PA Lookup

Home Health Services include medically necessary skilled nursing services, specialized therapies (physical therapy, speech-language pathology, and occupational therapy), home health aide services, and medical supplies provided to a beneficiary in any setting in which normal life activities take place, other than a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities. Home health services may be provided in an intermediate care facility for Individuals with Intellectual Disabilities that are not required to be provided by the facility under subpart I of part 483 or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Home health services cannot be limited to services furnished to a beneficiary who is homebound in accordance with 42 CFR 440.70.

Unit Value

1 visit

Limits

Miscellaneous supply billing without prior approval is limited to a total of $250 per beneficiary per year.

With prior approval, miscellaneous supply billing is limited to a maximum of $1500 per beneficiary per year.

• - Incontinence supplies for children under age 3 are not covered.

Exclusions

Medicaid does not cover medical supplies that were not ordered by a physician and included on the authorized plan of care or verbal order. It does not cover routine beneficiary-care supply items such as alcohol wipes, applicators, lubricants, mouth swabs, nonsterile gloves, or thermometers. Convenience or comfort items used by persons who are not ill or injured, such as soaps, shampoos, lotions, skin conditioners, and pantiliners or pads, are not covered. Nonsterile gloves for agency staff use are considered agency overhead and are not separately billable. Items not needed in the provision of physical therapy, occupational therapy, speech-language therapy, skilled nursing, or home health aide services are not covered under the home health medical supplies benefit and instead may be considered under medical equipment policies. Attachment B also states that items such as drugs and biologicals, medical equipment, orthotics and prosthetics, and nutritional supplements are examples of items not considered home health medical supplies. General home health exclusions also apply, including duplicate services, experimental or investigational services or services that are part of a clinical trial, lack of required documentation, services when home health is not the most appropriate setting, and services related to a terminal illness when hospice has been elected unless unrelated to the terminal illness.

Place of Service

Covered only in settings where normal life activities take place; not in a hospital, nursing facility, ICF/IID except as specified, or any setting where Medicaid inpatient payment including room and board is or could be made.

Additional Service Specifics

The home health agency furnishing the service shall bill for services with its individual NPI. Providers may bill only for those services ordered by a physician and documented in the beneficiary’s individual POC.

Other Information

Home health medical supplies are billed using revenue code 270, along with the applicable HCPCS code for the individual supply.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 3A
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required

Ambulance services provide medically necessary treatment for NC Medicaid Program beneficiaries. Transport is provided only if the beneficiary’s medical condition is such that the use of any other means of transportation is contraindicated. Ambulance services include emergency and non-emergency ambulance transport via ground and air medical ambulance for a Medicaid beneficiary.

Authorization Guidelines

Prior approval (PA) is required for non-emergency ambulance services for a Medicaid beneficiary by ground or air from North Carolina to another state, from one state to another, or from another state back to North Carolina.

The provider(s) shall submit to the Department of Health and Human Services (DHHS) Utilization Review Contractor the following:

• a. the prior approval request; and
• b. all health records and any other records that support the beneficiary has met

the specific criteria in this policy.

• c. Each trip requires a separate PA process and PA number.
• d. For non-emergency medically necessary ambulance transport, PA shall be

obtained before service is rendered for a Medicaid beneficiary.

• e. The PA is active for 30 calendar days.

Unit Value

The time of pick-up, in the range of 00–23 hours, is required on the claim form.

Limits

Ground ambulance loaded mileage is reimbursable only for out-of-county transport; in-county loaded ground mileage is not reimbursable.

Ambulance transports are covered only to specified destinations, including hospital, critical access hospital, skilled nursing facility, adult care home, ICF-IID, beneficiary's primary private residence, dialysis facility for ESRD when condition requires ambulance services, transfer site, and physician's office under stated criteria.

Air medical ambulance transport is covered only to an acute-care hospital.

The provider shall bill only one ambulance procedure code for the same date of service, the same hour or time of pick-up, and the same or a different provider.

The provider shall not bill a round-trip ambulance transport and a one-way-trip ambulance transport on the same date of service unless submitting an adjustment with documentation substantiating both.

Each trip requires a separate PA process and PA number; PA is active for 30 calendar days.

Exclusions

Air medical ambulance transport to a facility that is not an acute-care hospital is not covered. Ambulance transport of a deceased beneficiary is not covered if the beneficiary is pronounced dead before the ambulance is called. Loaded mileage to a facility that is not the nearest appropriate facility is not reimbursed. Other non-covered ambulance services include: an ambulance is called and no treatment is needed; false alarm calls; beneficiary refuses all medical services; transport for a medical service that is not Medicaid covered; commercial airline tickets; airstrip fees; taxes; separate additional charges for nursing personnel who are employees of a facility or ambulance service; waiting fees; and separate charges for oxygen and other items and supplies because these are included in the base rate. Services other than those listed in Subsection 3.2 are not covered. Routine pregnancy transport is not covered. Beneficiaries with Medicaid coverage through Family Planning are not covered to receive ambulance services.

