PA Lookup
If you have questions about prior authorizations, please call:
Member and Recipient Service Line: 1-877-685-2415
Provider Support Service Line: 1-855-250-1539
Community Transition
The purpose of Community Transition is to provide initial set-up expenses for adults to facilitate their transition from a Developmental Center (institution), community ICF-IID Group Home, nursing facility or another licensed living arrangement (group home, foster home, Psychiatric Residential Treatment Facility, alternative family living arrangement), a family home or one person AFL(Alternative Family Living) to a living arrangement where the individual is directly responsible for his or her own living expenses. This service may be provided only in a private home or apartment with a lease in the member’s, legal guardian’s, representative’s name or a home owned by the member.
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. Community Transition Checklist
- 7. Submission of applicable records that support the member has met the medical necessity criteria.
Limits
These services are available only during the three-month period that commences one calendar month in advance of the member’s move to an integrated living arrangement.
Additional Service Specifics
- • The cost of Community Transition has a life of the waiver limit of $5,000.00 per member. Community Transition includes the actual cost of services and does not cover provider overhead charges.
- • Community Transition does not cover monthly rental or mortgage expense; regular utility charges; and/or household appliances or diversional/recreational items such as televisions, streaming devices, VCR players and components and DVD players and components. Service and maintenance contracts and extended warranties are not covered.
- • Community Transition services can be accessed only one time from either the 1915b or 1915c waiver over the life of the waiver.
- • In situations when a member lives with a roommate, Community Transition cannot duplicate items that are currently available.
- • Community Transition expenses are furnished only to the extent that the member is unable to meet such expense or when the support cannot be obtained from other sources.
- • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
- • See the CCP for all applicable exclusions, limitations & exceptions.
How to Submit
Please submit your request to Carolina Complete Health through Availity
Resources
Vehicle Modifications
Vehicle Modifications are devices, service or controls that enable a member to increase their independence or physical safety by enabling their safe transport in and around the community.
Authorization Guidelines
- 1. TAR: Prior approval is required
- 2. SIS
- 3. Individual Budget: to include itemized shipping costs
- 4. Care Management Comprehensive Assessment
- 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) Long-range outcomes related to training needs associated with the utilization of the adaptations, e) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
- 6. Proof of actively making payments to purchase/own the vehicle
- 7. Auto Insurance Policy: w/ coverage sufficient to replace the adaptation in the event of an accident
- 8. PT/ OT Recommendation (must be less than 1 calendar year from date of request submission): a) Completed by a professional specializing in vehicle modification or a rehabilitation engineer or vehicle adaptation; b) includes the rationale for the selected mods; c) pre- driving assessment of the member driving the vehicle; d) condition of the vehicle to be modified; e) the insurance on the vehicle to be modified.
- 9. Vehicle Evaluation: by an adapted vehicle supplier to include “life expectancy” of the vehicle in relationship to the modifications
- 10. Estimated life of the equipment as well as the length of time the member is expected to benefit from the equipment
- 11. Certificate of MN /Prescription: completed by the MD/ DO, PA, or NP.
- 12. Letter of MN or Written Assessment/ Recommendation: by an MD/ DO, PA, NP, or appropriate professional, outlining MN for every item provided. If the MD/ DO, PA, or NP complete the Letter, as separate prescription is not required.
- 13. Two quotes for the requested item(s)
- 14. Training Plan: how the person and family will be trained on the use of the equipment
- 15. Submission of applicable records that support the member has met the medical necessity criteria.
Limits
When an assessment is completed by another professional recommending the MN of specific items, then an MD/ DO, PA, or NP must write a letter of MN OR sign off on the letter of MN prepared by professional AND write a prescription.
Exclusions
- • The service is limited to expenditures of $20,000 over the life of the waiver.
