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
Swingaway special construction leg rests, elevating, for weights 401 pounds and greater, pair
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
Oversized calf pads, pair
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
Oversized solid seat
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
Oversized solid back
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
Oversized full support footboard
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
Oversized full support calfboard
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
Replacement oversized innerspring mattress for hospital bed w/width to 39"
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
Inpatient Behavioral Health Services: Behavioral Health Treatment Milieu Therapy
In the event that not all of the criteria for continued acute state in an inpatient psychiatric facility are met, reimbursement may be provided for members through the age of 17 for continued stay in an inpatient psychiatric facility at a post-acute level of care to be paid at a residential rate established by NC Medicaid if the facility and program services are appropriate for the member’s treatment needs
Authorization Guidelines
- 1. TAR: prior authorization required.
- 2. Care Coordination Referral: On-going (at least weekly) coordination between the facility and the MCO satisfies this requirement.
- 3. Attending Physician Documentation: A) Documentation of the member’s history of sudden decompensation or measurable regression, and B) That the member currently experiences weakness in their environmental support system which is likely to trigger a decomp or regression
- 4. Submission of applicable records that support the member has met the medical necessity criteria.
Reauthorization Guidelines
- 1. TAR: prior authorization required.
- 2. Care Coordination Referral: On-going (at least weekly) coordination between the facility and the MCO satisfies this requirement.
- 3. Attending Physician Documentation: A) Documentation of the member’s history of sudden decompensation or measurable regression, and B) That the member currently experiences weakness in their environmental support system which is likely to trigger a decomp or regression
- 4. Submission of applicable records that support the member has met the medical necessity criteria.
Unit Value
Per diem based on the midnight bed count
Limits
- 1. The case management component of IIH, MST, CST, ACT, SAIOP, SACOT & CADT can be provided to those admitted to or discharged from this service. Support provided should be delivered in coordination with the Inpatient facility.
- 2. Medicaid eligibility must be verified each time a service is rendered.
- 3. Service is EPSDT eligible, but this does not eliminate the requirement for prior approval.
- 4. Discharge Planning shall begin upon admission to this service.
- 5. Medicaid shall not cover services in a freestanding psychiatric hospital for members over 21 or less than 65 years of age for mental health disorders.
- 6. Out-of-State emergency admissions do not require prior approval. The provider must contact Trillium within one business day of the emergency service or emergency admission.
Length of Stay
- 1. Initial requests: Up to 7 units per auth
- 2. Reauthorization requests: Up to 7 units per auth. Reauth requests must be submitted prior to the end of the current auth. A late submission resulting in unauthorized days requires splitting the stay for claims payment purposes.
Place of Service
This service may be provided at a psychiatric hospital or on an inpatient psychiatric unit within a licensed hospital licensed as inpatient psychiatric hospital beds or in State operated facilities.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
State-Funded Day Supports Service (IDD & TBI)
Day Supports is a group service that provides assistance to recipients with acquisition, retention, or improvement in socialization and daily living skills and is one option for a meaningful day. This service has historically been a facility-based service. However, person centered practices should be utilized to determine the appropriate amount of time to be spent on site, verses out in the community. Day Supports emphasizes inclusion and independence with a focus on enabling the recipient to attain or maintain maximum self-sufficiency, increase self-determination and enhance the recipient’s opportunity to have a meaningful day.
Authorization Guidelines
- 1. TAR: Prior authorization required
- 2. NC SNAP/ SIS: Required
- 3. Assessment: Psychological, neuropsych, or psychiatric assessment w/ the appropriate testing using validated tools showing the recipient has a developmental disability according to GS 122C-3 (12a) or TBI as defined in G.S. 122-C- 3(38a), including evidence of an IDD diagnosis prior to the age of 22. For those w/ DD but no intellectual disability, a physician assessment w/ a definitive dx and assoc, functional limitations is acceptable.
- 4. PCP or ISP: Required, w/ an expressed desire to obtain this service. Prevoc interventions must have employment-related goal.
- 5. Service Order: Required, signed by a QP, physician, licensed psychologist, PA, or NP
- 6. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
- 7. Submission of all records that support the recipient has met the medical necessity criteria.
Reauthorization Guidelines
- 1. TAR: Prior authorization required
- 2. NC SNAP/ SIS: Required
- 3. Service Order: Required, valid for one calendar year based on date of original PCP/ISP service order.
- 4. PCP or ISP: recently reviewed detailing the recipient’s progress with the service. If there is a need for increased service duration and frequency, clinical consideration must be given to other services with a more intense clinical component. Require an expressed desire to obtain or maintain this service. Prevocational interventions must have employment-related goal.
- 5. Evidence of IDD Eligibility: Meets IDD eligibility according to GS 122C-3 (12a), including evidence of an IDD dx before age of 22 or a TBI dx per G.S. 122C-3(38a).6. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
- 7. Submission of all records that support the recipient has met the medical necessity criteria.
Unit Value
One unit = 15 minutes
Limits
- 1. May not be provided to HCBS Waiver recipients or individuals receiving I/DD or TBI related (b)(3) meaningful day services (i.e., Individual Supports, Innovations look-alike services) or Medicaid In Lieu of Services (ILOS) with meaningful day component.
