PA Lookup
If you have questions about prior authorizations, please call:
Member and Recipient Service Line: 1-877-685-2415
Provider Support Service Line: 1-855-250-1539
Ambulatory Withdrawal Management (WM) WITH Extended On-Site Monitoring
This service is an organized outpatient service that provides medically supervised evaluation, withdrawal management, and referral in a licensed facility. This service is for a member who is assessed to be at moderate risk of severe withdrawal, free of severe physical and psychiatric complications and would safely respond to several hours of monitoring, medication, and treatment. These services are designed to treat the member’s level of clinical severity and to achieve safe and comfortable withdrawal from alcohol and other substances to effectively facilitate the member’s transition into ongoing treatment and recovery.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Unit Value
1 unit = 15 minutes
Limits
- 1. Provider shall verify each Medicaid member’s eligibility each time a service is rendered
- 2. Facility must operate a minimum of 8 hours per day, all 5 weekdays (Monday through Friday), and a minimum of 4 hours daily on the weekend (Saturday and Sunday). The hours of operation must be extended based on member need. This service must be available for admission seven days per week.
- 3. Services may not be provided on the same day as Substance Use Disorder Withdrawal Management or Residential Services, except on day of admission or discharge.
- 4. Clinical and administrative supervision is covered as an indirect cost and part of the rate
- 5. 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.6. A beneficiary may receive this service from only one provider organization during any episode of care.
Diagnosis Requirements
Primary Substance Use Diagnosis only
Age Group Details
Adolescents & Adults (Aged 18 and older)
Level of Care
ASAM Level 2-WM. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions.
Place of Service
Services are provided in an outpatient licensed facility
How to Submit
N/A - No authorization is required
Resources
Substance Abuse Intensive Outpatient Program Services
SAIOP provides a structured program of skilled treatment services for adults or adolescents with a primary SUD diagnosis. SAIOP include individual, group, and family counseling, medication management through consultation and referral, educational groups, and service coordination activities provided in amounts, frequencies, and intensities appropriate to the objectives of the member’s PCP. SAIOP can be delivered during the day, weekend, or evening.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Unit Value
One unit = 1 event per day (a minimum of 3 hours per day is an event)
Limits
- 1. SAIOP must be available in person at least 5 days per week, with no more than 2 consecutive days without services available.
- 2. SAIOP shall schedule a minimum of 3 service days per week for each member with a minimum of 3 hours per service day for adults, and a minimum of 2 hours per service day for adolescents.
- 3. SAIOP is a service that provides 9-19 hrs of skilled tx services per week for adults, and 6-19 hrs of skilled tx services per week for adolescents.
- 4. A member is not required to seek services through telehealth and shall have access to in-person services. Services must be available in person at least 5 days per week.
- 5. Providers and organizations that provide SAIOP shall provide crisis response 24-hours-a- day, seven-days-a-week, to a member who is receiving SAIOP services.
- 6. A member can receive SAIOP services from only one provider organization during an episode of care.
Exclusions
SAIOP must not be provided and billed during the same episode of care (except on the day of admission or discharge) as SACOT; Individual, family or group therapy for treatment of substance use disorder; Clinically Managed Residential Withdrawal Management; Medically Monitored Inpatient Withdrawal Management; Clinically Managed Population-Specific High-Intensity Residential Programs; Clinically Managed Residential Services; Medically Monitored Intensive Inpatient Services; PRTF; Partial Hospitalization.
Diagnosis Requirements
Primary Substance Use Diagnosis only
Age Group Details
Adolescent (aged 10-17) and Adult (aged 18+)
Level of Care
ASAM Level 2.1. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and document the determination for continued stay, discharge, or transfer to another LOC.
Place of Service
Must be provided in a facility licensed under 10A NCAC 27G .4400
Other Information
Revised benefit limits will go into effect on 1/1/2026. Current limits are in place through 12/31/2025.
