PA Lookup

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

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

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

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.

How to Submit

If applicable, please submit your request to Trillium.

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx

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

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

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx

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

A program designed for youth between the ages 7 through 17 who have antisocial, aggressive or violent behaviors, are at risk of out-of-home placement due to delinquency or; adjudicated youth returning from out-of-home placement or; chronic or violent juvenile offenders, or youth with serious emotional disturbances or a substance use disorder and their families. The purpose of this program is to keep youth in the home by delivering an intensive therapy to the family within the home. MST involves families and other systems such as the school, probation officers, extended families, and community connections.

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 tx episode

Limits

MST is limited to one tx episode per lifetime.

Length of Stay

• 1. The duration of MST is typically 5 months.
• 2. The initial auth may not exceed 5 month.
• 3. A minimum of 12 contacts must occur within the first month. For the 2nd and 3rd months, an average of 6 contacts must occur each month. It is expected that service frequency will be titrated over the last 2 months.

Exclusions

MST services may not be billed for recipients receiving IIH, CADT, SAIOP, Hourly Respite, individual, group or family therapy, child residential Level II–IV, or substance abuse residential services.

Age Group Details

Children & Adolescents (Ages 7 through 17)

Additional Service Specifics

A shadow claim should be billed every time an encounter occurs.

Other Information

Various standardized assessments are available for people working with youth who enter the juvenile justice system to determine the presence of a substance use, mental health, or co-occurring disorders. Examples of standardized assessment tools are listed on the Division of Public Safety’s (DPS’s) website. Entities/providers should confirm with the individual’s home entity that the assessment tools listed on the DPS website will suffice as a CCA.

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 Multisystemic Therapy (MST)
• Records Management and Documentation Manual

This is a program designed for youth between the ages 7 through 19 who: a) have antisocial, aggressive or violent behaviors; b) are at risk of out-of-home placement due to delinquency; c) adjudicated youth returning from out-of-home placement; d) chronic or violent juvenile offenders; or e) youth with serious emotional disturbances or a substance use disorder and their families. MST provides an intensive model of tx based on empirical data and evidence-based interventions that target specific behaviors with individualized behavioral interventions. The purpose of this program is to keep youth in the home by delivering an intensive therapy to the family within the home.

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 tx episode

Limits

A shadow claim should be billed every time an encounter occurs.

Exclusions

MST services cannot be provided during the same auth period as: CADT; Hourly Respite; Individual, Group and Family therapy; SAIOP; Child Residential Tx: Level II Program Type through Level IV; or Substance Abuse Residential Services

Age Group Details

Children & Adolescents (Age 7 through 19)

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.

Additional Service Specifics

A shadow claim should be billed every time an encounter occurs.

Other Information

Various standardized assessments are available for people working with youth who enter the juvenile justice system to determine the presence of a substance use, mental health, or co-occurring disorders. Examples of standardized assessment tools are listed on the Division of Public Safety’s (DPS’s) website. Entities/providers should confirm with the individual’s home entity that the assessment tools listed on the DPS website will suffice as a CCA.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No 8A: Enhanced Mental Health and Substance Abuse Services, Multisystemic Therapy (MST) Section
• Records Management and Documentation Manual
• Person Centered Planning
• MCO Communication Bulletin #J371

A program designed for youth between the ages 7 through 17 who have antisocial, aggressive or violent behaviors, are at risk of out-of-home placement due to delinquency or; adjudicated youth returning from out-of-home placement or; chronic or violent juvenile offenders, or youth with serious emotional disturbances or a substance use disorder and their families. The purpose of this program is to keep youth in the home by delivering an intensive therapy to the family within the home. MST involves families and other systems such as the school, probation officers, extended families, and community connections.

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 tx episode

Limits

MST is limited to one tx episode per lifetime.

Length of Stay

• 1. The duration of MST is typically 5 months.
• 2. The initial auth may not exceed 5 month.
• 3. A minimum of 12 contacts must occur within the first month. For the 2nd and 3rd months, an average of 6 contacts must occur each month. It is expected that service frequency will be titrated over the last 2 months.

Exclusions

MST services may not be billed for recipients receiving IIH, CADT, SAIOP, Hourly Respite, individual, group or family therapy, child residential Level II–IV, or substance abuse residential services.

Age Group Details

Children & Adolescents (Ages 7 through 17)

Additional Service Specifics

A shadow claim should be billed every time an encounter occurs.

