Member Record Procedure
Affected LCI Units: All
Effective Date: January 1, 2017 / Last Review Date: April 2017
Definitions:
· Designated Record Set (DRS): A group of records maintained by LCI regarding member enrollment, payment, claims adjudication and care management; records used, in whole or in part, by LCI to make decisions about a member’s care.
· Legal Member Record (LMR): As a subset of the DRS, these are the business records provided by LCI in response to a valid authorization or subpoena.
· Member Record Matrix (MRM): The table that identifies which documents comprises the member record and their designation as DRS or LMR (a subset of the DRS).
· Temporary Working Folder: A folder, whether electronic and/or paper, which may be kept by LCI staff containing documents or references not identified as being part of the LMR or DRS for an active member process necessary to assist with assessment, care planning, and care coordination.
· Carbon Copy Folder: A folder, whether electronic and/or paper, may be kept by LCI staff for each member containing unaltered LMR documents which are exact replicas of the documents found within the member record. These documents serve as a baseline to assist in re-assessment, evaluation, and decision-making.
Procedure:
LCI staff shall follow the MRM listed below for determining if a document is to be retained as part of the DRS, and if it is part of the LMR (which is a subset of the DRS).
IDT Staff:
1. Internal or external communication or documents received which are used to coordinate care must be summarized timely within a case note.
2. Refer to the MRM to determine which documents must be forwarded to the scanning mailbox/storage location or properly destroyed.
3. A carbon copy folder may be kept in an electronic or paper format consisting of unaltered LMR documents, which are exact replicas of the documents found within the member record.
4. A temporary working folder may be kept in an electronic or paper format which consists of documents necessary to conduct care management functions related to assessment, care planning, and care coordination while part of an active process. When the process is complete, the documents must be properly retained or destroyed.
Business/Provider Network/Quality:
1. Communication or documents received from outside the LCD which are used to determine care must be summarized within the MIDAS system.
2. Documents which have been summarized in MIDAS but not identified in the MRM must be properly destroyed.
3. Documents identified in the MRM which need to be retained are forwarded to the scanning mailbox or storage location for scanning or saved on the shared drive.
4. CONTINUE THIS LATER
Administrative Service Associate (ASA):
1. Verify that the document submitted for scanning is listed in the MRM.
2. If listed in the MRM, attach the document into MIDAS, selecting the appropriate category/sub-category, saving with the appropriate document name.
3. If the document is not listed in the MRM, do not proceed with attaching into MIDAS. Forward the document to the appropriate Care Management Supervisor for further review.
Care Management Supervisor:
1. Review the document received from the ASA that has been questioned on appropriateness for inclusion into the member record. If necessary, consult with the IDT staff to determine if the document has been misidentified.
a. If determined to be misidentified and is in fact on the MRM, return the document to the ASA with clarification of document type.
b. If the document is verified as not listed in the MRM, promote adherence to the Member Record Policy with IDT staff.
2. Summarize via e-mail to the Compliance Manager the type of documents being denied for attachment into the member record.
Compliance Manager:
1. Track documents which were denied for attachment into the member record.
2. Monitor trends to determine adherence to the overall policy, and determine if the MRM needs to be modified or if additional staff training is necessary.
Member Record Matrix Last Updated: 5/26/2017
SCANNED
Type of Record or Document / DRS or LMR / Type / Category / Sub-Category / Name / Date in Description(yyyy-mm-dd format) /
AFH Annual Admission & Rate Agreement / LMR / Scanned / Care Mgt / Network Relations / LMR_AFH Admit_Rate Agreement / Date Signed
Advance Directive Documents / Guardianship Papers / LMR / Scanned / Care Mgt / Legal / LMR_DNR