- 2. Must not be duplicative of other state funded services
- 3. May not be provided in a residential setting.
- 4. Payment does not include payments made directly to recipients of the individual’s immediate family.
- 5. CLS and ADVP can be auth’d at the same time as this service, but they cannot be provided at the same time of day.
Length of Stay
- 1. Initial & Reauth: Up to 30 hours (120 units) per week / 1560 hours (6240 units) per year
- 2. Max of 3 hrs/day (12 units) on school days for recipients 16 – 22 years of age who have not graduated from school, regardless of their enrollment status.
Age Group Details
Adolescents & Adults (age 16 or older)
Level of Care
SNAP: Overall Level of Eligible Support of 2 or higher OR SIS: Level C or higher OR TBI Assessment requiring minimum to low level of supervision and support in most settings.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Residential Supports (I/DD)
Residential Supports provides individualized services and supports to enable an individual to live successfully in a licensed Supervised Living facility or an unlicensed AFL setting of their choice and be an active participant in the community. The individual requires this service to learn and practice new skills and improve existing skills to assist the individual in increasing their level of independence for the I/DD population. For the TBI population, the service includes training and support for relearning skills, developing compensatory strategies and practicing new skills and for improvement of existing skills to assist the individual to complete activities to the greatest level of independence possible. Residential Supports includes supervision and assistance in activities of daily living when the individual is dependent on others to ensure health and safety.
Authorization Guidelines
- 1. TAR: Prior authorization required
- 2. NC SNAP or SIS: Required
- 3. Assessment: Psychological, neuropsych, or psychiatric eval w/ appropriate testing indicating the recipient meets ICF/IID criteria for IDD services, including evidence of an IDD dx before age of 22. For TBI, an exam noting a TBI dx per G.S. 122C-3(38a). For those w/ DD but no intellectual disability, a physician assessment w/ a definitive dx and assoc, functional limitations is acceptable.
- 4. Service Order: Required
- 5. Complete, integrated PCP: Required, w/ goals designed to support increasing independence (i.e., habilitative/ rehabilitative goal should be 75% of goals noted within the plan). Should include an expressed desire to obtain the service.
- 6. Submission of all records that support the recipient has met the medical necessity criteria.
Reauthorization Guidelines
- 1. TAR: Prior authorization required
- 2. NC SNAP or SIS: Required
- 3. Complete, integrated PCP: recently reviewed detailing the recipient’s progress with the service. Goals designed to support increasing independence (i.e., habilitative/ rehabilitative goal should be 75% of goals noted within the plan) are required. If MN dictates the need for increased service duration and frequency, consideration must be given to other services and interventions with a more intense clinical component. . Should include an expressed desire to maintain the service.
- 4. Evidence of IDD Eligibility: Meets IDD eligibility according to GS 122C-3 (12a), including evidence of an IDD dx before age of 22 or TBI.
- 5. Submission of all records that support the recipient has met the medical necessity criteria.
Unit Value
One unit = 1 day
Limits
- 1. No New Admissions
- 2. May not receive state-funded Community Living and Supports, Supported Living Periodic, DT, Personal Care Services, or State Funded Personal Care or PA. Respite can only be provided to those residing in an AFL.
- 3. Must not be duplicative of other state funded services the individual is receiving.
- 4. Relatives may not provide the service to family recipients. Relatives who own provider agencies may not provide services to family recipients.
- 5. Primary AFL Staff who provide service should not provide other services to the individual.
- 6. Cannot be used to purchase Assistive Technology Equipment.
- 7. May not also receive Medicaid funded residential services.
- 8. The site must be the primary residence of the AFL provider who receives reimbursement for the cost of care.
Length of Stay
Request length of stay can be for up to one calendar year or the end of the PCP (whichever comes first).
Age Group Details
Adolescents & Adults (age 16 or older)
Level of Care
Level of Care: SNAP level 2 or SIS level C. Individuals require minimal to low levels of supervision and support in most settings. Most are dx with mild/moderate IDD and/or a related condition.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
- State Funded Residential Supports (I/DD & TBI) Service Definition
- Records Management and Documentation Manual
- https://www.ncdhhs.gov/documents/files/joint-communication-bulletin-j325-idd-eligibility-state
- https://www.ncdhhs.gov/providers/provider-information/mental-health-development-disabilities-substance-use-services-and-traumatic-brain-injuries/nc-snap-nc-support-needs-assessment-profile
Community Living and Support (CLS)
Community Living and Support is an individualized service that enables individuals 3 years of age or older to live successfully in their own home, the home of their family or natural supports and be an active recipient of their community. A paraprofessional assists the individual to learn new skills and/or supports the individual in activities that are individualized and aligned with their preferences. Community Living and Support provides technical assistance to unpaid supports who live in the home of the individual to assist the individual to maintain the skills they have learned.