Other Information

Various standardized assessments are available for people working with youth who enter the juvenile justice system to determine the presence of a substance use, mental health, or co-occurring disorders. Examples of standardized assessment tools are listed on the Division of Public Safety’s (DPS’s) website. Entities/providers should confirm with the individual’s home entity that the assessment tools listed on the DPS website will suffice as a CCA.

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 Multisystemic Therapy (MST)
• Records Management and Documentation Manual

This is a program designed for youth between the ages 7 through 19 who: a) have antisocial, aggressive or violent behaviors; b) are at risk of out-of-home placement due to delinquency; c) adjudicated youth returning from out-of-home placement; d) chronic or violent juvenile offenders; or e) youth with serious emotional disturbances or a substance use disorder and their families. MST provides an intensive model of tx based on empirical data and evidence-based interventions that target specific behaviors with individualized behavioral interventions. The purpose of this program is to keep youth in the home by delivering an intensive therapy to the family within the home.

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 tx episode

Limits

A shadow claim should be billed every time an encounter occurs.

Exclusions

MST services cannot be provided during the same auth period as: CADT; Hourly Respite; Individual, Group and Family therapy; SAIOP; Child Residential Tx: Level II Program Type through Level IV; or Substance Abuse Residential Services

Age Group Details

Children & Adolescents (Age 7 through 19)

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.

Additional Service Specifics

A shadow claim should be billed every time an encounter occurs.

Other Information

Various standardized assessments are available for people working with youth who enter the juvenile justice system to determine the presence of a substance use, mental health, or co-occurring disorders. Examples of standardized assessment tools are listed on the Division of Public Safety’s (DPS’s) website. Entities/providers should confirm with the individual’s home entity that the assessment tools listed on the DPS website will suffice as a CCA.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No 8A: Enhanced Mental Health and Substance Abuse Services, Multisystemic Therapy (MST) Section
• Records Management and Documentation Manual
• Person Centered Planning
• MCO Communication Bulletin #J371

This service is provided in a 24-hour, 7 day a week community-based residential setting and is designed to tx a member experiencing functional limitations due to their SUD. Functional limitations include problems in the application of recovery skills; self-efficacy; and lack of connection to the community systems of work, education, or family life. This service provides the member the opportunity to develop and practice interpersonal and group living skills; strengthen their recovery skills; reintegrate into the community and family settings; and experience employment or academic pursuits. Clinical and recovery services are characterized by individual, group and family therapy, medication management, and psychoeducation.

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. Provider must provide crisis response 24 hours-a-day, 7 days a week to a member who is receiving services.
• 2. 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 Clinically managed residential services; Clinically Managed Residential Withdrawal Management; Medically Monitored Inpatient Withdrawal Management; Clinically Managed Population-Specific High-Intensity Residential Programs; Clinically Managed High-Intensity Residential Services; Medically Monitored Intensive Inpatient Services; SACOT; ACT; CST.

Diagnosis Requirements

Primary Substance Use Diagnosis only

Level of Care

ASAM Level 3.1. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and documented the determination for continued stay, discharge, or transfer to another LOC.

Place of Service

Must be provided in a facility licensed under 10A NCAC 27G.5600

How to Submit

N/A - No authorization is required

Resources

• State-Funded Clinically Managed Low-Intensity Residential Treatment Services Service Definition
• Records Management and Documentation Manual

Clinically managed low intensity residential services are provided in a 24-hour facility where the primary purpose of these services is the rehabilitation of individuals who have a substance use disorder and who require supervision when in the residence. Individuals receiving this service attend work, school, and substance use treatment services. The expected outcome of Halfway House is abstinence. Secondary outcomes include: sustained improvement in health and psychosocial functioning, reduction in any psychiatric symptoms (if present), reduction in public health or safety concerns, and a reduction in the risk of relapse as evidenced by improvement in empirically-supported modifiable relapse risk factors.

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 approval required

Conditional Requirements

The initial 90 calendar days of tx do not require prior authorization. Contract variations may allow for additional days.

Unit Value

One unit = 1 day

Limits

Individuals may be ineligible for a state-funded service due to coverage by other payors for the same or similar service funded by the state (e.g. individual is eligible for the same service covered by Medicaid, Health Choice or other third party payor).

