PA Lookup

Residential Supports provides individualized services and supports to enable a member to live successfully in a Group Home or Alternative Family Living (AFL) setting of their choice and be an active participant in his/her community. The intended outcome of the service is to increase or maintain the member’s life skills, provide the supervision needed, maximize his/her self-sufficiency, increase self- determination, and ensure the person’s opportunity to have full membership in his/her community. Residential Supports includes learning new skills, practice and improvement of existing skills, and retaining skills to assist the person to complete an activity to his/her level of independence. Residential Supports includes supervision and assistance in activities of daily living when the member is dependent on others to ensure health and safety.

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. Residential Supports may be provided in an AFL situation. The site must be the primary residence of the AFL provider (includes couples and single persons) who receive reimbursement for the cost of care. Primary AFL Staff who provide Residential Supports should not provide other waiver services to the member.
• 2. Individuals are provided opportunities to seek employment and work in competitive integrated settings, engage in community life and control personal resources.
• 3. Individuals select the setting from among available options, including non-disability specific settings and an option for a private unit in a residential setting (with consideration being given to financial resources)

Exclusions

• • The amount of Residential Supports is subject to the Limits on Sets of Services.
• • A member who receives Residential Supports may not receive Home Modifications, Community Living and Supports, Respite (unless the individual resides in an AFL), Supported Living, or State Plan Personal Care Services.
• • Assistive Technology Equipment & Supplies may be accessed when the item belongs to the individual and can transition to other settings with the individual.• This service is not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Living, Supported Employment or one of the State Plan Medicaid Services that works directly with the person such as Private Duty Nursing.
• • Payments for Residential Supports do not include payments for room and board, the cost of facility maintenance and upkeep.
• • In specific situations, to ensure member health and safety Trillium may approve the AFL to serve as short term back up staff for day services (Day Supports, Community Networking or Supported Employment). This approval must be documented in the Individuals record at both Trillium and the provider agency.
• • Transportation to and from the residence and points of travel in the community is included to the degree that they are not reimbursed by another funding source.
• • NC Innovations respite may also be used to provide temporary relief to individuals who reside in Licensed and Unlicensed AFLs, but it may not be billed on the same day as Residential Supports. Respite may also be provided for participation in non-integrated camps or for participation in non-integrated Support Groups
• • Back-up staff must be employees of the agency.
• • The setting is integrated in and supports full access of a member to the greater community.
• • Settings optimize, but do not regiment, individual initiative, autonomy and independence in making life choices.
• • Settings facilitate individual choice regarding services and supports, and who provides these.
• • In Provider Owned or Controlled Residential Settings: a) Provide, at a minimum, the same responsibilities and protections from eviction that tenants have under the landlord tenant law for the state, county, city or other designated entity; b) Provide privacy in sleeping or living unit; c) Provide freedom and support to control individual schedules and activities, and to have access to food at any time; d) Allow visitors of the member’s choosing at any time; e) Are physically accessible.
• • Refer to North Carolina DHHS’s HCBS Transition Plan for additional information https://www.ncdhhs.gov/about/department-initiatives/home-and-community-based-services-final-rule/hcbs-resources.
• • 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

Residential Supports levels are determined by the IBT and other evidence of support need. The SIS Level is only one piece of evidence that may be considered.

Level 1: SIS Level A Level 2: SIS Level B Level 3: SIS Level C and D Level 4: SIS Level E, F, and G

Other Information

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)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Residential Supports provides individualized services and supports to enable a member to live successfully in a Group Home or Alternative Family Living (AFL) setting of their choice and be an active participant in his/her community. The intended outcome of the service is to increase or maintain the member’s life skills, provide the supervision needed, maximize his/her self-sufficiency, increase self- determination, and ensure the person’s opportunity to have full membership in his/her community. Residential Supports includes learning new skills, practice and improvement of existing skills, and retaining skills to assist the person to complete an activity to his/her level of independence. Residential Supports includes supervision and assistance in activities of daily living when the member is dependent on others to ensure health and safety.

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. Residential Supports may be provided in an AFL situation. The site must be the primary residence of the AFL provider (includes couples and single persons) who receive reimbursement for the cost of care. Primary AFL Staff who provide Residential Supports should not provide other waiver services to the member.
• 2. Individuals are provided opportunities to seek employment and work in competitive integrated settings, engage in community life and control personal resources.
• 3. Individuals select the setting from among available options, including non-disability specific settings and an option for a private unit in a residential setting (with consideration being given to financial resources)

Exclusions

• • The amount of Residential Supports is subject to the Limits on Sets of Services.
• • A member who receives Residential Supports may not receive Home Modifications, Community Living and Supports, Respite (unless the individual resides in an AFL), Supported Living, or State Plan Personal Care Services.
• • Assistive Technology Equipment & Supplies may be accessed when the item belongs to the individual and can transition to other settings with the individual.• This service is not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Living, Supported Employment or one of the State Plan Medicaid Services that works directly with the person such as Private Duty Nursing.
• • Payments for Residential Supports do not include payments for room and board, the cost of facility maintenance and upkeep.
• • In specific situations, to ensure member health and safety Trillium may approve the AFL to serve as short term back up staff for day services (Day Supports, Community Networking or Supported Employment). This approval must be documented in the Individuals record at both Trillium and the provider agency.
• • Transportation to and from the residence and points of travel in the community is included to the degree that they are not reimbursed by another funding source.
• • NC Innovations respite may also be used to provide temporary relief to individuals who reside in Licensed and Unlicensed AFLs, but it may not be billed on the same day as Residential Supports. Respite may also be provided for participation in non-integrated camps or for participation in non-integrated Support Groups
• • Back-up staff must be employees of the agency.
• • The setting is integrated in and supports full access of a member to the greater community.
• • Settings optimize, but do not regiment, individual initiative, autonomy and independence in making life choices.
• • Settings facilitate individual choice regarding services and supports, and who provides these.
• • In Provider Owned or Controlled Residential Settings: a) Provide, at a minimum, the same responsibilities and protections from eviction that tenants have under the landlord tenant law for the state, county, city or other designated entity; b) Provide privacy in sleeping or living unit; c) Provide freedom and support to control individual schedules and activities, and to have access to food at any time; d) Allow visitors of the member’s choosing at any time; e) Are physically accessible.
• • Refer to North Carolina DHHS’s HCBS Transition Plan for additional information https://www.ncdhhs.gov/about/department-initiatives/home-and-community-based-services-final-rule/hcbs-resources.
• • 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

Residential Supports levels are determined by the IBT and other evidence of support need. The SIS Level is only one piece of evidence that may be considered.

Level 1: SIS Level A Level 2: SIS Level B Level 3: SIS Level C and D Level 4: SIS Level E, F, and G

Other Information

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)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Service is designed to help adults with psychiatric disabilities increase their functioning so that they can be successful and satisfied in the environments of their choice with the least amount of ongoing professional intervention. PSR focuses on skill and resource development related to life in the community and to increasing the participant’s ability to live as independently as possible, to manage their illness and their lives with as little professional intervention as possible, and to participate in community opportunities related to functional, social, educational and vocational goals.

