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317:35-17-16.Member annual level of care re-evaluation and annual re-authorization of service plan

[Revised 06-25-12]
(a) Annually, the case manager reassesses the member's needs using the UCAT Part I, III and then evaluates the current service plan, especially with respect to progress of the member toward service plan goals and objectives. Based on the reassessment, the case manager develops a new service plan with the member and service providers, as appropriate, and submits the new service plan to the AA for authorization. The case manager initiates the UCAT reassessment and development of the new service plan at least 40 days, but not more than 60 days, prior to the current service plan authorization end date.  The case manager provides the AA the new reassessment service plan packet no less than 30 days prior to the end date of the existing plan.  The new reassessment service plan packet includes the reassessed service plan, UCAT Parts I and III, Nurse Evaluation and any supporting documentation.
(b) OKDHS reviews the ADvantage case manager UCAT for a level of care redetermination.  If policy defined criteria for Nursing Facility level of care cannot be determined or cannot be justified from documentation available or via direct contact with the case manager, a UCAT is completed in the home by the local OKDHS nurse.  The local OKDHS nurse submits the UCAT evaluation to the area nurse, or nurse designee, to make the medical eligibility level of care determination.
(c) If medical eligibility redetermination is not made prior to current medical eligibility expiration, the existing medical eligibility certification is automatically extended until level of care redetermination is established.  If the member no longer meets medical eligibility the area nurse, or nurse designee, updates the system's "medical eligibility end date" and simultaneously notifies AA electronically.
(d) If OKDHS determines a member no longer meets medical eligibility, the AA communicates to the member's case manager that the member has been determined to no longer meet medical eligibility for ADvantage as of the effective date of the eligibility determination. The case manager communicates with the member and if requested, assists the member to access other services.

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.