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
Peer Support Services (PSS)
An evidenced-based mental health model of care that provides community-based recovery services directly to a Medicaid-eligible adult member diagnosed with an MH or SU disorder. PSS provides structured, scheduled services that promote recovery, self-determination, self-advocacy, engagement in self-care and wellness and enhancement of community living skills of beneficiaries
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 = 15 minutes
Limits
- 1. Telehealth or telephonically, audio-only communication is limited to 20% or less of total service time provided per fiscal year.
Exclusions
May not be provided during the same episode of care as ACTT or CST. Member with a sole diagnosis of IDD is not eligible this service.
Age Group Details
Adults (age 18 and older)
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
Peer Support Services (PSS)
An evidenced-based mental health model of care that provides community-based recovery services directly to a Medicaid-eligible adult member diagnosed with an MH or SU disorder. PSS provides structured, scheduled services that promote recovery, self-determination, self-advocacy, engagement in self-care and wellness and enhancement of community living skills of beneficiaries
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 = 15 minutes
Limits
- 1. Telehealth or telephonically, audio-only communication is limited to 20% or less of total service time provided per fiscal year.
Exclusions
May not be provided during the same episode of care as ACTT or CST. Member with a sole diagnosis of IDD is not eligible this service.
Age Group Details
Adults (age 18 and older)
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
Assertive Community Treatment (ACT) Program
An ACT team assists a member in advancing toward personal goals with a focus on enhancing community integration and regaining valued roles (example: worker, daughter, resident, spouse, tenant, or friend). A fundamental charge of ACT is to be the first line (and generally sole provider) of all the services that an ACT member needs. A member who is appropriate for ACT does not benefit from receiving services across multiple, disconnected providers, and may become at greater risk of hospitalization, homelessness, substance use, victimization, and incarceration.
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
Trillium has agreed to billing a weekly case rate up to 2 units per week with up to 4 units per calendar month
Exclusions
- 1. Members with a primary dx of a SU, IDD, TBI,
borderline personality disorder, or an autism spectrum disorder are not the intended member group for ACT and should not be referred if they do not have a cooccurring psychiatric disorder.
- 2. ACT cannot be provided concurrently w/: Outpatient
therapy, Med Management, or Psych Services; Mobile Crisis; PSR (after a 30-day transition period); CST;
Partial Hospitalization; Tenancy Support Services;
Nursing home facility, or IPS-Supported Employment or LTVS
Diagnosis Requirements
Covered diagnoses include schizophrenia, other psychotic disorders such as schizoaffective disorder, and bipolar disorder because these illnesses more often cause long-term psychiatric disability. Beneficiaries with other psychiatric illnesses may qualify depending on the level of long-term disability. Beneficiaries with a primary diagnosis of substance use disorder, intellectual developmental disabilities, borderline personality disorder, traumatic brain injury, or autism spectrum disorder are not the intended beneficiary group and should not be referred to ACT unless they have a co-occurring psychiatric disorder.
Age Group Details
Adults (age 18 and older)
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
A fundamental feature of ACT is that services are taken to the beneficiary in his or her natural environment, rather than having the beneficiary come into an office or clinic setting to receive services.
How to Submit
N/A - No authorization is required
Resources
Assertive Community Treatment (ACT)
An Assertive Community Treatment (ACT) team consists of a community-based group of medical, behavioral health, and rehabilitation professionals who use a team approach to meet the needs of an individual with severe and persistent mental illness. An individual who is appropriate for ACT does not benefit from receiving services across multiple, disconnected providers, and may become at greater risk of hospitalization, homelessness, substance use, victimization, and incarceration.
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 (including above detailed requirements): recently reviewed detailing the individual’s progress with the service.
- 3. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
- 4. Submission of all records that support the individual has met the medical necessity criteria.
Unit Value
One unit = 1 event.
Limits
State funds will not cover services provided to individuals with a primary dx of a SU disorder, IDD, ASD, personality disorders, or TBI.