Place of Service

Ambulance

Additional Service Specifics

Institutional providers must report one of the following condition codes: AK, AL, AM. Providers must report an origin and destination modifier for each ambulance trip provided. Providers must report QL modifier if the time of death pronouncement is made after dispatch but before the beneficiary is loaded onboard the ambulance.

Other Information

When multiple units respond to a call for services, the provider that transports the beneficiary is the only provider that may bill for the service. If both ground and air medical ambulances areinvolved, then each submits its own claim and each claim is processed and reimbursed independently of the other.

How to Submit

Please submit your request to Trillium Health Resources

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

Resources

• Clinical Coverage Policy No: 15
• Records Management and Documentation Manual

Community Living and Support is an individualized or group service that enables the waiver member to live successfully in their home and be an active member of their community. Community Living and Support enables the member to learn new skills, practice and/or improve existing skills. The intended outcome of the service is to increase or maintain the member’s life skills or provide the supervision needed to empower the member to live in the home of their family or natural supports or in their private primary residency, maximize self-sufficiency, increase self- determination and enhance the opportunity to have full membership in the community.

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, e) if applicable, member agrees with the employment of the relative and has been given the opportunity to consider employment of non-related staff. 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.

Unit Value

One unit = 15 minutes

Limits

Timeframes:

• 1. Requests up to 12 hours daily may be auth’d for the entire plan year.
• 2. Requests up to 16 hours daily may be auth’d for 6 months within the plan year.
• 3. Requests for more than 16 hours daily are auth’d for up to a 90-days within the plan year.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 6 months afterwards. The member or legally responsible person must sign this checklist.

Exclusions

• • The amount of Community Living and Supports is subject to the limitations on the sets of services.
• • A member who receives Community Living and Supports may not receive Residential Supports or Supported Living at the same time.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Living, Supported Employment, Respite or one of the State Plan Medicaid Services that works directly with the person, such as Private Duty Nursing.
• • Transportation to and from the school setting is not covered under the waiver and is the responsibility of the school system. (This service includes only transportation to/from the person’s home or any community location where the person is receiving services.)
• • Incidental housekeeping and meal preparation for other household members is not covered under the waiver. The paraprofessional is responsible for incidental housekeeping and meal preparation only for the member.
• • Parents of minor children enrolled in the waiver may provide CLS services to their child who has been indicated as having extraordinary support needs. Parents of minor children receiving CLS may provide this service (up to 40 hours and not exceeding 56 hours) to their child. Note: This does not apply to parents of minor children who are also the Employer of Record (EOR).
• • CLS service providers may be a relative of an adult waiver member. Relatives as providers for adult waiver members may provide CLS service over 56 hours/week not exceeding 84 hours/week.
• • Family members living under the same roof as the waiver individual may provide CLS services. Objective written documentation is required as to why there are no other providers available to provide the services. Family members who provide these services must meet the same standards as providers who are unrelated to the individual.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

N/A - No authorization is required

• 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

Community Living and Support is an individualized or group service that enables the waiver member to live successfully in their home and be an active member of their community. Community Living and Support enables the member to learn new skills, practice and/or improve existing skills. The intended outcome of the service is to increase or maintain the member’s life skills or provide the supervision needed to empower the member to live in the home of their family or natural supports or in their private primary residency, maximize self-sufficiency, increase self- determination and enhance the opportunity to have full membership in the community.

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, e) if applicable, member agrees with the employment of the relative and has been given the opportunity to consider employment of non-related staff. 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.

Conditional Requirements

Prior approval required. The request must be submitted by the TCM.

Unit Value

One unit = 15 minutes

Limits

Timeframes:

• 1. Requests up to 12 hours daily may be auth’d for the entire plan year.
• 2. Requests up to 16 hours daily may be auth’d for 6 months within the plan year.
• 3. Requests for more than 16 hours daily are auth’d for up to a 90-days within the plan year.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 6 months afterwards. The member or legally responsible person must sign this checklist.

