Documentation

Documentation is essential in assessing the effectiveness of service coordination activities. The documentation should be entered promptly, be factual and accurate, and inclusive of all components of the activity. All documentation in the SHCN Information System are legal documents of record. All contacts with or about the participant should be documented in the SHCN Information System as soon as possible, but no longer than ten (10) business days after the date of the contact.

• Documentation should be written in first person, using complete sentences or bullet style formatting.
• The use of the “Home Visit Template” for progress notes is encouraged.
• Documentation must be comprehensive enough to justify staff actions and shall include an action plan allowing others to intervene in the Service Coordinator's absence.
• Reports, Individual Educational Plans, etc., that are reviewed by staff and require no action should be dated and filed. Receipt and review of documentation along with a brief summary must be noted in the SHCN Information System.
• Do not copy and paste email correspondence (as a whole or as a screen shot) into the SHCN Information System. Instead, use a summarization to document the content of the message(s).

Entries in the SHCN Information System “Forms” screen do not require additional documentation the Progress Notes.

Annual Requirements

There are certain processes and documentation requirements that are required to be completed annually (at a minimum) after enrollment. These annual requirements include:

• A face to face visit for completion of the Service Coordination Assessment (SCA) (and subsequent service plan). (See Comprehensive Assessment section.)
• Review and obtain authorizing signatures on the following :
  • Rights and Responsibilities and Acknowledgement Form, and
  • Privacy Policies and Acknowledgement Form
• Review the Role of the Service Coordinator form and leave with the participant.
• Annual Financial Eligibility Review (AFER) – process for reviewing continued financial eligibility which takes place from January 1 to June 30 each year. Information on the AFER process and forms to be used are available on the AFER secure site.

It is recommended that all forms requiring review and signature (other than the AFER forms) be discussed with the participants during the annual face to face visit for completion of the annual assessment. The annual forms requirement (besides AFER) applies to all enrollments.

In order to meet the needs of participants, service coordination activities may require more than annual visits and documentation.

Bi-Annual Requirements

The ABI Service Coordinator shall periodically monitor and evaluate the treatment plan. Participants’ progress toward reaching outcomes and appropriateness of services shall be reviewed every six months (by phone or in person) and any time there is a significant change. A full assessment and review of continued eligibility will be conducted annually.

Records Management

Individuals who apply or enroll in the Program must have a legal participant record in the Regional or Contractor Office.

• It is recommended that file content be organized in sections.
• Documents must be filed in descending chronological order within their appropriate section.
• Participant records must be kept in a locked centralized filing area.

Records Retention:

• All records must be retained until the participant file is closed.
  • All closed participant records will be forwarded to the Regional Office (RO) upon request.
• An incomplete referral or an incomplete application for enrollment will be retained for three (3) months before the record is destroyed.
• A complete application for enrollment (signed CC-1 Application for Enrollment Form) which is determined ineligible shall be retained and archived..
• Mailed records should be sent via certified mail, with reinforced envelope/packaging closure, and email notification going from sender to recipient. Confirmation email should also be sent from recipient to sender once the records have been received. Both sender and recipient should document the transfer of the record in MOHSAIC progress notes using the contact type "Record Custody."

Preparing Legal Files for Archiving After Closure of a SHCN Record

Files must be appropriately prepared before sending them to the Regional Office for archiving. Prior to forwarding the file:

• Write the participant name, DCN and date of birth in pen on the file tab.
• Remove all staples, paperclips, dividers, and duplicate copies. (Shred all duplicates with identifying information, such as names and DCNs, which are removed.)
• Make a copy of the back of all two sided pages.
• All perforated forms should be separated at the perforation.
• Tape anything smaller than 3 x 5 on an 8 ½ x 11 sheet of paper. All information should be visible. Tape all four sides completely so no edge is loose.
• Remove post-it notes and tape to another sheet of paper.
• Remove any previously used tape. (Sticky surfaces will get stuck in the machine.)
• Cut off rough edges (spiral notebook paper edges, etc.).
• Correct participant’s name on the file folder to match the current name in the SHCN Information System.
• Number each file folder if there are more than one for a participant.
• Assure all papers are facing up.
• Write on the outside of the file in pencil “archive ready”.

Financial Eligibility Determination

Financial eligibility shall be determined by comparing the family income and size to the SHCN financial eligibility guideline.

Verifying Income:

• Federal Internal Revenue Service (IRS) income tax information shall be used to verify income.
• Income consists of the Adjusted Gross Income (AGI) reported on the applicant/participant's Federal IRS income tax form.
  • If the applicant/participant appears as a dependent on another person's IRS income tax form, use the AGI reported on the income tax form on which the applicant/participant appears as a dependent.
  • If the applicant/participant is 18 or over AND does not appear as a dependent on another person’s IRS income tax form, use the AGI reported on the income tax form of the applicant/participant.
• When a child is in foster care and is in the legal custody of the state, income is reported as zero (0).
• When a participant/family is not required to file a Federal IRS tax form, the income is reported as zero (0).
• When it is not possible to use the AGI of the person who claims the applicant/participant as a dependent, use the following default process to determine whose AGI should be used in calculating financial eligibility:
  • Use the AGI of the person assigned medical financial responsibility if the court has assigned medical financial responsibility, or
  • Use the AGI of the individual having "physical custody" of the participant if the participant lives with someone other than both parents (i.e., one parent, relative, friend, etc.), or
  • Use the AGI of the individual who has assumed medical responsibility if the participant is in a court-ordered situation and the person assigned medical financial responsibility is out of compliance with the court order, or
  • If the participant has no determinable responsible person or fits none of the examples, consult with the Program Manager to determine whose AGI to use.
• An estimated income may be substituted for the AGI when the income tax information is not reflective of the family's current financial status.
  • The income tax information shall be considered non-reflective of the current status when a change has been in effect for at least three (3) months or when the family separates and the custodial adult has been deprived of access to the income for three (3) months or more.
  • Use the actual gross income to date (calendar year) as evidenced by pay stubs or other documentation and estimate the rest of the yearly income.
  • If income is requested to be estimated for a second consecutive year, a written request for consideration must be made to the Program Manager.
• For participants filing a Federal IRS tax extension, use written estimation of income provided by the participant/responsible party.
  • The AGI from the tax form must be entered as soon as the taxes are filed but no longer than six (6) months from the tax extension file date.
• For participants applying for an Individual Tax Identification Number (ITIN), use the estimated income.
• All financial verification documents and calculations must be retained in the participant’s records.

