abdominal or vaginal approach $592.17 $592.17

59150 Laparoscopic treatment of ectopic pregnancy; without salpingectomy and/or oophorectomy

$573.90 $573.90

59320 Cerclage of cervix, during pregnancy; vaginal $115.15 $115.15

59409 Vaginal delivery only (with or without episiotomy and /or forceps) $887.86 $887.86

59410 Vaginal delivery only (with or without episiotomy and/or forceps) including postpartum care

$1,131.30 $1,131.30

59430 Postpartum care only (separate procedure) $151.54 $192.05

59514 Cesarean delivery only $1,003.02 $1,003.02

59515 Cesarean delivery including postpartum care $1,375.87 $1,375.87

59812 Treatment of incomplete abortion, any trimester, completed surgically $219.85 $233.68

59820 Treatment of incomplete abortion, any trimester, completed surgically $261.10 $274.94

59821 Treatment of missed abortion; completed surgically, second trimester $262.93 $278.33

64450 Circumcision nerve block $32.64 $54.05

http://www.wvdhhr.org/rfts



76801 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 wks. 0 days), transabdominal approach; single or first gestation

$82.51 $82.51

76801-TC Technical Component $46.21 $46.21

76801-26 Professional Component $36.29 $36.29

76802

Ultrasound, pregnant uterus, real time with imagine documentation, fetal and maternal evaluation, first trimester (<14 wks. 0 days), transabdominal approach; each additional gestation (list separately in addition to code for primary procedure)

$44.65 $44.65



76805 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14wks 0 days), transabdominal approach; single or first gestation

$94.52 $94.52



76810

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 wks 0 days), transabdominal approach; each additional gestation (list separate in addition to code for primary procedure)

$63.45 $63.45



76811 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation

$125.59 $125.59



76812

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; each additional gestation (list separately in addition to code or primary procedure)

$138.91 $138.91



76815 Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., fetal heartbeat, placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses

$56.66 $56.66



76816

Ultrasound, pregnant uterus, real time with image documentation, follow-up (e.g., re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus

$77.55 $77.55



76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal

$65.28 $65.28



76818 Fetal biophysical profile; with non-stress testing $83.55 $83.55





76819 Fetal biophysical profile; without non-stress testing $60.84 $60.84



76946 Ultrasonic guidance for amniocentesis, imaging supervision and interpretation

$22.45 $22.45



80053

Comprehensive metabolic panel. This panel must include the following: Albumin (82040), Bilirubin, Total (82247), Calcium (82310), Carbon Dioxide (bicarbonate) (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Phosphatase, alkaline (84075), Potassium (84132), Protein, total (84155), Sodium (84295), Transferase, alanine amino(ALT) (SGPT) (84460), Transferase, aspartate amino (AST) (SGOT) (84460), Urea nitrogen (BUN) (84520). Do not use 80053 in addition to 80048, 80076 (HepB).

Lab2 $14.49 $0.00

80055

Obstetric panel. This panel must include the following: Complete Blood Count (CBC), automated and automated differential WBC count (85025 or 85004) or Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009), Hepatitis B surface antigen (HBsAg) (87340), Antibody, rubella (86762), Syphilis test, qualitative (e.g. VDRL, RPR, ART) (86592), Antibody screen, RBC, each serum technique (86850), Blood typing, ABO and Blood typing RH (D) (86901).

Lab2 $65.58 $0.00

81000 Urinalysis, by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy

Lab2 $4.35 $0.00

81001 Urinalysis, by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy

Lab2 $4.35 $0.00

81002 Urinalysis, by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy

Lab2 $3.22 $0.00

81003 Urinalysis, by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy

Lab2 $3.08 $0.00

81005 Urinalysis; qualitative or semi-quantitative, except immunoassays Lab2 $2.97 $0.00

81015 Urinalysis; qualitative or semi-quantitative, except immunoassays microscopic only

Lab2 $4.18 $0.00

81025 Urine pregnancy test, by visual color comparison methods Lab2 $8.67 $0.00

82105 Alpha-fetoprotein; serum Lab2 $23.01 $0.00

82570 Creatinine; other source Lab2 $7.10 $0.00

82947 Glucose; quantitative, blood (except reagent strip) Lab2 $5.39 $0.00

82950 Glucose; post glucose dose (includes glucose) Lab2 $6.51 $0.00

82951 Glucose; tolerance test (GTT), three specimens (includes glucose) Lab2 $17.66 $0.00

84156 Protein, total, except by refractometry, urine Lab2 $5.03 $0.00

84702 Gonadotropin, chorionic (hCG); quantitative Lab2 $20.65 $0.00

85014 Blood count; hematocrit (Hct) Lab2 $3.25 $0.00

85018 Blood count; hemoglobin (Hgb) Lab2 $3.25 $0.00

85025 Blood count; automated differential WBC; complete count (CBC); automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count