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 recipient’s progress with the service, to include all required signatures and the 3-page crisis plan. For PSR, the PCP shall be reviewed at least every 6 months. The amount, duration, and frequency of services must be included in a recipient’s PCP.
• 3. Transition/ Stepdown Plan: Encouraged
• 4. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
• 5. Submission of applicable records that support the recipient has met the medical necessity criteria.

Unit Value

One unit = 15 minutes

Limits

Up to 30 hours (120 units) per week for 90-day auth period (up to 1542 units).

Length of Stay

• 1. Initial and Reauthorization Requests: Up to 90 days
• 2. Maximum length of service is 6 months in a rolling 12-month period.
• 3. This service is to be available for a period of five or more hours per day, at least five days per week, and it may be provided on weekends or in the evening.

Exclusions

PSR may not be provided during the same auth period as Partial Hospitalization and ACT.

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

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

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• State-Funded Psychosocial Rehabilitation
• Records Management and Documentation Manual
• DMHDDSUS Bulletins

Service is designed to help adults with psychiatric disabilities increase their functioning so that they can be successful and satisfied in the environments of their choice with the least amount of ongoing professional intervention. PSR focuses on skill and resource development related to life in the community and to increasing the participant’s ability to live as independently as possible, to manage their illness and their lives with as little professional intervention as possible, and to participate in community opportunities related to functional, social, educational, and vocational goals.

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

This service is to be available for a period of five or more hours per day at least five days per week and it may be provided on weekends or in the evening.

Length of Stay

The number of hours that a member receives PSR services are to be specified in his or her PCP.

Exclusions

PSR cannot be provided during the same episode of care as Partial Hospitalization, 1915i Individual and Transitional Support, and ACTT.

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

• Clinical Coverage Policy 8A: Enhanced Mental Health and Substance Abuse Services, Psychosocial Rehabilitation section
• Records Management and Documentation Manual

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 II Service provides a moderate to highly structured and supervised environment in a family or program 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.

Reauthorization Guidelines

• 1. TAR: prior authorization required
• 2. Complete PCP: recently reviewed detailing the member’s progress with the service. Should include progress towards each of the goals and involvement in therapy, to include family therapy if reunification is the goal. If family therapy is not occurring in this case, please explain.
• 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. Submission of applicable records that support the member has met the medical necessity criteria.

Unit Value

One unit = 1 day

Limits

MCD will not cover this service when the service duplicates another procedure, product, or service.

How to Submit

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

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8-D-2: Residential Treatment Services
• Records Management and Documentation Manual

Residential Supports provides individualized services and supports to enable a member to live successfully in a Group Home or Alternative Family Living (AFL) setting of their choice and be an active participant in his/her community. The intended outcome of the service is to increase or maintain the member’s life skills, provide the supervision needed, maximize his/her self-sufficiency, increase self- determination, and ensure the person’s opportunity to have full membership in his/her community. Residential Supports includes learning new skills, practice and improvement of existing skills, and retaining skills to assist the person to complete an activity to his/her level of independence. Residential Supports includes supervision and assistance in activities of daily living when the member is dependent on others to ensure health and safety.

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. Residential Supports may be provided in an AFL situation. The site must be the primary residence of the AFL provider (includes couples and single persons) who receive reimbursement for the cost of care. Primary AFL Staff who provide Residential Supports should not provide other waiver services to the member.
• 2. Individuals are provided opportunities to seek employment and work in competitive integrated settings, engage in community life and control personal resources.
• 3. Individuals select the setting from among available options, including non-disability specific settings and an option for a private unit in a residential setting (with consideration being given to financial resources)

Exclusions

• • The amount of Residential Supports is subject to the Limits on Sets of Services.
• • A member who receives Residential Supports may not receive Home Modifications, Community Living and Supports, Respite (unless the individual resides in an AFL), Supported Living, or State Plan Personal Care Services.
• • Assistive Technology Equipment & Supplies may be accessed when the item belongs to the individual and can transition to other settings with the individual.• This service is not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Living, Supported Employment or one of the State Plan Medicaid Services that works directly with the person such as Private Duty Nursing.
• • Payments for Residential Supports do not include payments for room and board, the cost of facility maintenance and upkeep.
• • In specific situations, to ensure member health and safety Trillium may approve the AFL to serve as short term back up staff for day services (Day Supports, Community Networking or Supported Employment). This approval must be documented in the Individuals record at both Trillium and the provider agency.
• • Transportation to and from the residence and points of travel in the community is included to the degree that they are not reimbursed by another funding source.
• • NC Innovations respite may also be used to provide temporary relief to individuals who reside in Licensed and Unlicensed AFLs, but it may not be billed on the same day as Residential Supports. Respite may also be provided for participation in non-integrated camps or for participation in non-integrated Support Groups
• • Back-up staff must be employees of the agency.
• • The setting is integrated in and supports full access of a member to the greater community.
• • Settings optimize, but do not regiment, individual initiative, autonomy and independence in making life choices.
• • Settings facilitate individual choice regarding services and supports, and who provides these.
• • In Provider Owned or Controlled Residential Settings: a) Provide, at a minimum, the same responsibilities and protections from eviction that tenants have under the landlord tenant law for the state, county, city or other designated entity; b) Provide privacy in sleeping or living unit; c) Provide freedom and support to control individual schedules and activities, and to have access to food at any time; d) Allow visitors of the member’s choosing at any time; e) Are physically accessible.
• • Refer to North Carolina DHHS’s HCBS Transition Plan for additional information https://www.ncdhhs.gov/about/department-initiatives/home-and-community-based-services-final-rule/hcbs-resources.
• • 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

Residential Supports levels are determined by the IBT and other evidence of support need. The SIS Level is only one piece of evidence that may be considered.

Level 1: SIS Level A Level 2: SIS Level B Level 3: SIS Level C and D Level 4: SIS Level E, F, and G

Other Information

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)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Service is a team approach designed to address the identified needs of children and adolescents who, due to serious and chronic symptoms of an emotional, behavioral, or SU disorder, are unable to remain stable in the community without intensive interventions. This is a time-limited, intensive child and family intervention based on the clinical needs of the individual. IIH services are auth’d for one individual child in the family. The parent or caregiver must be an active participant in the tx. Services are generally more intensive at the beginning of tx and decrease over time as the individual’s skills develop. This service is not delivered in a group 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.

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 episode.

Limits

This service is billed per diem, with a 2-hour minimum. When the total contact time per date of service meets or exceeds 2 hours, it is a billable event.

Typically 16 units per month for the initial auth, with reauthorizations titrating downward.

Length of Stay

• 1. Up to 60 days per authorization.
• 2. It is expected that service frequency will be titrated down after the initial auth. At least 12 face-to-face contacts are required in the first month, and at least 6 face-to-face contacts per month are required in the second and third months of IIH services.
• 3. No more than 6 months per calendar year.