Family Size:

• If the income is reported as zero (0), the family size is one (1).
• If the income is reported from the IRS income tax form, the family size is the number of all persons listed on the income tax form.
• Increase the family size by one (1) for each additional family member enrolled in a SHCN Program.

Computing Financial Eligibility:

• Identify the family size on the financial eligibility guidelines found on the ABI Webpage. [NEEDS LINK]
• If the family income exceeds the maximum eligible income for the family size, the participant is not financially eligible.

Annual Financial Eligibility Review (AFER):

• Participants enrolled in Paid Services will be reviewed for continued financial eligibility on an annual basis.
• The Annual Financial Eligibility Review (AFER) process will be conducted each year from January 1st through June 30th.
• Participants enrolled in Service Coordination will not be included in the AFER process.

Obtaining an Individual Tax Number (ITN)

Some of our participants/families will need to obtain an Individual Tax Identification Number (ITIN) in order to file their tax return. An ITIN is a nine-digit tax processing number issued by the Internal Revenue Service (IRS). It is issued to individuals who do not have and are not eligible to obtain a Social Security Number. ITINs are issued regardless of immigration status because both resident and non-resident aliens may have a U.S. tax return and payment responsibilities under the Internal Revenue Code. Individuals must have a filing requirement and file a valid federal income tax form to receive an ITIN, unless they meet an exception.

Participants/families that need to obtain an ITIN must complete the Application for Individual Taxpayer Identification Number (IRS Form W-7), attach it to the required certified or notarized documents and the completed tax form, and submit all documents to the IRS. The participants/families must be able to prove their foreign status and identity.

Participants/families can obtain assistance with completion of this process by calling the IRS toll-free at 1-800-829-1040, scheduling an appointment at an IRS Taxpayer Assistance Center, or using the service of an Acceptance Agent. An Acceptance Agent is someone authorized by the IRS to assist individuals in obtaining ITINs.

Complete information on ITINs can be found at www.irs.gov

For those who are waiting for an ITIN to be assigned and their tax form processed; you must enter a dollar amount if known in the “Adjusted Gross Income” field, you must select “Estimated”, and you must enter the “Family Size” in the SHCN Information System even though you do not have any financial information. It is the ABI Service Coordinator’s responsibility to track those participants who are waiting for an ITIN and close the case if a completed tax return is not received within nine months of enrollment. Continue to contact these participants/families on a monthly basis to determine the status of their ITIN application. If the required information is not provided within nine months, the case will be closed. Service Coordination can be provided as needed.

Enrollment and Closure Dates

Enrollment Dates

The initial enrollment date (into Service Coordination and/or Paid Services) shall be the date complete documentation is received verifying all applicable eligibility.

Closure Date

Participant and applicant cases are closed by the ABI Service Coordinator for various reasons. In all instances, good faith efforts must be made to contact the participant/family to discuss the closure. These good faith efforts must be documented in the SHCN Information System to show effective service coordination, and when appropriate, successful transition from Program services.

Reasons for closure may include:

• The applicant/participant demonstrates an unwillingness to cooperate with Program requirements such as responding to requests for information.
• Participant no longer meets eligibility criteria.
• Request of the participant/family.
• Unable to locate after good faith efforts.
• The participant has become institutionalized or a Ward of the Court.
• The participant reaches the age of 65 and is no longer eligible for the Program.
• Program services are no longer needed.

Once the determination has been made to close the file, the ABI Service Coordinator will document the reason for closure and closure date in the SHCN Information System.

The ABI Service Coordinator must complete and send a certified closure letter on all manual or automated closures.

The following are guidelines to assist in determining closure dates:

• Deceased - date of death if known; otherwise use the date staff became aware of the death (notify ABI Program Manager of all participant deaths on a Death Notification Form within 24 hours of notification of death),
• Moved Out of State – date of move if known; otherwise use the date that staff became aware of move,
• Over age – the day before the participant’s sixty-fifth (65) birthday,
• All others – fourteen (14) calendar days after the date of the written notice (Unable to contact letter) to participant/family notifying them of closure.

Appeal Process

ABI Program applicants/participants/representatives have the right to appeal decisions regarding eligibility, the services received, or the services denied. All activities concerning the appeal will be documented in the SHCN Information System within five (5) business days from the date of the receipt of the appeal. All documentation will be retained in the legal file.

• To appeal a decision made by the ABI Program, the applicant/participant/representative must notify the ABI Service Coordinator within thirty (30) calendar days to request a review the decision. The appeal must be in writing; the ABI Service Coordinator will assist, if necessary.
• Within five (5) business days of the receipt of the appeal, the ABI Service Coordinator will notify and forward the written appeal to the ABI Program Manager.
• The ABI Program Manager, in collaboration with the Section Administrator, will review the appeal. The ABI Program Manager and Section Administrator will render a written decision to the applicant/participant/representative, and send a copy of the decision to the appropriate ABI Service Coordinator within thirty (30) business days of the receipt of the appeal.
• If the decision is unsatisfactory to the applicant/participant/representative, the applicant/participant/representative must notify the ABI Service Coordinator, in writing, within thirty (30) calendar days of the receipt of the decision to request a hearing. The request must be addressed to the ABI Program Manager and must include the reason for the appeal and any supporting facts. The appeal must be signed, dated, and contain a return address.
• Within five (5) business days of the receipt of the request, the ABI Service Coordinator will notify the ABI Program Manager and the Section Administrator of the request for a hearing
• Within five (5) business days of the receipt of the request, the Section Administrator will follow the appropriate chain of command to forward the request to the Department Director, or designee.
• A hearing will be conducted at a reasonable time, date, and place. The notice of the hearing will be mailed to the applicant/participant/representative at the address indicated on the appeal letter at least twenty (20) calendar days prior to the hearing.
• The Department Director, or designee, will appoint a hearing officer who has not been involved in the initial determination of the action in question. The hearing officer will preside at the hearing and prepare a report consisting of a statement of issues, findings of fact, conclusions, and recommendations.
• The applicant/participant/representative will have adequate opportunity to record the hearing proceedings, examine the contents of the case file, bring witnesses, establish all pertinent facts, advance arguments without undue interference and questions, or refute any testimony or evidence.
• The Department Director, or designee, will make a final decision based on the evidence and other material introduced at the hearing and the hearing officer’s report. A letter outlining the Director’s, or designee’s, decision will be mailed to the applicant/participant/representative within ninety (90) calendar days after the hearing date. A copy of the letter will also be filed in the participant’s legal record.

