MSHO Unable to Reach Outreach Form

Instructions: Complete one MSHO Unable to Reach (UTR) Outreach form for each Health Risk Assessment (HRA) when the Care Coordinator was unable to reach a member to complete an initial, annual, change of condition or request for EW services HRA. All sections must be completed.

All outreach attempts and the unable to reach letter are to be completed on different dates and at different times. All outreach attempts and letter sent dates must be documented prior to the HRA date; no outreach attempts are conducted after the HRA date.

Completion of the form is required and needed to support CMS Data Validation/Primary Source Verification requirements. The form is to be retained in the member’s chart to ensure outreach attempts, including letter being sent, are clearly documented and identifiable. This form may be requested to support CMS Primary Source Verification.

General Information HealthPartners Member ID: Member Last Name: Member First Name:
Outreach Attempt Date of First Attempt: Time: Date of Second Attempt: Time: Date of Third Attempt: Time: Reason for no contact: Coverage termed Attempted, Invalid phone number Attempted, no ability to leave a message Attempted, no response to messages Other reason:
UTR Letter Sent to Member Was UTR letter sent to member? Yes No Date UTR letter sent to member:

Date: Care Coordinator Signature