PA Lookup
If you have questions about prior authorizations, please call:
Member and Recipient Service Line: 1-877-685-2415
Provider Support Service Line: 1-855-250-1539
Tuberculosis Control and Treatment Provided in Health Departments
This service refers specifically to the treatment of sexually transmitted diseases (STD) provided in the local health department setting. Service includes medical history, diagnostic examinations for sexually transmitted diseases, laboratory tests as medically indicated, treatment as indicated, and referral as appropriate.
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
Unit Value
Per Diem
Limits
4 units per day may be billed
Place of Service
Health Department
How to Submit
Please submit your request to Carolina Complete Health through Availity
Resources
Clinical Coverage Policy No: 10C
Authorization Guidelines
The prior approval process is deemed met by the IEP, IFSP, IHP, BIP or 504 Plan processes.
Unit Value
Per Diem
How to Submit
Please submit your request to Carolina Complete Health through Availity
Resources
LPN/LVN services, up to 15 minutes
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Clinical Coverage Policy No: 10C
Authorization Guidelines
The prior approval process is deemed met by the IEP, IFSP, IHP, BIP or 504 Plan processes.
How to Submit
Please submit your request to Carolina Complete Health through Availity
Resources
Respite Services
Respite services provide periodic or scheduled support and relief to the primary caregiver(s) from the responsibility and stress of caring for the member. This service also enables the individual to receive periodic support and relief from the primary caregiver(s) at his/her choice. NC Innovations respite may also be used to provide temporary relief to a member who resides in Licensed or Unlicensed AFL, but it may not be billed on the same day as Residential Supports unless it is for a member to access a summer camp or support group. This service enables the primary caregiver to meet or participate in planned or emergency events, and to have planned time for him/her and/or family members. Respite may be utilized during school hours for sickness, injury, or when a student is suspended or expelled.
Authorization Guidelines
- 1. TAR: Prior approval is required for each plan year.
- 2. SIS
- 3. Individual Budget
- 4. Care Management Comprehensive Assessment
- 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
- 6. Documentation that clearly indicates the service is needed for support and relief of the member or primary caregiver.
- 7. Submission of applicable records that support the member has met the medical necessity criteria.
Limits
Respite may include in and out-of-home services, inclusive of overnight, weekend care, or emergency care (family emergency based, not to include out of home crisis).
Exclusions
- • This service may not be used as a regularly scheduled daily service for individual support.
- • This service is not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Employment or one of the State Plan Medicaid Services that works directly with the person such as Private Duty Nursing.
- • Residential Support AFL cannot be billed on the same day as Per Diem Respite for the same member.
- • This service is not available to members who reside in licensed facilities that are licensed as 5600B or 5600C.
- • Staff sleep time is not reimbursable.
- • Respite services are only provided for the member; other family members, such as siblings of the member, may not receive care from the provider while Respite Care is being provided/billed.
- • Respite Care is not provided by any person who resides in the member’s primary place of residence.
- • For a member who is eligible for educational services under Individual’s With Disability Educational Act, Respite does not include transportation to and from school settings. This includes transportation to and from the member’s home, provider home where the member is receiving services before/after school or any community location where the member may be receiving services before or after school.
- • Respite may not be used for a member who is living alone or with a roommate.
- • The primary caregiver(s) is the person principally responsible for the care and supervision of the member and must maintain his/her primary residence at the same address as the member.
- • Services provided in the private home of the direct service employee are subject to the checklist and monthly monitoring by the qualified professional.Cost of 24 hours of respite care cannot exceed the per diem rate for the average community ICF-IID facility.• For services provided in the home of a direct service employee, the Provider Agency, Employer of Record or Agency With Choice is required to complete the Health and Safety Checklist and Justification for Services form prior to the delivery of service in that home and every six months afterwards, as long as the service continues to be provided in that location. The member or legally responsible person must sign this checklist.