An applicant/participant/representative who has exhausted all administrative remedies and who wishes to appeal the final decision of the Department will be entitled to judicial review.

Legal Topics

Legal Name Change

Program participants who change their name must provide written proof (legal document) of the change before the name can be officially changed in the participant record or in the SHCN Information System.

The ABI Service Coordinator will view the legal document and record the information (including effective date) in the Progress Notes of the SHCN Information System. A copy of the legal document must be kept in the participant’s file.

Subpoena of Participant Records

The ABI Program is required to respond to a subpoena for participant records. When a subpoena is received in a contracting agency office involving a participant’s legal record, the following must occur:

• The subpoena for ABI participant records shall be accepted by the ABI Service Coordinator.
• The ABI Service Coordinator shall notify the ABI Program Manager within twenty-four (24) hours. The instructions in the subpoena must be followed. The subpoena for an ABI Service Coordinator shall be accepted by the ABI Service Coordinator.

The ABI Program Manager will work in collaboration with the ABI Service Coordinator and contracting Agency Administrator to track the legal process and actions generated by the subpoena.

Obtaining or Releasing Information

All information about the participant/family (verbal, electronic, or in written form) is confidential. All access to health/medical information should be requested, released, or viewed using a written and signed Health Insurance Portability and Accountability (HIPAA) document considered by Department of Health and Senior Services (DHSS) to be compliant with current regulatory guidance. If in doubt please contact your designated HIPAA officer at the respective Local Public Health Agency (LPHA) or Program representative for assistance.

Compliant documents:

• DHSS Notice of Privacy Policy and Acknowledgement Form is required upon enrollment and annually thereafter.
• DHSS Authorization for Disclosure of Consumer Medical Health Information is necessary when requesting records and when sharing information on an as needed/need to know basis. An original signed Authorization must be obtained and kept in the hard file.

Staff of contracted agencies must use the DHSS Authorization for Disclosure of Consumer Medical Health Information form when releasing ABI information.

Contractors or Providers may also require their own Authorization form in conjunction with the DHSS Authorization for Disclosure of Consumer Medical Health Information form.

Requests for participant records for legal proceedings must be in writing and sent to the ABI Program Manager. ABI Program Manager will coordinate the release of information with the ABI Service Coordinator.

Complaints

The ABI Service Coordinator shall follow the complaint policy of the agency that has been contracted with SHCN. Complaints or concerns received from customers regarding program issues shall also be reported to the ABI Program Manager.

Customers include, but are not limited to, the following:

• Participant;
• Participant's family;
• Participant's representatives;
• Providers;
• Contracting agencies;
• Regulatory agencies;
• Payers;
• DHSS staff (outside of SHCN);
• Elected officials; and
• Appointed officials.

Medical Records Request and Fees

The ABI Program will consider paying the charges to obtain a copy of a participant’s medical record, when the provider who has the information is not a SHCN approved provider. The ABI Program will not pay the charges to obtain a copy of a participant’s medical record when the individual/facility that has the needed information is a SHCN approved provider.

It is customary for health care providers to waive fees for state agencies when the purpose of the review is to conduct state business. Because the services are provided through a contractual agreement with the LPHA’s, the request for reimbursement will be processed at the current rate posted on the DHSS website. [NEEDS LINK]

The ABI Service Coordinator shall attach a copy of the Fees for Medical Records form to each request for medical records. The form instructs the health care provider where tomail the records and who to bill for the records. The form must be individualized to reflect the ABI Service Coordinator’s name and address.

Providers that bill SHCN must itemize the handling and per page fees for medical records in order to have their invoices accepted and processed. Invoices billed by the contracted agencies will not be accepted.

Invoices received by the contractor agency should be sent to SHCN immediately.

Mission, Philosophical Statement and Core Values

Mission

To provide for the identification and integration of resources for all eligible Missouri residents who sustain a traumatic brain injury, thereby enhancing their opportunity to obtain the necessary supports that will enable them to return to a productive lifestyle in their community.

Philosophical Statement

The ABI Program respects the human dignity of each individual and recognizes that each person should function as independently as possible within their community.

Core Values

ABI Program decisions are guided by the following core values:

• Person-centered;
• Outcome-oriented;
• Community integration;
• Natural and external support involvement in immediate and long-term goal planning;
• Personal responsibility for functional improvements;
• Resumption of a productive lifestyle;
• Responsible resource management; and
• Supportive partnerships.

Core Value Definitions

The ABI core values are defined below:

Person-centered:

Each individual has the right to participate in the planning and design of his/her services to the best of his/her capability. The participant’s abilities, wishes and desires are primary in making decisions about their goals.

Outcome-oriented:

Each individual’s program goals and objectives are regularly evaluated by the ABI Service Coordinator to assure benchmarks are being accomplished toward the long-term goals.

Community integration:

Goals, objectives, and all associated activities sponsored by the ABI Program are designed to encourage community integration and participation in age- appropriate life activities.