Length of Stay
- 1. Up to 30 days for all authorization requests.
- 2. No more than 5 months in a rolling year will be authorized.
- 3. Team must see individuals, on average, 1.5 times per week for at least 60 minutes per week. It is expected that additional face-to-face and phone contacts are made with individuals, their natural supports, and other providers on their behalf.
Exclusions
ACT cannot be provided concurrently with: Individual, Group, or Family Outpatient; OPT Med Management; Outpatient Psychiatric Services; d. Mobile Crisis Management; PSR or CST (after a 30-day transition period; Partial Hospitalization; Tenancy Support Services; Nursing home facility, IPS-SE or LTVS.
Diagnosis Requirements
State funds will not cover services provided to individuals with a primary dx of a SU disorder, IDD, ASD, personality disorders, or TBI.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Assertive Community Treatment (ACT) Program
An ACT team assists a member in advancing toward personal goals with a focus on enhancing community integration and regaining valued roles (example: worker, daughter, resident, spouse, tenant, or friend). A fundamental charge of ACT is to be the first line (and generally sole provider) of all the services that an ACT member needs. A member who is appropriate for ACT does not benefit from receiving services across multiple, disconnected providers, and may become at greater risk of hospitalization, homelessness, substance use, victimization, and incarceration.
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
- 1. One unit = 1 event
- 2. Trillium has agreed to billing a weekly case rate up to 2 units per week with up to 4 units per calendar month (instead of the prescribed 1 unit per week). A shadow claim should be billed every time an encounter occurs.
- 3. The expectation is most ACT members will receive more than 4 contacts per month, with most seeing at least 3 team members in a given month.
Exclusions
ACT cannot be provided concurrently w/: Outpatient therapy, Med Management, or Psych Services; Mobile Crisis; PSR (after a 30-day transition period); CST; Partial Hospitalization; Tenancy Support Services; Nursing home facility, or IPS-Supported Employment or LTVS.
Diagnosis Requirements
Members with a primary dx of a SU, IDD, TBI, borderline personality disorder, or an autism spectrum disorder are not the intended member group for ACT and should not be referred if they do not have a co-occurring psychiatric disorder.
Age Group Details
Adults (age 18 and older)
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
A fundamental feature of ACT is that services are taken to the beneficiary in his or her natural environment, rather than having the beneficiary come into an office or clinic setting to receive services.
How to Submit
N/A - No authorization is required
Resources
Assertive Community Treatment (ACT) Program
An ACT team assists a member in advancing toward personal goals with a focus on enhancing community integration and regaining valued roles (example: worker, daughter, resident, spouse, tenant, or friend). A fundamental charge of ACT is to be the first line (and generally sole provider) of all the services that an ACT member needs. A member who is appropriate for ACT does not benefit from receiving services across multiple, disconnected providers, and may become at greater risk of hospitalization, homelessness, substance use, victimization, and incarceration.
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
- 1. One unit = 1 event
- 2. Trillium has agreed to billing a weekly case rate up to 2 units per week with up to 4 units per calendar month (instead of the prescribed 1 unit per week). A shadow claim should be billed every time an encounter occurs.
- 3. The expectation is most ACT members will receive more than 4 contacts per month, with most seeing at least 3 team members in a given month.
Exclusions
ACT cannot be provided concurrently w/: Outpatient therapy, Med Management, or Psych Services; Mobile Crisis; PSR (after a 30-day transition period); CST; Partial Hospitalization; Tenancy Support Services; Nursing home facility, or IPS-Supported Employment or LTVS.
Diagnosis Requirements
Members with a primary dx of a SU, IDD, TBI, borderline personality disorder, or an autism spectrum disorder are not the intended member group for ACT and should not be referred if they do not have a co-occurring psychiatric disorder.
Age Group Details
Adults (age 18 and older)
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
A fundamental feature of ACT is that services are taken to the beneficiary in his or her natural environment, rather than having the beneficiary come into an office or clinic setting to receive services.