Exclusions

• • The amount of Community Living and Supports is subject to the limitations on the sets of services.
• • A member who receives Community Living and Supports may not receive Residential Supports or Supported Living at the same time.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Living, Supported Employment, Respite or one of the State Plan Medicaid Services that works directly with the person, such as Private Duty Nursing.
• • Transportation to and from the school setting is not covered under the waiver and is the responsibility of the school system. (This service includes only transportation to/from the person’s home or any community location where the person is receiving services.)
• • Incidental housekeeping and meal preparation for other household members is not covered under the waiver. The paraprofessional is responsible for incidental housekeeping and meal preparation only for the member.
• • Parents of minor children enrolled in the waiver may provide CLS services to their child who has been indicated as having extraordinary support needs. Parents of minor children receiving CLS may provide this service (up to 40 hours and not exceeding 56 hours) to their child. Note: This does not apply to parents of minor children who are also the Employer of Record (EOR).
• • CLS service providers may be a relative of an adult waiver member. Relatives as providers for adult waiver members may provide CLS service over 56 hours/week not exceeding 84 hours/week.
• • Family members living under the same roof as the waiver individual may provide CLS services. Objective written documentation is required as to why there are no other providers available to provide the services. Family members who provide these services must meet the same standards as providers who are unrelated to the individual.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

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

• 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

Community Living and Support is an individualized or group service that enables the waiver member to live successfully in their home and be an active member of their community. Community Living and Support enables the member to learn new skills, practice and/or improve existing skills. The intended outcome of the service is to increase or maintain the member’s life skills or provide the supervision needed to empower the member to live in the home of their family or natural supports or in their private primary residency, maximize self-sufficiency, increase self- determination and enhance the opportunity to have full membership in the community.

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, e) if applicable, member agrees with the employment of the relative and has been given the opportunity to consider employment of non-related staff. 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.

Conditional Requirements

Prior approval required. The request must be submitted by the TCM.

Unit Value

One unit = 15 minutes

Limits

Timeframes:

• 1. Requests up to 12 hours daily may be auth’d for the entire plan year.
• 2. Requests up to 16 hours daily may be auth’d for 6 months within the plan year.
• 3. Requests for more than 16 hours daily are auth’d for up to a 90-days within the plan year.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 6 months afterwards. The member or legally responsible person must sign this checklist.

Exclusions

• • The amount of Community Living and Supports is subject to the limitations on the sets of services.
• • A member who receives Community Living and Supports may not receive Residential Supports or Supported Living at the same time.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Living, Supported Employment, Respite or one of the State Plan Medicaid Services that works directly with the person, such as Private Duty Nursing.
• • Transportation to and from the school setting is not covered under the waiver and is the responsibility of the school system. (This service includes only transportation to/from the person’s home or any community location where the person is receiving services.)
• • Incidental housekeeping and meal preparation for other household members is not covered under the waiver. The paraprofessional is responsible for incidental housekeeping and meal preparation only for the member.
• • Parents of minor children enrolled in the waiver may provide CLS services to their child who has been indicated as having extraordinary support needs. Parents of minor children receiving CLS may provide this service (up to 40 hours and not exceeding 56 hours) to their child. Note: This does not apply to parents of minor children who are also the Employer of Record (EOR).
• • CLS service providers may be a relative of an adult waiver member. Relatives as providers for adult waiver members may provide CLS service over 56 hours/week not exceeding 84 hours/week.
• • Family members living under the same roof as the waiver individual may provide CLS services. Objective written documentation is required as to why there are no other providers available to provide the services. Family members who provide these services must meet the same standards as providers who are unrelated to the individual.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

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

• 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

CL&S is an individualized or group service that enables the member to live successfully in their own home, the home of their family, or natural supports and be an active member of their community. A paraprofessional assists the member to learn new skills and supports the member in activities that are individualized and aligned with the member’s preferences. The goal is to maximize self-sufficiency, increase self-determination and enhance the members’ opportunity to have full membership in their community. Community Living and Support enables the members to learn new skills, practice or improve existing skills, provide supervision and assistance to complete an activity to their level of independence. This service is available for members who meet the IDD or TBI eligibility criteria.

Authorization Guidelines

• 1. Independent Assessment: Required, completed by a TCM or the CIHA for Tribal members that indicates the Member would benefit from CL&S 2 Independent Evaluation: Required, completed by DHB/ Carelon to determine eligibility for 1915(i) 3. Evidence of IDD or TBI: Required, as defined by the CCP.
• 4. Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
• 5. Service Order: Required, completed by QP, Licensed BH clinician, Licensed Psychologist, MD/ DO, NP, PA
• 6. 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

Limits

• 1. School-aged Members

(through age 21 unless proof of graduation is provided): Up to 15 hours (60 units) a week when school is in session and up to 28 hours (112 units) a week when school is not in session

• 2. Members aged 22 and

up (or graduated, with proof of graduation): Up to 28 hours (or 112 units) a week

• 3. Proof of Graduation:

includes graduation with a degree in a standard or occupational course of study, a GED, a Certificate of Completion, or proof of the exhaustion of their educational course of study)

Exclusions

Relatives who live in the same home as a member who is under 18 years old may not provide CLS.