Exclusions

IIH services may not be provided during the same authorization period as: MST; CADT; individual, group and family therapy; SAIOP; child residential treatment services Level II Program Type through Level IV; PRTF; or substance abuse residential services. No more than one individual in the home may receive IIH services during any active auth period.

Age Group Details

Children & Adolescents (Ages 3 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)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• State-Funded Intensive In-Home
• Records Management and Documentation Manual

Intensive In-Home (IIH) service is a team approach designed to address the identified needs of children and adolescents who, due to serious and chronic symptoms of an emotional, behavioral, or substance use disorder, are unable to remain stable in the community without intensive interventions. This is a time-limited, intensive child and family intervention based on the clinical needs of the member. Services are authorized for one individual child in the family and the parent or caregiver must be an active participant in the treatment.

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. One event = a contact of at least 2 hours.

Length of Stay

It is expected that service frequency shall decrease over time: at least 12 face-to-face contacts are required in the 1st month, and at least 6 face-to face contacts per month are required in the 2nd & 3rd months.

Exclusions

IIH services cannot be provided during the same auth period as: a) MST; b) CADT; c) Individual, Group and Family therapy; d) SAIOP; e) Child Residential Tx: Level II Program Type through Level IV; f) PRTF; or g) Substance Abuse Residential Services

Level of Care

ASAM Level 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

• Clinical Coverage Policy No 8A: Enhanced Mental Health and Substance Abuse Services, Intensive In-Home Services section
• Records Management and Documentation Manual
• Person Centered Planning

This is a comprehensive evidence-based model of intensive in-home tx for at risk youth and their families. Designed to promote permanency goals, FCT treats the youth and his/her family through individualized therapeutic interventions. All phases of FCT involve the family intensively in tx. FCT therapists are to be available 24/7 to support the youth and family when needed. The objective is to provide an alternative to out-of-home placements, minimize the length of stay in out-of-home placements, and reduce the risk of additional out-of-home placements by improving child/youth and family functioning.

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

Reauthorization Requests:

• 1. TAR: prior authorization required.
• 2. Complete PCP: recently reviewed detailing the member’s progress with the service
• 3. Submission of applicable records that support the member has met the medical necessity criteria.

Conditional Requirements

No prior authorization required for the initial 6 calendar months of tx

Unit Value

1 unit = 30 days; Post Discharge Outcome Payment: 1 unit = 1 outcome

Limits

Eligibility for Outcome PaymentEligibility for Outcome Payments dependent upon the following:

• • Enrolled in FCT for at least 60 days
• • No inpatient admissions
• • No residential Level II or higher from discharge (planned or unplanned)
• • No return to FCT, admission to IIH or MST.s dependent upon the following:

Length of Stay

• 1. National target standards are 6 months.
• 2. Expected Outcomes Include: Decrease in crisis episodes and inpatient stays, decrease the length of stay in crisis and inpatient facilities, and a decrease in Emergency Room Visits.

Exclusions

FCT services cannot be provided during the same auth period as: IIH; MST; Intercept; Individual, Group and Family therapy.

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

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

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Family Centered Treatment In-Lieu Of Service Definition
• Records Management and Documentation Manual
• Person Centered Planning

This is a comprehensive evidence-based model of intensive in-home tx for at risk youth and their families. Designed to promote permanency goals, FCT treats the youth and his/her family through individualized therapeutic interventions. All phases of FCT involve the family intensively in tx. FCT therapists are to be available 24/7 to support the youth and family when needed. The objective is to provide an alternative to out-of-home placements, minimize the length of stay in out-of-home placements, and reduce the risk of additional out-of-home placements by improving child/youth and family functioning.

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

Reauthorization Requests:

• 1. TAR: prior authorization required.
• 2. Complete PCP: recently reviewed detailing the member’s progress with the service
• 3. Submission of applicable records that support the member has met the medical necessity criteria.

Conditional Requirements

No prior authorization required for the initial 6 calendar months of tx

Unit Value

1 unit = 30 days; Post Discharge Outcome Payment: 1 unit = 1 outcome

Limits

Eligibility for Outcome PaymentEligibility for Outcome Payments dependent upon the following:

• • Enrolled in FCT for at least 60 days
• • No inpatient admissions
• • No residential Level II or higher from discharge (planned or unplanned)
• • No return to FCT, admission to IIH or MST.s dependent upon the following:

Length of Stay

• 1. National target standards are 6 months.
• 2. Expected Outcomes Include: Decrease in crisis episodes and inpatient stays, decrease the length of stay in crisis and inpatient facilities, and a decrease in Emergency Room Visits.

Exclusions

FCT services cannot be provided during the same auth period as: IIH; MST; Intercept; Individual, Group and Family therapy.

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

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

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Family Centered Treatment In-Lieu Of Service Definition
• Records Management and Documentation Manual
• Person Centered Planning

This is a comprehensive evidence-based model of intensive in-home tx for at risk youth and their families. Designed to promote permanency goals, FCT treats the youth and his/her family through individualized therapeutic interventions. All phases of FCT involve the family intensively in tx. FCT therapists are to be available 24/7 to support the youth and family when needed. The objective is to provide an alternative to out-of-home placements, minimize the length of stay in out-of-home placements, and reduce the risk of additional out-of-home placements by improving child/youth and family functioning.

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

Reauthorization Requests:

• 1. TAR: prior authorization required.
• 2. Complete PCP: recently reviewed detailing the member’s progress with the service
• 3. Submission of applicable records that support the member has met the medical necessity criteria.

Conditional Requirements

No prior authorization required for the initial 6 calendar months of tx

Unit Value

1 unit = 30 days; Post Discharge Outcome Payment: 1 unit = 1 outcome

Limits

Eligibility for Outcome PaymentEligibility for Outcome Payments dependent upon the following:

• • Enrolled in FCT for at least 60 days
• • No inpatient admissions
• • No residential Level II or higher from discharge (planned or unplanned)
• • No return to FCT, admission to IIH or MST.s dependent upon the following:

Length of Stay

• 1. National target standards are 6 months.
• 2. Expected Outcomes Include: Decrease in crisis episodes and inpatient stays, decrease the length of stay in crisis and inpatient facilities, and a decrease in Emergency Room Visits.

Exclusions

FCT services cannot be provided during the same auth period as: IIH; MST; Intercept; Individual, Group and Family therapy.

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

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

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Family Centered Treatment In-Lieu Of Service Definition
• Records Management and Documentation Manual
• Person Centered Planning

IPS is a person-centered behavioral health service with a focus on employment and education. IPS assists in choosing, acquiring, and maintaining competitive paid employment in the community for a member 16 years and older, with significant behavioral health needs, for whom employment has not been achieved or employment has been interrupted or intermittent. The foundation for this service is the IPS evidence-based Supported Employment model and Fidelity Scale. IPS teams assist in addressing barriers to employment through behavioral health integration.

