Billing Documents
- EBL NCM Reimbursement Process
- EBL NCM Home Visits Reimbursement Form for PHN Visits
- PHN: FSR Supplemental Form – Medicaid
- PHN: FSR Supplemental Form – Non-Medicaid
- NCM Reimbursement Requirements for FY 26
- Tips and Tricks for NCM Reimbursement Spreadsheet
Pilot Case Management Forms and Procedures – effective August 1st, 2024
Procedures
- Nursing Case Management Documentation Standards Procedure Pilot V1.1
- Scope of Standards and Standards of Practice Pilot
- Managing Elevated Capillary Blood Tests Procedures Pilot
- Managing Elevated Venous Blood Lead Tests Procedures Pilot
- Case Closure of Elevated Venous Blood Lead Levels Procedure Pilot
- Community Health Worker Documentation Standards Procedure New Pilot V1
- Community Health Worker Responding to Elevated Venous Blood Lead Test Procedures New Pilot V1
- Community Health Worker Responding to Elevated Capillary Blood Lead Test Procedure New Pilot V1
- PHN Chelation Checklist Pilot
Forms
Instructions for form usage – please click on links below to download forms. Forms will be placed in a download file on your computer, then when you open form, you must click “Enable Editing” to begin filling in fields.
Training Materials
Scenarios
- Scenario 1 – Initial Nursing Case Management Home Visit
- MDHHS-6117 Initial Home Visit Form Scenario 1 Example
- MDHHS-6135 Individualized Plan of Care Form Scenario 1 Example
- Scenario 2 – Chelation
- Scenario 3 – Post Chelation Follow Up Visit
- MDHHS-6134 Follow Up Nursing Home Visit Chelation Scenarios
- MDHHS-6136 Chelation Addendum – Chelation Scenarios
Community Health Workers Guide and Forms
CLPPP Policies
Letters for Providers
- Letter for Provider – Unable to Reach
- Letter for Provider – Unable to Reach (Spanish)
- Letter for Provider – Unable to Reach (Arabic)
- Letter for Provider – Unable to Reach (Burmese)
- Letter for Provider – Unable to Reach (Swahali)
- Letter for Provider – NCM Complete
- Letter for Provider – NCM Complete (Spanish)
- Letter for Provider – NCM Complete (Arabic)
- Letter for Provider – NCM Complete (Burmese)
- Letter for Provider – NCM Complete (Swahali)
- Letter for Provider – NCM Declined
- Letter for Provider – NCM Declined (Spanish)
- Letter for Provider – NCM Declined (Arabic)
- Letter for Provider – NCM Declined (Burmese)
- Letter for Provider – NCM Declined (Swahali)
Other Documents
Letters for Families
- Letter for Family – Case Closure
- Letter for Family – Case Closure (Spanish)
- Letter for Family – Case Closure (Arabic)
- Letter for Family – Case Closure (Burmese)
- Letter for Family – Case Closure (Swahali)
- Letter for Family – Confirmatory Venous
- Letter for Family – Confirmatory Venous (Spanish)
- Letter for Family – Confirmatory Venous (Arabic)
- Letter for Family – Confirmatory Venous (Burmese)
- Letter for Family – Confirmatory Venous (Swahali)
- Letter for Family – Opted Out of NCM
- Letter for Family – Opted Out of NCM (Spanish)
- Letter for Family – Opted Out of NCM (Arabic)
- Letter for Family – Opted Out of NCM (Burmese)
- Letter for Family – Opted Out of NCM (Swahali)
- Letter for Family – Test Due
- Letter for Family – Test Due (Spanish)
- Letter for Family – Test Due (Arabic)
- Letter for Family – Test Due (Burmese)
- Letter for Family – Test Due (Swahali)
- Letter for Family – Test Overdue
- Letter for Family – Test Overdue (Spanish)
- Letter for Family – Test Overdue (Arabic)
- Letter for Family – Test Overdue (Burmese)
- Letter for Family – Test Overdue (Swahali)
- Letter for Family – Unable to Reach
- Letter for Family – Unable to Reach (Spanish)
- Letter for Family – Unable to Reach (Arabic)
- Letter for Family – Unable to Reach (Burmese)
- Letter for Family – Unable to Reach (Swahali)