How to Submit
N/A - No authorization is required
Resources
Substance Abuse Intensive Outpatient Program (SAIOP)
SAIOP provides a structured program of skilled tx services for adults or adolescents with a primary SUD diagnosis. SAIOP provides 9-19 hours of skilled tx services per week for adults, and 6-19 hours of skilled tx services per week for adolescents. SAIOP tx services include individual, group, and family counseling, medication management through consultation and referral, educational groups, and service coordination activities provided in amounts, frequencies, and intensities appropriate to the member’s PCP. SAIOP tx services can be delivered during the day, weekend, or evening.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Unit Value
One unit = 1 event per day (a minimum of three hours per day is an event)
Limits
- 1. SAIOP must be available in person at least 5 days per week, with no more than 2 consecutive days without services available.
- 2. SAIOP shall schedule a minimum of 3 service days per week for each member with a minimum of 3 hours per service day for adults, and a minimum of 2 hours per service day for adolescents.
- 3. Providers must provide crisis response 24-hours-a-day, seven-days-a-week, to a member who is receiving SAIOP services.
- 4. Provider must verify member’s Medicaid eligibility each time a service is rendered.
- 5. A member is not required to seek services through telehealth and shall have access to in-person services. Services must be available in person at least 5 days per week.
- 6. A member can receive SAIOP services from only one provider during an episode of care.
Length of Stay
One unit = 1 event per day (a minimum of three hours per day is an event)
Exclusions
SAIOP must not be provided and billed during the same episode of care (except on the day of admission or discharge) as SACOT; Individual, family or group therapy for treatment of substance use disorder; Clinically Managed Residential Withdrawal Management; Medically Monitored Inpatient Withdrawal Management; Clinically Managed Population-Specific High-Intensity Residential Programs; Clinically Managed Residential Services; Medically Monitored Intensive Inpatient Services; PRTF; Partial Hospitalization.
Diagnosis Requirements
Primary Substance Use Diagnosis only
Age Group Details
Children/ Adolescents (age 10 – 17) & Adults (age 18+)
Level of Care
ASAM Level 2.1 Intensive Outpatient Services. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and document the determination for continued stay, discharge, or transfer to another LOC.
Place of Service
: Must be provided in a facility licensed under 10A NCAC 27G .4400. Refer to Tribal & Urban Indian Health Centers | HRSA when the service is provided by IHS.
How to Submit
N/A - No authorization is required
Resources
H0019 HK - Long Term Resid Lvl IV(1-4 Beds)
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
Please submit your request to Trillium Health Resources
Residential Treatment Services: Level III (Non-SAY Program) Level IV/ Secure
Residential treatment provides a structured, therapeutic, and supervised environment to improve the level of functioning for beneficiaries. There are four levels of residential treatment. Residential Treatment Level III Service (Residential Treatment High) has a highly structured and supervised environment in a program setting only. Staff are awake during sleep hours and supervision is continuous. Residential Treatment Level IV Service (Residential Treatment Secure) has a physically secure, locked environment in a program setting only. Staff are awake during sleep hours and supervision is continuous.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Reauthorization Guidelines
- 1. TAR: Prior authorization required
- 2. Complete PCP: recently reviewed detailing the member’s progress with the service.
- 3. CCA: Re-assessment is required when new behavioral concerns are identified, there are changed/ unmet service or tx needs, and/or as part of the annual review of the service plan. Assessment must include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
- 4. Child/Adolescent Discharge/Transition Plan: Required, to include measurable plan with active planning. There must be a discharge/transition plan developed by the Child and Family Team. This discharge/transition plan must be updated and submitted with each TAR.
- 5. Submission of applicable records that support the member has met the medical necessity criteria.
Unit Value
One unit = 1 day
Limits
- 1. MCD will not cover this service when the service duplicates another procedure, product, or service.
- 2. Prior to admission to Level III or Level IV residential treatment, there must be a discharge/transition plan developed by the Child and Family Team. This discharge/transition plan must be updated and submitted with each TAR. Child and Adolescent Residential Treatment providers are required to document collaboration with Trillium and the System of Care (SOC) Coordinator throughout the youth’s stay in the residential treatment facility. SOC Coordinators may be required to sign off on the discharge plan.