• • 1915(i) CLS and SE may not exceed a combined limit of 40 hrs per week.
• • Transportation to and from the school setting is not covered.
• • Individuals who are enrolled in the Innovations or TBI waiver are not eligible for 1915(i) services.
• • This service may not be provided during the same time as any other direct support Medicaid service.
• • Relatives who live in the same primary residence as beneficiary, who is over 18 years old, can provide Community Living and Supports if the relative meets the required staffing qualifications

Diagnosis Requirements

The service is available for beneficiaries who meet I/DD or TBI eligibility criteria.

Age Group Details

Covered only for beneficiaries age 3 or older

Place of Service

The beneficiary's primary private residence or in the community

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

• 8H-5, Community Living and Supports
• Records Management and Documentation Manual
• https://medicaid.ncdhhs.gov/tailored-care-management
• https://medicaid.ncdhhs.gov/north-carolinas-transition-1915b3-benefits-1915i

Community Living and Support is an individualized or group service that enables the waiver member to live successfully in their home and be an active member of their community. Community Living and Support enables the member to learn new skills, practice and/or improve existing skills. The intended outcome of the service is to increase or maintain the member’s life skills or provide the supervision needed to empower the member to live in the home of their family or natural supports or in their private primary residency, maximize self-sufficiency, increase self- determination and enhance the opportunity to have full membership in the community.

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, e) if applicable, member agrees with the employment of the relative and has been given the opportunity to consider employment of non-related staff. 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.

Conditional Requirements

Prior approval required. The request must be submitted by the TCM.

Unit Value

One unit = 15 minutes

Limits

Timeframes:

• 1. Requests up to 12 hours daily may be auth’d for the entire plan year.
• 2. Requests up to 16 hours daily may be auth’d for 6 months within the plan year.
• 3. Requests for more than 16 hours daily are auth’d for up to a 90-days within the plan year.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 6 months afterwards. The member or legally responsible person must sign this checklist.

Exclusions

• • The amount of Community Living and Supports is subject to the limitations on the sets of services.
• • A member who receives Community Living and Supports may not receive Residential Supports or Supported Living at the same time.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Living, Supported Employment, Respite or one of the State Plan Medicaid Services that works directly with the person, such as Private Duty Nursing.
• • Transportation to and from the school setting is not covered under the waiver and is the responsibility of the school system. (This service includes only transportation to/from the person’s home or any community location where the person is receiving services.)
• • Incidental housekeeping and meal preparation for other household members is not covered under the waiver. The paraprofessional is responsible for incidental housekeeping and meal preparation only for the member.
• • Parents of minor children enrolled in the waiver may provide CLS services to their child who has been indicated as having extraordinary support needs. Parents of minor children receiving CLS may provide this service (up to 40 hours and not exceeding 56 hours) to their child. Note: This does not apply to parents of minor children who are also the Employer of Record (EOR).
• • CLS service providers may be a relative of an adult waiver member. Relatives as providers for adult waiver members may provide CLS service over 56 hours/week not exceeding 84 hours/week.
• • Family members living under the same roof as the waiver individual may provide CLS services. Objective written documentation is required as to why there are no other providers available to provide the services. Family members who provide these services must meet the same standards as providers who are unrelated to the individual.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

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

• 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

CL&S is an individualized or group service that enables the member to live successfully in their own home, the home of their family, or natural supports and be an active member of their community. A paraprofessional assists the member to learn new skills and supports the member in activities that are individualized and aligned with the member’s preferences. The goal is to maximize self-sufficiency, increase self-determination and enhance the members’ opportunity to have full membership in their community. Community Living and Support enables the members to learn new skills, practice or improve existing skills, provide supervision and assistance to complete an activity to their level of independence. This service is available for members who meet the IDD or TBI eligibility criteria.