Natural and external support involvement in immediate and long-term goal planning:

While the participant is at the center of the planning process, their family and friends have a special knowledge of the participant that is considered and incorporated into all decision making, whether for small activities or long-term goals. The natural and external supports are expected to be willing to actively participate in the individual’s functional improvement with the participant at the center of the planning process.

Personal responsibility for functional improvements:

Participants are expected to actively participate in decisions about their care, and to engage in recommended strategies to progress towards the agreed-upon long-term goal(s). 

Resumption of a productive lifestyle:

Participants are expected to engage in specific goals of resuming a lifestyle of productivity such as return to work (paid or unpaid), school, independent living (supported or non-supported).

Responsible resource management:

The ABI Program is committed to the responsible management of any and all financial or programmatic resources available to the participant to assure maximum benefit from each.

Supportive partnerships:

The ABI Program requires that all parties/agencies involved in assisting participants collaborate and plan together for transitions from service to service and toward community reintegration.

Adult Brain Injury Program Service Coordinator Role

The ABI Service Coordinator (SC) is the contact person for the ABI Program. The SC will gather the required documentation needed for enrollment (i.e. medical, financial, lawful presence, etc.). The SC will assist with identifying goals, developing your treatment plan, and increasing independence.

Service Coordination Process

Service Coordination is a culturally competent, collaborative, proactive and comprehensive health care process designed to help each person achieve the best possible health and greatest degree of independence.

The primary mechanisms of service coordination are:

• Individualized Assessment;
• Planning;
• Plan implementation;
• Monitoring; and
• Transitioning

Refer to the Training Guide Development of Service Coordination Assessment located on the Training Resource Web Page for specific processes, activities, and principles regarding the primary mechanisms of Service Coordination.

Service Coordination Model

Definition, Principles and Key Components
Revised 5/2022

Referrals

A referral is a contact about a potential participant from any source, hospital, physician, family, friend, state agency, etc. When a referral is received, the information shall be entered into the SHCN Information System.

A response to the referral shall be made within ten (10) business days of the date of the referral by contacting the participant and initiating the enrollment process.

When transferring a participant from one Service Coordinator to other, a contact to the participant shall be made within ten (10) business days from the date of the records being received. Upon receipt of records, SHCN Information System shall be updated with the new Service Coordinator.

All individuals currently incarcerated are ineligible for enrollment; a denial letter will be mailed within ten (10) business days of the date of the referral.

An information/application packet consisting of at least (not limited to) the following items shall be given to the prospective participant/family:

• Application for Enrollment Letter (for mailing purposes);
• Enrollment Information, CC-1;
• ABI Program Fact Sheet;
• Special Health Care Needs Brochure;
• Missouri Greenbook: Living with Brain Injury;
• HIPAA Privacy Policy Acknowledgement Form;
• Authorization for Disclosure of Consumer Medical/Health Information;
• Rights and Responsibilities;
• Role of the Brain Injury Service Coordinator; and
• Brain Injury Association of Missouri Fact Sheet/Enrollment Form.

If the ABI Service Coordinator is unable to reach the potential participant after three attempts by phone, letter or in person visit or the family does not respond within 30 days after reaching them, the record may be closed.

The participant may be enrolled in Service Coordination after Lawful Presence verification, for a maximum of 180 days while additional documentation is gathered.

Eligibility and Enrollment

The ABI Program provides assistance in locating, coordinating and authorizing rehabilitation and psychological services for individuals who are twenty-one (21) up to sixty-five (65) years of age who have a traumatic brain injury medical diagnosis. RSMo Section 192.735 defines TBI as "a sudden insult or damage to the brain or its coverings, not of a degenerative nature. Such insult may produce an altered state of consciousness and may result in a decrease of one (1) or more of the following: mental, cognitive, behavioral, or physical functioning resulting in partial or total disability. Cerebral vascular accidents, aneurysms and congenital deficits shall be specifically excluded from this definition."

The forms in the application packet must be completed and signed by the legally responsible person. The forms include:

• Application for Enrollment form CC-1 (complete, sign and date);
• Rights and Responsibilities (sign and date);
• HIPAA Privacy Policy Acknowledgement form (sign and date); and
• Authorization for Disclosure of Consumer Medical Information (complete, sign and date for applicable purposes).

The participant must be a resident of the state of Missouri, be age twenty-one (21) up to sixty-five (65), and have sustained a traumatic brain injury (TBI). Financial eligibility is required only if the participant is to receive paid rehabilitative services from the ABI Program. To meet financial eligibility, the annual income must be 185 percent or less of the federal poverty level. Documentation of income must be provided to verify financial eligibility. (See the section on Financial Eligibility for further instruction.) All participants must provide affirmative proof of United States Citizenship or lawful presence in the United States before enrollment can occur. (See the section on Lawful Presence for further instruction.)

Service coordination is provided by the ABI Service Coordinator to all ABI participants. Participants enrolled in Paid Services are eligible to receive the rehabilitation services offered by the ABI Program.

The rehabilitation services are authorized by the ABI Service Coordinator and delivered by providers that have a contract to provide these services (this process is referred to later in the ABI Program Guidebook). A listing of the rehabilitation services provided by the ABI Program, along with a detailed description and information on service limits can be located in the ABI Program Provider Manual.

Medical Eligibility

Medical Eligibility is verified by obtaining copies of medical records that document injury to the brain caused by an external force, jolt, or penetration of the head. The diagnosis of traumatic brain injury can only be made by a practitioner licensed to diagnose. Every effort shall be made to obtain medical records verifying medical eligibility. In rare occasions when medical records cannot be obtained and good faith efforts have been exhausted, a letter from a physician or practitioner licensed to diagnose attesting to the evidence of a traumatic brain injury may be accepted with approval by the Program Manager. Medical records documenting a TBI must be obtained to verify medical eligibility. A listing of the eligible ICD codes is available in the SHCN Information System.