How to Submit
N/A - No authorization is required
Resources
Assertive Community Treatment (ACT) Shadow Claims
An Assertive Community Treatment (ACT) team consists of a community-based group of medical, behavioral health, and rehabilitation professionals who use a team approach to meet the needs of an individual with severe and persistent mental illness. An individual who is appropriate for ACT does not benefit from receiving services across multiple, disconnected providers, and may become at greater risk of hospitalization, homelessness, substance use, victimization, and incarceration.
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 (including above detailed requirements): recently reviewed detailing the individual’s progress with the service.
- 3. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
- 4. Submission of all records that support the individual has met the medical necessity criteria.
Unit Value
One unit = 1 event.
Limits
State funds will not cover services provided to individuals with a primary dx of a SU disorder, IDD, ASD, personality disorders, or TBI.
Length of Stay
- 1. Up to 30 days for all authorization requests.
- 2. No more than 5 months in a rolling year will be authorized.
- 3. Team must see individuals, on average, 1.5 times per week for at least 60 minutes per week. It is expected that additional face-to-face and phone contacts are made with individuals, their natural supports, and other providers on their behalf.
Exclusions
ACT cannot be provided concurrently with: Individual, Group, or Family Outpatient; OPT Med Management; Outpatient Psychiatric Services; d. Mobile Crisis Management; PSR or CST (after a 30-day transition period; Partial Hospitalization; Tenancy Support Services; Nursing home facility, IPS-SE or LTVS.
Diagnosis Requirements
State funds will not cover services provided to individuals with a primary dx of a SU disorder, IDD, ASD, personality disorders, or TBI.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Community Transition, 1915(i)
Community Transition provides funding for a onetime initial setup of expenses for a member transitioning from an institutional or other approved setting, into their own private residence where the member is responsible for their own living expenses. Community Transition can support a member being diverted from entry into ACHs or any institutional level of care due to preadmission, screening, and diversion efforts, provided that the member is moving to a living arrangement where they are directly responsible for their own living expenses.
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 approval required. The request must be submitted by the TCM.
Unit Value
One unit per episode
Limits
Community Transition has a limit of $5,000 per individual during the five-year period.
Length of Stay
Available up to 3 months before the move to an integrated living arrangement and up to 90 consecutive days after move-in.- Limited to once per 5-year period
Exclusions
- • Community Transition only covers the actual
items purchased, not the time spent assisting the member to purchase them. Providers currently providing a community-based service like CST or ACT to a SMI/SUD members can bill the time spent helping members purchase these items.
- • An institutional or other approved setting can
include a state developmental center, community Intermediate Care Facility, nursing facility, licensed group home, Alternative Family Living (AFL), foster home, adult care home, State Operated Healthcare Facility, or a Psychiatric Residential Treatment Facility (PRTF).
- • May be provided only in a private home or
apartment with a lease in the individual’s/ legal guardian’s/ representative’s name or a home owned by the individual.
- • May not be provided by family members.
- • Services cannot duplicate items that are
currently available from a roommate.
- • Furnished only to the extent that the member is
unable to meet such expense, or when the support cannot be obtained from other sources or services.
- • May not be provided to members enrolled in the
CAP/C or CAP/DA wavier
- • May not be provided to a member residing in an
Institution for Mental Disease (IMD) regardless of the facility type.
- • Medicaid will not cover:
- o Monthly rental or mortgage expenses
- o Repairs to a property Regular or recurring utility bills or fees
associated with lawn care, property facilities, homeowners’ associations, or recurring pest eradication.
- o Household appliances (exception: a
microwave)
- o Recreational items such as televisions,
gaming systems, cell phones, CD or DVD players and components.
- o Food or groceries
- o Care management services or activities
- o Maintenance contracts and extended
warranties
Diagnosis Requirements
For Medicaid-specific coverage, the beneficiary must have a primary diagnosis of intellectual or developmental disability, traumatic brain injury, serious mental illness, severe and persistent mental illness, or severe substance use disorder.