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 milestone

Limits

• 1. IPS services shall not be provided during the same auth period as ACT.
• 2. Individuals may not be disqualified from engaging in employment because of perceived readiness factors, such as active substance use, criminal background issues, active MH symptoms, or personal presentation. The individual’s assessment and the Career Profile must be submitted within the first 30 calendar days of service initiation.
• 3. State funds will not cover:
• a. Services provided to teach academics, to include special education provided under the Individuals with Disabilities Education Act (IDEA)
• b. Pre-vocational classes and/or group employment searches or classes
• c. Supports or services to help with volunteering
• d. Set-aside jobs for people with disabilities, such as enclaves, and will not cover group employment/work crews.
• e. Services to acquire, retain, and improve the self-help, socialization, and adaptive skills necessary to reside successfully in community settings, to include time spent attending or participating in recreational activities
• f. Childcare services
• g. Service provided under the Rehabilitation Act of 1973
• h. IPS services can only be billed when providing employment services and support directly to the individual or on behalf of the beneficiary and cannot be billed for meetings, paperwork, documentation, or travel time.
• 4. State funds will only reimburse services not covered in an EIPD milestone.

Length of Stay

The duration and frequency at which IPS is provided must be based on MN and progress made by the individual toward goals outlined in the Career Profile. Ongoing should be based on the level of intensity required to acquire stable employment or interventions required for continued employment.

Diagnosis Requirements

Adults & Adolescents (age 16 years and older) with:

• 1. A serious mental illness (SMI) that includes severe and persistent mental illness (SPMI); OR
• 2. A serious emotional disturbance (SED); OR
• 3. A severe substance use disorder (SUD)

Age Group Details

Adults & Adolescents (age 16 years 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

• State-Funded IPS Service Definition
• Records Management and Documentation Manual
• DMHDDSUS Bulletins

SE services provide assistance with choosing, acquiring, and maintaining a job. The service is available when competitive, integrated employment (CIE) has not been achieved or has been interrupted or intermittent. SE services may be either temporary or long-term. The intent of SE service is to assist a member with developing skills to seek, obtain and maintain competitive, integrated employment or develop and operate a micro-enterprise. Employment positions are found based on members’ preferences, strengths, and experiences. Job finding is used to explore options for competitive, integrated employment and is not based on placement from a pool of jobs that are available or set aside specifically for individuals with disabilities.

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. Prior approval required. The request must be submitted by TCM.
• 2. Updated Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above). Detailed documentation of goals specific to long-term support needs must reflect how the services are received and preparing the member for working as independently as possible.
• 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 the TCM.

Unit Value

One unit = 15 minutes

Length of Stay

• 1. Pre-employment and Employment Stabilization Phase: A maximum of 20 hours (80 units) per week for up to 180 days of services for initial job development, training, and support. If the member obtains employment and their schedule and support needs require more than 20 hours a week of services, add’l hours can be authorized.
• 2. Employment Stabilization Phase: Based on the members’ work schedule and support needs, not to exceed 40 hours a week (160 units). Services can be auth’d for up to 365 days if the work schedule/ needs are not anticipated to change.
• 3. Long-Term Supported Employment Phase: For a member who is stable in their employment and has minimal support needs, a maximum of 10 hours (40 units) per month may be approved annually for periodic long-term support. If there is an increased support need, add’l hours may be

authorized. For a member with ongoing support needs, SE may be authorized for the number of hours necessary to support the member to remain stable in their employment; not to exceed 40 hours (160 units) a week.

Exclusions

• • Employment Phases: o Pre-employment Phase: If the Member needs more than 180 consecutive days for initial job development, additional requests can be made and must provide justification as to why additional job development time is necessary. No more than 6 months in a typical situation. o Employment Stabilization Phase: It is critical that job fading occurs early during this phase to allow the Member to develop on-the-job and natural supports. The Employment Stabilization Phase is not expected to exceed a year. o Employment Stabilization Phase: should not continue solely as a means of transportation to and from the worksite. An individualized plan of assistance must be provided to identify appropriate long-term modes of transportation and how to use them.
• • Services must occur in integrated environments with nondisabled individuals or in a business owned by the member. Services do not occur in licensed community day programs.
• • IPS programs should not receive referrals for members that are receiving care management within their agency.
• • 1915(i) SE and CLS may not exceed a combined limit of 40 hrs per week.
• • SE may not be provided by family members who live in the same household as the member.• SE Group is not covered unless the

members work in the same CIE setting and have support needs at the same day(s) and time(s) and the needs of the members can all be met by the staff. The max group size is 3 members to 1 staff.

• • May not be provided during the same

time/ at the same place as any other direct support Medicaid service.

• • May not be provided if the service is

otherwise available under a program funded under the Rehabilitation Act of 1973 or under the Individuals with Disabilities Education Act.

• • A provider shall not bill both DVRS and

UM Contractor at the same time for duplicative Supported Employment activities. Medicaid is always the payer of last resort.

• • May not be provided to a member living in

an ICF-IID.

• • FFP is not to be claimed for incentive

payments, subsidies, or unrelated vocational training expenses.

• • Subsidized provision of this service is not

allowed. The following indicate subsidies:

• o The position would not exist if the

provider agency was not being paid to provide the service.

• o The position would end if the member

chose a different provider agency to provide the service.

• o The hours of employment have a one

to-one correlation with the amount of service hours authorized

Age Group Details

Age 16 and older

Level of Care

The member must meet the criteria for IDD or TBI as defined by the CCP.

Place of Service

Member’s job site or a community setting where Supported Employment service activities are taking place.

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

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• CCP 8H-1: Supported Employment for I/DD and TBI
• Records Management and Documentation Manual
• https://medicaid.ncdhhs.gov/tailored-care-management
• https://medicaid.ncdhhs.gov/north-carolinas-transition-1915b3-benefits-1915i

SE services provide assistance with choosing, acquiring, and maintaining a job. The service is available when competitive, integrated employment (CIE) has not been achieved or has been interrupted or intermittent. SE services may be either temporary or long-term. The intent of SE service is to assist a member with developing skills to seek, obtain and maintain competitive, integrated employment or develop and operate a micro-enterprise. Employment positions are found based on members’ preferences, strengths, and experiences. Job finding is used to explore options for competitive, integrated employment and is not based on placement from a pool of jobs that are available or set aside specifically for individuals with disabilities.

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. Prior approval required. The request must be submitted by TCM.
• 2. Updated Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above). Detailed documentation of goals specific to long-term support needs must reflect how the services are received and preparing the member for working as independently as possible.
• 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 the TCM.