Authorization Guidelines

• 1. Independent Assessment: Required, completed by a TCM or the CIHA for Tribal members that indicates the Member would benefit from CL&S 2 Independent Evaluation: Required, completed by DHB/ Carelon to determine eligibility for 1915(i) 3. Evidence of IDD or TBI: Required, as defined by the CCP.
• 4. Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
• 5. Service Order: Required, completed by QP, Licensed BH clinician, Licensed Psychologist, MD/ DO, NP, PA
• 6. 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

Limits

• 1. School-aged Members

(through age 21 unless proof of graduation is provided): Up to 15 hours (60 units) a week when school is in session and up to 28 hours (112 units) a week when school is not in session

• 2. Members aged 22 and

up (or graduated, with proof of graduation): Up to 28 hours (or 112 units) a week

• 3. Proof of Graduation:

includes graduation with a degree in a standard or occupational course of study, a GED, a Certificate of Completion, or proof of the exhaustion of their educational course of study)

Exclusions

Relatives who live in the same home as a member who is under 18 years old may not provide CLS.

• • 1915(i) CLS and SE may not exceed a combined limit of 40 hrs per week.
• • Transportation to and from the school setting is not covered.
• • Individuals who are enrolled in the Innovations or TBI waiver are not eligible for 1915(i) services.
• • This service may not be provided during the same time as any other direct support Medicaid service.
• • Relatives who live in the same primary residence as beneficiary, who is over 18 years old, can provide Community Living and Supports if the relative meets the required staffing qualifications

Diagnosis Requirements

The service is available for beneficiaries who meet I/DD or TBI eligibility criteria.

Age Group Details

Covered only for beneficiaries age 3 or older

Place of Service

The beneficiary's primary private residence or in the community

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

• 8H-5, Community Living and Supports
• Records Management and Documentation Manual
• https://medicaid.ncdhhs.gov/tailored-care-management
• https://medicaid.ncdhhs.gov/north-carolinas-transition-1915b3-benefits-1915i

CL&S is an individualized or group service that enables the member to live successfully in their own home, the home of their family, or natural supports and be an active member of their community. A paraprofessional assists the member to learn new skills and supports the member in activities that are individualized and aligned with the member’s preferences. The goal is to maximize self-sufficiency, increase self-determination and enhance the members’ opportunity to have full membership in their community. Community Living and Support enables the members to learn new skills, practice or improve existing skills, provide supervision and assistance to complete an activity to their level of independence. This service is available for members who meet the IDD or TBI eligibility criteria.

Authorization Guidelines

• 1. Independent Assessment: Required, completed by a TCM or the CIHA for Tribal members that indicates the Member would benefit from CL&S 2 Independent Evaluation: Required, completed by DHB/ Carelon to determine eligibility for 1915(i) 3. Evidence of IDD or TBI: Required, as defined by the CCP.
• 4. Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
• 5. Service Order: Required, completed by QP, Licensed BH clinician, Licensed Psychologist, MD/ DO, NP, PA
• 6. 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

Limits

• 1. School-aged Members

(through age 21 unless proof of graduation is provided): Up to 15 hours (60 units) a week when school is in session and up to 28 hours (112 units) a week when school is not in session

• 2. Members aged 22 and

up (or graduated, with proof of graduation): Up to 28 hours (or 112 units) a week

• 3. Proof of Graduation:

includes graduation with a degree in a standard or occupational course of study, a GED, a Certificate of Completion, or proof of the exhaustion of their educational course of study)

Exclusions

Relatives who live in the same home as a member who is under 18 years old may not provide CLS.

• • 1915(i) CLS and SE may not exceed a combined limit of 40 hrs per week.
• • Transportation to and from the school setting is not covered.
• • Individuals who are enrolled in the Innovations or TBI waiver are not eligible for 1915(i) services.
• • This service may not be provided during the same time as any other direct support Medicaid service.
• • Relatives who live in the same primary residence as beneficiary, who is over 18 years old, can provide Community Living and Supports if the relative meets the required staffing qualifications

Diagnosis Requirements

The service is available for beneficiaries who meet I/DD or TBI eligibility criteria.

Age Group Details

Covered only for beneficiaries age 3 or older

Place of Service

The beneficiary's primary private residence or in the community

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

• 8H-5, Community Living and Supports
• Records Management and Documentation Manual
• https://medicaid.ncdhhs.gov/tailored-care-management
• https://medicaid.ncdhhs.gov/north-carolinas-transition-1915b3-benefits-1915i

CL&S is an individualized or group service that enables the member to live successfully in their own home, the home of their family, or natural supports and be an active member of their community. A paraprofessional assists the member to learn new skills and supports the member in activities that are individualized and aligned with the member’s preferences. The goal is to maximize self-sufficiency, increase self-determination and enhance the members’ opportunity to have full membership in their community. Community Living and Support enables the members to learn new skills, practice or improve existing skills, provide supervision and assistance to complete an activity to their level of independence. This service is available for members who meet the IDD or TBI eligibility criteria.