Age Group Details
Available only for beneficiaries age 18 and older, subject to EPSDT exception for Medicaid beneficiaries under 21
Additional Service Specifics
For individuals with IDD/TBI:
- 1. Providers (non-TCMs/care coordinators) will be responsible for providing Community Transition services.
- 2. The TCM/care coordinator and the provider must work together to identify the Community Transition needs
of the individuals.
- 3. The TCM/care coordinator
completes the care plan/ISP which indicates the request for Community Transition.
- 4. The tx team then reviews
the hours needed to support the individual to access Community Transition.
- 5. The tx team works with the
TCM/care coordinator to update the care plan/goals to address specific hours needed through the Community Living Supports service to support the individual.
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
H0043U4 - Community Transition
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 approval required. The request must be submitted by TCM.
How to Submit
If applicable, please submit your request to Trillium.
Respite, 1915(i)
Respite services provide periodic support and temporary relief to the primary caregiver(s) from the responsibility and stress of caring for a member that requires continuous supervision due to their diagnosis. Respite services also provide the member periodic support and relief from the primary caregiver(s). Members must require assistance in at least one area of major life activity, as appropriate to the person’s age, and not have the ability to care for themselves in the absence of a primary caregiver. Members must also have needs that exceed that of a child without behavioral health concerns/ developmental disabilities that could have care provided by a traditional babysitter or day care. Service specific age requirements apply.
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
. Prior approval required. The request must be submitted by TCM.
- 2. Updated Care Plans/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
- 3. Submission of applicable records that support the member has met the medical necessity criteria
Conditional Requirements
Prior approval required. The request must be submitted by TCM.
Unit Value
One unit = 15 minutes
Limits
No more than 1200 units (300 hours) can be provided in a care plan year, based on the members’ initial care plan for the year. This is regardless of provider transitions. If a member changes providers and receives a brand-new care plan, the 1200 unit limit based on the previous plan still applies.
Exclusions
- • Respite must not be provided by relatives or legal guardians if they live in the same home as the member. Respite care may not be provided by any person who resides in the individual’s primary place of residence.
- • The member receiving this service must live in a non licensed setting, with non-paid caregiver(s). Exception: Those residing in a licensed or unlicensed AFL or Therapeutic Foster Care (TFC).
- • Respite may not be billed on the same day as Residential Supports.
- • Staff sleep time is not billable.
- • This service is not available to members who reside in a 5600B or 5600C licensed facility.
- • Emergency care applies to family emergencies and does not include out of home crisis.
- • This service may not be used as a regularly scheduled daily service for individual support.
- • Respite may not be used for members who are living alone or with a roommate.
- • Members enrolled in the CAP/C or CAP/DA waiver are not eligible for Respite services
Age Group Details
- • Aged 3 through 21 w/ a documented primary diagnosis of a SED (as defined by the CCP) or primary diagnosis of SUD, severe (as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM 5)) OR
- • Aged 3 and older w/ a primary diagnosis of IDD or TBI, as defined by the CCP or the DSM or a genetically diagnosed syndrome that is typically associated with IDD
Place of Service
Member’s private primary residence, in a shelter, licensed group home, adult care home, the community or in an office setting.
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
Respite, 1915(i)
Respite services provide periodic support and temporary relief to the primary caregiver(s) from the responsibility and stress of caring for a member that requires continuous supervision due to their diagnosis. Respite services also provide the member periodic support and relief from the primary caregiver(s). Members must require assistance in at least one area of major life activity, as appropriate to the person’s age, and not have the ability to care for themselves in the absence of a primary caregiver. Members must also have needs that exceed that of a child without behavioral health concerns/ developmental disabilities that could have care provided by a traditional babysitter or day care. Service specific age requirements apply.
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
. Prior approval required. The request must be submitted by TCM.