Unit Value

One unit = 15 minutes

Length of Stay

• 1. Pre-employment and Employment Stabilization Phase: A maximum of 20 hours (80 units) per week for up to 180 days of services for initial job development, training, and support. If the member obtains employment and their schedule and support needs require more than 20 hours a week of services, add’l hours can be authorized.
• 2. Employment Stabilization Phase: Based on the members’ work schedule and support needs, not to exceed 40 hours a week (160 units). Services can be auth’d for up to 365 days if the work schedule/ needs are not anticipated to change.
• 3. Long-Term Supported Employment Phase: For a member who is stable in their employment and has minimal support needs, a maximum of 10 hours (40 units) per month may be approved annually for periodic long-term support. If there is an increased support need, add’l hours may be

authorized. For a member with ongoing support needs, SE may be authorized for the number of hours necessary to support the member to remain stable in their employment; not to exceed 40 hours (160 units) a week.

Exclusions

• • Employment Phases: o Pre-employment Phase: If the Member needs more than 180 consecutive days for initial job development, additional requests can be made and must provide justification as to why additional job development time is necessary. No more than 6 months in a typical situation. o Employment Stabilization Phase: It is critical that job fading occurs early during this phase to allow the Member to develop on-the-job and natural supports. The Employment Stabilization Phase is not expected to exceed a year. o Employment Stabilization Phase: should not continue solely as a means of transportation to and from the worksite. An individualized plan of assistance must be provided to identify appropriate long-term modes of transportation and how to use them.
• • Services must occur in integrated environments with nondisabled individuals or in a business owned by the member. Services do not occur in licensed community day programs.
• • IPS programs should not receive referrals for members that are receiving care management within their agency.
• • 1915(i) SE and CLS may not exceed a combined limit of 40 hrs per week.
• • SE may not be provided by family members who live in the same household as the member.• SE Group is not covered unless the

members work in the same CIE setting and have support needs at the same day(s) and time(s) and the needs of the members can all be met by the staff. The max group size is 3 members to 1 staff.

• • May not be provided during the same

time/ at the same place as any other direct support Medicaid service.

• • May not be provided if the service is

otherwise available under a program funded under the Rehabilitation Act of 1973 or under the Individuals with Disabilities Education Act.

• • A provider shall not bill both DVRS and

UM Contractor at the same time for duplicative Supported Employment activities. Medicaid is always the payer of last resort.

• • May not be provided to a member living in

an ICF-IID.

• • FFP is not to be claimed for incentive

payments, subsidies, or unrelated vocational training expenses.

• • Subsidized provision of this service is not

allowed. The following indicate subsidies:

• o The position would not exist if the

provider agency was not being paid to provide the service.

• o The position would end if the member

chose a different provider agency to provide the service.

• o The hours of employment have a one

to-one correlation with the amount of service hours authorized

Age Group Details

Age 16 and older

Level of Care

The member must meet the criteria for IDD or TBI as defined by the CCP.

Place of Service

Member’s job site or a community setting where Supported Employment service activities are taking place.

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

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• CCP 8H-1: Supported Employment for I/DD and TBI
• Records Management and Documentation Manual
• https://medicaid.ncdhhs.gov/tailored-care-management
• https://medicaid.ncdhhs.gov/north-carolinas-transition-1915b3-benefits-1915i

IPS is a person centered behavioral health service with a focus on employment and education. IPS assists in choosing, acquiring, and maintaining competitive paid employment in the community for a member 16 years and older, with significant behavioral health needs, for whom employment has not been achieved or employment has been interrupted or intermittent. The foundation for this service is the IPS evidence-based Supported Employment model and Fidelity Scale. IPS teams assist in addressing barriers to employment through behavioral health integration.

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.

Unit Value

One unit = 1 milestone

Limits

Services must occur in integrated environments with nondisabled individuals or in a business owned by the member. Services do not occur in licensed community day programs.

• • IPS providers must align service delivery to the fidelity model.
• • IPS programs should not receive referrals for members that are receiving care management within their agency. IPS teams must have a zero

exclusion criterion, meaning that a member is not disqualified from engaging in employment because of readiness factors.

• • Members cannot be required

to participate in pre-vocational training or other job readiness models.

• • Medicaid funds will only

reimburse services not covered by EIPD or in an employment milestone funded by EIPD.

• • Medicaid will not cover:
• o Services provided to teach

academic subjects.

• o Services that support

members in set-aside jobs for people with disabilities, enclaves, mobile work crews, or transitional employment positions.

• o Services provided under the

Rehabilitation Act of 1973 or special education provided under the Individuals with Disabilities Education Act (IDEA).

• • Federal financial participation

(FFP) cannot be claimed for incentive payments, subsidies, or unrelated vocational training expenses.

• • Subsidized provision of this

service is not allowed. The following indicate subsidies:

• o The position would not exist

if the provider agency was not being paid to provide the service.

• o The position would end if the

member chose a different provider agency to provide the service.

• o The hours of employment

have a one-to-one correlation with the amount of service hours authorized.

Length of Stay

• 1. Service is individualized and has time-unlimited support.
• 2. Frequency and intensity of services must be documented in the beneficiary’s Career Profile and must be individualized.

Exclusions

Services must not be provided during the same auth period as ACT.

Age Group Details

Adolescents & Adults (16 years of age and older)

Level of Care

The member must meet the criteria for SED, SMI, SPMI, or severe SUD as defined by the CCP.

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

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• CCP 8H-2: Individual Placement & Support (IPS) for Mental Health & Substance Use
• Records Management and Documentation Manual
• https://medicaid.ncdhhs.gov/tailored-care-management
• https://medicaid.ncdhhs.gov/north-carolinas-transition-1915b3-benefits-1915i

SE services provide assistance with choosing, acquiring, and maintaining a job. The service is available when competitive, integrated employment (CIE) has not been achieved or has been interrupted or intermittent. SE services may be either temporary or long-term. The intent of SE service is to assist a member with developing skills to seek, obtain and maintain competitive, integrated employment or develop and operate a micro-enterprise. Employment positions are found based on members’ preferences, strengths, and experiences. Job finding is used to explore options for competitive, integrated employment and is not based on placement from a pool of jobs that are available or set aside specifically for individuals with disabilities.

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. Prior approval required. The request must be submitted by TCM.
• 2. Updated Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above). Detailed documentation of goals specific to long-term support needs must reflect how the services are received and preparing the member for working as independently as possible.
• 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 the TCM.

Unit Value

One unit = 15 minutes

Length of Stay

• 1. Pre-employment and Employment Stabilization Phase: A maximum of 20 hours (80 units) per week for up to 180 days of services for initial job development, training, and support. If the member obtains employment and their schedule and support needs require more than 20 hours a week of services, add’l hours can be authorized.
• 2. Employment Stabilization Phase: Based on the members’ work schedule and support needs, not to exceed 40 hours a week (160 units). Services can be auth’d for up to 365 days if the work schedule/ needs are not anticipated to change.
• 3. Long-Term Supported Employment Phase: For a member who is stable in their employment and has minimal support needs, a maximum of 10 hours (40 units) per month may be approved annually for periodic long-term support. If there is an increased support need, add’l hours may be

authorized. For a member with ongoing support needs, SE may be authorized for the number of hours necessary to support the member to remain stable in their employment; not to exceed 40 hours (160 units) a week.