Authorization Guidelines

• 1. Independent Assessment: Required, completed by a TCM or the CIHA for Tribal members that indicates the Member would benefit from CL&S 2 Independent Evaluation: Required, completed by DHB/ Carelon to determine eligibility for 1915(i) 3. Evidence of IDD or TBI: Required, as defined by the CCP.
• 4. Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
• 5. Service Order: Required, completed by QP, Licensed BH clinician, Licensed Psychologist, MD/ DO, NP, PA
• 6. 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

Limits

• 1. School-aged Members

(through age 21 unless proof of graduation is provided): Up to 15 hours (60 units) a week when school is in session and up to 28 hours (112 units) a week when school is not in session

• 2. Members aged 22 and

up (or graduated, with proof of graduation): Up to 28 hours (or 112 units) a week

• 3. Proof of Graduation:

includes graduation with a degree in a standard or occupational course of study, a GED, a Certificate of Completion, or proof of the exhaustion of their educational course of study)

Exclusions

Relatives who live in the same home as a member who is under 18 years old may not provide CLS.

• • 1915(i) CLS and SE may not exceed a combined limit of 40 hrs per week.
• • Transportation to and from the school setting is not covered.
• • Individuals who are enrolled in the Innovations or TBI waiver are not eligible for 1915(i) services.
• • This service may not be provided during the same time as any other direct support Medicaid service.
• • Relatives who live in the same primary residence as beneficiary, who is over 18 years old, can provide Community Living and Supports if the relative meets the required staffing qualifications

Diagnosis Requirements

The service is available for beneficiaries who meet I/DD or TBI eligibility criteria.

Age Group Details

Covered only for beneficiaries age 3 or older

Place of Service

The beneficiary's primary private residence or in the community

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

• 8H-5, Community Living and Supports
• 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

Community Living and Support is an individualized or group service that enables the waiver member to live successfully in their home and be an active member of their community. Community Living and Support enables the member to learn new skills, practice and/or improve existing skills. The intended outcome of the service is to increase or maintain the member’s life skills or provide the supervision needed to empower the member to live in the home of their family or natural supports or in their private primary residency, maximize self-sufficiency, increase self- determination and enhance the opportunity to have full membership in the community.

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, e) if applicable, member agrees with the employment of the relative and has been given the opportunity to consider employment of non-related staff. 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.

Unit Value

One unit = 15 minutes

Limits

Timeframes:

• 1. Requests up to 12 hours daily may be auth’d for the entire plan year.
• 2. Requests up to 16 hours daily may be auth’d for 6 months within the plan year.
• 3. Requests for more than 16 hours daily are auth’d for up to a 90-days within the plan year.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 6 months afterwards. The member or legally responsible person must sign this checklist.

Exclusions

• • The amount of Community Living and Supports is subject to the limitations on the sets of services.
• • A member who receives Community Living and Supports may not receive Residential Supports or Supported Living at the same time.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Living, Supported Employment, Respite or one of the State Plan Medicaid Services that works directly with the person, such as Private Duty Nursing.
• • Transportation to and from the school setting is not covered under the waiver and is the responsibility of the school system. (This service includes only transportation to/from the person’s home or any community location where the person is receiving services.)
• • Incidental housekeeping and meal preparation for other household members is not covered under the waiver. The paraprofessional is responsible for incidental housekeeping and meal preparation only for the member.
• • Parents of minor children enrolled in the waiver may provide CLS services to their child who has been indicated as having extraordinary support needs. Parents of minor children receiving CLS may provide this service (up to 40 hours and not exceeding 56 hours) to their child. Note: This does not apply to parents of minor children who are also the Employer of Record (EOR).
• • CLS service providers may be a relative of an adult waiver member. Relatives as providers for adult waiver members may provide CLS service over 56 hours/week not exceeding 84 hours/week.
• • Family members living under the same roof as the waiver individual may provide CLS services. Objective written documentation is required as to why there are no other providers available to provide the services. Family members who provide these services must meet the same standards as providers who are unrelated to the individual.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

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

• 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

Community Living and Support is an individualized or group service that enables the waiver member to live successfully in their home and be an active member of their community. Community Living and Support enables the member to learn new skills, practice and/or improve existing skills. The intended outcome of the service is to increase or maintain the member’s life skills or provide the supervision needed to empower the member to live in the home of their family or natural supports or in their private primary residency, maximize self-sufficiency, increase self- determination and enhance the opportunity to have full membership in the community.

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, e) if applicable, member agrees with the employment of the relative and has been given the opportunity to consider employment of non-related staff. 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.

