Library: Policy

317:30-5-1014. Documentation of records

Revised 6-25-12

All case management services rendered must be reflected by documentation in the records. All units of SoonerCare DDSDTCM services provided are documented by the case manager weekly in Client Contact Manager. The following conditions must be met in order for case management services to reimbursed under SoonerCare.

(1) The case manager must conduct a face-to-face interview with the member in order to determine member needs and develop approaches to meet these needs.
(2) The case manager with a team including the member or member's representative, must develop a plan of care which is documented in the case record.
(3) The case manager must reassess the plan of care when necessary but at a minimum annually.
(4) The case manager must provide documentation to supplement the plan of care which includes:

(A) information supporting the selection of outcomes;
(B) information supporting the approaches selected;
(C) information supporting case management decisions and actions;
(D) documentation of communication with the member and, as appropriate, his/her representative;
(E) documentation of linkages with resources;
(F) documentation of follow-up and monitoring of the plan; and
(G) other factual information relevant to the case.