LMR_POA-HC
LMR_POA-FIN
LMR_GDN-Person
LMR_GDN-Estate / Date of Document
Appeal & Grievance Letters (member) / LMR / Scanned / Care Mgt / Appeal and Grievance / LMR_Appeal (identify type of letter) / Date of Letter
Behavioral Intervention Plans (LCI created) / LMR / Scanned / Care Mgt / Behavioral Support/Intervention Plan / LMR_BIP / Date of Document
Behavioral Intervention Plans (Provider created) / DRS / Scanned / Care Mgt / Behavioral Support/Intervention Plan / DRS_BIP / Date of Document
Behavior Support Plans (LCI created) / LMR / Scanned / Care Mgt / Behavioral Support/Intervention Plan / LMR_BSP / Date of Document
Behavior Support Plans (Provider created) / DRS / Scanned / Care Mgt / Behavioral Support/Intervention Plan / DRS_BSP / Date of Document
Certified Mail Receipts / LMR / Scanned / Care Mgt / Correspondence / LMR_Cert Mail Receipt / Date of receipt
Change in Level of Care Letter / LMR / Scanned / Care Mgt / Letters to Members or Correspondence / LMR_LOC Change / Date of LOC change
Client Rights Limitations Forms / LMR / Scanned / Care Mgt / Member Rights / LMR_Client Rights Limitations / Date of Document
Coordination of Benefits/Insurance (insurance cards, determination of insurance, EOBs, subrogation documents, VA benefits, etc) / DRS / Scanned / Enrollment / Other / DRS_Med Insurance / Date of Document
Correspondence (LCI initiated regarding member) / LMR / Scanned / Care Mgt / Correspondence / LMR_(correspondence type & purpose) / Date of Document
Cost Share and Room & Board *Forms
*Documentation
*Letters (past due, payment plans, overpayment reimbursements, etc)
*Invoices
*Adjustments
*MREs / LMR / Fiscal
MIDAS/ Scanned
S/Drive-(pdf) / Fiscal / Correspondence / LMR_(document type) / Date of Document
County Crisis Plans / LMR / Scanned / Care Mgt / Behavioral Support/Intervention Plan / LMR_Crisis Plan / Date of Document
Disenrollment/Change Routing Form / LMR / Scanned / Enrollment / Disenrollment / LMR_Disenrollment / Date of Disenrollment
Emergency Protocol Plan / LMR / Scanned / Care Mgt / Behavioral Support/Intervention Plan / LMR_Emergency Protocol Plan / Date of Document
Enrollment / LMR / Scanned / Enrollment / Enrollment / LMR_Enrollment / Date of Enrollment
Financial Eligibility Pending Agreement / LMR / Scanned / Enrollment / Other / LMR_Financial Eligibility Agreement / Date Signed
Financial Repayment Form / LMR / Scanned / Fiscal / Correspondence from Finance / LMR_Financial Repayment Form / Date of Document
Home Modification Agreement Form / LMR / Scanned / Care Mgt / Member Forms / LMR_Home Mod Agreement / Date of Document
Inter-county Agreement / LMR / Scanned / Care Mgt / Legal / LMR_Inter County Agreement / Date of Agreement
Letters to Members / LMR / Scanned / Care Mgt / Correspondence / LMR_(purpose of letter) / Date of Letter
Long-Term Care Functional Screen (upon disenrollment) / LMR / Scanned / Enrollment / Disenrollment / LMR_FS / Disenrollment Date
Median Task Guide / LMR / Scanned / Care Mgt / Median Task Guides/RCET/SHC_PC Tool / LMR_MTG / Date of Document
Medical Mileage Reimbursement (Common Carrier) / LMR / Scanned / Care Mgt / Member Forms / LMR_Med Mileage / Month of Service
Medical Travel Accommodation Form and Receipts / LMR / Scanned / Care Mgt / Member Forms / LMR_Med Travel Accommodation (Form or Receipt) / Month of Service
Member Centered Plan (packet may include Member Centered Plan, Service Plan, Medication List) / LMR / MIDAS/ Scanned / Care Mgt / Signed Care Plans / LMR_MCP / Date Signed
Member Specific Rate Requests / LMR / Scanned / Care Mgt / Network Relations / LMR_Member Specific Rate Request / Date of Request
Member’s Use of Personal Resources Fax Form / LMR / Scanned / Care Mgt / Member Forms / LMR_MUPR / Date of Document
Mini-Cog Tool & Fax (scan together) / LMR / Scanned / Care Mgt / Correspondence / LMR_Mini-Cog / Date of Fax
Money Follows the Person -Informed Consent Form / LMR / Scanned / Care Mgt / Member Forms / LMR_MFP Consent Form / Date of Document
Money Follows the Person - Participant Emergency Back-up Information / LMR / Scanned / Care Mgt / Member Forms / LMR_MFP Back-up Info / Date of Document
Money Follows the Person - Participant Reporting Form / LMR / Scanned / Care Mgt / Member Forms / LMR_MFP Participant Reporting Form / Date of Document
Notice Of Actions / LMR / MIDAS/ Scanned / Care Mgt / NOA / LMR_NOA / Date of Notice