Level of Care
ASAM Level 3.5 (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Residential Treatment Services:
Residential treatment provides a structured, therapeutic, and supervised environment to improve the level of functioning for beneficiaries. There are four levels of residential treatment. Residential Treatment Level III Service (Residential Treatment High) has a highly structured and supervised environment in a program setting only. Staff are awake during sleep hours and supervision is continuous.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Reauthorization Guidelines
- 1. TAR: prior authorization required
- 2. Complete PCP: recently reviewed detailing the member’s progress with the service.
- 3. CCA: Re-assessment is required when new behavioral concerns are identified, there are changed/ unmet service or tx needs, and/or as part of the annual review of the service plan. Assessment must include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
- 4. Child/Adolescent Discharge/Transition Plan: There must be a discharge/transition plan developed by the Child and Family Team. This discharge/transition plan must be updated and submitted with each TAR.
- 5. Submission of applicable records that support the member has met the medical necessity criteria.
Unit Value
One unit = 1 day
Limits
- 1. MCD will not cover this service when the service duplicates another procedure, product, or service.
- 2. Prior to admission to Level III or Level IV residential treatment, there must be a discharge/transition plan developed by the Child and Family Team. This discharge/transition plan must be updated and submitted with each TAR. Child and Adolescent Residential Treatment providers are required to document collaboration with Trillium and the System of Care (SOC) Coordinator throughout the youth’s stay in the residential treatment facility. SOC Coordinators may be required to sign off on the discharge plan.
Level of Care
ASAM Level 3.5 (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Residential Treatment Services: Level III (Non-SAY Program) Level IV/ Secure
Residential treatment provides a structured, therapeutic, and supervised environment to improve the level of functioning for beneficiaries. There are four levels of residential treatment. Residential Treatment Level III Service (Residential Treatment High) has a highly structured and supervised environment in a program setting only. Staff are awake during sleep hours and supervision is continuous. Residential Treatment Level IV Service (Residential Treatment Secure) has a physically secure, locked environment in a program setting only. Staff are awake during sleep hours and supervision is continuous.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Reauthorization Guidelines
- 1. TAR: Prior authorization required
- 2. Complete PCP: recently reviewed detailing the member’s progress with the service.
- 3. CCA: Re-assessment is required when new behavioral concerns are identified, there are changed/ unmet service or tx needs, and/or as part of the annual review of the service plan. Assessment must include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
- 4. Child/Adolescent Discharge/Transition Plan: Required, to include measurable plan with active planning. There must be a discharge/transition plan developed by the Child and Family Team. This discharge/transition plan must be updated and submitted with each TAR.
- 5. Submission of applicable records that support the member has met the medical necessity criteria.
Unit Value
One unit = 1 day
Limits
- 1. MCD will not cover this service when the service duplicates another procedure, product, or service.
- 2. Prior to admission to Level III or Level IV residential treatment, there must be a discharge/transition plan developed by the Child and Family Team. This discharge/transition plan must be updated and submitted with each TAR. Child and Adolescent Residential Treatment providers are required to document collaboration with Trillium and the System of Care (SOC) Coordinator throughout the youth’s stay in the residential treatment facility. SOC Coordinators may be required to sign off on the discharge plan.
Level of Care
ASAM Level 3.5 (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Residential Treatment Services:
Residential treatment provides a structured, therapeutic, and supervised environment to improve the level of functioning for beneficiaries. There are four levels of residential treatment. Residential Treatment Level III Service (Residential Treatment High) has a highly structured and supervised environment in a program setting only. Staff are awake during sleep hours and supervision is continuous.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Reauthorization Guidelines
- 1. TAR: prior authorization required
- 2. Complete PCP: recently reviewed detailing the member’s progress with the service.