Exclusions

• • Employment Phases: o Pre-employment Phase: If the Member needs more than 180 consecutive days for initial job development, additional requests can be made and must provide justification as to why additional job development time is necessary. No more than 6 months in a typical situation. o Employment Stabilization Phase: It is critical that job fading occurs early during this phase to allow the Member to develop on-the-job and natural supports. The Employment Stabilization Phase is not expected to exceed a year. o Employment Stabilization Phase: should not continue solely as a means of transportation to and from the worksite. An individualized plan of assistance must be provided to identify appropriate long-term modes of transportation and how to use them.
• • Services must occur in integrated environments with nondisabled individuals or in a business owned by the member. Services do not occur in licensed community day programs.
• • IPS programs should not receive referrals for members that are receiving care management within their agency.
• • 1915(i) SE and CLS may not exceed a combined limit of 40 hrs per week.
• • SE may not be provided by family members who live in the same household as the member.• SE Group is not covered unless the

members work in the same CIE setting and have support needs at the same day(s) and time(s) and the needs of the members can all be met by the staff. The max group size is 3 members to 1 staff.

• • May not be provided during the same

time/ at the same place as any other direct support Medicaid service.

• • May not be provided if the service is

otherwise available under a program funded under the Rehabilitation Act of 1973 or under the Individuals with Disabilities Education Act.

• • A provider shall not bill both DVRS and

UM Contractor at the same time for duplicative Supported Employment activities. Medicaid is always the payer of last resort.

• • May not be provided to a member living in

an ICF-IID.

• • FFP is not to be claimed for incentive

payments, subsidies, or unrelated vocational training expenses.

• • Subsidized provision of this service is not

allowed. The following indicate subsidies:

• o The position would not exist if the

provider agency was not being paid to provide the service.

• o The position would end if the member

chose a different provider agency to provide the service.

• o The hours of employment have a one

to-one correlation with the amount of service hours authorized

Age Group Details

Age 16 and older

Level of Care

The member must meet the criteria for IDD or TBI as defined by the CCP.

Place of Service

Member’s job site or a community setting where Supported Employment service activities are taking place.

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

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• CCP 8H-1: Supported Employment for I/DD and TBI
• Records Management and Documentation Manual
• https://medicaid.ncdhhs.gov/tailored-care-management
• https://medicaid.ncdhhs.gov/north-carolinas-transition-1915b3-benefits-1915i

Supported Employment services provide assistance, based on individual circumstances and need, to explore, seek, choose, acquire, maintain, increase and/or advance in competitive integrated employment. Supported Employment services occur in integrated environments with non-disabled individuals or is a business owned by the member. This service is available to any member ages 16 and older for whom individualized, competitive integrated employment has not been achieved, and/or has been interrupted or intermittent. Assistance with increasing or advancing in competitive integrated employment is available to members, ages 16 and older, for whom their current competitive integrated employment is insufficient in terms of meeting the member’s goals for hours worked and income earned, or is considered underemployment in that the member desires, and could reasonably be expected to achieve, a promotion to a position with increased responsibilities and pay. Supported Employment- Long Term Follow Along services provide assistance, based on individual circumstances and need, to maintain, increase and/or advance in competitive integrated employment.

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

Long-Term Follow-Along Supported Employment-Individual services must involve, at minimum, monthly face-to-face contact with the supported employee and monthly contact with the employer.

• - Amount of Supported Employment Services is subject to the limitation on the sets of services.
• - If the beneficiary receives residential supports and is age 22 or older, no more than 40 hours/week total may be authorized for any combination of community networking, day supports, and supported employment.
• - If through age 21 and receiving residential supports, no more than 20 hours/week during the school year, or up to 40 hours/week when school is not in session, for that same combination.
• - If age 22 or older and living in a private home, no more than 84 hours/week total may be authorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports.
• - If through age 21 and living in a private home, no more than 54 hours/week during the school year, or up to 84 hours/week when school is not in session, for that same combination.

Exclusions

• 1. Competitive integrated employment is an individual job in competitive or customized employment, or self-employment, in an integrated work setting in the general workforce for which an individual is compensated at or above the minimum wage.
• 2. Services should be targeted and time limited.
• 3. Job finding is not based on a pool of jobs that are available or set aside specifically for individuals with disabilities.
• 4. Fading of initial coaching and employment support activities should begin at some level within the first month of employment and incremental fading gains should be expected to continue over time, as the person becomes more independent on the job and can rely on natural supervisors and co-workers for needed supports, until fading has been maximized and/or the person completes their probation period, at which point the person should transition to Long-Term Follow-Along Supported Employment.
• 5. The transition to Long-Term Follow-Along Supported Employment- services should typically occur within one year of the individual starting competitive integrated employment. A focus on identifying and implementing strategies for fading should continue in Long- Term Follow-Along Supported Employment services.
• 6. The setting is integrated in and supports full access of a member to the greater community.
• 7. Individuals are provided opportunities to seek employment and work in competitive integrated settings, engage in community life and control personal resources.
• 8. Individuals receive services in the community to the same degree of access as individuals not services.

Age Group Details

Available only to beneficiaries age 16 and older.

Additional Service Specifics

• • The amount of Supported Employment Services is subject to the limitation on the sets of services.
• • Documentation is maintained in the file of each provider agency specifying that the particular service(s) being provided under this service category is not otherwise available, without undue delay, to the individual under a program funded under Section 110 of the Rehabilitation Act of 1973, or under the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.).
• • FFP is not to be claimed for incentive payments, subsidies, or unrelated vocational training expenses such as: a) Incentive payments made to an employer to encourage or subsidize the employer’s participation in a supported employment program; b) Payments that are passed through to users of supported employment programs; or, c) Payments for training that are not directly related to a member’s supported employment program.
• • While it is not prohibited to both employ a member and provide service to that same member, the use of Medicaid funds to pay for Supported Employment Services to providers that are subsidizing their participation in providing this service is improper. The following types of situations are indicative of a provider subsidizing its participation in supported employment: a) The job/position would not exist if the provider agency was not being paid to provide the service; b) The job/position would end if the member chose a different provider agency to provide service; c) The hours of employment have a one to one correlation with the amount of hours of service that are authorized.
• • For a member who is eligible for educational services under the Individuals With Disability Educational Act, Supported Employment does not include transportation to or from school settings. This includes transportation to/from the member’s home, provider home where the member may be receiving services before or after school or any other community location where the member may be receiving services before or after school.
• • This service is not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Living, Residential Supports, Respite or one of the State Plan Medicaid services that works directly with the person.
• • Settings optimize, but do not regiment, individual initiative, autonomy and independence in making life choices;
• • Settings facilitate individual choice regarding services and supports, and who provides these.
• • Refer to North Carolina DHHS’s HCBS Transition Plan for additional information https://www.ncdhhs.gov/about/department-initiatives/home-and-community-based-services-final-rule/hcbs-resources.
• • 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.