Notice of Privacy Practices / LMR / Scanned / Enrollment / Enrollment / LMR_Privacy Notice / Date of Notice
Nursing Home Bed Hold or Hospice Request / LMR / Scanned / Care Mgt / Network Relations / LMR_Bed Hold / Date of Form
Physician’s Order for Medical Necessity / LMR / Scanned / Care Mgt / Medical Records / LMR_Physician Order / Date of Order
Protective Placements / DRS / Scanned / Care Mgt / Legal / DRS_Protective Placement / Date of Placement
Provider Modification Form / LMR / Scanned / Care Mgt / Network Relations / LMR_Provider Modification Form / Date of Form
Provider Plans of Care/ISPs – Residential and Long-Term Nursing Home (Holistic only; Coordination of benefits within or outside the benefit package) / DRS / Scanned / Care Mgt / Provider Plans of Care / DRS_(provider name, item) / Date of Document
Provider Quotes (home/vehicle mods only) / DRS / Scanned / Care Mgt / Network Relations / DRS_(provider name, item) / Date of Quote
RADS / LMR / Scanned / Care Mgt / RAD Worksheet / LMR_RAD (service) / Date of Document
Rate Assessment Tool (AFH Assessments) / LMR / Scanned / Care Mgt / Network Relations / LMR_Rate Assessment / Date of Assessment
Release of Information / LMR / Scanned / Care Mgt / Release of Information / LMR_ROI (provider name) / Date Signed
Relocation Plans (state only) / LMR / Scanned / Care Mgt / Signed Care Plans / LMR_Relocation / Date of Relocation
Residential Cost Effectiveness Tool / DRS / Scanned / Care Mgt / Median Task Guides/RCET/SHC_PC Tool / DRS_RCET / Date Received
Residential Waiver Forms / LMR / Scanned / Care Mgt / Member Rights / LMR_Residential Waiver / Date of Document
Restrictive Measures Packet (Applications, Approvals, etc) / LMR / Scanned / Care Mgt / Member Rights / LMR_Restrictive Measures (Application, Approval, etc) / Date Approved
Risk Reduction Agreement / LMR / MIDAS/ Scanned / Care Mgt / Signed Care Plans / LMR_Risk Agreement / Date Signed
Safety Plans / LMR / Scanned / Care Mgt / Behavioral Support/Intervention Plan / LMR_Safety Plan / Date of Document
Self-Directed Supports Budget Authorizations Forms (should phase out, replaced by SDS Worksheets) / LMR / MIDAS/ Scanned / Care Mgt / SDS / LMR_SDS Auths / Date of Document
Self-Directed Supports Budget Creation Tool (should phase out, replaced by SDS worksheets) / DRS / Scanned / Care Mgt / SDS / DRS_Budget Creation Tool / Date of Creation
Self-Directed Job Description / LMR / Scanned / Care Mgt / SDS / LMR_SDS Job Description / Date of Document
Self-Directed Supports Participation Agreement / LMR / Scanned / Care Mgt / SDS / LMR_SDS Participation Agreement / Date Signed
Self-Directed Supports Worksheets (workbook containing the referral form, budget creation tool, budget auth form) / LMR / Scanned / Care Mgt / SDS / LMR_SDS Worksheets / Date of Creation
Service Agreement – Enhanced Services / LMR / Scanned / Care Mgt / Enhanced Service Agreements / LMR_Enhanced SA / Date Signed
SHC_PC Assessment Tool / LMR / Scanned / Care Mgt / Median Task Guides/RCET/SHC_PC Tool / LMR_SHC_PC Assessment Tool / Date of Document
SMS/OTC Prescription Form/ Pharmacy Fax Cover Letter / LMR / Scanned / Care Mgt / Member Forms / LMR_SMS.OTC RX Form/ LMR_Pharmacy Fax / Date Signed/Date of Fax
SSI-E Information (only what LCI creates) / DRS / Scanned / Care Mgt / Financial Reports / DRS_SSI-E / Date of Document
Note: Name of document is a guide only, please be more specific if possible as applicable.
NOT SCANNED (but part of member record)
Type of Record or Document / DRS or LMR / Type / Category / Sub-Category / Name / Date in Description(yyyy-mm-dd format) /
Assessment Worksheets / LMR / MIDAS / n/a / n/a / n/a / n/a
Case Notes / LMR / MIDAS / n/a / n/a / n/a / n/a
Cost Share and Room & Board
*CARES screen shots
*Verification of wages, rent, costs, etc / DRS / Fiscal / n/a / n/a / n/a / n/a
Demographic Information / LMR / MIDAS / n/a / n/a / n/a / n/a
Interpreter Services / DRS / Fiscal / n/a / n/a / n/a / n/a
Letters to Members – Mass Mailing / LMR / Pdf on S/Drive / n/a / n/a / n/a / n/a
Letters to Members – Staff Changes / LMR / Pdf on S/Drive / Member info/comment
Long-Term Care Functional Screen (routine) / LMR / LTCFS Website / n/a / n/a / n/a / n/a
Non-Covered Benefits Letter / LMR / MIDAS / n/a / n/a / n/a / n/a
Service Authorizations / LMR / MIDAS / n/a / n/a / n/a / n/a
LMR is subset of DRS 6