Medically Complex Children and Youth Guidebook

This section references the HCY Case Management service that is requested and delivered by a MO HealthNet Case Management provider such as a local public health agency, doctor, or community based clinic. The role of the HCY SC is to authorize these services and process prior authorizations as appropriate. 

HCY Case Management is an activity under which responsibility for locating, coordinating, and monitoring a group of necessary services for a participant rests with a designated person or organization in order to promote the effective and efficient access to necessary comprehensive health services. HCY Case Management seeks to promote the good health of participants and includes referral to various agencies for other needed services, such as Women, Infant and Children (WIC). It centers on the process of collecting information on the health needs of the participant, making and following up on referrals as needed, maintaining a health history, and activating the examination/diagnosis/treatment ‘loop’.

HCY Case Management may be used to reach out beyond the bounds of the MO HealthNet Program to coordinate access to a broad range of services, regardless of the source of funding for the services to which access is gained. The services to which access is gained must be found by the MO HealthNet Program to be medically necessary for the participant. HCY Case Management services are intended to assist MO HealthNet eligible individuals in gaining access to needed medical, social, educational, and other services. However, MO HealthNet cannot pay for social, educational, and other services that are not medical in nature even though HCY Case Management which assists the individual in accessing these services is covered. 

Case Management Authorization

To provide and bill for HCY Case Management, a provider must be approved and enrolled as a Case Management provider with MO HealthNet.

Prior Authorization requests must be initiated by the provider who will be performing the HCY Case Management services. The provider must submit a Prior Authorization (PA) to the SHCN office. A separate procedure code and reimbursement have been established for the first month that HCY Case Management services are provided. (This includes the assessment and development of a care plan and a face-to-face encounter that includes an educational component.) The initial month should be written on a separate line, with the appropriate procedure code, than the subsequent months. The ‘from’ date in the initial month is the date the services were initiated. The ‘through’ date in the initial month is the last day of that calendar month. Subsequent months should be entered on separate lines with the appropriate code. (The Procedure Code for subsequent months cannot be billed during the same month as the initial case management visit.) The PA cannot be written to exceed more than 6 calendar months.

The HCY Facilitator shall review the PA upon SHCN receipt to assure the accuracy and completeness of the required information.

The HCY SC shall review the plan of care prepared by the Case Management Provider. The plan of care must indicate the date of the full/partial/interperiodic screen that resulted in the establishment of the medically necessary case management services and the date of the most recent full HCY screen. If the participant has not received a full screen, the Case Management Provider must make arrangements for a full screen and follow up that the screen was obtained, including all age-appropriate immunizations and lead screening, if indicated. The plan must contain the type of interventions, frequency of visits, if home visits are necessary, and an end date. The SC shall indicate the approval or denial of HCY Case Management services, sign the PA, and the HCY Facilitator will process the PA.