- • 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.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Respite Services
Respite services provide periodic or scheduled support and relief to the primary caregiver(s) from the responsibility and stress of caring for the member. This service also enables the individual to receive periodic support and relief from the primary caregiver(s) at his/her choice. NC Innovations respite may also be used to provide temporary relief to a member who resides in Licensed or Unlicensed AFL, but it may not be billed on the same day as Residential Supports unless it is for a member to access a summer camp or support group. This service enables the primary caregiver to meet or participate in planned or emergency events, and to have planned time for him/her and/or family members. Respite may be utilized during school hours for sickness, injury, or when a student is suspended or expelled.
Authorization Guidelines
- 1. TAR: Prior approval is required for each plan year.
- 2. SIS
- 3. Individual Budget
- 4. Care Management Comprehensive Assessment
- 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
- 6. Documentation that clearly indicates the service is needed for support and relief of the member or primary caregiver.
- 7. Submission of applicable records that support the member has met the medical necessity criteria.
Limits
Respite may include in and out-of-home services, inclusive of overnight, weekend care, or emergency care (family emergency based, not to include out of home crisis).
Exclusions
- • This service may not be used as a regularly scheduled daily service for individual support.
- • This service is not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Employment or one of the State Plan Medicaid Services that works directly with the person such as Private Duty Nursing.
- • Residential Support AFL cannot be billed on the same day as Per Diem Respite for the same member.
- • This service is not available to members who reside in licensed facilities that are licensed as 5600B or 5600C.
- • Staff sleep time is not reimbursable.
- • Respite services are only provided for the member; other family members, such as siblings of the member, may not receive care from the provider while Respite Care is being provided/billed.
- • Respite Care is not provided by any person who resides in the member’s primary place of residence.
- • For a member who is eligible for educational services under Individual’s With Disability Educational Act, Respite does not include transportation to and from school settings. This includes transportation to and from the member’s home, provider home where the member is receiving services before/after school or any community location where the member may be receiving services before or after school.
- • Respite may not be used for a member who is living alone or with a roommate.
- • The primary caregiver(s) is the person principally responsible for the care and supervision of the member and must maintain his/her primary residence at the same address as the member.
- • Services provided in the private home of the direct service employee are subject to the checklist and monthly monitoring by the qualified professional.Cost of 24 hours of respite care cannot exceed the per diem rate for the average community ICF-IID facility.• For services provided in the home of a direct service employee, the Provider Agency, Employer of Record or Agency With Choice is required to complete the Health and Safety Checklist and Justification for Services form prior to the delivery of service in that home and every six months afterwards, as long as the service continues to be provided in that location. The member or legally responsible person must sign this checklist.
- • 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.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
T1015 HI- FQHC/RCH Core Visit -Other Services
How to Submit
N/A - No authorization is required
T1015 HI- FQHC/RCH Core Visit -Other Services
How to Submit
N/A - No authorization is required
T1017 HT Targeted Case Management Non-Innovations Waiver Base Code
How to Submit
N/A - No authorization is required
T1017 HT CG Targeted Case Management Innovations Waiver Base Code
How to Submit
N/A - No authorization is required
T1017 U4 Targeted Case Management 1915i Add-on Code
How to Submit
N/A - No authorization is required
Individual and Transitional Support (ITS), 1915(i)
Individual and Transitional Support is a direct, one-on one service that provides structured, scheduled interventions to improve a member’s ability to manage IADLs and promote independent functioning in the community and recovery. This service provides support in acquiring, retaining, and improving self help, socialization, and adaptive skills necessary to be successful in employment, education, community life, maintaining housing, and residing successfully in the community. A paraprofessional assists the person in learning new skills and/or supports the person in activities that are individualized and aligned with the person’s preferences.s.
Authorization Guidelines
Required Prior to Service Provision:
- 1. Independent Assessment: Required, completed by a TCM or the CIHA for Tribal members that indicate the member would benefit from ITS.
- 2. Independent Evaluation: Required, completed by DHB/ Carelon to determine eligibility for 1915(i) Maintained in the Record (not all inclusive):
- 1. Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above). Progress made toward goals must be outlined in the care plan.