- • If purchasing a vehicle with a lift on it, the price of the new lift may be covered. The cost of a used lift on vehicle must be assessed and the current value (not the replacement value) may be approved under this service definition to cover this part of the purchase price. In such instances, the member or family may not take possession of the lift prior to approval by Trillium.
- • Vehicle Modifications are only available to a member who receives Residential Supports, or who lives in licensed residential facility, when the vehicle belongs to the member and can transition to other settings with the individual.
- • The cost of renting/leasing a vehicle with adaptations; service and maintenance contracts and extended warranties; and adaptations purchased for exclusive use at the school/home school are not covered.
- • Items that are not of direct or remedial benefit to the member are excluded from this service.
- • Vehicle modifications are not covered for leased vehicles.
- • Modifications do not include the cost of the vehicle.
- • All items must meet applicable standards of manufacture, design, and installation. Installation must be performed by the adaptive equipment manufacturer’s authorized dealer according to the manufacturer’s installation instructions, National Mobility Equipment Dealer’s Association, Society of Automotive Engineers, National Highway Traffic Safety Administration guidelines.
- • Repair of equipment is covered for items purchased through the waiver or purchased prior to waiver participation, as long as the item is identified within this service definition and the cost of the repair does not exceed the cost of purchasing a replacement piece of equipment.
- • If paying for labor and costs of moving devices or equipment from one vehicle to another vehicle, then training on the use of the device is not required.
- • The modification must meet applicable standards and safety codes. The Care Coordinator verifies that the modification has been completed and received by the member, and note any health or safety concerns.
- • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
- • See the CCP for all applicable exclusions, limitations & exceptions.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Community Navigator
The purpose of Community Navigator Services is to promote self-determination, support the member in making life choices, provide advocacy and identify opportunities to become a part of their community. Community Navigator provides support to the member and planning teams in developing social networks and connections within local communities. Community Navigator Services emphasizes, promotes, and coordinates the use of generic resources to address the members needs in addition to paid services. Community Navigator provides an annual informational session on Self-Determination and Self Direction. The member and legally responsible person may choose to opt out of this annual informational session.
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
One unit = 1 month
Exclusions
- • Community Navigation services are used to support members self-directing waiver services; therefore, it is only available for individuals participating in self-direction. Community Navigation service is only available if the member is self-directing one or more of their services through the Agency with Choice or Employer of Record Model.
- • Community Navigator is mandatory for all Employers of Record until competence in directing service is demonstrated.
- • This service does not duplicate Care Coordination. Care coordination under managed care includes the development of the ISP, completing or gathering evaluations inclusive of the re-evaluation of the level of care, monitoring the implementation of the ISP, choosing service providers, coordination of benefits and monitoring the health and safety of the member consistent with 42 CFR 438.208(c).
- • The creation and the facilitation of the Individual Support Plan is the responsibility of the Care Coordinator. The Community Navigator can assist the member with preparing for the Individual Support Plan.
- • If a provider does not provide Agency with Choice Services, the only other service that they may provide to the same member, in addition to Community Navigator Services, is Community Transition.
- • An agency may provide both Community Navigator Services and Agency with Choice Services to the same individual, in addition to Community Transition, Financial Support Services, Individual Goods and Services, and Primary Crisis Response Services.
- • The Community Navigator Self-Directed activities can only to be used to provide support to the individual under Individual and Family Directed Supports: Employer of Record and Agency with Choice Models, as approved in this Waiver.
- • 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 Carolina Complete Health through Availity
Resources
Community Navigator
The purpose of Community Navigator Services is to promote self-determination, support the member in making life choices, provide advocacy and identify opportunities to become a part of their community. Community Navigator provides support to the member and planning teams in developing social networks and connections within local communities. Community Navigator Services emphasizes, promotes, and coordinates the use of generic resources to address the members needs in addition to paid services. Community Navigator provides an annual informational session on Self-Determination and Self Direction. The member and legally responsible person may choose to opt out of this annual informational session.