Lawful Presence

Pursuant to RSMo 208.009, all applicants 18 years of age and over must provide affirmative proof of United States citizenship or lawful presence in the United States to be eligible to receive public benefit.

ABI Service Coordinators shall notify designated Central Office staff of a referral. Designated Central Office staff will attempt to access and provide the ABI Service Coordinator with a copy of Missouri Birth Certificate information to be placed in the participant’s record. If this attempt is unsuccessful, the ABI Service Coordinator must request verifying documentation from the participant/family and maintain a copy of the documentation in the participant’s record. Once verification is received, a progress note shall be entered into the SHCN Information System identifying the document type used to verify lawful presence and a copy of the documentation shall be maintained in the participant’s record. Acceptable forms of verification, recognized by the Department of Revenue, include:

• Valid Driver or Non-Driver License;
• U.S. Birth Certificate – certified with an embossed, stamped or raised seal issued by a state or local government (Hospital-issued birth certificates are not acceptable);
• U.S. Passport;
• Certificate of Citizenship, Naturalization, or Birth Abroad; or
• Any document issued by the federal government that confirms an alien’s lawful presence in the United States.

If the name on the verification document does not match the participant’s current name, additional documentation will be required to verify the name change. (See Legal Topics – Legal Name Change [NEEDS LINK])

The ABI Service Coordinator must obtain all verifying documentation of lawful presence before Program enrollment can occur.

Good Faith Effort

A good faith effort consists of three (3) documented attempts to reach the participant/family.

These attempts should consist of two (2) phone calls or letters and at least one (1) attempted face to face contact.

All contacts and attempted contacts must be documented in the SHCN Information System on the date of each attempt.

Participants who do not respond to multiple attempts to schedule appointments, to obtain signatures on required paperwork, or who do not comply with Program guidelines should be discontinued from the Program and the record closed.

Comprehensive Assessment

Service Coordination Assessment

Assessment is a continuous activity that begins when the referral/application is received and continues throughout the service coordination process. Service Coordination Assessments (SCA) are due annually but no later than thirteen (13) months from the last completed assessment.

The assessment information is obtained through the use of the SCA. The initial SCA must be completed within thirty (30) calendar days of initial enrollment during a face to face visit with the participant/family. If the SCA was completed on initial visit and the enrollment process takes greater than six months, a new assessment is required within 30 days of actual enrollment. If a home visit is not feasible, contact the ABI Program Manager to request an exception to the home visit requirement.

A SCA must be completed initially, annually, and more frequently when warranted due to changing circumstances for all participants enrolled in Service Coordination and Paid Services.

No Prior Authorization (PA) of funds will be considered prior to the completion of a SCA, including entry into the SHCN Information System.

Information obtained during the comprehensive assessment will be used in the development of the service plan.

Contact the participant/family to schedule a face to face visit to complete the SCA and service plan. During the face to face visit, the ABI Service Coordinator will:

• Conduct an interview (using the SCA) with the participant/family to obtain assessment information,
• Identify services that the participant is currently receiving,
• Determine if additional services are needed,
• Explain what services are available and how to obtain these services,
• Provide contact names, addresses and telephone numbers, and
• Provide information about other resources that may be helpful to the participant/family

Review and obtain authorizing signatures on:

• Rights and Responsibilities and Acknowledgement Form,
• Privacy Policies and Acknowledgement Form, and
• Authorization for Disclosure of Information (as needed)

Review all available information, such as:

• Medical reports and written information, and
• Enrollment Information (ABI CC-1)

When the SCA and the plan of care have been completed, the ABI Service Coordinator will enter the information in the SHCN Information System.

The ABI Program Paid Service enrollment requires an unmet need, goal, and plan statement in at least one section of the SCA if receiving rehabilitation services. If there are no unmet needs, goals, or plans identified in any section of the SCA, but the participant wishes to remain enrolled in the ABI Program service coordination only, a statement will need to be entered in the Participant/Family Statement section of the SCA.

Provider Selection

The ABI Service Coordinator shall facilitate obtaining services for a participant with an enrolled ABI Program Provider. The participant shall be given a comprehensive list of providers available in their area regardless of referral source.

Participants have the right and responsibility to choose their own provider. When a participant waives their right to choose, the participant shall be assigned to a provider through a rotation basis amongst all eligible providers. The ABI Provider Choice Form must be completed by the participant when selecting a provider.

The ABI Service Coordinator shall document the list of providers given to the participant and theparticipant’s choice of provider within the SHCN Information System. When the participant waives their right to choose, the Service Coordinator shall document their refusal of selection along with the provider assigned for the participant within the CHSI Information System.

The Provider Selection Guide for the ABI Program form has been created to use as a tool to help the participant select a provider for their Rehabilitation Services that are funded by the ABI Program. It is up to the participant to carefully select a provider that best meets their needs. Distribute this form to the participant when they are ready to choose a provider. The form can be found under the Forms/Tools section of the guidebook.

Changing Provider Selection:

When a participant voices concerns over a provider’s performance, the ABI Service Coordinator shall empower the participant to communicate those concerns directly to appropriate provider staff (direct care staff and/or supervisor).

If the concerns remain unresolved to the satisfaction of the participant after written notification to the provider agency supervisor, the participant may choose to terminate their relationship with the provider agency. The agency shall be given a 30 day termination notice. If the participant chooses not to engage in services with the provider during the 30 days, the participant will not be authorized with another provider until the 30 days has lapsed.

In the case of issues related to participant well-being (abuse, neglect or exploitation), a provider/participant relationship may be terminated without the 30 day notice period. Any other issues that may require an exception to this guidance shall be brought to the ABI Program Manager for approval.

Treatment Plan and Progress Report

Treatment Plan

A treatment plan must be submitted by the provider for each individual and service that the provider delivers for the ABI Program participants. The treatment plan shall be developed with the input of the participant’s planning and treatment team, which includes the ABI Service Coordinator. The ABI Service Coordinator serves as the central point of knowledge about the participant’s functioning and needs, and shall assure that the provider’s treatment plan matches the needs of the participant at the time of service.