- 2. Service Order: Required, completed by QP, Licensed BH clinician, Licensed Psychologist, MD/ DO, NP, PA
- 3. Submission of applicable records that support the member has met the medical necessity criteria
Unit Value
One unit = 15 minutes
Limits
Family members or LRP are not eligible to provide this service. Cannot be provided if the service is otherwise available under the Rehabilitation Act of 1973 or under the Individuals with Disabilities Education Act. Transportation, childcare services, and room & board are not covered. Medicaid will not cover services provided to teach academic subjects. A member transitioning from a MH or SUD residential setting or an adult care home into independent housing may receive this service up to 90 days prior to their discharge. Cannot be provided during the same time as another direct support Medicaid service. This service may not be provided in a group.
Length of Stay
The duration and frequency must be based on MN and progress made by the member toward goals outlined in the care plan. It is expected that the service intensity titrates down as the member demonstrates improvement.
Exclusions
Cannot be provided during the same authorization period as Assertive Community Treatment (ACT), Community Support Team (CST), Intensive In-Home (IIH), Multi-Systemic Therapy (MST), Psychosocial Rehabilitation (PSR), IMD, or to members aged 16 to 21 who reside in a Medicaid funded group residential treatment facility or any other duplicative service
Diagnosis Requirements
A diagnosis of SED, SMI, SPMI, or severe SUD as defined by the CCP is required.
Age Group Details
Adolescents & Adults (16 years of age and older)
Place of Service
Individual and Transitional Support can be provided in the beneficiary's private primary residence, in a shelter, licensed group home, adult care home, mental health and SUD residential setting, the community or in an office setting. It may not be provided in the residence of provider staff.
How to Submit
N/A - No authorization is required
Resources
Individual and Transitional Support (ITS), 1915(i)
Individual and Transitional Support is a direct, one-on one service that provides structured, scheduled interventions to improve a member’s ability to manage IADLs and promote independent functioning in the community and recovery. This service provides support in acquiring, retaining, and improving self help, socialization, and adaptive skills necessary to be successful in employment, education, community life, maintaining housing, and residing successfully in the community. A paraprofessional assists the person in learning new skills and/or supports the person in activities that are individualized and aligned with the person’s preferences.s.
Authorization Guidelines
Required Prior to Service Provision:
- 1. Independent Assessment: Required, completed by a TCM or the CIHA for Tribal members that indicate the member would benefit from ITS.
- 2. Independent Evaluation: Required, completed by DHB/ Carelon to determine eligibility for 1915(i) Maintained in the Record (not all inclusive):
- 1. Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above). Progress made toward goals must be outlined in the care plan.
- 2. Service Order: Required, completed by QP, Licensed BH clinician, Licensed Psychologist, MD/ DO, NP, PA
- 3. Submission of applicable records that support the member has met the medical necessity criteria
Unit Value
One unit = 15 minutes
Limits
Family members or LRP are not eligible to provide this service.
- • Cannot be provided if the service is otherwise available under the Rehabilitation Act of 1973 or under the Individuals with Disabilities Education Act.
- • Transportation, childcare services, and room & board are not covered.
- • Medicaid will not cover services provided to teach academic subjects.
- • A member transitioning from a MH or SUD residential setting or an adult care home into independent housing may receive this service up to 90 days prior to their discharge.
- • Cannot be provided during the same time as another direct support Medicaid service.
- • This service may not be provided in a group.
Length of Stay
Length of Stay: The duration and frequency must be based on MN and progress made by the member toward goals outlined in the care plan. It is expected that the service intensity titrates down as the member demonstrates improvement.
Exclusions
Cannot be provided during the same authorization period as Assertive Community Treatment (ACT), Community Support Team (CST), Intensive In-Home (IIH), Multi-Systemic Therapy (MST), Psychosocial Rehabilitation (PSR), IMD, or to members aged 16 to 21 who reside in a Medicaid funded group residential treatment facility or any other duplicative service
Diagnosis Requirements
A diagnosis of SED, SMI, SPMI, or severe SUD as defined by the CCP is required.