- 3. CCA: Re-assessment is required when new behavioral concerns are identified, there are changed/ unmet service or tx needs, and/or as part of the annual review of the service plan. Assessment must include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
- 4. Child/Adolescent Discharge/Transition Plan: There must be a discharge/transition plan developed by the Child and Family Team. This discharge/transition plan must be updated and submitted with each TAR.
- 5. Submission of applicable records that support the member has met the medical necessity criteria.
Unit Value
One unit = 1 day
Limits
- 1. MCD will not cover this service when the service duplicates another procedure, product, or service.
- 2. Prior to admission to Level III or Level IV residential treatment, there must be a discharge/transition plan developed by the Child and Family Team. This discharge/transition plan must be updated and submitted with each TAR. Child and Adolescent Residential Treatment providers are required to document collaboration with Trillium and the System of Care (SOC) Coordinator throughout the youth’s stay in the residential treatment facility. SOC Coordinators may be required to sign off on the discharge plan.
Level of Care
ASAM Level 3.5 (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Residential Treatment Services: Level III (Non-SAY Program) Level IV/ Secure
Residential treatment provides a structured, therapeutic, and supervised environment to improve the level of functioning for beneficiaries. There are four levels of residential treatment. Residential Treatment Level III Service (Residential Treatment High) has a highly structured and supervised environment in a program setting only. Staff are awake during sleep hours and supervision is continuous. Residential Treatment Level IV Service (Residential Treatment Secure) has a physically secure, locked environment in a program setting only. Staff are awake during sleep hours and supervision is continuous.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Reauthorization Guidelines
- 1. TAR: Prior authorization required
- 2. Complete PCP: recently reviewed detailing the member’s progress with the service.
- 3. CCA: Re-assessment is required when new behavioral concerns are identified, there are changed/ unmet service or tx needs, and/or as part of the annual review of the service plan. Assessment must include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
- 4. Child/Adolescent Discharge/Transition Plan: Required, to include measurable plan with active planning. There must be a discharge/transition plan developed by the Child and Family Team. This discharge/transition plan must be updated and submitted with each TAR.
- 5. Submission of applicable records that support the member has met the medical necessity criteria.
Unit Value
One unit = 1 day
Limits
- 1. MCD will not cover this service when the service duplicates another procedure, product, or service.
- 2. Prior to admission to Level III or Level IV residential treatment, there must be a discharge/transition plan developed by the Child and Family Team. This discharge/transition plan must be updated and submitted with each TAR. Child and Adolescent Residential Treatment providers are required to document collaboration with Trillium and the System of Care (SOC) Coordinator throughout the youth’s stay in the residential treatment facility. SOC Coordinators may be required to sign off on the discharge plan.
Level of Care
ASAM Level 3.5 (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Residential Treatment Services: Level III (Non-SAY Program) Level IV/ Secure
Residential treatment provides a structured, therapeutic, and supervised environment to improve the level of functioning for beneficiaries. There are four levels of residential treatment. Residential Treatment Level III Service (Residential Treatment High) has a highly structured and supervised environment in a program setting only. Staff are awake during sleep hours and supervision is continuous. Residential Treatment Level IV Service (Residential Treatment Secure) has a physically secure, locked environment in a program setting only. Staff are awake during sleep hours and supervision is continuous.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Reauthorization Guidelines
- 1. TAR: Prior authorization required
- 2. Complete PCP: recently reviewed detailing the member’s progress with the service.
- 3. CCA: Re-assessment is required when new behavioral concerns are identified, there are changed/ unmet service or tx needs, and/or as part of the annual review of the service plan. Assessment must include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
- 4. Child/Adolescent Discharge/Transition Plan: Required, to include measurable plan with active planning. There must be a discharge/transition plan developed by the Child and Family Team. This discharge/transition plan must be updated and submitted with each TAR.
- 5. Submission of applicable records that support the member has met the medical necessity criteria.
Unit Value
One unit = 1 day
Limits
- 1. MCD will not cover this service when the service duplicates another procedure, product, or service.
