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This is an organized service that provides intensive evaluation and treatment delivered in an acute care inpatient setting by medical and nursing professionals under the supervision of a psychiatrist. This service is designed to provide continuous treatment for members with acute psychiatric problems. This service focuses on reducing acute psychiatric symptoms through in person, structured group and individual treatment.

Authorization Guidelines

Prior authorization is not required for the first 72 hours of service. Initial Requests (after pass through):

• 1. TAR: prior authorization required within the first 72 hours of service initiation.
• 2. Certificate of Need (CON): Required at admission to a freestanding psych hospital or within 14 calendar days of an emergency admission for members under 21.
• 3. CCA or DA: Required. An H&P/ Initial Psychiatric Evaluation may satisfy this requirement.
• 4. Service Order: Required, signed by a physician, LP, PA, or NP. A signed H&P/ Initial Psychiatric Eval meets this requirement.
• 5. Service Plan: Required
• 6. Submission of all records that support the individual has met the medical necessity criteria.

Reauthorization Guidelines

• 1. TAR: prior authorization required.
• 2. Updated Tx Plan/ PCP: Required
• 3. Submission of applicable records that support the member has met the medical necessity criteria.

Conditional Requirements

For Behavioral Health, prior authorization is not required for the first 72 hours of service.  For Physical Health, no prior authorization is required.

Unit Value

Per diem based on the midnight bed count

Limits

• 1. The case management component of IIH, MST, CST, ACT, SAIOP,

SACOT & CADT can be provided to those admitted to or discharged from this service. Support provided should be delivered in coordination with the Inpatient facility.

• 2. Medicaid eligibility must be verified each time a service is rendered.
• 3. Service is EPSDT eligible, but this does not eliminate the requirement

for prior approval.

• 4. Discharge Planning shall begin upon admission to this service.
• 5. Medicaid shall not cover services in a freestanding psychiatric hospital

for members over 21 or less than 65 years of age for mental health disorders.

• 6. Prior authorization is not required for MCD BH Services rendered to

Medicare/Medicaid dual eligible members or members with 3rd-party insurance because MCD is the payer of last resort. When MCD becomes the primary payer, a primary payer auth denial/ exhaustion of benefits letter is submitted with the MCD TAR.

• 7. Out-of-State emergency admissions do not require prior approval. The

provider must contact Trillium within one business day of the emergency service or emergency admission.

Length of Stay

• 1. Reauth requests must be submitted prior to the end of the current auth. A late submission resulting in unauthorized days requires splitting the stay for claims payment purposes. Retrospective auths due to late submissions is not permitted.
• 2. For state psychiatric hospitals, the initial auth will be for a minimum of 10 days (including the pass-through days).

Age Group Details

Adolescent and Adult

Place of Service

This service may be provided at a psychiatric hospital or on an inpatient psychiatric unit within a licensed hospital licensed as inpatient psychiatric hospital beds or in State operated facilities.

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

• Trillium iTransact Portal
• Trillium Provider Direct Portal

Resources

• Clinial Coverage Policy No: 8-B, Inpatient Behavioral Health Services
• https://medicaid.ncdhhs.gov/documents/july-2012-medicaid-bulletin

This is an ASAM Level 4 for adolescent and adult members whose acute biomedical, emotional, behavioral and cognitive problems are so severe that they require primary medical and nursing care. The outcome of this level of care is stabilization of acute signs and symptoms of substance use, and a primary focus of the treatment plan should be coordination of care to ensure a smooth transition to the next clinically appropriate level of care.

Authorization Guidelines

Prior authorization is not required for the first 72 hours of service. Initial Requests (after pass through):

• 1. TAR: prior authorization required within the first 72 hours of service initiation.
• 2. Certificate of Need (CON): Required at admission to a freestanding psych hospital or within 14 calendar days of an emergency admission for members under 21.
• 3. CCA or DA: Required. An H&P/ Initial Psychiatric Evaluation may satisfy this requirement.
• 4. Service Order: Required, signed by a physician, LP, PA, or NP. A signed H&P/ Initial Psychiatric Eval meets this requirement.
• 5. Service Plan: Required
• 6. Submission of all records that support the individual has met the medical necessity criteria.