- 2. Updated Care Plans/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
- 3. Submission of applicable records that support the member has met the medical necessity criteria
Conditional Requirements
Prior approval required. The request must be submitted by TCM.
Unit Value
One unit = 15 minutes
Limits
No more than 1200 units (300 hours) can be provided in a care plan year, based on the members’ initial care plan for the year. This is regardless of provider transitions. If a member changes providers and receives a brand-new care plan, the 1200 unit limit based on the previous plan still applies.
Exclusions
- • Respite must not be provided by relatives or legal guardians if they live in the same home as the member. Respite care may not be provided by any person who resides in the individual’s primary place of residence.
- • The member receiving this service must live in a non licensed setting, with non-paid caregiver(s). Exception: Those residing in a licensed or unlicensed AFL or Therapeutic Foster Care (TFC).
- • Respite may not be billed on the same day as Residential Supports.
- • Staff sleep time is not billable.
- • This service is not available to members who reside in a 5600B or 5600C licensed facility.
- • Emergency care applies to family emergencies and does not include out of home crisis.
- • This service may not be used as a regularly scheduled daily service for individual support.
- • Respite may not be used for members who are living alone or with a roommate.
- • Members enrolled in the CAP/C or CAP/DA waiver are not eligible for Respite services
Age Group Details
- • Aged 3 through 21 w/ a documented primary diagnosis of a SED (as defined by the CCP) or primary diagnosis of SUD, severe (as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM 5)) OR
- • Aged 3 and older w/ a primary diagnosis of IDD or TBI, as defined by the CCP or the DSM or a genetically diagnosed syndrome that is typically associated with IDD
Place of Service
Member’s private primary residence, in a shelter, licensed group home, adult care home, the community or in an office setting.
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
H0046 High Risk Intervention - Level I
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
Clinically Managed Population Specific High-Intensity Residential Program
This is a therapeutic rehabilitation service delivered by trained and experienced medical and nursing professionals, as well as clinical and support staff for a member with both SUD and TBI. This service provides a 24-hour structured recovery environment in combination with high-intensity clinical services, designed to meet the functional and cognitive limitations of a member and to support recovery from substance use disorders. This tx service focuses on overcoming a lack of awareness or ambivalence about the effects of addiction and preventing relapse. The service also focuses on promoting reintegration into the community.
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. A minimum of 2 staff shall be on-site at all times when a member is present.
- 2. Must be staffed to screen and accept admissions a minimum of eight (8) hours a day, five (5) days a week.
- 3. Service can be received from only one provider during any active episode of care.
Exclusions
Service must not be billed on the same day (except day of admission or discharge) as Residential levels of care; Other residential levels of care; Withdrawal management services; Outpatient treatment services; SAIOP; SACOT; ACT; CST; Supported Employment; PSR; PSS; Partial Hospitalization; Facility Based Crisis; or TBI State-funded program services.
Diagnosis Requirements
Must have both a substance use disorder and TBI diagnosis
Level of Care
Must be provided in a facility licensed under 10A NCAC 27G.5600
Place of Service
Must be provided in a facility licensed under 10A NCAC 27G.5600
How to Submit
N/A - No authorization is required
Resources
Clinically Managed Population Specific High-Intensity Residential Program
This service provides a 24-hour structured recovery environment in combination with high-intensity clinical services. This service is for a member with both a substance use disorder (SUD) and traumatic brain injury (TBI). It is designed to meet the functional and cognitive limitations of a member and to support recovery from substance use disorders. The effects of the substance use disorder combined with the cognitive limitations are such that outpatient or other levels of residential care are not feasible or effective. This tx service focuses on overcoming a lack of awareness or ambivalence about the effects of addiction and preventing relapse. The service also focuses on promoting reintegration into the community.
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 = 1 Day
Limits
- 1. Provider shall verify each Medicaid member’s eligibility each time a service is rendered
- 2. A minimum of 2 staff shall be on-site at all times when a member is present.