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
One unit = 1 month
Exclusions
- • Community Navigation services are used to support members self-directing waiver services; therefore, it is only available for individuals participating in self-direction. Community Navigation service is only available if the member is self-directing one or more of their services through the Agency with Choice or Employer of Record Model.
- • Community Navigator is mandatory for all Employers of Record until competence in directing service is demonstrated.
- • This service does not duplicate Care Coordination. Care coordination under managed care includes the development of the ISP, completing or gathering evaluations inclusive of the re-evaluation of the level of care, monitoring the implementation of the ISP, choosing service providers, coordination of benefits and monitoring the health and safety of the member consistent with 42 CFR 438.208(c).
- • The creation and the facilitation of the Individual Support Plan is the responsibility of the Care Coordinator. The Community Navigator can assist the member with preparing for the Individual Support Plan.
- • If a provider does not provide Agency with Choice Services, the only other service that they may provide to the same member, in addition to Community Navigator Services, is Community Transition.
- • An agency may provide both Community Navigator Services and Agency with Choice Services to the same individual, in addition to Community Transition, Financial Support Services, Individual Goods and Services, and Primary Crisis Response Services.
- • The Community Navigator Self-Directed activities can only to be used to provide support to the individual under Individual and Family Directed Supports: Employer of Record and Agency with Choice Models, as approved in this Waiver.
- • 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)
Resources
Community Navigator Training
The purpose of Community Navigator Services is to promote self-determination, support the member in making life choices, provide advocacy and identify opportunities to become a part of their community. Community Navigator provides support to the member and planning teams in developing social networks and connections within local communities. Community Navigator Services emphasizes, promotes, and coordinates the use of generic resources to address the members needs in addition to paid services. Community Navigator provides an annual informational session on Self-Determination and Self Direction. The member and legally responsible person may choose to opt out of this annual informational session.
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
One unit = 15 minutes
Exclusions
- • Community Navigation services are used to support members self-directing waiver services; therefore, it is only available for individuals participating in self-direction. Community Navigation service is only available if the member is self-directing one or more of their services through the Agency with Choice or Employer of Record Model.
- • Community Navigator is mandatory for all Employers of Record until competence in directing service is demonstrated.
- • This service does not duplicate Care Coordination. Care coordination under managed care includes the development of the ISP, completing or gathering evaluations inclusive of the re-evaluation of the level of care, monitoring the implementation of the ISP, choosing service providers, coordination of benefits and monitoring the health and safety of the member consistent with 42 CFR 438.208(c).
- • The creation and the facilitation of the Individual Support Plan is the responsibility of the Care Coordinator. The Community Navigator can assist the member with preparing for the Individual Support Plan.
- • If a provider does not provide Agency with Choice Services, the only other service that they may provide to the same member, in addition to Community Navigator Services, is Community Transition.
- • An agency may provide both Community Navigator Services and Agency with Choice Services to the same individual, in addition to Community Transition, Financial Support Services, Individual Goods and Services, and Primary Crisis Response Services.
- • The Community Navigator Self-Directed activities can only to be used to provide support to the individual under Individual and Family Directed Supports: Employer of Record and Agency with Choice Models, as approved in this Waiver.
- • 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)
Resources
Community Navigator Training
The purpose of Community Navigator Services is to promote self-determination, support the member in making life choices, provide advocacy and identify opportunities to become a part of their community. Community Navigator provides support to the member and planning teams in developing social networks and connections within local communities. Community Navigator Services emphasizes, promotes, and coordinates the use of generic resources to address the members needs in addition to paid services. Community Navigator provides an annual informational session on Self-Determination and Self Direction. The member and legally responsible person may choose to opt out of this annual informational session.
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
One unit = 15 minutes
Exclusions
- • Community Navigation services are used to support members self-directing waiver services; therefore, it is only available for individuals participating in self-direction. Community Navigation service is only available if the member is self-directing one or more of their services through the Agency with Choice or Employer of Record Model.