Length of Stay

Initial (after pass-through) and Reauthorization requests shall not exceed 90 calendar days. Contract variations may allow for additional days.

Diagnosis Requirements

Primary Substance Use Diagnosis only

Level of Care

ASAM Level 3.1 Clinically Managed Low-Intensity Residential Services or Level 3.3 NC Modified A/ASAM. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions.

Other Information

Service is transitioning to Clinically Managed Low-Intensity Residential Treatment Services on 1/1/2026

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 Enhanced Mental Health and Substance Abuse Service Definition
• Records Management and Documentation Manual

This service is provided 24-hour, seven days a week in a community based residential setting providing clinical and recovery services. This service is designed to treat members experiencing problems in the application of recovery skills, self-efficacy, and a lack of connection to the community systems of work, education, or family life. This service provides the member the opportunity to develop and practice interpersonal and group living skills, strengthen their recovery skills, reintegrate into the community and family settings, and experience employment or academic pursuits. Services are characterized by individual, group, and family therapy, medication management, and psychoeducation. The service must provide crisis response 24 hours-a-day, 7 days a week.

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. Service must provide a minimum of at least 5 hours of clinically directed program activities per week.
• 3. Service must support a member prescribed medications to address their SU or MH diagnosis. Coordination of care with the prescribing physician or physician extender is required.
• 4. Care coordination/ management for linkage and referrals for counseling, as well as medical, psychiatric, and continuing care is required.

Exclusions

Service can only be provided by one provider during any active episode of care. Services must not be provided and billed on the same day (except day of admission or discharge) as: Clinically managed residential services, Clinically Managed Residential Withdrawal Management, Medically Monitored Inpatient Withdrawal Management, Clinically Managed Population-Specific High-Intensity Residential Programs, Clinically Managed High-Intensity Residential Services, Medically Monitored Intensive Inpatient Services, SACOT, ACT, or CST.

Diagnosis Requirements

Primary SU Diagnosis only

Age Group Details

Adults (aged 18+)

Level of Care

ASAM Level 3.1. 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

• CCP 8D-3: Clinically Managed Low-Intensity Residential Treatment Services
• Records Management and Documentation Manual

SACOT is a clinically intensive partial hospitalization program that provides skilled tx services in a structured outpatient recovery environment, for a member w/ a primary SUD dx. SACOT provides 20 or more hrs of clinically intensive programming per week, as specified in the member’s PCP. SACOT services consist of individual, group, and family counseling, medication management through consultation and referral, and service coordination activities. In addition, SACOT must include access to psychiatric, medical, and laboratory services, educational groups, and other therapies. SACOT services can be provided during the day, weekend, or evening.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Unit Value

One unit = 1 hour (member must attend at least 4 hours a day for this service to be billed).

Limits

• 1. There must be at least 1 Clinical Staff for every 10 or fewer members when facilitating a group counseling session.
• 2. SACOT must operate at least 20 hrs per week offering a minimum of 4 hours scheduled services per service day, with the availability of in person SACOT services at least 5 days per week, with no more than 2 consecutive days without services available.
• 3. A member is not required to seek services through telehealth and shall have access to in-person services.
• 4. Providers and organizations that provide SACOT shall provide crisis response 24-hours-a-day, seven-days-a-week, to a member who is receiving SACOT services.
• 5. A member can receive SACOT services from only one provider organization during any episode of care

Exclusions

SACOT must not be provided and billed during the same episode of care (except on the day of admission or discharge) as SAIOP; Individual, family or group therapy for tx of substance use disorder; Clinically Managed Residential Withdrawal Management; Medically Monitored Inpatient Withdrawal Management; Clinically Managed Population-Specific High-Intensity Residential Programs; Clinically Managed Residential Services; Medically Monitored Intensive Inpatient Services; PRTF; Partial Hospitalization.

Diagnosis Requirements

Primary Substance Use Diagnosis only

Level of Care

ASAM Level 2.5 Partial Hospitalization ASAM Criteria. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and documented the determination for continued stay, discharge, or transfer to another LOC.

Place of Service

Must be provided in a facility licensed under 10A NCAC 27G .4500

Other Information

Revised benefit limits will go into effect on 1/1/2026. Current limits are in place through 12/31/2025

How to Submit

N/A - No authorization is required

Resources

• State-Funded Substance Abuse Comprehensive Outpatient Treatment Service Definition
• Records Management and Documentation Manual