Reauthorization Guidelines

• 1. TAR: prior authorization required.
• 2. Updated Tx Plan/ PCP: Required
• 3. Submission of applicable records that support the member has met the medical necessity criteria.

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

Unit Value

Per diem based on the midnight bed count

Limits

• 1. The case management component of IIH, MST, CST, ACT, SAIOP, SACOT & CADT can be provided to those admitted to or discharged from this service. Support provided should be delivered in coordination with the Inpatient facility.
• 2. Discharge planning shall begin upon admission to the service.
• 3. This level of care must be capable of initiating or continuing any MAT that supports the member in their recovery from substance use.
• 4. Prior authorization is not required for MCD BH Services rendered to Medicare/Medicaid dual eligible members or members with 3rd-party insurance because MCD is the payer of last resort. When MCD becomes the primary payer, a primary payer auth denial/ exhaustion of benefits letter is submitted with the MCD TAR.
• 5. For ADATCs: For members under the age of 21, admission authorization shall be requested by the facility the next business day following admission if the individual presents directly to the facility, by submitting a completed Non-Covered State Medicaid Plan Services Request Form to the Health Plan. To request re-authorization, the ADATC shall submit a completed Electronic Authorization Request to the Health Plan prior to the expiration of the admission authorization. The form shall be submitted by the ADATC on the last covered day of the existing authorization (or the previous business day if the last covered day occurs on a weekend or holiday).

Length of Stay

• 1. Reauth requests must be submitted prior to the end of the current auth. A late submission resulting in unauthorized days requires splitting the stay for claims payment purposes. Retrospective auths due to late submissions is not permitted.
• 2. For state psychiatric hospitals, the initial auth will be for a minimum of 10 days (including the pass-through days).

Age Group Details

Adolescent and Adult

Level of Care

• 1. Initial & Reauthorization requests (after the pass-through): must be submitted prior to the end of the current auth. A late submission resulting in unauthorized days requires splitting the stay for claims payment purposes.
• 2. Retrospective auths due to late submissions is not permitted.

Place of Service

This service may be provided in a licensed community hospital or a facility licensed under 10A NCAC 27G .6000, unless provided by an IHS or compact operated by a Federally Recognized Tribe as allowed in 25 USC 1621t and 1647a, or provided by a State or Federally operated facility as allowed by §122C-22. (a)(3). This substance use disorder service may be provided in an IMD.

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

• Trillium iTransact Portal
• Trillium Provider Direct Portal

Resources

• Clinial Coverage Policy No: 8-B, Inpatient Behavioral Health Services
• https://medicaid.ncdhhs.gov/documents/july-2012-medicaid-bulletin

This is an organized service that provides intensive evaluation and treatment delivered in an acute care inpatient setting by medical and nursing professionals under the supervision of a psychiatrist. This service is designed to provide continuous treatment for individuals with acute psychiatric problems. This service offers physical health psychiatric and therapeutic interventions including such treatment modalities as medication management, psychotherapy, group therapy, dual diagnosis treatment for comorbid psychiatric and substance use disorders and milieu treatment; medical care and treatment as needed; and supportive services including room and board.

Authorization Guidelines

• 1. TAR: prior authorization required within the first 72 hours of service initiation.
• 2. Certificate of Need (CON): Must be obtained by the admitting hospital for persons under age 21.
• 3. CCA or DA: Required. An H&P/ Initial Psychiatric Evaluation may meet this requirement.
• 4. Service Order: Required, signed by a physician, LP, PA, or NP. A signed H&P/ Initial Psychiatric Eval meets this requirement.
• 5. Service Plan: Required
• 6. Submission of all records that support the individual has met the medical necessity criteria.

Reauthorization Guidelines

• 1. TAR: Prior approval required
• 2. Updated Service Plan/ Treatment Plan/ PCP: recently reviewed detailing the individual’s progress with the service.
• 3. Submission of all records that support the individual has met the medical necessity criteria.

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

Unit Value

Per diem based on the midnight bed count. Physician and other professional time not included in the daily rate is billed separately.

Limits

Provider must verify eligibility each time a service is rendered. Discharge planning shall begin upon admission to the service.Three-Way Contracts includes ASAM Levels 3.1, or higher, if applicable.

Length of Stay

• 1. Initial (after the pass-through) & Reauthorization requests: Up to 7 days/ units per auth.
• 2. Concurrent requests must be submitted prior to the end of the current auth. A late submission resulting in unauth’d days requires splitting the stay for claims payment purposes.