- 2. Prior to admission to Level III or Level IV residential treatment, there must be a discharge/transition plan developed by the Child and Family Team. This discharge/transition plan must be updated and submitted with each TAR. Child and Adolescent Residential Treatment providers are required to document collaboration with Trillium and the System of Care (SOC) Coordinator throughout the youth’s stay in the residential treatment facility. SOC Coordinators may be required to sign off on the discharge plan.
Level of Care
ASAM Level 3.5 (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Opioid Treatment Program Services
This is an organized, outpatient treatment service for an individual with an opioid use disorder. The OTP service utilizes methadone, buprenorphine formulations, naltrexone or other drugs approved by the FDA for the treatment of opioid use disorders. This service is delivered by an interdisciplinary team of professionals trained in the treatment of opioid use disorder. The team provides person-centered, recovery-oriented-treatment, case management, and health education. A range of cognitive, behavioral, and substance use disorder (SUD) focused therapies are provided to address substance use that could compromise recovery.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Unit Value
One unit = 1 day
Limits
- 1. State funds do not cover any services in the OTP Service per diem as separate billable services and do not cover interventions not identified in the individual’s PCP.
- 2. No person under 18 may be admitted to treatment unless a parent, legal guardian, or responsible adult designated by the relevant State authority consents in writing to such treatment.
- 3. In addition to the bundled rate activities, providers can bill separately for: a) evaluation and management billing codes; b) diagnostic assessments or comprehensive clinical assessments; c) laboratory testing (excluding pregnancy test, TB test, & drug toxicology); d) individual, group, and family counseling (provided beyond the minimum two (2) counseling of therapy sessions per month during the first year or one (1) counseling or therapy session per month thereafter) (licensed professionals only); and e) Peer Support Services. The program physician can bill E/M codes separately for the admission evaluation and physical exam.
Length of Stay
Providers may provide and bill for more than one week of take-home doses to meet individual’s need. At least one service must be provided to the individual within the weekly service payment unit to bill the bundled rate.
Diagnosis Requirements
Primary Substance Use Diagnosis only
Age Group Details
Those under 18 years of age are required to have two documented unsuccessful attempts at short-term detoxification or drug-free treatment within a 12-month period to be eligible for this service [42 C.F.R. § 8.12(e)(2)].
Level of Care
Opioid Treatment Services (OTS) ASAM Criteria Level of Care. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions.
Additional Service Specifics
Activities in the bundled rate for this service are: a) managing medical plan of care and medical monitoring; b) individualized recovery focused person-centered plan; c) a minimum of two (2) required counseling or therapy sessions per individual per month during the first year of opioid treatment services and one required counseling session per individual per month thereafter; d) nursing services related to administering medication, preparation, monitoring, and distribution of take-home medications; e) cost of the medication; f) presumptive drug screens and definitive drug tests; ) pregnancy tests; h) TB tests; i) psychoeducation consisting of HIV and AIDS education and other health education services; and j) service coordination activities consisting of coordination with care management entity and coordination of on and off-site treatment and supports.
How to Submit
N/A - No authorization is required
Resources
Opioid Treatment Program Services
This is an organized, outpatient treatment service for those with an opioid use disorder. The OTP service utilizes methadone, buprenorphine formulations, naltrexone or other drugs approved by the FDA for the treatment of opioid use disorders. This service is delivered by an interdisciplinary team of professionals trained in the treatment of opioid use disorder. The team provides person-centered, recovery-oriented treatment, case management, and health education. A range of cognitive, behavioral, and substance use disorder focused therapies are provided to address substance use that could compromise recovery.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Unit Value
One unit = 1 week
Limits
- 1. In addition to the bundled rate activities, providers can bill separately for: a) evaluation and management billing codes; b) diagnostic assessments or comprehensive clinical assessments; c) laboratory testing (excluding pregnancy test, TB test, and drug toxicology); d) individual, group, and family counseling (provided beyond the minimum 2 counseling of therapy sessions per month during the first year or 1 counseling or therapy session per month thereafter) (licensed professionals only); and e) Peer Support Services. The program physician can bill E/M codes separately for the admission evaluation and physical exam.