A treatment plan from the provider that coincides with the dates of authorized services must be submitted to the ABI Service Coordinator bi-annually. When a new participant is referred for services, the provider has 30 days from the first date of services authorized to complete and submit the treatment plan. Subsequent treatment plans must be submitted along with the request for authorization for continued services. The ABI Service Coordinator may deny authorization of services if an acceptable treatment plan is not received from the provider.

Treatment plans are due to the ABI Service Coordinator by the 10th of the month, prior to the authorized service period. When the 10th falls on a weekend, treatment plans are due by close of business on the Friday before the 10th. The following is a schedule of treatment plan and prior authorization due dates for participants in continuous services:

The treatment plan shall be submitted on the ABI Treatment Plan and Monthly Program Report by the provider with the exception of Neuropsychological Evaluations (reference documentation requirements in the Provider Manual).

Monthly Progress Reports

The Monthly Progress Report (after each month of service provided) must be submitted to the ABI Service Coordinator by the 10th of the month following the month the services were received. When the 10th falls on a weekend, monthly progress reports are due by close of business on the Friday before the 10th. The following is a schedule of progress report due dates:

The Monthly Progress Report is an update on the participant that communicates timely and relevant issues to the ABI Service Coordinator. The ABI Service Coordinator’s knowledge of these issues is key to enabling the ABI Service Coordinator to assist in the comprehensive service coordination needs of the participant. Significant changes in participant’s status or identification or concerns for the participant should be reported immediately to the ABI Service Coordinator without waiting for the submission of a Monthly Progress Report.

The Monthly Progress Report shall be submitted on the ABI Treatment Plan and Monthly Progress Report by the provider with the exception of Neuropsychological Evaluations (reference documentation requirements in the Provider Manual). A clinical evaluation report of a neuropsychological examination must be submitted to the ABI Service Coordinator following the examination.

The treatment plan and monthly progress reports must be submitted typewritten or in legible handwriting. If submitted in handwriting that is not legible, the ABI Service Coordinator may request a typewritten report. The ABI Service Coordinator may request additional information from the provider if needed to consider continuation of the service.

Participant Treatment Plan/Progress Meeting

In order to facilitate effective services for the participant, the ABI Service Coordinator, provider and participant shall have a team meeting at least once every six (6) months to discuss progress and further treatment plans. This meeting will be facilitated by the ABI Service Coordinator. An ABI Service Coordinator, provider or the participant may request the team to meet more often.

Prior Authorization and Prior Authorization Modification of Services

All rehabilitation services provided through the ABI Program must be prior authorized. Refer to ABI Provider Manual under Rehabilitation Services for a detailed and thorough review of comprehensive services offered by the program. Services are authorized on a monthly basis up to thirteen (13) months within an authorization period.

No more than two rehabilitation services may be authorized for the same time period foreach participant.

The following steps are to be followed in the prior authorization process:

1. The provider submits a request for services directly to the ABI Service Coordinator by the tenth (10th) of the month prior to the month in which the service is to be provided, by completing the ABI Program Prior Authorization form. The prior authorization may be automatically denied if the provider does not submit an authorization prior to the 10th of the month. (Applies specifically to renewal of services.)
2. The ABI Service Coordinator shall review the prior authorization request and make recommendation (approval, denial, or approval with modification) by considering the following:
   1. the participant is properly enrolled;
   2. the participant meets financial eligibility;
   3. all other payer sources have been considered for requested service and it is determined that the ABI Program is payer of last resort;
   4. the requested service is in accordance with the participant’s goals in the individualized treatment plan; and
   5. the requested amounts of service are within the acceptable service limit thresholds as defined for each service in the ABI Provider Manual (Reference SHCN Information System Financial Management Cap History field.)
      
      If the participant does not meet financial eligibility, the ABI Service Coordinator shall recommend denial and assist the participant in locating other resources.
      
      If the participant is enrolled, meets financial eligibility, the service is appropriate, and service limits have not been exhausted, the ABI Service Coordinator shall recommend approval following guidelines as established in the ABI Program Provider Manual.
3. If the participant is enrolled, meets financial eligibility, and the service is appropriate but the ABI Service Coordinator determines the units requested needs to be modified; the ABI Service Coordinator will approve with modification and indicate the number of modified units. The ABI Service Coordinator shall complete the Service Coordinator portion of the ABI Program Prior Authorization form, and submit to Central Office within five (5) working days after the 10th of the month, or by the date specified by the Program Manager.
4. Central Office staff shall process the prior authorization request based on available funds and shall notify the provider and ABI Service Coordinator of approval or denial by the first (1st) working day of the next month.
5. The ABI Service Coordinator will receive the approved prior authorizations after final processing by the ABI Program Manager. ABI Service Coordinators may also run a report, listing the services authorized for each participant for a given time period.

Participants shall be authorized for services by the Program Manager, dependent on available funds, in the following order of priority:

• Participants who are already receiving ABI paid services deemed appropriate by his/her individualized treatment plan, shall have priority for service funds in order to assure accomplishment of the participant’s goals;
• Participants who have had ABI paid services within the last six (6) months from the last date of paid service of the last paid claim may be considered for priority for service funds; and
• Participants on the waiting list: Authorization off the waiting list is by the order in which participants were placed on the waiting list.

Prior Authorization Modification of Services

If a participant’s needs should change during the originally authorized time frame, it may be appropriate to request an increase or decrease in services as appropriate to the participant’s situation. In this event, the Provider shall complete an ABI Program Prior Authorization Modification Form. This form is then submitted to the Service Coordinator for review. The ABI Service Coordinator will submit the ABI Program Prior Authorization Modification Form to SHCNBrainInjuryPA@health.mo.gov for final approval of the modification request. This approval is based upon the recommendation of the Service Coordinator regarding appropriateness and the availability of funding if the modification requires an increase in services.

The Service Coordinator and Provider will receive a copy of the ABI Program Prior Authorization Modification Form, once processed by SHCNBrainInjuryPA@health.mo.gov .