Exclusions

The case management component of IIH, MST, CST, ACT, SAIOP, SACOT & CADT can be provided to those admitted to or discharged from this service. Support provided should be delivered in coordination with the Inpatient facility.

Diagnosis Requirements

Primary Mental Health Diagnosis only

Place of Service

This service may be provided at a psychiatric hospital or on an inpatient psychiatric unit within a licensed hospital licensed as inpatient psychiatric hospital beds or in State operated facilities. A psychiatric hospital or an inpatient program in a hospital shall be accredited in accordance with 42 CFR 441.151(a)(2), unless provided by an IHS or compact operated by a Federally Recognized Tribe as allowed in 25 USC 1621t and 1647a, or provided by a State or Federally operated facility as allowed by §122C-22.(a)(3).

Additional Service Specifics

Prior authorization is not required for the first 72 hours of service.

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

• Trillium iTransact Portal
• Trillium Provider Direct Portal

Resources

• State Funded Inpatient Behavioral Health Service Definition
• Records Management and Documentation Manual

This is an ASAM Level 4 for adolescents and adults whose acute biomedical, emotional, behavioral and cognitive problems are so severe that they require primary medical and nursing care. The outcome of this level of care is stabilization of acute signs and symptoms of substance use, and a primary focus of the treatment plan should be coordination of care to ensure a smooth transition to the next clinically appropriate level of care.

Authorization Guidelines

• 1. TAR: prior authorization required within the first 72 hours of service initiation.
• 2. Certificate of Need (CON): Must be obtained by the admitting hospital for persons under age 21.
• 3. CCA or DA: Required. An H&P/ Initial Psychiatric Evaluation may meet this requirement.
• 4. Service Order: Required, signed by a physician, LP, PA, or NP. A signed H&P/ Initial Psychiatric Eval meets this requirement.
• 5. Service Plan: Required
• 6. Submission of all records that support the individual has met the medical necessity criteria.

Reauthorization Guidelines

• 1. TAR: Prior approval required
• 2. Updated Service Plan/ Treatment Plan/ PCP: recently reviewed detailing the individual’s progress with the service.
• 3. Submission of all records that support the individual has met the medical necessity criteria.

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

Unit Value

Per diem based on the midnight bed count. Physician and other professional time not included in the daily rate is billed separately.

Limits

Provider must verify eligibility each time a service is rendered. Discharge planning shall begin upon admission to the service.This level of care must be capable of initiating or continuing any MAT that supports the individual in their recovery from substance use.

Length of Stay

• 1. Initial (after the pass-through) & Reauthorization requests: Up to 7 days/ units per auth.
• 2. Concurrent requests must be submitted prior to the end of the current auth. A late submission resulting in unauth’d days requires splitting the stay for claims payment purposes.

Exclusions

The case management component of IIH, MST, CST, ACT, SAIOP, SACOT & CADT can be provided to those admitted to or discharged from this service. Support provided should be delivered in coordination with the Inpatient facility.

Diagnosis Requirements

Primary Substance Use Diagnosis only

Age Group Details

Adolescents & Adults

Level of Care

ASAM Level 4

Place of Service

Services provided in a licensed 24-hour inpatient setting. This service may be provided in a licensed community hospital or a facility licensed under 10A NCAC 27G .6000, unless provided by an IHS or compact operated by a Federally Recognized Tribe as allowed in 25 USC 1621t and 1647a.

Additional Service Specifics

Prior authorization is not required for the first 72 hours of service.

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

• Trillium iTransact Portal
• Trillium Provider Direct Portal

Resources

• State Funded Inpatient Behavioral Health Service Definition
• Records Management and Documentation Manual

This is an ASAM Level 4-WM for adults whose withdrawal signs and symptoms are sufficiently severe to require primary medical and nursing care, 24-hour observation, monitoring, and withdrawal management services in a medically monitored inpatient setting. The intended outcome of this level of care is to sufficiently resolve the signs and symptoms of withdrawal so the individual can be safely managed at a less intensive level of care.