Lab2 $10.66 $0.00

85027 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count)

Lab2 $8.87 $0.00

86580 Skin test; tuberculosis, intradermal $5.22 $4.99



86701 HIV – 1 Lab2 $12.19 $0.00

86803 Hepatitis C antibody Lab2 $18.08 $0.00

87070 Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates

Lab2 $11.82 $0.00

87081 Culture, presumptive, pathogenic organisms, screening only Lab2 $9.09 $0.00

87086 Culture, bacterial; quantitative colony count, urine Lab2 $11.07 $0.00

87088 Culture, bacterial; with isolation and presumptive identification of isolates, urine

Lab2 $11.10 $0.00

87110 Culture, Chlamydia, any source Lab2 $26.88 $0.00

87149 Culture, typing; identification by nucleic acid probe Lab2 $27.51 $0.00

87210 Smear, primary source with interpretation; wet mount for infectious agents (e.g., saline, India ink, KOH preps)

Lab2 $5.65 $0.00

87220 Tissue examination by KOH slide of samples from skin, hair or nails for fungi or ectoparasite ova or mites (e.g., scabies)

Lab2 $3.95 $0.00

87252 Virus isolation; tissue culture inoculation, observation and presumptive identification by cytopathic effect

Lab2 $35.76 $0.00

87254 Virus isolation; centrifuge enhanced (shell vial) technique, includes identification with immunofluorescence stain, each virus

Lab2 $26.83 $0.00

87340 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semi-quantitative, multiple step method; Hepatitis B surface antigen (HBsAg)

Lab2 $12.77 $0.00

87490 Chlamydia trachomatis, direct probe Lab2 $27.51 $0.00

87491 Chlamydia trachomatis, amplified probe technique Lab2 $48.14 $0.00

87590 Neisseria gonorrhoeae, direct probe technique Lab2 $27.51 $0.00

87591 Neisseria gonorrhoeae, amplified probe technique Lab2 $48.14 $0.00

88141 Cytopathology, cervical or vaginal (any reporting system) requiring interpretation by physician

$22.31 $22.31

88142 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision

Lab2 $27.14 $0.00

88164 Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision

Lab2 $14.49 $0.00

J2790 4Rho (D) immune globulin(Rhlg), human, full-dose, for intramuscular use $81.73 $81.73

99213-TH 3Office/Outpatient Visit Prenatal $36.55 $50.13

99238 Hospital discharge day management; 30 minutes or less $51.18 $51.18

99460 History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records. (This code should also be used for birthing room deliveries.)

$71.54 $71.54

99463

History and examination of the normal newborn infant, including the preparation of medical records. (This code should only be used for newborns assessed and discharged from the hospital or birthing room on the same date.)

$84.86 $84.86

99464 Attendance at delivery (when by delivering physician) and initial stabilization of newborn

$55.35 $55.35

1 Facility and Non-Facility fees are based on the 2016 RBRVS. A copy of this report can be downloaded at: http://www.dhhr.wv.gov/bms/FEES/Pages/WV-Medicaid-Physician's-RBRVS-Fee-Schedules.aspx

2 Lab fees are based on CLAB2016 schedule. A copy of this schedule can be downloaded at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/clinlab.html

3 Limited to 20 visits or a six month period.

4 Carrier-priced procedure code: Medicaid will establish the fee for service considered unlisted CPT procedure codes and for services for which CMS has not established “relative value units”, typically low-volume services. Invoices are priced on an individual basis and yearly fees rarely change.

http://www.dhhr.wv.gov/bms/FEES/Pages/WV-Medicaid-Physician's-RBRVS-Fee-Schedules.aspx

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/clinlab.html

policy and procedures manual - wvdhhr.org · wvdhhr/bph/omcfh/dpwh/wvhvp/october 2017 right from...

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