Age Group Details
Adolescents & Adults (16 years of age and older)
Place of Service
Individual and Transitional Support can be provided in the beneficiary's private primary residence, in a shelter, licensed group home, adult care home, mental health and SUD residential setting, the community or in an office setting. It may not be provided in the residence of provider staff. No numeric place of service codes are listed in the policy.
How to Submit
N/A - No authorization is required
Resources
Home health aide or certified nurse assistant, per visit
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Contracted home health agency services, all services provided under contract, per day
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Diagnostic Assessment
A diagnostic assessment (DA) is an intensive clinical and functional evaluation of a member’s MH, IDD, or SU condition. A DA determines whether the member meets medical necessity and can benefit from BH services based on the member’s diagnosis, presenting problems, and tx and recovery goals. It evaluates the member’s level of readiness and motivation to engage in tx. This assessment is designed to be delivered in a team approach that results in the issuance of a written report that provides the clinical basis for the development of the member’s treatment or service plan. The written report must be kept in the service record.
Authorization Guidelines
- 1. The presenting problems, including source of distress, precipitating events, & associated problems or symptoms;
- 2. Chronological general health, past trauma hx & BH history (including both MH & SU including tobacco use) of the beneficiary’s symptoms, tx, & tx response.
- 3. Current meds for medical, psychiatric, & SU disorder tx. Identify past meds that were ineffective or caused significant side effects or adverse reactions.
- 4. Review of biological, psychological, familial, social, developmental & environmental dimensions to identify strengths, needs, & risks in each area.
- 5. Evidence of member & legally responsible person’s (if applicable) participation in the assessment.
- 6. Analysis & interpretation of the assessment info with an appropriate case formulation including determination of ASAM level of care when a SU disorder is present.
- 7. Diagnosis, including MH, SU disorders, or IDD, as well as PH conditions & functional impairment.
- 8. Recommendations for additional assessments, services, supports or tx based on the results of the DA.
- 9. Must be signed & dated by the licensed professionals completing the assessment & by the MD, DO, PA, NP, or LP (serving as the initial service order included in the PCP).
- 10. Evidence of an interdisciplinary team service note that documents the team’s review & discussion of the assessment. The involvement of the team in the delivery of the service is very important & is documented in the team note. Particular emphasis is made on the involvement & participation of all members of the team in the formulation of diagnoses & tx recommendations.
Conditional Requirements
Prior authorization is not required for this service for the first event in a fiscal year. Additional events in the same fiscal year require prior authorization.
Unit Value
1 unit = 1 event
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.
Other Information
Modifier(s):
GT: Telehealth
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Diagnostic Assessment
A diagnostic assessment (DA) is an intensive clinical and functional evaluation of a member’s MH, IDD, or SU condition. A DA determines whether the member meets medical necessity and can benefit from BH services based on the member’s diagnosis, presenting problems, and tx and recovery goals. It evaluates the member’s level of readiness and motivation to engage in tx. This assessment is designed to be delivered in a team approach that results in the issuance of a written report that provides the clinical basis for the development of the member’s treatment or service plan. The written report must be kept in the service record.
Authorization Guidelines
Prior authorization is not required for this service.
DA Elements (the DA must include the following):
- 1. The presenting problems, including source of distress, precipitating events, & associated problems or symptoms;
- 2. Chronological general health, past trauma hx & BH history (including both MH & SU including tobacco use) of the beneficiary’s symptoms, tx, & tx response.
- 3. Current meds for medical, psychiatric, & SU disorder tx. Identify past meds that were ineffective or caused significant side effects or adverse reactions.
- 4. Review of biological, psychological, familial, social, developmental & environmental dimensions to identify strengths, needs, & risks in each area.
- 5. Evidence of member & legally responsible person’s (if applicable) participation in the assessment.
- 6. Analysis & interpretation of the assessment info with an appropriate case formulation including determination of ASAM level of care when a SU disorder is present.
- 7. Diagnosis, including MH, SU disorders, or IDD, as well as PH conditions & functional impairment.
- 8. Recommendations for additional assessments, services, supports or tx based on the results of the DA.
- 9. Must be signed & dated by the licensed professionals completing the assessment & by the MD, DO, PA, NP, or LP (serving as the initial service order included in the PCP).
- 10. Evidence of an interdisciplinary team service note that documents the team’s review & discussion of the assessment. The involvement of the team in the delivery of the service is very important & is documented in the team note. Particular emphasis is made on the involvement & participation of all members of the team in the formulation of diagnoses & tx recommendations.
All services are subject to post-payment review.
Unit Value
1 unit = 1 event
Limits
- 1. Medicaid shall not cover diagnostic assessment if psychological testing or specialized assessments are indicated. The testing or assessments are covered separately using appropriate CPT codes for psychological, developmental, or neuropsychological testing.
- 2. Results from a DA include an appropriate case formulation, an interpretation of the assessment info including recommendations for services, supports, tx or additional assessments; appropriate case formulation, a service order for immediate needs, and the development of PCP. For a beneficiary with a SU disorder diagnosis, a diagnostic assessment must recommend the ASAM level of care.
- 3. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.
Level of Care
While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.
Place of Service
Can be provided in any location except an IMD (for adults) or in a public institution (jail, detention center).
How to Submit
N/A - No authorization is required
Resources
Assessment of home, physical and family environment, to determine suitability to meet patient's medical needs
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Home Infusion Therapy
The Home Infusion Therapy (HIT) program covers self-administered infusion therapy and enteral supplies provided to a NC Medicaid (Medicaid) beneficiary residing in a private residence or to a Medicaid beneficiary residing in an adult care home. Covered services include the following: a. Total parenteral nutrition (TPN); b. Enteral nutrition (EN); c. Intravenous chemotherapy; d. Intravenous antibiotic therapy; and e. Pain management therapy, including subcutaneous, epidural, intrathecal, and intravenous pain management therapy.
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
Unit Value
Per Diem
Place of Service
Outpatient
How to Submit
Please submit your request to Carolina Complete Health through Availity
Resources
Individual Goods and Services
Individual Goods and Services are services, equipment or supplies not otherwise provided through this waiver or through the Medicaid State Plan that address an identified need in the Individual Support Plan (including improving and maintaining the member’s opportunities for full membership in the community) and meet the following requirements: a) the item or service would decrease the need for other Medicaid services, OR; b) promote inclusion in the community, OR; c) increase the member’s safety in the home environment, AND; d) the member does not have the funds to purchase the item or service.
Authorization Guidelines
- 1. TAR: Prior approval is required
- 2. SIS
- 3. Individual Budget
- 4. Care Management Comprehensive Assessment
- 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) how each of the applicable requirements are met, e) that the member does not have the funds to purchase the item or service, f) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
- 6. Submission of applicable records that support the member has met the medical necessity criteria.
Limits
- • The cost of individual directed goods and services for each member cannot exceed $2,000.00 per member plan year annually.
- • Individual Goods and Services do not include experimental goods and services inclusive of items which may be defined as restrictive under NC G.S. 122C-60.
- • This service is available only to members who self-direct at least one of their services. The purchase, rental, or leasing of cars/ vans/ trucks is not permissible.
- • The purchase of animals, food, nutritional supplements, alcohol, and tobacco are not covered.
- • 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.
How to Submit
If your request is for outpatient Durable Medical Equipment, Personal Care Service, or Private Duty Nursing, please submit request to Carolina Complete Health. If your request is NOT for outpatient Durable Medical Equipment, Personal Care Service, or Private Duty Nursing, please submit request to Trillium.
Resources
If you find any wrong or out of date information on our pages, we want to know. Please email info@TrilliumNC.org with any corrections.