Authorization Guidelines

• 1. TAR: prior authorization required within the first 72 hours of service initiation.
• 2. Certificate of Need (CON): Must be obtained by the admitting hospital for persons under age 21.
• 3. CCA or DA: Required. An H&P/ Initial Psychiatric Evaluation may meet this requirement.
• 4. Service Order: Required, signed by a physician, LP, PA, or NP. A signed H&P/ Initial Psychiatric Eval meets this requirement.
• 5. Service Plan: Required
• 6. Submission of all records that support the individual has met the medical necessity criteria.

Reauthorization Guidelines

• 1. TAR: Prior approval required
• 2. Updated Service Plan/ Treatment Plan/ PCP: recently reviewed detailing the individual’s progress with the service.
• 3. Submission of all records that support the individual has met the medical necessity criteria.

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

Unit Value

Per diem based on the midnight bed count. Physician and other professional time not included in the daily rate is billed separately.

Limits

Provider must verify eligibility each time a service is rendered. Discharge planning shall begin upon admission to the service.This level of care must be capable of initiating or continuing any MAT that supports the individual in their recovery from substance use.Detoxification rating scale tables, e.g., Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Are), and flow sheets, which include tabulation of vital signs, are to be used as needed, or any other nationally normed scale.

Length of Stay

• 1. Initial (after the pass-through) & Reauthorization requests: Up to 7 days/ units per auth.
• 2. Concurrent requests must be submitted prior to the end of the current auth. A late submission resulting in unauth’d days requires splitting the stay for claims payment purposes.

Exclusions

The case management component of IIH, MST, CST, ACT, SAIOP, SACOT & CADT can be provided to those admitted to or discharged from this service. Support provided should be delivered in coordination with the Inpatient facility.

Diagnosis Requirements

Primary Substance Use Diagnosis only

Level of Care

ASAM Level 4

Place of Service

Services shall be provided in a licensed 24-hour inpatient setting. This service may be provided in a licensed community hospital or a facility licensed under 10A NCAC 27G .6000 unless provided by an IHS or compact operated by a Federally Recognized Tribe as allowed in 25 USC 1621t and 1647a. This substance use disorder service may be provided in an IMD.

Additional Service Specifics

Prior authorization is not required for the first 72 hours of service.

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

• Trillium iTransact Portal
• Trillium Provider Direct Portal

Resources

• State Funded Inpatient Behavioral Health Service Definition
• Records Management and Documentation Manual

This is an organized service that provides intensive evaluation and treatment delivered in an acute care inpatient setting by medical and nursing professionals under the supervision of a psychiatrist. This service is designed to provide continuous treatment for individuals with acute psychiatric problems. This service offers physical health psychiatric and therapeutic interventions including such treatment modalities as medication management, psychotherapy, group therapy, dual diagnosis treatment for comorbid psychiatric and substance use disorders and milieu treatment; medical care and treatment as needed; and supportive services including room and board.

Authorization Guidelines

• 1. TAR: prior authorization required within the first 72 hours of service initiation.
• 2. Certificate of Need (CON): Must be obtained by the admitting hospital for persons under age 21.
• 3. CCA or DA: Required. An H&P/ Initial Psychiatric Evaluation may meet this requirement.
• 4. Service Order: Required, signed by a physician, LP, PA, or NP. A signed H&P/ Initial Psychiatric Eval meets this requirement.
• 5. Service Plan: Required
• 6. Submission of all records that support the individual has met the medical necessity criteria.

Reauthorization Guidelines

• 1. TAR: Prior approval required
• 2. Updated Service Plan/ Treatment Plan/ PCP: recently reviewed detailing the individual’s progress with the service.
• 3. Submission of all records that support the individual has met the medical necessity criteria.

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

Unit Value

Per diem based on the midnight bed count. Physician and other professional time not included in the daily rate is billed separately.

Limits

Provider must verify eligibility each time a service is rendered. Discharge planning shall begin upon admission to the service.Three-Way Contracts includes ASAM Levels 3.1, or higher, if applicable. Includes ASAM Levels 3.1, 3.3, 3.5, 3.7, and 4.

Length of Stay

• 1. Initial (after the pass-through) & Reauthorization requests: Up to 7 days/ units per auth.
• 2. Concurrent requests must be submitted prior to the end of the current auth. A late submission resulting in unauth’d days requires splitting the stay for claims payment purposes.

Exclusions

The case management component of IIH, MST, CST, ACT, SAIOP, SACOT & CADT can be provided to those admitted to or discharged from this service. Support provided should be delivered in coordination with the Inpatient facility.

Diagnosis Requirements

Primary Mental Health Diagnosis only

Place of Service

This service may be provided at a psychiatric hospital or on an inpatient psychiatric unit within a licensed hospital licensed as inpatient psychiatric hospital beds or in State operated facilities. A psychiatric hospital or an inpatient program in a hospital shall be accredited in accordance with 42 CFR 441.151(a)(2), unless provided by an IHS or compact operated by a Federally Recognized Tribe as allowed in 25 USC 1621t and 1647a, or provided by a State or Federally operated facility as allowed by §122C-22.(a)(3).

Additional Service Specifics

Prior authorization is not required for the first 72 hours of service.

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

• Trillium iTransact Portal
• Trillium Provider Direct Portal

Resources

• State Funded Inpatient Behavioral Health Service Definition
• Records Management and Documentation Manual

This is an ASAM Level 4-WM for adult members whose withdrawal signs and symptoms are sufficiently severe to require primary medical and nursing care, 24-hour observation, monitoring, and withdrawal management services in a medically monitored inpatient setting. The intended outcome of this level of care is to sufficiently resolve the signs and symptoms of withdrawal so the member can be safely managed at a less intensive level of care.

Authorization Guidelines

Prior authorization is not required for the first 72 hours of service.

Initial Requests (after pass-through):

• 1. TAR: prior authorization required within the first 72 hours of service initiation.
• 2. CCA or DA: Required, an initial assessment must be completed within 72 hours of admission and updated prior to discharge to determine the next clinically appropriate level of care. See CCP Section 7.5 for specific requirements.
• 3. Certificate of Need (CON): Required at admission to a freestanding psych hospital or within 14 calendar days of an emergency admission for members under 21.
• 4. Service Order: Required, signed by a physician, LP, PA, or NP. A signed H&P/ Initial Psychiatric Eval meets this requirement.
• 5. Service Plan/ Plan of Care/ Tx Plan: Required
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Prior authorization is not required for the first 72 hours of service.

Initial Requests (after pass-through):

• 1. TAR: prior authorization required within the first 72 hours of service initiation.
• 2. CCA or DA: Required, an initial assessment must be completed within 72 hours of admission and updated prior to discharge to determine the next clinically appropriate level of care. See CCP Section 7.5 for specific requirements.
• 3. Certificate of Need (CON): Required at admission to a freestanding psych hospital or within 14 calendar days of an emergency admission for members under 21.
• 4. Service Order: Required, signed by a physician, LP, PA, or NP. A signed H&P/ Initial Psychiatric Eval meets this requirement.
• 5. Service Plan/ Plan of Care/ Tx Plan: Required
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Guidelines

• 1. TAR: prior authorization required.
• 2. Updated Tx Plan/ PCP: Required
• 3. Submission of applicable records that support the member has met the medical necessity criteria.

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

Unit Value

Per diem based on the midnight bed count

Limits

• 1. The case management component of IIH, MST, CST, ACT, SAIOP, & SACOT can be provided to those admitted to or discharged from this service. Support provided should be delivered in coordination with the Inpatient facility.
• 2. Discharge planning shall begin upon admission to the service.
• 3. This level of care must be capable of initiating or continuing any MAT that supports the member in their recovery from substance use.
• 4. Detoxification rating scale tables, e.g., Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Are), and flow sheets, which include tabulation of vital signs, are to be used as needed, or any other nationally normed scale.
• 5. Prior authorization is not required for MCD BH Services rendered to Medicare/Medicaid dual eligible members or members with 3rd-party insurance because MCD is the payer of last resort. When MCD becomes the primary payer, a primary payer auth denial/ exhaustion of benefits letter is submitted with the MCD TAR.
• 6. For ADATCs: For members under the age of 21, admission authorization shall be requested by the facility the next business day following admission if the individual presents directly to the facility, by submitting a completed Non-Covered State Medicaid Plan Services Request Form to the Health Plan. To request re-authorization, the ADATC shall submit a completed Electronic Authorization Request to the Health Plan prior to the expiration of the admission authorization. The form shall be submitted by the ADATC on the last covered day of the existing authorization (or the previous business day if the last covered day occurs on a weekend or holiday).

Length of Stay

• 1. Initial & Reauthorization requests (after the pass-through): must be submitted prior to the end of the current auth. A late submission resulting in unauthorized days requires splitting the stay for claims payment purposes.
• 2. Retrospective auths due to late submissions is not permitted.

Age Group Details

18 and older

Place of Service

May be provided in a licensed community hospital or a facility licensed under 10A NCAC 27G .6000 unless provided by an IHS or compact operated by a Federally Recognized Tribe as allowed in 25 USC 1621t and 1647a, or provided by a State or Federally operated facility as allowed by §122C-22.(a)(3). This substance use disorder service may be provided in an IMD.

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

• Trillium iTransact Portal
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No: 8-B, Inpatient Behavioral Health Services
• Records Management and Documentation Manual
• https://medicaid.ncdhhs.gov/july-2012-medicaid-bulletin
• https://www.ncdhhs.gov/documents/files/joint-communication-bulletin-j265-clarification-services

An Intermediate Care Facility for Individuals with Intellectual Disabilities is an institution that functions primarily for the diagnosis, treatment or rehabilitation of individuals with intellectual disabilities or persons with a related condition and provides ongoing evaluation, planning, 24-hour supervision, coordination, and integration of health or rehabilitative services to help each individual function at his or her greatest ability.

Authorization Guidelines

• 1. LOC Eligibility Determination Tool and Med Eval Attachment: Required, signed by the physician w/in the last 30 days.
• 2. Meets ICF/IID criteria for IDD services, including evidence of an IDD dx before age of 22 or TBI.
• 3. NC SNAP/ SIS: Either the NC-SNAP or the SIS is required for all individuals with intellectual or developmental disabilities.
• 4. Submission of applicable records that support the member has met the medical necessity criteria.

Reauthorization Guidelines

• 1. LOC Eligibility Determination Tool and Med Eval Attachment: Required, updated w/in the last 180 days.
• 2. Meets ICF/IID criteria for IDD services, including evidence of an IDD dx before age of 22 or TBI.
• 3. Submission of applicable records that support the member has met the medical necessity criteria.

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

Unit Value

One day = 1 unit

Length of Stay

• 1. Up to 366 days for all requests
• 2. LOC forms must still be submitted every 180 days from the doctor’s signature even when there is an authorization in place.
• 3. LOCs are uploaded in Provider Direct, in the IDD LOC Module.
• 4. If unable to submit through the IDD Module, email to UM@Trilliumnc.org.

Exclusions

• 1. MCD will not cover this service to maintain generally independent members who are able to function with little supervision or in the absence of a continuous active treatment program.
• 2. The date of admission is counted as the 1st day the member occupies a bed at the midnight census. The date of discharge is counted as the last day the member occupies a bed at the midnight census.
• 3. The discharge date is not considered a day of patient care and is not billable to Medicaid.
• 4. Reimbursement is at a per diem rate that is all inclusive except for medical and dental services.
• 5. Medical examinations can be performed by a physician or a physician extender. According to N.C.G.S. §90-18.3, “Whenever a statute or State agency rule requires that a physical examination shall be conducted by a physician, the examination may be conducted and the form signed by a NP or a PA, and a physician need not be present.”
• 6. Rubicon Process: RUBICON members must follow the process outlined by RUBICON. For Rubicon members, do not send LOCs directly to Trillium, please forward them to RUBICON Management. Rubicon will upload LOCs and notify UM by email only when unable to upload in IDD LOC Module.

Level of Care

Eligibility for ICF/IID level of care is based on each member’s need for the service and not merely on the dx. Attachment B of the CCP details the functional limitations as defined by the developmental disabilities’ assistance and bill of rights act of 2000.

How to Submit

Please submit your request to Trillium Health Resources

• Trillium iTransact Portal

Resources

• Clinical Coverage Policy No 8E: Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

If applicable, please submit your request to Trillium.

• Trillium iTransact Portal

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

Please submit your request to Trillium Health Resources

• Trillium iTransact Portal

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

Please submit your request to Trillium Health Resources

• Trillium iTransact Portal

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

Please submit your request to Trillium Health Resources

• Trillium iTransact Portal

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

Please submit your request to Trillium Health Resources

• Trillium iTransact Portal