All requests for increases in services originally authorized require the submission of the ABI Program Prior Authorization Modification Form. The request should be submitted prior to delivering the additional services. The ABI Program is not responsible for services delivered that are not authorized. Requests for a decrease in services originally authorized are required when the amount of service delivered is less than the original amount authorized. The request for a decrease in authorization is also submitted on the ABI Program Prior Authorization Modification Form. This form should be submitted to the ABI Service Coordinator by the10th of the month following the month of service.

Implementation of the Service Plan, Monitoring and Evaluation, Transition and Closure

The participant/family shall receive efficient and effective delivery of services as specified in the treatment plan. It is the ultimate goal of the ABI Service Coordinator to assist the participant/family to become as independent as possible and develop the skills needed to obtain services with minimal assistance.

Implementation of the Treatment Plan

Once a treatment plan is developed (through the annual Service Coordination Assessment), the ABI Service Coordinator shall implement the service plan by assisting the participant/family in linkages and access to community resources and agency services that will assist the participant in fulfilling their unmet needs and goals. During the implementation stages, the ABI Service Coordinator fulfills such roles as educator, advocator, facilitator, collaborator, coordinator, etc.

Monitoring and Evaluation

The ABI Service Coordinator shall periodically monitor and evaluate the treatment plan. Participants’ progress toward reaching outcomes and appropriateness of services shall be reviewed every six months (by phone or in person) and any time there is a significant change. A full assessment and review of continued eligibility will be conducted annually.

Transition

Participants will have a transition plan in place for all appropriate times of transition, such as age, service discontinuation, change in a Service Coordinator or agency, or major life event.

Discussions about transition begin as soon as the participant is enrolled in the ABI Program and continue periodically throughout enrollment. Discussions should include expected outcomes and behaviors appropriate to Health Care, Educational/Vocational, and Independent Living. Collaborate with other agencies to identify appropriate transition team members including the participant and the caregiver/family. When possible, schedule a transition meeting with the family and other appropriate key players within six (6) months of the anticipated transition.

The Transition Plan form may be completed to identify action steps, timelines, and person(s) responsible including incorporating participant/family concerns and priorities. Document that a Transition Plan has been placed in the participant file in the SHCN Information System. When a Transition Plan Form is not utilized, documentation is necessary in the transition activities in the SHCN Information System.

Closure

The length of time participants are enrolled in services is unique to the individual’s needs and progress towards goals. At the point that a participant has reached all their goals and sustained them over some time, the ABI Service Coordinator and participant/family may discuss a change in program enrollment (Service Coordination only vs. Paid Services) or possible closure from either enrollment. Through effective Service Coordination, it is the goal for all participants to ultimately be able to achieve and maintain their independence and no longer require our services.

Telehealth

ABI providers may be considered to provide services through telehealth for ABI participants that have the capabilities of doing so.

Telehealth services may be used for Transitional Home & Community Services (THCS), Adjustment Counseling and Special Instruction services

Approval to deliver telehealth services must be granted by the ABI Service Coordinator as well as the ABI Program Manager.

The provider must supply a detailed explanation in writing as to how services will be delivered.

The explanation must be submitted to the ABI Service Coordinator for review, who will then send to the ABI Program Manager for approval.

Telehealth approvals will be granted on a month to month basis. If at any time the participant, ABI Service Coordinator, or ABI Program Manager feels that services aren’t being provided appropriately, telehealth services will be terminated effective immediately.

Mandatory Reporting

Abuse and neglect occurs when a person(s) responsible for the care of a child, person over the age of 60 or person with a disability, either deliberately or by extraordinary inattentiveness, permits the individual in his/her care to experience avoidable suffering and/or fails to provide one or more of the components deemed essential for developing a person’s physical, intellectual, and emotional capacities.

When an ABI Service Coordinator first meets with a family/participant the ABI Service Coordinator may want to make them aware that one of the roles of an ABI Service Coordinator is as a mandated reporter. ABI Service Coordinators must report suspected abuse/neglect, whether or not it involves an enrolled participant with the ABI Program. ABI Service Coordinators receiving third party allegations must direct the reporter to call the hotline and report the incident as well as make a hotline report themselves. The determination as to whether the event is investigated is the responsibility of the protective service agency.

Concerns to report may include, but are not limited to:

• Suspected neglect,
• Any non-accidental physical injury or injury which is at variance with the history given,
• Suspected sexual abuse,
• Suspected emotional abuse,
• Non-organic failure to thrive, and
• Suspected financial exploitation.

How to report:

The following procedure shall be carried out when the decision to report suspected abuse/neglect:

• For suspected abuse/neglect of individuals ages 0 thru 17 years, call the Children’s Division at (800) 392-3738 or report on-line.
• For suspected abuse or neglect of a person with a disability 18 years of age or older or a person 60 years of age or older, staff will call the Division of Senior and Disability Services at (800) 392-0210 or report on-line.
• Notify the Program Manager within one (1) business day of making the report by completing the Confidential Event Report Form and emailing it to the Program Manager

How to Document:

Documentation of a Mandated Report requires two (2) separate progress note entries.

• The first progress note entry records the entire incident (without mention of making a Mandatory Report (Hotline Call)).
  • Appropriate Contact Type selection will indicate how the Service Coordinator learned of the incident, i.e., participant visit or participant contact.
• The second progress note entry records the action of physically making the Mandated Report (Hotline Call).
  • Contact Type selection is always ‘Other’.
  • The body of the progress note will only state ‘A hotline call was made.’
  • No additional statement is to be entered.
  • This progress note entry will follow the first progress note in date/time sequence.

Your employer may require you to follow additional protocol.

Emergency Response Identification and Information

The ABI Service Coordinator will offer assistance to all participants/families that are enrolled in the ABI Program to establish an Emergency Response Plan.

Emergency management and response materials/publications should be given to each participant/family. The ABI Service Coordinator will offer assistance with the completion of an emergency management plan. The plan will be reviewed with the participant/family annually.

When an emergency such as a natural disaster or terrorism event occurs, the ABI Service Coordinator shall contact participants/families whose care may have been compromisedas soon as possible, after the event to assess for unmet needs. The contact may be by phone or in-person and shall be documented in the SHCN Information System.

Responsible Party/Alternate Contact Person

In an effort to maintain lines of communication, a responsible party and alternate contact person shall be identified. Contact information for both shall be obtained and documented in the SHCN Information System for each Program participant.

The responsible party is identified as the individual who holds legal responsibility for the participant. The responsible party is a person with whom sensitive health information can be shared by the ABI Service Coordinator, or designated representatives of SHCN. All forms must be completed and signed by the legally responsible party. Documentation verifying legal custody, guardianship, or relative caregiver must be obtained and placed in the participant’s legal record.

The responsible party is determined as one of the following:

• A participant who is an emancipated minor;
• A participant eighteen (18) years of age or older;
• A participant eighteen (18) years of age or older and the parent (if the participant is claimed as a dependent on someone else’s federal tax form);
• Any parent who has legal custody of his/her minor child;
• Any minor who is lawfully married;
• Any minor parent for himself/herself and any child in his/her legal custody;
• Any legal (court appointed) guardian for the participant;
• The individual with “physical” custody of the participant when living with other than both parents; or
• The legal guardian when the participant is in foster care.

The alternate contact person is someone who will know how to get in touch with the participant/family and can assist in contacting the family. Sensitive health information may not be shared with the alternate contact person.

The ABI Service Coordinator will request the participant/family to identify both a responsible party and an alternate contact person during the initial interview and annually thereafter. If participant doesn’t have an alternate contact, the ABI Service Coordinator will make a progress note in the SHCN Information System using contact type (other) and state that participant does not have an alternate contact.

Transporting Participants

ABI Service Coordinators are not permitted to transport participants. Through service coordination, identify other means of transportation available for participants.

Interpreter Services

Service Coordinators must provide interpreter (language, Braille, or sign) services for a participant/family when the provision of service coordination is not possible due to the inability to communicate.

In an effort to promote a higher degree of independence and health literacy, consideration of referrals to resources to reduce language barriers are encouraged. Language barriers may interfere with the provision of services to the participant/family leading to misunderstandings and impacting program effectiveness. Effective language services through a professional interpreter can help prevent these problems. Service Coordinators must offer and encourage the utilization of professional interpreter services during any communication with the participant/family when there is a language barrier present. If professional interpreter services are refused by the patrician/family, this refusal must be documented in progress notes to justify the use of a non-professional interpreter (i.e. bilingual family member, friend, etc…)

Service Coordinators should use the current state contract for providing interpretation and translation services. All interpreter services must be documented in the SHCN Information System services screen and limited to direct Program service coordination. Participants/families should be instructed in the use of interpreter services, if applicable. (See ABI Interpreter Usage Data Sheet, including the ABI Interpreter Process and Resource Guide for completion.)

ABI may also provide interpreter (language, Braille, or sign) services for a participant/family through an individual who is enrolled as a SHCN provider when the provision of service coordination is not possible due to the inability to communicate and the use of the state contract is not possible. If unable to use the state contract or an ABI provider, supporting documentation must be entered in the SHCN Information System, including the participant/family refusal of professional interpreter services.

Outreach

Outreach activities are vital to the success and implementation of the ABI Program. Providing information to the public regarding program services is an important part of service coordination. Much needed information will help communities respond to the special needs of brain injury survivors and assist their families to access needed resources. A very large service network is comprised of hospitals, clinics, public health organizations, rehabilitation centers, government agencies and community groups, all of which serve special needs populations in various ways. The opportunities are almost endless for engaging in outreach activities and making connections in Missouri communities.

What is outreach?

An organized effort to expand awareness of and participation in SHCN programs throughout Missouri. In essence, outreach is the mission of SHNC: “To develop, promote and support community-based systems that enable the best possible health and greatest degree of independence for Missourians with special health care needs.”

How does it strengthen the program?

• Provides community/organizations with awareness of services that the Program offers.
• Provides an opportunity to learn how other agencies’ services can benefit Program participants.
• Provides opportunities to work with stakeholders in an effort to promote positive outcomes, as well as advocate for brain injury survivors and their families.
• Provides opportunities for feedback to improve program and/or services.
• Builds collaboration with providers to assure participant’s needs are met.

What are strategies for maintaining outreach?

Outreach is always a collaborative effort. Partnering agencies and organizations are often very interested in networking opportunities that will promote understanding and provide needed services to brain injury survivors and their families. Opportunities and strategies for conducting and maintaining outreach may be found in the following areas: medical and agency/community.

Medical

• Provide information to medical rehabilitation facilities, hospitals, doctors, nurses, therapists, and social workers.

Agency/Community

• Become involved with local community coalitions.
• Promote Support Group activities.
• Present at local meetings.
• Make it a part of your routine by researching and visiting various organizations that may benefit participants.
• Engage in conversations, such as phone referrals, explaining how to make referrals and share community resources.

Suggestions on how to conduct outreach

• Network with various organizations that have a similar mission and often provide services to the same population (health alliances, family coalitions, immigrant/refugee coalitions).
• Recognize the differences in providing outreach in urban vs. rural areas.
• Utilize outreach tools for identifying outreach sources and tracking activities.
• Adult Brain Injury Outreach Presentation located on the ABI Service Coordinator Secure Website.

Waiting List

The ABI Program Provider manual describes in detail the requirements to be a provider for the ABI Program. Providers must be enrolled with SHCN before submitting authorizations for services. The current manual may be accessed here. This same link can also be accessed on the ABI Service Coordinator Secure webpage.

Additional information for Providers can be located by clicking on the ABI Providers link located on the SHCN webpage [BROKEN LINK]. Provider questions regarding service claims shall be referred to SHCN Central Office at (573) 751-6246.