Unit Value

One unit = 15 minutes

Limits

Timeframes:

• 1. Requests up to 12 hours daily may be auth’d for the entire plan year.
• 2. Requests up to 16 hours daily may be auth’d for 6 months within the plan year.
• 3. Requests for more than 16 hours daily are auth’d for up to a 90-days within the plan year.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 6 months afterwards. The member or legally responsible person must sign this checklist.

Exclusions

• • The amount of Community Living and Supports is subject to the limitations on the sets of services.
• • A member who receives Community Living and Supports may not receive Residential Supports or Supported Living at the same time.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Living, Supported Employment, Respite or one of the State Plan Medicaid Services that works directly with the person, such as Private Duty Nursing.
• • Transportation to and from the school setting is not covered under the waiver and is the responsibility of the school system. (This service includes only transportation to/from the person’s home or any community location where the person is receiving services.)
• • Incidental housekeeping and meal preparation for other household members is not covered under the waiver. The paraprofessional is responsible for incidental housekeeping and meal preparation only for the member.
• • Parents of minor children enrolled in the waiver may provide CLS services to their child who has been indicated as having extraordinary support needs. Parents of minor children receiving CLS may provide this service (up to 40 hours and not exceeding 56 hours) to their child. Note: This does not apply to parents of minor children who are also the Employer of Record (EOR).
• • CLS service providers may be a relative of an adult waiver member. Relatives as providers for adult waiver members may provide CLS service over 56 hours/week not exceeding 84 hours/week.
• • Family members living under the same roof as the waiver individual may provide CLS services. Objective written documentation is required as to why there are no other providers available to provide the services. Family members who provide these services must meet the same standards as providers who are unrelated to the individual.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

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

• 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

Community Living and Support is an individualized or group service that enables the waiver member to live successfully in their home and be an active member of their community. Community Living and Support enables the member to learn new skills, practice and/or improve existing skills. The intended outcome of the service is to increase or maintain the member’s life skills or provide the supervision needed to empower the member to live in the home of their family or natural supports or in their private primary residency, maximize self-sufficiency, increase self- determination and enhance the opportunity to have full membership in the community.

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, e) if applicable, member agrees with the employment of the relative and has been given the opportunity to consider employment of non-related staff. 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.

Unit Value

One unit = 15 minutes

Limits

Timeframes:

• 1. Requests up to 12 hours daily may be auth’d for the entire plan year.
• 2. Requests up to 16 hours daily may be auth’d for 6 months within the plan year.
• 3. Requests for more than 16 hours daily are auth’d for up to a 90-days within the plan year.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 6 months afterwards. The member or legally responsible person must sign this checklist.

Exclusions

• • The amount of Community Living and Supports is subject to the limitations on the sets of services.
• • A member who receives Community Living and Supports may not receive Residential Supports or Supported Living at the same time.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Living, Supported Employment, Respite or one of the State Plan Medicaid Services that works directly with the person, such as Private Duty Nursing.
• • Transportation to and from the school setting is not covered under the waiver and is the responsibility of the school system. (This service includes only transportation to/from the person’s home or any community location where the person is receiving services.)
• • Incidental housekeeping and meal preparation for other household members is not covered under the waiver. The paraprofessional is responsible for incidental housekeeping and meal preparation only for the member.
• • Parents of minor children enrolled in the waiver may provide CLS services to their child who has been indicated as having extraordinary support needs. Parents of minor children receiving CLS may provide this service (up to 40 hours and not exceeding 56 hours) to their child. Note: This does not apply to parents of minor children who are also the Employer of Record (EOR).
• • CLS service providers may be a relative of an adult waiver member. Relatives as providers for adult waiver members may provide CLS service over 56 hours/week not exceeding 84 hours/week.
• • Family members living under the same roof as the waiver individual may provide CLS services. Objective written documentation is required as to why there are no other providers available to provide the services. Family members who provide these services must meet the same standards as providers who are unrelated to the individual.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

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

• 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

CL&S is an individualized or group service that enables the member to live successfully in their own home, the home of their family, or natural supports and be an active member of their community. A paraprofessional assists the member to learn new skills and supports the member in activities that are individualized and aligned with the member’s preferences. The goal is to maximize self-sufficiency, increase self-determination and enhance the members’ opportunity to have full membership in their community. Community Living and Support enables the members to learn new skills, practice or improve existing skills, provide supervision and assistance to complete an activity to their level of independence. This service is available for members who meet the IDD or TBI eligibility criteria.