Other Information

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)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Supported Employment services provide assistance, based on individual circumstances and need, to explore, seek, choose, acquire, maintain, increase and/or advance in competitive integrated employment. Supported Employment services occur in integrated environments with non-disabled individuals or is a business owned by the member. This service is available to any member ages 16 and older for whom individualized, competitive integrated employment has not been achieved, and/or has been interrupted or intermittent. Assistance with increasing or advancing in competitive integrated employment is available to members, ages 16 and older, for whom their current competitive integrated employment is insufficient in terms of meeting the member’s goals for hours worked and income earned, or is considered underemployment in that the member desires, and could reasonably be expected to achieve, a promotion to a position with increased responsibilities and pay. Supported Employment- Long Term Follow Along services provide assistance, based on individual circumstances and need, to maintain, increase and/or advance in competitive integrated employment.

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

Long-Term Follow-Along Supported Employment-Individual services must involve, at minimum, monthly face-to-face contact with the supported employee and monthly contact with the employer.

• - Amount of Supported Employment Services is subject to the limitation on the sets of services.
• - If the beneficiary receives residential supports and is age 22 or older, no more than 40 hours/week total may be authorized for any combination of community networking, day supports, and supported employment.
• - If through age 21 and receiving residential supports, no more than 20 hours/week during the school year, or up to 40 hours/week when school is not in session, for that same combination.
• - If age 22 or older and living in a private home, no more than 84 hours/week total may be authorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports.
• - If through age 21 and living in a private home, no more than 54 hours/week during the school year, or up to 84 hours/week when school is not in session, for that same combination.

Exclusions

• 1. Competitive integrated employment is an individual job in competitive or customized employment, or self-employment, in an integrated work setting in the general workforce for which an individual is compensated at or above the minimum wage.
• 2. Services should be targeted and time limited.
• 3. Job finding is not based on a pool of jobs that are available or set aside specifically for individuals with disabilities.
• 4. Fading of initial coaching and employment support activities should begin at some level within the first month of employment and incremental fading gains should be expected to continue over time, as the person becomes more independent on the job and can rely on natural supervisors and co-workers for needed supports, until fading has been maximized and/or the person completes their probation period, at which point the person should transition to Long-Term Follow-Along Supported Employment.
• 5. The transition to Long-Term Follow-Along Supported Employment- services should typically occur within one year of the individual starting competitive integrated employment. A focus on identifying and implementing strategies for fading should continue in Long- Term Follow-Along Supported Employment services.
• 6. The setting is integrated in and supports full access of a member to the greater community.
• 7. Individuals are provided opportunities to seek employment and work in competitive integrated settings, engage in community life and control personal resources.
• 8. Individuals receive services in the community to the same degree of access as individuals not services.

Age Group Details

Available only to beneficiaries age 16 and older.

Additional Service Specifics

• • The amount of Supported Employment Services is subject to the limitation on the sets of services.
• • Documentation is maintained in the file of each provider agency specifying that the particular service(s) being provided under this service category is not otherwise available, without undue delay, to the individual under a program funded under Section 110 of the Rehabilitation Act of 1973, or under the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.).
• • FFP is not to be claimed for incentive payments, subsidies, or unrelated vocational training expenses such as: a) Incentive payments made to an employer to encourage or subsidize the employer’s participation in a supported employment program; b) Payments that are passed through to users of supported employment programs; or, c) Payments for training that are not directly related to a member’s supported employment program.
• • While it is not prohibited to both employ a member and provide service to that same member, the use of Medicaid funds to pay for Supported Employment Services to providers that are subsidizing their participation in providing this service is improper. The following types of situations are indicative of a provider subsidizing its participation in supported employment: a) The job/position would not exist if the provider agency was not being paid to provide the service; b) The job/position would end if the member chose a different provider agency to provide service; c) The hours of employment have a one to one correlation with the amount of hours of service that are authorized.
• • For a member who is eligible for educational services under the Individuals With Disability Educational Act, Supported Employment does not include transportation to or from school settings. This includes transportation to/from the member’s home, provider home where the member may be receiving services before or after school or any other community location where the member may be receiving services before or after school.
• • This service is not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Living, Residential Supports, Respite or one of the State Plan Medicaid services that works directly with the person.
• • Settings optimize, but do not regiment, individual initiative, autonomy and independence in making life choices;
• • Settings facilitate individual choice regarding services and supports, and who provides these.
• • Refer to North Carolina DHHS’s HCBS Transition Plan for additional information https://www.ncdhhs.gov/about/department-initiatives/home-and-community-based-services-final-rule/hcbs-resources.
• • 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.

Other Information

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)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Supported Employment services provide assistance, based on individual circumstances and need, to explore, seek, choose, acquire, maintain, increase and/or advance in competitive integrated employment. Supported Employment services occur in integrated environments with non-disabled individuals or is a business owned by the member. This service is available to any member ages 16 and older for whom individualized, competitive integrated employment has not been achieved, and/or has been interrupted or intermittent. Assistance with increasing or advancing in competitive integrated employment is available to members, ages 16 and older, for whom their current competitive integrated employment is insufficient in terms of meeting the member’s goals for hours worked and income earned, or is considered underemployment in that the member desires, and could reasonably be expected to achieve, a promotion to a position with increased responsibilities and pay. Supported Employment- Long Term Follow Along services provide assistance, based on individual circumstances and need, to maintain, increase and/or advance in competitive integrated employment.

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

Long-Term Follow-Along Supported Employment-Individual services must involve, at minimum, monthly face-to-face contact with the supported employee and monthly contact with the employer.

• - Amount of Supported Employment Services is subject to the limitation on the sets of services.
• - If the beneficiary receives residential supports and is age 22 or older, no more than 40 hours/week total may be authorized for any combination of community networking, day supports, and supported employment.
• - If through age 21 and receiving residential supports, no more than 20 hours/week during the school year, or up to 40 hours/week when school is not in session, for that same combination.
• - If age 22 or older and living in a private home, no more than 84 hours/week total may be authorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports.
• - If through age 21 and living in a private home, no more than 54 hours/week during the school year, or up to 84 hours/week when school is not in session, for that same combination.

Exclusions

• 1. Competitive integrated employment is an individual job in competitive or customized employment, or self-employment, in an integrated work setting in the general workforce for which an individual is compensated at or above the minimum wage.
• 2. Services should be targeted and time limited.
• 3. Job finding is not based on a pool of jobs that are available or set aside specifically for individuals with disabilities.
• 4. Fading of initial coaching and employment support activities should begin at some level within the first month of employment and incremental fading gains should be expected to continue over time, as the person becomes more independent on the job and can rely on natural supervisors and co-workers for needed supports, until fading has been maximized and/or the person completes their probation period, at which point the person should transition to Long-Term Follow-Along Supported Employment.
• 5. The transition to Long-Term Follow-Along Supported Employment- services should typically occur within one year of the individual starting competitive integrated employment. A focus on identifying and implementing strategies for fading should continue in Long- Term Follow-Along Supported Employment services.
• 6. The setting is integrated in and supports full access of a member to the greater community.
• 7. Individuals are provided opportunities to seek employment and work in competitive integrated settings, engage in community life and control personal resources.
• 8. Individuals receive services in the community to the same degree of access as individuals not services.

