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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

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

See the Carolina Complete Health site for specific requirements

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 Carolina Complete Health

• https://www.carolinacompletehealth.com/trillium-preauth.html

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

N/A - No authorization is required

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.

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 service provides 24-hour access to continuous intensive evaluation and treatment delivered in an Institute for Mental Disease (IMD) for acute and subacute inpatient psychiatric disorders. Delivery of service is provided by nursing and medical professionals under the supervision of a psychiatrist. Providers must follow the requirements for inpatient level of care outlined in Clinical Coverage Policy (CCP) 8-B, Inpatient Behavioral Health Services.

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. See CCP Section 7.5 for additional requirements. An H&P/ Initial Psychiatric Evaluation may satisfy this requirement.
• 3. Service Order: Required, signed by a physician, LP, PA, or NP. A signed H&P/ Initial Psychiatric Eval meets this requirement.
• 4. Service Plan: Required
• 5. Submission of all records that support the individual 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. See CCP Section 7.5 for additional requirements. An H&P/ Initial Psychiatric Evaluation may satisfy this requirement.
• 3. Service Order: Required, signed by a physician, LP, PA, or NP. A signed H&P/ Initial Psychiatric Eval meets this requirement.
• 4. Service Plan: Required
• 5. Submission of all records that support the individual has met the medical necessity criteria.

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. Discharge Planning shall begin upon admission to this service.
• 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. 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. Members receiving tx for MH diagnoses are limited to no more than 15 authorized days each calendar month. For admissions spanning two consecutive months, the total length of stay may exceed 15 days, but no more than 15 days may be authorized in each month. There is not a day limit for members receiving SU services.
• 2. For State ADATC’s, the initial authorization will be for at least 7 days.
• 3. 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.
• 4. Retrospective auths due to late submissions is not permitted.

Age Group Details

Adults aged 21-64

Place of Service

Institute for Mental Disease (IMD)

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• Trillium iTransact Portal
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No: 8-B
• Records Management and Documentation Manual
• https://medicaid.ncdhhs.gov/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. 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. CCA or DA: Required. See CCP Section 7.5 for additional requirements. An H&P/ Initial Psychiatric Evaluation may satisfy this requirement.
• 3. Service Order: Required, signed by a physician, LP, PA, or NP. A signed H&P/ Initial Psychiatric Eval meets this requirement.
• 4. Service Plan: Required
• 5. Submission of all records that support the individual has met the medical necessity criteria.

Unit Value

Per diem based on the midnight bed count

Limits

• 1. Trillium will issue an auth decision within 14 days after receipt of the TAR.
• 2. 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.
• 3. Medicaid eligibility must be verified each time a service is rendered.
• 4. Discharge Planning shall begin upon admission to this service.
• 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.

Length of Stay

• 1. Provider must submit a TAR covering the member’s length of stay on the next business day following the Individual’s discharge.
• 2. Member’s that present directly to the facility as an emergency commitment or as a self-referral, the facility shall submit a TAR by the next business day.
• 3. Members receiving tx for MH diagnoses are limited to no more than 15 authorized days each calendar month. For admissions spanning two consecutive months, the total length of stay may exceed 15 days, but no more than 15 days may be authorized in each month. There is not a day limit for members receiving SU services.

Age Group Details

Adults aged 21-64

Place of Service

Institute for Mental Disease (IMD)

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• Trillium iTransact Portal
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No: 8-B
• Records Management and Documentation Manual
• https://medicaid.ncdhhs.gov/july-2012-medicaid-bulletin

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.

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

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.

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

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