Section 4 - Care Management/Authorizations

MLTSS Care Management

Horizon NJ Health provides every MLTSS member with a Care Manager and Care Management team. The Care Manager, usually a nurse or social worker, leads the coordination and care of the member's health care needs. The Care Management team also includes a clinical support coordinator.

The Plan of Care is based on the member's health status and health care needs. The role of the provider

(Primary Care Provider, specialist or other provider) is very important. The member, along with his/her Care Manager, will work together to develop a Plan of Care. The Plan of Care will outline the member's health care needs, focus on the member's chosen goals, what services the member may receive, frequency of service and name of provider decided upon by the member. MLTSS Services will be provided within 45 calendar days of enrollment and member agreement to the Plan of Care, except for residential modification and vehicle modification. The Plan of Care is facilitated by the Care Manager who ensures direct involvement of the member, member's family and/or authorized representative. The Care Manager is responsible for facilitating placement/ services based on assessed needs and member's provider. The provider may receive a copy of the Plan of Care via fax.

The Care Manager will conduct a face-to-face visit every 90 days. The Care Manager will review the member's Plan of Care at least every 90 days or sooner if there are changes in the member's condition. Horizon NJ Health members must use in-network, contracted providers to get covered MLTSS services.

Horizon NJ Health ensures that its MLTSS Care Managers work in a conflict-free environment. Care Managers cannot work directly with members who are blood relatives or related by marriage. They also cannot be a direct-paid caregiver or be financially responsible for or empowered to make financial or health-related decisions on behalf of a member they are assigned to.

MLTSS Prior Authorization Process

When the Plan of Care is complete and the Care Manager and member are in agreement with the Plan of Care, authorizations will be entered into the medical management system in accordance with the agreed upon Plan of Care. Services are authorized exactly as written in the signed Plan of Care. If there are questions about authorizations, those questions are discussed with the MLTSS Care Manager prior to completing and signing the Plan of Care.

The MLTSS care management team will make all the necessary arrangements to ensure that services mandated via the Plan of Care are executed in a timely manner. Horizon NJ Health will make every attempt to arrange services with the provider chosen by the member. If the contacted provider cannot provide the service, the MLTSS care management team will try to identify a provider who can provide the services. This process continues until a provider can be found to meet the expectations of the Plan of Care.

Once it is confirmed that the provider is able to provide the service, an authorization is created in the medical management system for that specific provider with the authorization limits/requirements listed in the Plan of Care. The provider is given an authorization number, the start and end date of the service, and the type of service that will need to be provided. An authorization letter with the above information is also triggered from the medical management system and mailed to the provider.

Defining Critical Incidents

The Centers for Medicare and Medicaid Services (CMS), as well as the State of New Jersey, requires that measures be employed to protect the health and welfare of Horizon NJ Health MLTSS members. This includes guidelines for reporting critical incidents.

Per the State of New Jersey, critical incidents include but are not limited to the following situations:

  • Unexpected Death of a Member
  • Media involvement\Potential Media involvement
  • Physical abuse\seclusion\restraints\physical\chemi
  • Psychological\Verbal abuse
  • Sexual Abuse or Suspected Sexual Abuse
  • Fall resulting in the need for medical treatment
  • Medical emerg resulting in need for medical tx
  • Medication Error
  • Psych emerg resulting in the need for medical tx
  • Severe Injury or Fall
  • Suicide attempt resulting in need for medical tx
  • Neglect\Mistreatment, caregiver(paid or unpaid)
  • Neglect\Mistreatment, self
  • Neglect\Mistreatment, other
  • Exploitation, financial
  • Exploitation, theft
  • Exploitation, destruction of property
  • Exploitation, other
  • Theft with Law Enforcement Involvement
  • Failed Back Up Plan
  • Elopement or Wandering
  • Inaccessible for Initial On-Site Meeting
  • Unable to Contact
  • Inappropriate Provider Conduct
  • Cancellation of Utilities
  • Eviction or Loss of Home
  • Facility Closure
  • Natural Disaster
  • Operational breakdown
  • Other

Reporting Requirements for Critical Incidents

MLTSS providers with suspicion or evidence of critical incidents must report them to Horizon NJ Health. Upon discovery of a Critical Incident, providers are to take steps to prevent further harm to members and promptly respond to these members' needs. These steps may include reporting potential violations of criminal law to law enforcement authorities.

For MLTSS members, providers are responsible for reporting Critical Incidents to Horizon NJ Health, within 1 Business Day of discovery by faxing the “Critical Incident Reporting Guide” form to 1-609-583-3003.

The Critical Incident Reporting Form can be found online. Horizon NJ Health's Critical Incident Team will subsequently contact/follow up with the provider as warranted, and has a dedicated fax to receive subsequent Provider Investigation Findings and Resolution summaries from providers to ensure incidents are resolved promptly though appropriate referrals and corrective action. The Horizon NJ Health MLTSS Critical Incident Team will notify the State of New Jersey of any critical incidents via a state-specified web-based system.

MLTSS providers who have reported critical incidents are required to independently conduct an internal critical incident investigation and submit a report on their findings to Horizon NJ Health. The report should be submitted no longer than 15 calendar days after the date of the incident or discovery of its occurrence. Under extenuating circumstances, but only with the approval of Horizon NJ Health, the report can be submitted within 30 calendar days after the date of the Incident.