- 3. Must be staffed to screen and accept admissions a minimum of eight (8) hours a day, five (5) days a week.
Exclusions
Must not be provided and billed on the same day (except day of admission or discharge) as: Other residential levels of care, Withdrawal management services, Outpatient treatment services, SAIOP, SACOT, ACT, CST, Supported Employment, PSR, PSS, Partial Hospitalization, Facility Based Crisis (Adult), or TBI State-funded program services.
Diagnosis Requirements
Must have both a substance use disorder and TBI diagnosis
Age Group Details
Adults (aged 18+)
Level of Care
ASAM Level 3.3. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions.
Place of Service
Must be provided in a facility licensed under 10A NCAC 27G.5600. 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
Mobile Crisis Management (MCM)
Mobile Crisis Management (MCM) involves all support, services and treatments necessary to provide integrated crisis response, crisis stabilization interventions, and crisis prevention activities. This service is designed to rapidly assess crisis situations and a member’s clinical condition, to triage the severity of the crisis, and to provide immediate, focused crisis intervention services which are mobilized based on the type and severity of crisis.
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. The crisis management provider must contact the MCO to determine if the member is enrolled with a provider that should be involved with the response. Medicaid shall not cover services when the service unnecessarily duplicates another provider’s authorized service.
- 2. Service shall be used to divert members from inpatient psychiatric and detoxification services.
- 3. Priority should be given to a member with a history of multiple crisis episodes or who are at substantial risk of future crises.
Exclusions
May not be provided concurrently w/: ACT, CST, IIH, MST, MCSART, NMCSART, Withdrawal services, Inpatient services, PRTF (Except on the day of admission for Inpatient & PRTF).
Age Group Details
Children, Adolescents & Adults
Place of Service
Community settings
How to Submit
N/A - No authorization is required
Resources
Mobile Crisis Management Services
Involves all support, services, and tx necessary to provide integrated crisis response, crisis stabilization interventions, and crisis prevention activities. Services are always available, 24 hours a day, seven days a week, 365 days a year. Crisis response provides an immediate evaluation, triage and access to acute MH, IDD, or SU services, tx, and supports to effect symptom reduction, harm reduction, or to safely transition persons in acute crises to appropriate crisis stabilization and detox supports or services. Services will be used to divert individuals from inpatient psychiatric and detox services. These services are not used as “step down” services from inpatient hospitalization.
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 not required for the first 32 units of crisis services per episode; prior authorization required within 48 hours of exhausting unmanaged units.
Unit Value
One unit = 15 minutes
Limits
- 1. Priority should be given to individuals with a history of multiple crisis episodes or who are at substantial risk of future crises.
- 2. Mobile Crisis Management must develop a Crisis Plan before discharge for individuals new to the public system.
- 3. Services related to this policy are not covered when the service duplicates another provider’s service.
- 4. Services that may not be concurrently provided include: ACT, CST, IIH, MST, Medical Community Substance Abuse Residential Tx, Non-Medical Community Substance Abuse Residential Tx, Detoxification Services, Inpatient SU Tx, Inpatient Psychiatric Tx, and Psychiatric Residential Tx Facility except for the day of admission.
Exclusions
- 4. Services that may not be concurrently provided include: ACT, CST, IIH, MST, Medical Community Substance Abuse Residential Tx, Non-Medical Community Substance Abuse Residential Tx, Detoxification Services, Inpatient SU Tx, Inpatient Psychiatric Tx, and Psychiatric Residential Tx Facility except for the day of admission.
Diagnosis Requirements
Mental Health, Substance Use and Intellectual/ Developmental Disability
Additional Service Specifics
Prior authorization is not required for the first 32 units of crisis services per episode.
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
Crisis Services
Crisis Supports provide intervention and stabilization for a member experiencing a crisis. Crisis Supports are for a member who experiences acute crises and who presents a threat to the member’s health and safety or the health and safety of others. These behaviors may result in the member losing his or her home, job, or access to activities and community involvement. Crisis Supports promote prevention of crises as well as assistance in stabilizing the member when a behavioral crisis occurs. Crisis Supports are an immediate intervention available 24 hours per day, 7 days per week, to support the individual.
Out-of-home crisis is a short-term service for an individual experiencing a crisis and requiring a period of structured support and/or programming. The service takes place in a licensed facility. Out of-home crisis may be used when an individual cannot be safely supported in the home, due to his/her behavior, and implementation of formal behavior interventions have failed to stabilize the behaviors, and all other approaches to ensure health and safety have failed. In addition, the service may be used as a planned respite stay for waiver members who have heightened behavioral needs.
Crisis consultation is for individuals that have significant, intensive, or challenging behaviors or medical conditions that have resulted or have the potential to result in a crisis. Consultation is provided by staff that meets the minimum staffing requirements of a Qualified Professional and who have crisis experience.
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.
Limits
- 1. Following service auth, any needed modifications to the ISP and individual budget will occur within five working days of the date of verbal service authorization.
- 2. Out-of-Home Crisis services are authorized in increments of up to 30 calendar days.
- 3. Crisis Intervention & Stabilization Supports may be authorized for periods of up to 14 calendar day increments per event.
Exclusions
- • This service may not duplicate services provided under Specialized Consultation Services.
- • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
- • See the CCP for all applicable exclusions, limitations & exceptions.
Additional Service Specifics
Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
H2012HA Day Treatment Child
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
State Funded Child and Adolescent Day Treatment
A structured tx service in a licensed facility for children or adolescents and their families that builds on strengths and addresses identified needs. This service is designed to serve children who, as a result of their MH or SU disorder tx needs, are unable to benefit from participation in academic or vocational services at a developmentally appropriate level in a traditional school or work setting. The provider implements therapeutic interventions that are coordinated with the individual’s academic or vocational services available through enrollment in an educational setting. Each CADT provider must follow a clearly identified clinical model(s) or evidence-based tx(s) consistent with best practice. Day Treatment provides case mngmnt 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 is required
- 2. Complete PCP: recently reviewed detailing the individual’s progress with the service.
- 3. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
- 4. Submission of all records that support the individual has met the medical necessity criteria.
Unit Value
One unit = 1 hour.
Limits
Up to 258 units per 60 days.
Length of Stay
- 1. This is a time limited service, and services should be titrated based on the transition plan in the PCP.
- 2. This is a day or night service that shall be available year-round for a minimum of three hours a day during all days of operation.
- 3. Up to 60 days for the initial and reauth period.
Exclusions
- 1. CADT services may not be provided during the same auth period as: IIH; MST; Individual, group, and family therapy; SAIOP; Child Residential Treatment services–Levels II through IV; PRTF; Substance abuse residential services; or Inpatient hospitalization.
- 2. CADT programs may not operate as simply an after-school program.
Age Group Details
Children & Adolescents (Ages 5 through 17)
Level of Care
ASAM Level of 2.1 (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
Child and Adolescent Day Treatment
This is a structured tx service in a licensed facility for youth and their families that builds on strengths and addresses identified needs. This service is designed to serve children who, as a result of their mental health or substance use disorder tx needs, are unable to benefit from participation in academic or vocational services at a developmentally appropriate level in a traditional school or work setting. The provider implements therapeutic interventions that are coordinated with the member’s academic or vocational services available through enrollment in an educational setting.
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 hour.
Limits
Transition and discharge planning begin at admission and must be documented in the PCP.
Exclusions
- 1. CADT services cannot be provided during the same auth period as: IIH; MST; Individual, Group and Family therapy; SAIOP; Child Residential Tx: Level II Program Type through Level IV; PRTF; Substance Abuse Residential Services, or; Inpatient Hospitalization.
- 2. CADT programs may not operate as simply
Age Group Details
Children & Adolescents (Age 5 through 20)
Level of Care
ASAM Level of 2.1 (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
N/A - No authorization is required
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.