Age Group Details

Available only to beneficiaries age 16 and older.

Additional Service Specifics

• • The amount of Supported Employment Services is subject to the limitation on the sets of services.
• • Documentation is maintained in the file of each provider agency specifying that the particular service(s) being provided under this service category is not otherwise available, without undue delay, to the individual under a program funded under Section 110 of the Rehabilitation Act of 1973, or under the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.).
• • FFP is not to be claimed for incentive payments, subsidies, or unrelated vocational training expenses such as: a) Incentive payments made to an employer to encourage or subsidize the employer’s participation in a supported employment program; b) Payments that are passed through to users of supported employment programs; or, c) Payments for training that are not directly related to a member’s supported employment program.
• • While it is not prohibited to both employ a member and provide service to that same member, the use of Medicaid funds to pay for Supported Employment Services to providers that are subsidizing their participation in providing this service is improper. The following types of situations are indicative of a provider subsidizing its participation in supported employment: a) The job/position would not exist if the provider agency was not being paid to provide the service; b) The job/position would end if the member chose a different provider agency to provide service; c) The hours of employment have a one to one correlation with the amount of hours of service that are authorized.
• • For a member who is eligible for educational services under the Individuals With Disability Educational Act, Supported Employment does not include transportation to or from school settings. This includes transportation to/from the member’s home, provider home where the member may be receiving services before or after school or any other community location where the member may be receiving services before or after school.
• • This service is not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Living, Residential Supports, Respite or one of the State Plan Medicaid services that works directly with the person.
• • Settings optimize, but do not regiment, individual initiative, autonomy and independence in making life choices;
• • Settings facilitate individual choice regarding services and supports, and who provides these.
• • Refer to North Carolina DHHS’s HCBS Transition Plan for additional information https://www.ncdhhs.gov/about/department-initiatives/home-and-community-based-services-final-rule/hcbs-resources.
• • 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.

Other Information

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)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Supported Employment services provide assistance, based on individual circumstances and need, to explore, seek, choose, acquire, maintain, increase and/or advance in competitive integrated employment. Supported Employment services occur in integrated environments with non-disabled individuals or is a business owned by the member. This service is available to any member ages 16 and older for whom individualized, competitive integrated employment has not been achieved, and/or has been interrupted or intermittent. Assistance with increasing or advancing in competitive integrated employment is available to members, ages 16 and older, for whom their current competitive integrated employment is insufficient in terms of meeting the member’s goals for hours worked and income earned, or is considered underemployment in that the member desires, and could reasonably be expected to achieve, a promotion to a position with increased responsibilities and pay. Supported Employment- Long Term Follow Along services provide assistance, based on individual circumstances and need, to maintain, increase and/or advance in competitive integrated employment.

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

Long-Term Follow-Along Supported Employment-Individual services must involve, at minimum, monthly face-to-face contact with the supported employee and monthly contact with the employer.

• - Amount of Supported Employment Services is subject to the limitation on the sets of services.
• - If the beneficiary receives residential supports and is age 22 or older, no more than 40 hours/week total may be authorized for any combination of community networking, day supports, and supported employment.
• - If through age 21 and receiving residential supports, no more than 20 hours/week during the school year, or up to 40 hours/week when school is not in session, for that same combination.
• - If age 22 or older and living in a private home, no more than 84 hours/week total may be authorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports.
• - If through age 21 and living in a private home, no more than 54 hours/week during the school year, or up to 84 hours/week when school is not in session, for that same combination.

Exclusions

• 1. Competitive integrated employment is an individual job in competitive or customized employment, or self-employment, in an integrated work setting in the general workforce for which an individual is compensated at or above the minimum wage.
• 2. Services should be targeted and time limited.
• 3. Job finding is not based on a pool of jobs that are available or set aside specifically for individuals with disabilities.
• 4. Fading of initial coaching and employment support activities should begin at some level within the first month of employment and incremental fading gains should be expected to continue over time, as the person becomes more independent on the job and can rely on natural supervisors and co-workers for needed supports, until fading has been maximized and/or the person completes their probation period, at which point the person should transition to Long-Term Follow-Along Supported Employment.
• 5. The transition to Long-Term Follow-Along Supported Employment- services should typically occur within one year of the individual starting competitive integrated employment. A focus on identifying and implementing strategies for fading should continue in Long- Term Follow-Along Supported Employment services.
• 6. The setting is integrated in and supports full access of a member to the greater community.
• 7. Individuals are provided opportunities to seek employment and work in competitive integrated settings, engage in community life and control personal resources.
• 8. Individuals receive services in the community to the same degree of access as individuals not services.

Age Group Details

Available only to beneficiaries age 16 and older.

Additional Service Specifics

• • The amount of Supported Employment Services is subject to the limitation on the sets of services.
• • Documentation is maintained in the file of each provider agency specifying that the particular service(s) being provided under this service category is not otherwise available, without undue delay, to the individual under a program funded under Section 110 of the Rehabilitation Act of 1973, or under the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.).
• • FFP is not to be claimed for incentive payments, subsidies, or unrelated vocational training expenses such as: a) Incentive payments made to an employer to encourage or subsidize the employer’s participation in a supported employment program; b) Payments that are passed through to users of supported employment programs; or, c) Payments for training that are not directly related to a member’s supported employment program.
• • While it is not prohibited to both employ a member and provide service to that same member, the use of Medicaid funds to pay for Supported Employment Services to providers that are subsidizing their participation in providing this service is improper. The following types of situations are indicative of a provider subsidizing its participation in supported employment: a) The job/position would not exist if the provider agency was not being paid to provide the service; b) The job/position would end if the member chose a different provider agency to provide service; c) The hours of employment have a one to one correlation with the amount of hours of service that are authorized.
• • For a member who is eligible for educational services under the Individuals With Disability Educational Act, Supported Employment does not include transportation to or from school settings. This includes transportation to/from the member’s home, provider home where the member may be receiving services before or after school or any other community location where the member may be receiving services before or after school.
• • This service is not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Living, Residential Supports, Respite or one of the State Plan Medicaid services that works directly with the person.
• • Settings optimize, but do not regiment, individual initiative, autonomy and independence in making life choices;
• • Settings facilitate individual choice regarding services and supports, and who provides these.
• • Refer to North Carolina DHHS’s HCBS Transition Plan for additional information https://www.ncdhhs.gov/about/department-initiatives/home-and-community-based-services-final-rule/hcbs-resources.
• • 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.

Other Information

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)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver