Case Management Agency Exceptions Process and Forms

While the primary function of the Weld County Case Management Agency (WCCMA) is to provide case management to members residing within the Weld County Designated Service Area (DSA), providing case management to members residing outside of Weld County will be considered on a case-by-case basis. 

These processes demonstrate a structured approach to handling member requests and ensuring a smooth transition, either with WCCMA continuing services or facilitating a transfer to another case management agency based on the member's needs and preferences.

In compliance with the federal mandate for conflict-free case management, the Colorado Department of Health Care Policy and Financing (HCPF) has undertaken a redesign of its case management system. The objective is to enhance the quality, accountability, simplicity, and stability of long-term care programs throughout the state. Consequently, HCPF has initiated a competitive solicitation process to choose a qualified CMA for each of the twenty designated service areas in Colorado. These selected CMAs will be responsible for delivering case management services for all long-term care programs within their respective service areas.

Individuals enrolled in a Colorado Medicaid or State General Fund Long Term Care program are allocated to a CMA within a specified service area corresponding to their residence. Should members prefer not to receive services from their designated agency, they are required to collaborate with their current agency and adhere to its procedures for choosing an alternative qualified CMA. Members have the option to initiate a request for transfer to another agency through this established procedure. The chosen agency must express willingness and demonstrate capability to fulfill the necessary case management functions, as well as bear the associated costs of serving a member residing outside their designated service area.

Member Request Receipt:

When a member residing in the Weld County DSA submits an exception request, the assigned Case Manager will receive and document the request.

Request Review:

The assigned Case Manager will:

• Review the exception request with the member.
• Inform the Division Director (or designee) of the Member’s request and reason for requested exception.

Contacting Selected CMA:

The assigned Case Manager will contact the selected CMA chosen by the member and discuss the selected CMA's ability and willingness to comply with contractual case management requirements and accept associated costs.

Approval by Selected CMA:

The assigned Case Manager will:

• Establish the transition date with the member and the selected CMA.
• Notify Member through the Member Exception Notification Letter, indicating outcome for the request.
• Inform the Division Director (or designee) of the approval to transfer.
• Document the member's selection and the reason for the exception in the Care and Case Management (CCM) system.

Decline by Selected CMA:

The assigned Case Manager will:

• Notify Member through the Member Exception Notification Letter, indicating outcome for the request.
• Inform the Division Director (or designee) of the denial to transfer.
• Document the decision in the Care and Case Management (CCM) system.

Member Request Receipt:

When a member residing within another DSA submits an exception request and would like WCCMA to be their Case Management Agency, the WCCMA team member receiving the request will forward it to the WCCMA Supervisor(s) for review.

Request Review:

The WCCMA Supervisor will:

• Review the exception request and review criteria for Member Requests.
• Will contact and review the request with the Member and/or current CMA.
• Inform the Division Director (or designee) of the Member’s request and review decision for final approval.

Review Criteria for Member Exception Requests:

WCCMA will consider the following criteria to determine if they can meet contractual requirements and accept additional costs associated with serving a Member outside of the DSA:

Staffing Levels and Capacity:

Evaluate if there are appropriate staffing levels and capacity to complete required case management functions adequately.

Feasibility Based on Geographic Location:

Assess the feasibility of providing required case management services considering factors such as mileage, in-person visits, and Member access.

Local Knowledge and Community Resources:

Ensure there is adequate local knowledge and access to community resources to support the Member's needs.

Decision Issuance within 10 Business Days:

WCCMA will issue their decision on the Member exception request within 10 business days by:

• Notify the current CMA of the approval or denial of the exception request.
• Notify the Member through the Member Exception Notification Letter, indicating the outcome of the request.

Upon Approval:

If the Member exception request is approved, WCCMA will:

• Document all approvals on the HCPF Exception tracking system.
• Assign a Case Manager
• The assigned Case Manager will:
  • Coordinate a transition date with the current CMA.
  • Add Member information to the WCCMA data tracking system.
  • Schedule an in-person visit and provide a case summary update within 10 business days of the transfer.

Member Request Receipt:

When a member who was receiving services from the WCCMA moves outside the Weld County DSA and requests to continue receiving services from the WCCMA, the assigned Case Manager will receive and document the request.

Request Review:

• The assigned Case Manager will review the exception request with the member.
• Inform the Division Director (or designee) of the Member’s request and review decision for final approval.

Review Criteria for Member Exception Requests:

WCCMA will consider the following criteria to determine if they can meet contractual requirements and accept additional costs associated with continuing to serve a Member that has moved outside of the DSA. Consideration will include:

Staffing Levels and Capacity:

Evaluate if there are appropriate staffing levels and capacity to complete required case management functions adequately.

Feasibility Based on Geographic Location:

Assess the feasibility of providing required case management services considering factors such as mileage, in-person visits, and Member access.

Local Knowledge and Community Resources:

Ensure there is adequate local knowledge and access to community resources to support the Member's needs.

Decision Issuance within 10 Business Days:

WCCMA will issue their decision on the Member exception request within 10 business days by:

• Notify the Member through the Member Exception Notification Letter, indicating the outcome of the request.

Upon Approval:

If the Member exception request is approved, WCCMA will:

• Document all approvals on the HCPF Exception tracking system.
• Document the decision in the Care and Case Management (CCM) system.
• Member will remain with the current Case Manager