- 2. MCD will not cover any services in the OTP Service per diem as separate billable services or interventions not identified in the members’ PCP. Provider must verify each MCD member’s eligibility each time a service is rendered
Diagnosis Requirements
Primary Substance Use Diagnosis
Age Group Details
Adults (aged 18+)
Level of Care
Opioid Treatment Services (OTS) ASAM Criteria Level of Care. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions.
Additional Service Specifics
Bundled Activities:
Activities in the bundled rate for this service are: a) managing medical plan of care and medical monitoring; b) individualized recovery focused person-centered plan; c) a minimum of 2 required counseling or therapy sessions per member per month during the first year of opioid treatment services and one required counseling session per member per month thereafter; d) nursing services related to administering medication, preparation, monitoring, and distribution of take-home medications; e) cost of the medication; f) presumptive drug screens and definitive drug tests; g) pregnancy tests; h) TB tests; i) psychoeducation consisting of HIV and AIDS education and other health education services; and j) service coordination activities consisting of coordination with care management entity and coordination of on and off-site treatment and supports.
How to Submit
N/A - No authorization is required
Resources
H0031 TM Mental Health Assessment School Based Therapy
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
N/A - No authorization is required
High Fidelity Wraparound (HFW)
High Fidelity Wraparound is an intensive, team-based, person-centered service that provides coordinated, holistic, family-driven care to meet the complex needs of youth/young adults who are involved with multiple systems (e.g., mental health, child welfare, juvenile/criminal justice, special education), experiencing serious emotional or behavioral difficulties, are at risk of placement in Psychiatric Residential Treatment Facilities (PRTFs) or other institutional settings, or are aging out of Department of Social Services (DSS) care.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
Prior authorization is required for any services provided after the initial 12-month NPA period.
Unit Value
One unit = 1 month
Limits
- 1. A member receiving HFW will be excluded from TCM. An overlap of 30 days is allowed during transitions.
- 2. The following cannot be provided during the same auth period as HFW: MST, FCT, ACTT, CST, or Substance Use Residential Treatment.
- 3. The following may be provided during the same auth period if the Plan and request clearly detail the roles of each team, along with why coordination beyond HFW is needed: OPT, IIHS, Lifeset, Day Tx, SAIOP, and/or SACOT. HFW may occur on a short-term basis with child residential treatment services to assist in facilitation of discharge planning.
Length of Stay
- 1. Targeted Length of service is up to 12 months (12 units). Maximum of 18 months.
- 2. The initial request following the NPA period may be for up to 6 months.
- 3. A minimum of four contacts per month.
- 4. HFW activities are grouped into four phases:
- 1) Engagement and Team Prep (2-4 weeks);
- 2) Plan Dev (1-2 weeks);
- 3) Plan Implementation (2-12 months), and;
- 4) Transition (typically 1-4 meetings).
Diagnosis Requirements
Serious Emotional Disturbance (SED) or Serious Mental Illness (SMI)
Age Group Details
Children & Adolescents (ages 3 – 20)
Level of Care
While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.
Place of Service
Home and Community
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
H0032 U5 High Fidelity Wraparound
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Conditional Requirements
No prior authorization (NPA) is required for the first 12 months of treatment. Prior authorization is required for any services provided after the initial 12-month NPA period.
How to Submit
If applicable, please submit your request to Trillium.
Partial Hospitalization
A short-term service for acutely mentally ill children or adults, which provides a broad range of intensive therapeutic approaches which may include: group activities or therapy, individual therapy, recreational therapy, community living skills or training, increases the individual’s ability to relate to others and to function appropriately, coping skills, medical services. This service is designed to prevent hospitalization or to serve as an interim step for those leaving an inpatient facility. A physician shall participate in diagnosis, tx planning, and admission or discharge decisions. Physician involvement shall be one factor that distinguishes Partial Hospitalization from Day Treatment services.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Reauthorization Guidelines
- 1. TAR: prior authorization required.
- 2. Complete PCP: recently reviewed detailing the individual’s progress with the service, to include all required signatures and the 3-page crisis plan.
- 3. Medicaid Application: Evidence of individual applying for Medicaid or update on application status.
- 4. Submission of applicable records that support the individual has met the medical necessity criteria.
Conditional Requirements
Prior authorization is not required for the first 7 days (7 units)
Unit Value
One unit = 1 event
Limits
This is day or night service provided a minimum of 4 hrs/day, 5 days/week, and 12 months/year (excluding transportation time). Excludes legal or governing body designated holidays.1. Individuals may be ineligible for a state-funded service due to coverage by other payors that would make them ineligible for the same or similar service funded by the state (e.g. individual is eligible for the same service covered by Medicaid or other third party payor)
Length of Stay
- 1. Initial (after pass-through) and Reauthorization requests shall not exceed 7 calendar days.
- 2. Maximum length of stay is 30 days in a 12-month period.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
State-Funded Enhanced Mental Health and Substance Use Service, Partial Hospitalization
A short-term service for acutely mentally ill children or adults, which provides a broad range of intensive therapeutic approaches which may include: group activities or therapy, individual therapy, recreational therapy, community living skills or training, increases the individual’s ability to relate to others and to function appropriately, coping skills, medical services. This service is designed to prevent hospitalization or to serve as an interim step for those leaving an inpatient facility. A physician shall participate in diagnosis, tx planning, and admission or discharge decisions. Physician involvement shall be one factor that distinguishes Partial Hospitalization from Day Treatment services.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Reauthorization Guidelines
- 1. TAR: prior authorization required.
- 2. Complete PCP: recently reviewed detailing the individual’s progress with the service.
- 3. Medicaid Application: Evidence of individual applying for Medicaid or update on application status.
- 4. Submission of applicable records that support the individual has met the medical necessity criteria.
Conditional Requirements
Prior authorization is not required for the first 7 days (7 units)
Unit Value
One unit = 1 event
Limits
This is day or night service provided a minimum of 4 hrs/day, 5 days/week, and 12 months/year (excluding transportation time). Excludes legal or governing body designated holidays.
Length of Stay
- 1. Initial (after pass-through) and Reauthorization requests shall not exceed 7 calendar days.
- 2. Maximum length of service is 30 days per fiscal year.
Exclusions
Individuals may be ineligible for a state-funded service due to coverage by other payors that would make them ineligible for the same or similar service funded by the state (e.g. individual is eligible for the same service covered by Medicaid or other third-party payor)
Level of Care
While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.
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
Resources
Partial Hospitalization
A short-term service for acutely mentally ill children or adults, which provides a broad range of intensive therapeutic approaches which may include: group activities or therapy, individual therapy, recreational therapy, community living skills or training, increases the individual’s ability to relate to others and to function appropriately, coping skills, medical services. This service is designed to prevent hospitalization or to serve as an interim step for those leaving an inpatient facility.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Unit Value
One unit = 1 event
Limits
This is day or night service provided a minimum of 4 hrs/day, 5 days/week, and 12 months/year (excluding transportation time). Excludes legal or governing body designated holidays.
Level of Care
While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.
How to Submit
N/A - No authorization is required
Resources
Partial Hospitalization
A short-term service for acutely mentally ill children or adults, which provides a broad range of intensive therapeutic approaches which may include: group activities or therapy, individual therapy, recreational therapy, community living skills or training, increases the individual’s ability to relate to others and to function appropriately, coping skills, medical services. This service is designed to prevent hospitalization or to serve as an interim step for those leaving an inpatient facility.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Unit Value
One unit = 1 event
Limits
This day or night service is provided a minimum of 4 hrs/day, 5 days/week, and 12 months/year (excluding transportation time). Excludes legal or governing body designated holidays.
Level of Care
While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.
How to Submit
N/A - No authorization is required
Resources
H0036 HE - Intercept
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
Please submit your request to Trillium Health Resources
If you find any wrong or out of date information on our pages, we want to know. Please email info@TrilliumNC.org with any corrections.