PA Lookup

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

Authorization Guidelines

• 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

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

BHUC offers a safe alternative and diversion from the use of hospital EDs to address the needs of individuals experiencing BH crises. Service is a designated service for individuals experiencing a BH crisis related to a SU disorder, MH disorder, and/or I/DD dx or any combo of the above. A BHUC is designed to provide triage, crisis risk assessment, evaluation and intervention to individuals whose crisis response needs are deemed to be urgent or emergent. Individuals receiving this service will be evaluated, then stabilized and/or referred to the most appropriate level of care.

Unit Value

One unit = 1 event

Limits

• 1. BHUC services are either Tier III or Tier IV. Tier III BHUC operates at least 12 hours per day 7 days a week, 365 days a year w/ at least 6 hours occurring after 4:00 PM each day. A Tier IV BHUC is open 24 hours a day, 7 days a week, 365 days a year.
• 2. Only members meeting criteria for urgent or emergent are eligible for this BHUC service. If an individual is screened and the need is determined to be routine, they will be referred to a community-based service provider for follow up.
• 3. Triage must be initiated within 15 minutes of arrival.
• 4. The Crisis/Risk Assessment must be initiated within 2 hours of arrival at the BHUC.
• 5. If the individual is at a Tier IV BHUC and it is determined that there is a need for admission to a community hospital or an FBC and there is no immediate bed available (within 2 hours) the individual will be placed into Observation status. A voluntary individual is able to stay in Observation for a maximum length of stay of 23 hours and 59 minutes (23:59). Individuals that meet medical necessity for IVC can be held in observation beyond 23 hours and 59 minutes. During this time the individual is continuously being assessed for the need of continued stay or determination that the crisis has been resolved, and the person is able to return independently to the community with follow up services.
• 6. Upon discharge, individuals will be provided with written discharge instructions including information such as medications, community resource referrals, and scheduled appointment date, time and location.
• 7. Disposition coordination and discharge planning includes communicating with Trillium Care Coordination and/or other care management entities.

Length of Stay

Individuals receiving this service will be evaluated, then stabilized and/or referred to the most appropriate level of care.

Exclusions

• 1. Not a step-down service for inpatient/FBC discharge
• 2. Not for routine follow up for med management and cannot administer routine injectable meds
• 3. Not to replace first responder services
• 4. Not to replace MCM nor to be used as a diversion from MCM
• 5. Not to be billed at the same time as other services.

Diagnosis Requirements

All Behavioral Health Diagnosis

Age Group Details

Children, Adolescents & Adults (aged 4 and older)

Place of Service

Office and clinics as clinically indicated

How to Submit

N/A - No authorization is required

Resources

• State-Funded Behavioral Health Urgent Care Service Definition
• Records Management and Documentation Manual

This service is designed to provide triage, crisis risk assessment, evaluation, and intervention within a Behavioral Health Urgent Care (BHUC) setting for members experiencing a behavioral health crisis meeting emergent or urgent triage standards. Individuals receiving this service will be evaluated, then stabilized and/or referred to the most appropriate level of care. A BHUC setting is an alternative, but not a replacement, to a community hospital Emergency Department.

Unit Value

One unit = 1 event with a clinical assessment by a licensed clinician (required for billing).

Diagnosis Requirements

Behavioral Health Urgent Care (BHUC)

Age Group Details

Children, Adolescents & Adults (Individuals 4 years or older)

Level of Care

Members experiencing a behavioral health crisis with any combination of MH, SUD and co-occurring BH/IDD issue

Additional Service Specifics

Individuals receiving this service will be evaluated, then stabilized and/or referred to the most appropriate level of care.

How to Submit

N/A - No authorization is required

Resources

• In-Lieu Of Behavioral Health Crisis Assessment and Intervention Service Definition
• Records Management and Documentation Manual

CLFS is an innovative, community-based, comprehensive service for adults with intellectual and/or developmental disabilities. CLFS for individuals with intellectual disability is an alternative definition in lieu of ICF-IID under the Medicaid 1915(b) benefit. This service enables Trillium to provide comprehensive and individualized active treatment services to adults to maintain and promote their functional status and independence. This is also an alternative to home and community-based services waivers for individuals that potentially meet the ICF/IID level of care. Individuals who choose CLFS instead of placement in an ICF-IID including state institutions or because they do not have access to an Innovations Waiver slot, choose to live in their own homes or homes where they control their lease for the room in the home along with the choice of the agency or other people who support them.

Authorization Guidelines

• 1. TAR: prior approval required
• 2. NC SNAP or SIS: Required
• 3. Psychological Eval: Must meets ICF/IID criteria for IDD services, including evidence of an IDD dx before age of 22 or TBI
• 4. Complete PCP: Required
• 5. Service Order: Required, signed by MD/ DO, LP, NP, or PA
• 6. Meaningful Day Schedule: Required, identifying the member’s chosen meaningful day activities, demonstrating distinction from the residential component of CLFS, and reflecting the minimum of 6 hours per day/5 days per week.
• 7. A progress summary, if currently receiving services.
• 8. Recipients must maintain position on the Registry of Unmet Needs (RUN) list.

Reauthorization Guidelines

• 1. TAR: prior approval required
• 2. NC SNAP or SIS: Required, to ensure Level of Care eligibility.
• 3. Complete PCP: recently reviewed detailing the member’s progress with the service
• 4. Meaningful Day Schedule: Required, identifying the member’s chosen meaningful day activities, demonstrating distinction from the residential component of CLFS, and reflecting the minimum of 6 hours per day/5 days per week.
• 5. A progress summary with each 6-month request
• 6. Step Down/ Transition Plan: If the recipient is functioning effectively with this service for 6 months or longer, a transition plan to assure that the person lives in the least restrictive environment is required.
• 7. Continues to meet ICF/IID criteria for IDD services, including evidence of an IDD dx before age of 22 or TBI
• 8. Recipients must maintain position on the Registry of Unmet Needs (RUN) list.

Unit Value

One unit per day

Limits

• 1. One unit per day
• 2. Requests can be for up to 183 units per auth for Levels 2 through 5 and 125 units for Level 1.
• 3. Up to 366 units per year for Levels 2 through 5 and 250 units for Level 1.

Length of Stay

Up to six months for all requests

Exclusions

• 1. Admissions open to Tailored Plan Medicaid members; No New Admissions for Medicaid Direct members at this time
• 2. Members receiving CLFS are excluded from receiving any State Funded Services, Medicaid state plan personal care or other Medicaid benefits included in this bundled service.
• 3. CLFS does not include room and board payments.
• 4. An individualized Meaningful day schedule, demonstrating distinction from the residential component of CLFS, and reflecting the minimum of 6 hours per day/5 days per week is required.
• 5. An independent care coordinator to provide info about affordable housing, sources of financial support such as SSI, and oversight of their overall service needs is required.
• 6. Member must either stay in homes they own; their family owns or have a lease in the community.

Age Group Details

Adults (ages 22 and older) who are functionally eligible for, but not enrolled in, the NC Innovations 1915(c) waiver program

Level of Care

• • Level 1: A minimum NC SNAP score of 1 or a SIS Level of A through C
• • Level 2: A minimum NC SNAP score of 1 or a SIS Level of A through C
• • Level 3: A minimum NC SNAP score of 3 or a SIS Level of D through G
• • Level 4: A minimum NC SNAP score of 3 or a SIS Level of D through G
• • Level 5: A minimum NC SNAP score of 3 or a SIS Level of D through G

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

• Community Living Facilities and Support (CLFS) ILO Service Definition
• Records Management and Documentation Manual
• Innovations Waiver

CLFS is an innovative, community-based, comprehensive service for adults with intellectual and/or developmental disabilities. CLFS for individuals with intellectual disability is an alternative definition in lieu of ICF-IID under the Medicaid 1915(b) benefit. This service enables Trillium to provide comprehensive and individualized active treatment services to adults to maintain and promote their functional status and independence. This is also an alternative to home and community-based services waivers for individuals that potentially meet the ICF/IID level of care. Individuals who choose CLFS instead of placement in an ICF-IID including state institutions or because they do not have access to an Innovations Waiver slot, choose to live in their own homes or homes where they control their lease for the room in the home along with the choice of the agency or other people who support them.

Authorization Guidelines

• 1. TAR: prior approval required
• 2. NC SNAP or SIS: Required
• 3. Psychological Eval: Must meets ICF/IID criteria for IDD services, including evidence of an IDD dx before age of 22 or TBI
• 4. Complete PCP: Required
• 5. Service Order: Required, signed by MD/ DO, LP, NP, or PA
• 6. Meaningful Day Schedule: Required, identifying the member’s chosen meaningful day activities, demonstrating distinction from the residential component of CLFS, and reflecting the minimum of 6 hours per day/5 days per week.
• 7. A progress summary, if currently receiving services.
• 8. Recipients must maintain position on the Registry of Unmet Needs (RUN) list.

Reauthorization Guidelines

• 1. TAR: prior approval required
• 2. NC SNAP or SIS: Required, to ensure Level of Care eligibility.
• 3. Complete PCP: recently reviewed detailing the member’s progress with the service
• 4. Meaningful Day Schedule: Required, identifying the member’s chosen meaningful day activities, demonstrating distinction from the residential component of CLFS, and reflecting the minimum of 6 hours per day/5 days per week.
• 5. A progress summary with each 6-month request
• 6. Step Down/ Transition Plan: If the recipient is functioning effectively with this service for 6 months or longer, a transition plan to assure that the person lives in the least restrictive environment is required.
• 7. Continues to meet ICF/IID criteria for IDD services, including evidence of an IDD dx before age of 22 or TBI
• 8. Recipients must maintain position on the Registry of Unmet Needs (RUN) list.

Unit Value

One unit per day

Limits

• 1. One unit per day
• 2. Requests can be for up to 183 units per auth for Levels 2 through 5 and 125 units for Level 1.
• 3. Up to 366 units per year for Levels 2 through 5 and 250 units for Level 1.

Length of Stay

Up to six months for all requests

Exclusions

• 1. Admissions open to Tailored Plan Medicaid members; No New Admissions for Medicaid Direct members at this time
• 2. Members receiving CLFS are excluded from receiving any State Funded Services, Medicaid state plan personal care or other Medicaid benefits included in this bundled service.
• 3. CLFS does not include room and board payments.
• 4. An individualized Meaningful day schedule, demonstrating distinction from the residential component of CLFS, and reflecting the minimum of 6 hours per day/5 days per week is required.
• 5. An independent care coordinator to provide info about affordable housing, sources of financial support such as SSI, and oversight of their overall service needs is required.
• 6. Member must either stay in homes they own; their family owns or have a lease in the community.

Age Group Details

Adults (ages 22 and older) who are functionally eligible for, but not enrolled in, the NC Innovations 1915(c) waiver program

Level of Care

• • Level 1: A minimum NC SNAP score of 1 or a SIS Level of A through C
• • Level 2: A minimum NC SNAP score of 1 or a SIS Level of A through C
• • Level 3: A minimum NC SNAP score of 3 or a SIS Level of D through G
• • Level 4: A minimum NC SNAP score of 3 or a SIS Level of D through G
• • Level 5: A minimum NC SNAP score of 3 or a SIS Level of D through G

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

• Community Living Facilities and Support (CLFS) ILO Service Definition
• Records Management and Documentation Manual
• Innovations Waiver

CLFS is an innovative, community-based, comprehensive service for adults with intellectual and/or developmental disabilities. CLFS for individuals with intellectual disability is an alternative definition in lieu of ICF-IID under the Medicaid 1915(b) benefit. This service enables Trillium to provide comprehensive and individualized active treatment services to adults to maintain and promote their functional status and independence. This is also an alternative to home and community-based services waivers for individuals that potentially meet the ICF/IID level of care. Individuals who choose CLFS instead of placement in an ICF-IID including state institutions or because they do not have access to an Innovations Waiver slot, choose to live in their own homes or homes where they control their lease for the room in the home along with the choice of the agency or other people who support them.

Authorization Guidelines

• 1. TAR: prior approval required
• 2. NC SNAP or SIS: Required
• 3. Psychological Eval: Must meets ICF/IID criteria for IDD services, including evidence of an IDD dx before age of 22 or TBI
• 4. Complete PCP: Required
• 5. Service Order: Required, signed by MD/ DO, LP, NP, or PA
• 6. Meaningful Day Schedule: Required, identifying the member’s chosen meaningful day activities, demonstrating distinction from the residential component of CLFS, and reflecting the minimum of 6 hours per day/5 days per week.
• 7. A progress summary, if currently receiving services.
• 8. Recipients must maintain position on the Registry of Unmet Needs (RUN) list.

Reauthorization Guidelines

• 1. TAR: prior approval required
• 2. NC SNAP or SIS: Required, to ensure Level of Care eligibility.
• 3. Complete PCP: recently reviewed detailing the member’s progress with the service
• 4. Meaningful Day Schedule: Required, identifying the member’s chosen meaningful day activities, demonstrating distinction from the residential component of CLFS, and reflecting the minimum of 6 hours per day/5 days per week.
• 5. A progress summary with each 6-month request
• 6. Step Down/ Transition Plan: If the recipient is functioning effectively with this service for 6 months or longer, a transition plan to assure that the person lives in the least restrictive environment is required.
• 7. Continues to meet ICF/IID criteria for IDD services, including evidence of an IDD dx before age of 22 or TBI
• 8. Recipients must maintain position on the Registry of Unmet Needs (RUN) list.

Unit Value

One unit per day

Limits

• 1. One unit per day
• 2. Requests can be for up to 183 units per auth for Levels 2 through 5 and 125 units for Level 1.
• 3. Up to 366 units per year for Levels 2 through 5 and 250 units for Level 1.

Length of Stay

Up to six months for all requests

Exclusions

• 1. Admissions open to Tailored Plan Medicaid members; No New Admissions for Medicaid Direct members at this time
• 2. Members receiving CLFS are excluded from receiving any State Funded Services, Medicaid state plan personal care or other Medicaid benefits included in this bundled service.
• 3. CLFS does not include room and board payments.
• 4. An individualized Meaningful day schedule, demonstrating distinction from the residential component of CLFS, and reflecting the minimum of 6 hours per day/5 days per week is required.
• 5. An independent care coordinator to provide info about affordable housing, sources of financial support such as SSI, and oversight of their overall service needs is required.
• 6. Member must either stay in homes they own; their family owns or have a lease in the community.

Age Group Details

Adults (ages 22 and older) who are functionally eligible for, but not enrolled in, the NC Innovations 1915(c) waiver program

Level of Care

• • Level 1: A minimum NC SNAP score of 1 or a SIS Level of A through C
• • Level 2: A minimum NC SNAP score of 1 or a SIS Level of A through C
• • Level 3: A minimum NC SNAP score of 3 or a SIS Level of D through G
• • Level 4: A minimum NC SNAP score of 3 or a SIS Level of D through G
• • Level 5: A minimum NC SNAP score of 3 or a SIS Level of D through G

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

• Community Living Facilities and Support (CLFS) ILO Service Definition
• Records Management and Documentation Manual
• Innovations Waiver

CLFS is an innovative, community-based, comprehensive service for adults with intellectual and/or developmental disabilities. CLFS for individuals with intellectual disability is an alternative definition in lieu of ICF-IID under the Medicaid 1915(b) benefit. This service enables Trillium to provide comprehensive and individualized active treatment services to adults to maintain and promote their functional status and independence. This is also an alternative to home and community-based services waivers for individuals that potentially meet the ICF/IID level of care. Individuals who choose CLFS instead of placement in an ICF-IID including state institutions or because they do not have access to an Innovations Waiver slot, choose to live in their own homes or homes where they control their lease for the room in the home along with the choice of the agency or other people who support them.

Authorization Guidelines

• 1. TAR: prior approval required
• 2. NC SNAP or SIS: Required
• 3. Psychological Eval: Must meets ICF/IID criteria for IDD services, including evidence of an IDD dx before age of 22 or TBI
• 4. Complete PCP: Required
• 5. Service Order: Required, signed by MD/ DO, LP, NP, or PA
• 6. Meaningful Day Schedule: Required, identifying the member’s chosen meaningful day activities, demonstrating distinction from the residential component of CLFS, and reflecting the minimum of 6 hours per day/5 days per week.
• 7. A progress summary, if currently receiving services.
• 8. Recipients must maintain position on the Registry of Unmet Needs (RUN) list.

Reauthorization Guidelines

• 1. TAR: prior approval required
• 2. NC SNAP or SIS: Required, to ensure Level of Care eligibility.
• 3. Complete PCP: recently reviewed detailing the member’s progress with the service
• 4. Meaningful Day Schedule: Required, identifying the member’s chosen meaningful day activities, demonstrating distinction from the residential component of CLFS, and reflecting the minimum of 6 hours per day/5 days per week.
• 5. A progress summary with each 6-month request
• 6. Step Down/ Transition Plan: If the recipient is functioning effectively with this service for 6 months or longer, a transition plan to assure that the person lives in the least restrictive environment is required.
• 7. Continues to meet ICF/IID criteria for IDD services, including evidence of an IDD dx before age of 22 or TBI
• 8. Recipients must maintain position on the Registry of Unmet Needs (RUN) list.

Unit Value

One unit per day

Limits

• 1. One unit per day
• 2. Requests can be for up to 183 units per auth for Levels 2 through 5 and 125 units for Level 1.
• 3. Up to 366 units per year for Levels 2 through 5 and 250 units for Level 1.

Length of Stay

Up to six months for all requests

Exclusions

• 1. Admissions open to Tailored Plan Medicaid members; No New Admissions for Medicaid Direct members at this time
• 2. Members receiving CLFS are excluded from receiving any State Funded Services, Medicaid state plan personal care or other Medicaid benefits included in this bundled service.
• 3. CLFS does not include room and board payments.
• 4. An individualized Meaningful day schedule, demonstrating distinction from the residential component of CLFS, and reflecting the minimum of 6 hours per day/5 days per week is required.
• 5. An independent care coordinator to provide info about affordable housing, sources of financial support such as SSI, and oversight of their overall service needs is required.
• 6. Member must either stay in homes they own; their family owns or have a lease in the community.

Age Group Details

Adults (ages 22 and older) who are functionally eligible for, but not enrolled in, the NC Innovations 1915(c) waiver program

Level of Care

• • Level 1: A minimum NC SNAP score of 1 or a SIS Level of A through C
• • Level 2: A minimum NC SNAP score of 1 or a SIS Level of A through C
• • Level 3: A minimum NC SNAP score of 3 or a SIS Level of D through G
• • Level 4: A minimum NC SNAP score of 3 or a SIS Level of D through G
• • Level 5: A minimum NC SNAP score of 3 or a SIS Level of D through G

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

• Community Living Facilities and Support (CLFS) ILO Service Definition
• Records Management and Documentation Manual
• Innovations Waiver

CLFS is an innovative, community-based, comprehensive service for adults with intellectual and/or developmental disabilities. CLFS for individuals with intellectual disability is an alternative definition in lieu of ICF-IID under the Medicaid 1915(b) benefit. This service enables Trillium to provide comprehensive and individualized active treatment services to adults to maintain and promote their functional status and independence. This is also an alternative to home and community-based services waivers for individuals that potentially meet the ICF/IID level of care. Individuals who choose CLFS instead of placement in an ICF-IID including state institutions or because they do not have access to an Innovations Waiver slot, choose to live in their own homes or homes where they control their lease for the room in the home along with the choice of the agency or other people who support them.

Authorization Guidelines

• 1. TAR: prior approval required
• 2. NC SNAP or SIS: Required
• 3. Psychological Eval: Must meets ICF/IID criteria for IDD services, including evidence of an IDD dx before age of 22 or TBI
• 4. Complete PCP: Required
• 5. Service Order: Required, signed by MD/ DO, LP, NP, or PA
• 6. Meaningful Day Schedule: Required, identifying the member’s chosen meaningful day activities, demonstrating distinction from the residential component of CLFS, and reflecting the minimum of 6 hours per day/5 days per week.
• 7. A progress summary, if currently receiving services.
• 8. Recipients must maintain position on the Registry of Unmet Needs (RUN) list.

Reauthorization Guidelines

• 1. TAR: prior approval required
• 2. NC SNAP or SIS: Required, to ensure Level of Care eligibility.
• 3. Complete PCP: recently reviewed detailing the member’s progress with the service
• 4. Meaningful Day Schedule: Required, identifying the member’s chosen meaningful day activities, demonstrating distinction from the residential component of CLFS, and reflecting the minimum of 6 hours per day/5 days per week.
• 5. A progress summary with each 6-month request
• 6. Step Down/ Transition Plan: If the recipient is functioning effectively with this service for 6 months or longer, a transition plan to assure that the person lives in the least restrictive environment is required.
• 7. Continues to meet ICF/IID criteria for IDD services, including evidence of an IDD dx before age of 22 or TBI
• 8. Recipients must maintain position on the Registry of Unmet Needs (RUN) list.

Unit Value

One unit per day

Limits

• 1. One unit per day
• 2. Requests can be for up to 183 units per auth for Levels 2 through 5 and 125 units for Level 1.
• 3. Up to 366 units per year for Levels 2 through 5 and 250 units for Level 1.

Length of Stay

Up to six months for all requests

Exclusions

• 1. Admissions open to Tailored Plan Medicaid members; No New Admissions for Medicaid Direct members at this time
• 2. Members receiving CLFS are excluded from receiving any State Funded Services, Medicaid state plan personal care or other Medicaid benefits included in this bundled service.
• 3. CLFS does not include room and board payments.
• 4. An individualized Meaningful day schedule, demonstrating distinction from the residential component of CLFS, and reflecting the minimum of 6 hours per day/5 days per week is required.
• 5. An independent care coordinator to provide info about affordable housing, sources of financial support such as SSI, and oversight of their overall service needs is required.
• 6. Member must either stay in homes they own; their family owns or have a lease in the community.

Age Group Details

Adults (ages 22 and older) who are functionally eligible for, but not enrolled in, the NC Innovations 1915(c) waiver program

Level of Care

• • Level 1: A minimum NC SNAP score of 1 or a SIS Level of A through C
• • Level 2: A minimum NC SNAP score of 1 or a SIS Level of A through C
• • Level 3: A minimum NC SNAP score of 3 or a SIS Level of D through G
• • Level 4: A minimum NC SNAP score of 3 or a SIS Level of D through G
• • Level 5: A minimum NC SNAP score of 3 or a SIS Level of D through G

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

• Community Living Facilities and Support (CLFS) ILO Service Definition
• Records Management and Documentation Manual
• Innovations Waiver

This service is designed to provide triage, crisis risk assessment, evaluation, and intervention within a Behavioral Health Urgent Care (BHUC) setting for members experiencing a behavioral health crisis meeting emergent or urgent triage standards. Individuals receiving this service will be evaluated, then stabilized and/or referred to the most appropriate level of care. A BHUC setting is an alternative, but not a replacement, to a community hospital Emergency Department.

Unit Value

One unit = 1 event with a clinical assessment by a licensed clinician (required for billing).

Diagnosis Requirements

Behavioral Health Urgent Care (BHUC)

Age Group Details

Children, Adolescents & Adults (Individuals 4 years or older)

Level of Care

Members experiencing a behavioral health crisis with any combination of MH, SUD and co-occurring BH/IDD issue

Additional Service Specifics

Individuals receiving this service will be evaluated, then stabilized and/or referred to the most appropriate level of care.

How to Submit

N/A - No authorization is required

Resources

• In-Lieu Of Behavioral Health Crisis Assessment and Intervention Service Definition
• Records Management and Documentation Manual

BHUC offers a safe alternative and diversion from the use of hospital EDs to address the needs of individuals experiencing BH crises. Service is a designated service for individuals experiencing a BH crisis related to a SU disorder, MH disorder, and/or I/DD dx or any combo of the above. A BHUC is designed to provide triage, crisis risk assessment, evaluation and intervention to individuals whose crisis response needs are deemed to be urgent or emergent. Individuals receiving this service will be evaluated, then stabilized and/or referred to the most appropriate level of care.

Unit Value

One unit = 1 event

Limits

• 1. BHUC services are either Tier III or Tier IV. Tier III BHUC operates at least 12 hours per day 7 days a week, 365 days a year w/ at least 6 hours occurring after 4:00 PM each day. A Tier IV BHUC is open 24 hours a day, 7 days a week, 365 days a year.
• 2. Only members meeting criteria for urgent or emergent are eligible for this BHUC service. If an individual is screened and the need is determined to be routine, they will be referred to a community-based service provider for follow up.
• 3. Triage must be initiated within 15 minutes of arrival.
• 4. The Crisis/Risk Assessment must be initiated within 2 hours of arrival at the BHUC.
• 5. If the individual is at a Tier IV BHUC and it is determined that there is a need for admission to a community hospital or an FBC and there is no immediate bed available (within 2 hours) the individual will be placed into Observation status. A voluntary individual is able to stay in Observation for a maximum length of stay of 23 hours and 59 minutes (23:59). Individuals that meet medical necessity for IVC can be held in observation beyond 23 hours and 59 minutes. During this time the individual is continuously being assessed for the need of continued stay or determination that the crisis has been resolved, and the person is able to return independently to the community with follow up services.
• 6. Upon discharge, individuals will be provided with written discharge instructions including information such as medications, community resource referrals, and scheduled appointment date, time and location.
• 7. Disposition coordination and discharge planning includes communicating with Trillium Care Coordination and/or other care management entities.

Length of Stay

Individuals receiving this service will be evaluated, then stabilized and/or referred to the most appropriate level of care.

Exclusions

• 1. Not a step-down service for inpatient/FBC discharge
• 2. Not for routine follow up for med management and cannot administer routine injectable meds
• 3. Not to replace first responder services
• 4. Not to replace MCM nor to be used as a diversion from MCM
• 5. Not to be billed at the same time as other services.

Diagnosis Requirements

All Behavioral Health Diagnosis

Age Group Details

Children, Adolescents & Adults (aged 4 and older)

Place of Service

Office and clinics as clinically indicated

How to Submit

N/A - No authorization is required

Resources

• State-Funded Behavioral Health Urgent Care Service Definition
• Records Management and Documentation Manual

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

Authorization Guidelines

• 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

Day Supports is a group, facility-based service that helps the member with acquisition, retention, or improvement in socialization and daily living skills and is one option for a meaningful day. Day Supports emphasizes inclusion and independence with a focus on enabling the individual to attain or maintain his/her maximum self-sufficiency, increase self-determination and enhance the person’s opportunity to have a meaningful day.

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.

Unit Value

Day Supports is billed in 1-hour unit increments.

Limits

• • The amount of Day Supports is subject to the Limits on Sets of services.
• • For individuals who are eligible for educational services under the Individuals with Disability Educational Act, Day Supports is the payer of last resort for Developmental Day.
• • Day Supports are furnished in a non-residential setting, separate from the home or residential setting where the member resides.
• • Transportation to/from the member’s home, the day supports facility and travel within the community is included in the payment rate. Transportation to and from the licensed day program is the responsibility of the Day Supports provider.
• • This service may not duplicate services, nor can they be furnished or billed at the same time of day as services, provided under Community Networking, In-Home Intensive Supports, Community Living and Supports, Supported Living, Residential Supports, Supported Employment and/or one of the State Plan Medicaid Services that works directly with the member.
• • Waiver funding is not available for vocational services delivered in facility based, sheltered work settings, or Adult Developmental Vocational Program.
• • Individuals are provided opportunities to seek employment and work in competitive integrated settings, engage in community life and control personal resources.
• • Each individual’s rights of privacy, dignity, respect and freedom from coercion and restraint are protected.
• • Settings optimize, but do not regiment, individual initiative, autonomy and independence in making life choices.
• • Settings facilitate individual choice regarding services and support, and who provides these.
• • 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.

Length of Stay

Billed in 1-hour unit increments; at least 15 minutes of service must be provided before one 1-hour unit may be billed. Subject to limits on sets of services: with residential supports, adults max 40 hours/week and children max 20 hours/week during school year or 40 when school is not in session; in private homes, adults max 84 hours/week and children max 54 hours/week during school year or 84 when school is not in session, for the applicable combined service sets.

Age Group Details

Day Supports is a group, facility-based service; Developmental Day is for school-aged or younger children in a licensed childcare center.

• - Individuals new to the service who are age 16 or older must receive education during the planning meeting on available meaningful-day options.

Place of Service

Day Supports must be furnished in a non-residential setting separate from the home or residential setting where the beneficiary resides, though it may occur outside the facility if consistent with ISP goals.

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

Day Supports is a group, facility-based service that helps the member with acquisition, retention, or improvement in socialization and daily living skills and is one option for a meaningful day. Day Supports emphasizes inclusion and independence with a focus on enabling the individual to attain or maintain his/her maximum self-sufficiency, increase self-determination and enhance the person’s opportunity to have a meaningful day.

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.

Unit Value

Day Supports is billed in 1-hour unit increments.

Limits

• • The amount of Day Supports is subject to the Limits on Sets of services.
• • For individuals who are eligible for educational services under the Individuals with Disability Educational Act, Day Supports is the payer of last resort for Developmental Day.
• • Day Supports are furnished in a non-residential setting, separate from the home or residential setting where the member resides.
• • Transportation to/from the member’s home, the day supports facility and travel within the community is included in the payment rate. Transportation to and from the licensed day program is the responsibility of the Day Supports provider.
• • This service may not duplicate services, nor can they be furnished or billed at the same time of day as services, provided under Community Networking, In-Home Intensive Supports, Community Living and Supports, Supported Living, Residential Supports, Supported Employment and/or one of the State Plan Medicaid Services that works directly with the member.
• • Waiver funding is not available for vocational services delivered in facility based, sheltered work settings, or Adult Developmental Vocational Program.
• • Individuals are provided opportunities to seek employment and work in competitive integrated settings, engage in community life and control personal resources.
• • Each individual’s rights of privacy, dignity, respect and freedom from coercion and restraint are protected.
• • Settings optimize, but do not regiment, individual initiative, autonomy and independence in making life choices.
• • Settings facilitate individual choice regarding services and support, and who provides these.
• • 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.

Length of Stay

Billed in 1-hour unit increments; at least 15 minutes of service must be provided before one 1-hour unit may be billed. Subject to limits on sets of services: with residential supports, adults max 40 hours/week and children max 20 hours/week during school year or 40 when school is not in session; in private homes, adults max 84 hours/week and children max 54 hours/week during school year or 84 when school is not in session, for the applicable combined service sets.

Age Group Details

Day Supports is a group, facility-based service; Developmental Day is for school-aged or younger children in a licensed childcare center.

• - Individuals new to the service who are age 16 or older must receive education during the planning meeting on available meaningful-day options.

Place of Service

Day Supports must be furnished in a non-residential setting separate from the home or residential setting where the beneficiary resides, though it may occur outside the facility if consistent with ISP goals.

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

Day Supports is a group, facility-based service that helps the member with acquisition, retention, or improvement in socialization and daily living skills and is one option for a meaningful day. Day Supports emphasizes inclusion and independence with a focus on enabling the individual to attain or maintain his/her maximum self-sufficiency, increase self-determination and enhance the person’s opportunity to have a meaningful day.

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.

Unit Value

Day Supports is billed in 1-hour unit increments.

Limits

• • The amount of Day Supports is subject to the Limits on Sets of services.
• • For individuals who are eligible for educational services under the Individuals with Disability Educational Act, Day Supports is the payer of last resort for Developmental Day.
• • Day Supports are furnished in a non-residential setting, separate from the home or residential setting where the member resides.
• • Transportation to/from the member’s home, the day supports facility and travel within the community is included in the payment rate. Transportation to and from the licensed day program is the responsibility of the Day Supports provider.
• • This service may not duplicate services, nor can they be furnished or billed at the same time of day as services, provided under Community Networking, In-Home Intensive Supports, Community Living and Supports, Supported Living, Residential Supports, Supported Employment and/or one of the State Plan Medicaid Services that works directly with the member.
• • Waiver funding is not available for vocational services delivered in facility based, sheltered work settings, or Adult Developmental Vocational Program.
• • Individuals are provided opportunities to seek employment and work in competitive integrated settings, engage in community life and control personal resources.
• • Each individual’s rights of privacy, dignity, respect and freedom from coercion and restraint are protected.
• • Settings optimize, but do not regiment, individual initiative, autonomy and independence in making life choices.
• • Settings facilitate individual choice regarding services and support, and who provides these.
• • 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.

Length of Stay

Billed in 1-hour unit increments; at least 15 minutes of service must be provided before one 1-hour unit may be billed. Subject to limits on sets of services: with residential supports, adults max 40 hours/week and children max 20 hours/week during school year or 40 when school is not in session; in private homes, adults max 84 hours/week and children max 54 hours/week during school year or 84 when school is not in session, for the applicable combined service sets.

Age Group Details

Day Supports is a group, facility-based service; Developmental Day is for school-aged or younger children in a licensed childcare center.

• - Individuals new to the service who are age 16 or older must receive education during the planning meeting on available meaningful-day options.

Place of Service

Day Supports must be furnished in a non-residential setting separate from the home or residential setting where the beneficiary resides, though it may occur outside the facility if consistent with ISP goals.

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

Day Supports is a group, facility-based service that helps the member with acquisition, retention, or improvement in socialization and daily living skills and is one option for a meaningful day. Day Supports emphasizes inclusion and independence with a focus on enabling the individual to attain or maintain his/her maximum self-sufficiency, increase self-determination and enhance the person’s opportunity to have a meaningful day.

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.

Unit Value

Day Supports is billed in 1-hour unit increments.

Limits

• • The amount of Day Supports is subject to the Limits on Sets of services.
• • For individuals who are eligible for educational services under the Individuals with Disability Educational Act, Day Supports is the payer of last resort for Developmental Day.
• • Day Supports are furnished in a non-residential setting, separate from the home or residential setting where the member resides.
• • Transportation to/from the member’s home, the day supports facility and travel within the community is included in the payment rate. Transportation to and from the licensed day program is the responsibility of the Day Supports provider.
• • This service may not duplicate services, nor can they be furnished or billed at the same time of day as services, provided under Community Networking, In-Home Intensive Supports, Community Living and Supports, Supported Living, Residential Supports, Supported Employment and/or one of the State Plan Medicaid Services that works directly with the member.
• • Waiver funding is not available for vocational services delivered in facility based, sheltered work settings, or Adult Developmental Vocational Program.
• • Individuals are provided opportunities to seek employment and work in competitive integrated settings, engage in community life and control personal resources.
• • Each individual’s rights of privacy, dignity, respect and freedom from coercion and restraint are protected.
• • Settings optimize, but do not regiment, individual initiative, autonomy and independence in making life choices.
• • Settings facilitate individual choice regarding services and support, and who provides these.
• • 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.

Length of Stay

Billed in 1-hour unit increments; at least 15 minutes of service must be provided before one 1-hour unit may be billed. Subject to limits on sets of services: with residential supports, adults max 40 hours/week and children max 20 hours/week during school year or 40 when school is not in session; in private homes, adults max 84 hours/week and children max 54 hours/week during school year or 84 when school is not in session, for the applicable combined service sets.

Age Group Details

Day Supports is a group, facility-based service; Developmental Day is for school-aged or younger children in a licensed childcare center.

• - Individuals new to the service who are age 16 or older must receive education during the planning meeting on available meaningful-day options.

Place of Service

Day Supports must be furnished in a non-residential setting separate from the home or residential setting where the beneficiary resides, though it may occur outside the facility if consistent with ISP goals.

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

Specialized Consultation Services provide expertise, training and technical assistance in a specialty area (psychology, behavior intervention, speech therapy, therapeutic recreation, augmentative communication, assistive technology equipment, occupational therapy, physical therapy, nutrition, nursing, and other licensed professionals who possess experience with individuals with Intellectual / Developmental Disabilities) to assist family members, support staff and other natural supports in assisting the member with developmental disabilities. Under this model, family members and other paid/unpaid caregivers are trained by a certified, licensed, and/or registered professional, or qualified assistive technology professional to carry out therapeutic interventions, consistent with the Individual Support Plan.

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

This service may be used for evaluations for adults when the State Plan limits have been exceeded.

Exclusions

• • Specialized Consultative Services excludes services provided through Natural Supports Education and Crisis Services. This service may not duplicate services provided to family members through natural supports education
• • 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.

Diagnosis Requirements

Coverage is limited to Medicaid beneficiaries with intellectual or developmental disabilities, or both, who meet NC Innovations waiver criteria. The beneficiary must meet ICF-IID level of care requirements, reside in an ICF-IID facility or be at high risk of placement in one, be able to maintain health, safety, and well-being in the community with NC Innovations services, require NC Innovations services identified through a person-centered planning process, and require at least one waiver service monthly as indicated in the ISP and Individual Budget.

Specific Diagnosis Codes Required

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

Specialized Consultation Services provide expertise, training and technical assistance in a specialty area (psychology, behavior intervention, speech therapy, therapeutic recreation, augmentative communication, assistive technology equipment, occupational therapy, physical therapy, nutrition, nursing, and other licensed professionals who possess experience with individuals with Intellectual / Developmental Disabilities) to assist family members, support staff and other natural supports in assisting the member with developmental disabilities. Under this model, family members and other paid/unpaid caregivers are trained by a certified, licensed, and/or registered professional, or qualified assistive technology professional to carry out therapeutic interventions, consistent with the Individual Support Plan.

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

This service may be used for evaluations for adults when the State Plan limits have been exceeded.

Exclusions

• • Specialized Consultative Services excludes services provided through Natural Supports Education and Crisis Services. This service may not duplicate services provided to family members through natural supports education
• • 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.

Diagnosis Requirements

Coverage is limited to Medicaid beneficiaries with intellectual or developmental disabilities, or both, who meet NC Innovations waiver criteria. The beneficiary must meet ICF-IID level of care requirements, reside in an ICF-IID facility or be at high risk of placement in one, be able to maintain health, safety, and well-being in the community with NC Innovations services, require NC Innovations services identified through a person-centered planning process, and require at least one waiver service monthly as indicated in the ISP and Individual Budget.

Specific Diagnosis Codes Required

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