Authorization Guidelines

• 1. Independent Assessment: Required, completed by a TCM or the CIHA for Tribal members that indicates the Member would benefit from CL&S 2 Independent Evaluation: Required, completed by DHB/ Carelon to determine eligibility for 1915(i) 3. Evidence of IDD or TBI: Required, as defined by the CCP.
• 4. Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
• 5. Service Order: Required, completed by QP, Licensed BH clinician, Licensed Psychologist, MD/ DO, NP, PA
• 6. 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

Limits

• 1. School-aged Members

(through age 21 unless proof of graduation is provided): Up to 15 hours (60 units) a week when school is in session and up to 28 hours (112 units) a week when school is not in session

• 2. Members aged 22 and

up (or graduated, with proof of graduation): Up to 28 hours (or 112 units) a week

• 3. Proof of Graduation:

includes graduation with a degree in a standard or occupational course of study, a GED, a Certificate of Completion, or proof of the exhaustion of their educational course of study)

Exclusions

Relatives who live in the same home as a member who is under 18 years old may not provide CLS.

• • 1915(i) CLS and SE may not exceed a combined limit of 40 hrs per week.
• • Transportation to and from the school setting is not covered.
• • Individuals who are enrolled in the Innovations or TBI waiver are not eligible for 1915(i) services.
• • This service may not be provided during the same time as any other direct support Medicaid service.
• • Relatives who live in the same primary residence as beneficiary, who is over 18 years old, can provide Community Living and Supports if the relative meets the required staffing qualifications

Diagnosis Requirements

The service is available for beneficiaries who meet I/DD or TBI eligibility criteria.

Age Group Details

Covered only for beneficiaries age 3 or older

Place of Service

The beneficiary's primary private residence or in the community

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

• 8H-5, Community Living and Supports
• Records Management and Documentation Manual
• https://medicaid.ncdhhs.gov/tailored-care-management
• https://medicaid.ncdhhs.gov/north-carolinas-transition-1915b3-benefits-1915i

CL&S is an individualized or group service that enables the member to live successfully in their own home, the home of their family, or natural supports and be an active member of their community. A paraprofessional assists the member to learn new skills and supports the member in activities that are individualized and aligned with the member’s preferences. The goal is to maximize self-sufficiency, increase self-determination and enhance the members’ opportunity to have full membership in their community. Community Living and Support enables the members to learn new skills, practice or improve existing skills, provide supervision and assistance to complete an activity to their level of independence. This service is available for members who meet the IDD or TBI eligibility criteria.

Authorization Guidelines

• 1. Independent Assessment: Required, completed by a TCM or the CIHA for Tribal members that indicates the Member would benefit from CL&S 2 Independent Evaluation: Required, completed by DHB/ Carelon to determine eligibility for 1915(i) 3. Evidence of IDD or TBI: Required, as defined by the CCP.
• 4. Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
• 5. Service Order: Required, completed by QP, Licensed BH clinician, Licensed Psychologist, MD/ DO, NP, PA
• 6. 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

Limits

• 1. School-aged Members

(through age 21 unless proof of graduation is provided): Up to 15 hours (60 units) a week when school is in session and up to 28 hours (112 units) a week when school is not in session

• 2. Members aged 22 and

up (or graduated, with proof of graduation): Up to 28 hours (or 112 units) a week

• 3. Proof of Graduation:

includes graduation with a degree in a standard or occupational course of study, a GED, a Certificate of Completion, or proof of the exhaustion of their educational course of study)

Exclusions

Relatives who live in the same home as a member who is under 18 years old may not provide CLS.

• • 1915(i) CLS and SE may not exceed a combined limit of 40 hrs per week.
• • Transportation to and from the school setting is not covered.
• • Individuals who are enrolled in the Innovations or TBI waiver are not eligible for 1915(i) services.
• • This service may not be provided during the same time as any other direct support Medicaid service.
• • Relatives who live in the same primary residence as beneficiary, who is over 18 years old, can provide Community Living and Supports if the relative meets the required staffing qualifications

Diagnosis Requirements

The service is available for beneficiaries who meet I/DD or TBI eligibility criteria.

Age Group Details

Covered only for beneficiaries age 3 or older

Place of Service

The beneficiary's primary private residence or in the community

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

• 8H-5, Community Living and Supports
• Records Management and Documentation Manual
• https://medicaid.ncdhhs.gov/tailored-care-management
• https://medicaid.ncdhhs.gov/north-carolinas-transition-1915b3-benefits-1915i

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

Authorization Guidelines

• 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. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

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

Exclusions

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

Additional Service Specifics

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

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

Other Information

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

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

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

Resources

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

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

Authorization Guidelines

• 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. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

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

Exclusions

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

Additional Service Specifics

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

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

Other Information

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

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

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

Resources

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

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

Authorization Guidelines

• 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. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

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

Exclusions

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

Additional Service Specifics

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

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

Other Information

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

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

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

Resources

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