- • Community Navigator is mandatory for all Employers of Record until competence in directing service is demonstrated.
- • This service does not duplicate Care Coordination. Care coordination under managed care includes the development of the ISP, completing or gathering evaluations inclusive of the re-evaluation of the level of care, monitoring the implementation of the ISP, choosing service providers, coordination of benefits and monitoring the health and safety of the member consistent with 42 CFR 438.208(c).
- • The creation and the facilitation of the Individual Support Plan is the responsibility of the Care Coordinator. The Community Navigator can assist the member with preparing for the Individual Support Plan.
- • If a provider does not provide Agency with Choice Services, the only other service that they may provide to the same member, in addition to Community Navigator Services, is Community Transition.
- • An agency may provide both Community Navigator Services and Agency with Choice Services to the same individual, in addition to Community Transition, Financial Support Services, Individual Goods and Services, and Primary Crisis Response Services.
- • The Community Navigator Self-Directed activities can only to be used to provide support to the individual under Individual and Family Directed Supports: Employer of Record and Agency with Choice Models, as approved in this Waiver.
- • 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)
Resources
Family Navigator
Medicaid beneficiaries and their families often have a difficult time accessing or navigating healthcare and other systems because they are not designed to best support this population’s unique needs. Family Navigators can assist members and families to navigate these challenging times and to understand the changes in systems through lived experience. Family Navigator is a way of working with children, adolescents and/or adults with an I/DD or TBI diagnosis and who are experiencing challenges navigating the systems that can provide support for the health and well-being of this population. NC already offers this for adults who experience Mental Health and Substance use disorders using a Peer support model. Family Navigator is the equivalent for Medicaid beneficiaries who experience I/DD or TBI. It is designed as a short-term outreach and engagement service targeted to populations or specific member circumstances that prevent the individual from fully participating in needed care for intellectual or developmental disability or traumatic brain injury.
Unit Value
One unit = 15 minutes
Length of Stay
- 1. Up to 60 days for the initial request
- 2. This service is limited to 40 units per month.
Exclusions
- 1. Members cannot be on the Innovations Waiver and cannot receive Community Guide or Community Navigator at the same time as Family Navigator.
- 2. Family Navigator cannot duplicate the roles of Tailored Care Management.
- 3. Members cannot currently reside in an ICF/ IDD.
- 4. The Family Navigator cannot work for the same agency/organization from whom they receive care/services. The Family Navigator cannot provide services to self, their child(ren) and/or a family member. The Family Navigator cannot be currently receiving Family Navigator services.
- 5. This service is episodic in nature to provide support navigation related to specific identified needs. This service is not intended to be ongoing.
- 6. The creation and the facilitation of the ISP or PCP is the responsibility of the Care Coordinator on the Care Team. The Care Team role includes the development of the ISP, completing or gathering evaluations inclusive of the re-evaluation of the LOC, monitoring the implementation of the ISP, choosing service providers, coordination of benefits and monitoring the health and safety of the beneficiary. This is not a part of the Family Navigator role.
Level of Care
Individuals with I/DD and/or TBI with significant risk of placement in an ICF-IID or state facilities due to complex needs and a lack of Medicaid funding services.
How to Submit
N/A - No authorization is required
Resources
Adult sized disposable incontinence product, brief/diaper, small, each
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Adult sized disposable incontinence product, brief/diaper, medium, each
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Adult sized disposable incontinence product, brief/diaper, large, each
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Adult sized disposable incontinence product, brief/diaper, extra large, each
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Adult sized disposable incontinence product, protective underwear/pull-on, small size, each
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, each
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Pediatric sized disposable incontinence product, brief/diaper, large size, each
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Pediatric sized disposable incontinence product, protective underwear/pull-on, small/medium size, each
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Youth sized disposable incontinence product, brief/diaper, each
Authorization Guidelines
See the Carolina Complete Health site for specific requirements
Reauthorization Guidelines
See the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
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