Authorization Guidelines
- 1. TAR: Required, submitted by a QP
- 2. NC SNAP/ SIS/ TBI Assessment: Required
- 3. Assessment: Psychological, neuropsych, or psychiatric assessment w/ the appropriate testing using validated tools showing the recipient has a developmental disability according to GS 122C-3 (12a) or TBI as defined in G.S. 122-C- 3(38a), including evidence of an IDD diagnosis prior to the age of 22. For those w/ DD but no intellectual disability, a physician assessment w/ a definitive dx and assoc, functional limitations is acceptable.
- 4. PCP or ISP: Required, to include an expressed desire to obtain the service.
- 5. Service Order: Required, signed by a QP, physician, licensed psychologist, PA, or NP
- 6. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
- 7. Submission of all records that support the recipient has met the medical necessity criteria.
Reauthorization Guidelines
- 1. TAR: Required, submitted by a QP
- 2. NC SNAP/ SIS/ / TBI Assessment: Required
- 3. PCP or ISP: recently reviewed detailing the recipient’s progress with the service, to include an expressed desire to maintain the service. If there is a need for increased service duration and frequency, clinical consideration must be given to other services with a more intense clinical component.
- 4. Evidence of IDD Eligibility: Meets IDD eligibility according to GS 122C-3 (12a), including evidence of an IDD dx before age of 22 or a TBI dx per G.S. 122C-3(38a).
- 5. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
- 6. Submission of all records that support the recipient has met the medical necessity criteria.
Unit Value
One unit = 15 minutes
Length of Stay
- 1. Initial & Reauth: Up to 28 hours (112 units) per week / 1456 hours (5824 units) per year
- 2. May not exceed 15 hours per week (60 units) when school is in session for individuals under 22 years of age who have not graduated, regardless of their enrollment status.
- 3. Request length of stay can be for up to one calendar year or the end of the PCP (whichever comes first).
Exclusions
- 1. No New Admissions
- 2. May not be provided during the same auth period as Innovations Waiver services, (b)(3) day services, or Medicaid 1915i services or In Lieu of Services (ILOS) which include a meaningful day component.
- 3. Must not be duplicative of other state funded services the individual is receiving.
- 4. Those receiving CL&S may not receive any residential services or Supported Living Periodic.
- 5. Services may not be provided in the home of provider staff.
Age Group Details
Adolescents & Adults (age 16 or older)
Level of Care
SNAP: Overall Level of Eligible Support of 3 or higher OR SIS: Level D or higher OR TBI Assessment requiring a moderate to high level of supervision and support in most settings.
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 Living and Support (CLS)
Community Living and Support is an individualized service that enables individuals 3 years of age or older to live successfully in their own home, the home of their family or natural supports and be an active recipient of their community. A paraprofessional assists the individual to learn new skills and/or supports the individual in activities that are individualized and aligned with their preferences. Community Living and Support provides technical assistance to unpaid supports who live in the home of the individual to assist the individual to maintain the skills they have learned.
Authorization Guidelines
- 1. TAR: Required, submitted by a QP
- 2. NC SNAP/ SIS/ TBI Assessment: Required
- 3. Assessment: Psychological, neuropsych, or psychiatric assessment w/ the appropriate testing using validated tools showing the recipient has a developmental disability according to GS 122C-3 (12a) or TBI as defined in G.S. 122-C- 3(38a), including evidence of an IDD diagnosis prior to the age of 22. For those w/ DD but no intellectual disability, a physician assessment w/ a definitive dx and assoc, functional limitations is acceptable.
- 4. PCP or ISP: Required, to include an expressed desire to obtain the service.
- 5. Service Order: Required, signed by a QP, physician, licensed psychologist, PA, or NP
- 6. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
- 7. Submission of all records that support the recipient has met the medical necessity criteria.
Reauthorization Guidelines
- 1. TAR: Required, submitted by a QP
- 2. NC SNAP/ SIS/ / TBI Assessment: Required
- 3. PCP or ISP: recently reviewed detailing the recipient’s progress with the service, to include an expressed desire to maintain the service. If there is a need for increased service duration and frequency, clinical consideration must be given to other services with a more intense clinical component.
- 4. Evidence of IDD Eligibility: Meets IDD eligibility according to GS 122C-3 (12a), including evidence of an IDD dx before age of 22 or a TBI dx per G.S. 122C-3(38a).
- 5. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
- 6. Submission of all records that support the recipient has met the medical necessity criteria.
Unit Value
One unit = 15 minutes
Length of Stay
- 1. Initial & Reauth: Up to 28 hours (112 units) per week / 1456 hours (5824 units) per year
- 2. May not exceed 15 hours per week (60 units) when school is in session for individuals under 22 years of age who have not graduated, regardless of their enrollment status.
- 3. Request length of stay can be for up to one calendar year or the end of the PCP (whichever comes first).
Exclusions
- 1. No New Admissions
- 2. May not be provided during the same auth period as Innovations Waiver services, (b)(3) day services, or Medicaid 1915i services or In Lieu of Services (ILOS) which include a meaningful day component.
- 3. Must not be duplicative of other state funded services the individual is receiving.
- 4. Those receiving CL&S may not receive any residential services or Supported Living Periodic.
- 5. Services may not be provided in the home of provider staff.
Age Group Details
Adolescents & Adults (age 16 or older)
Level of Care
SNAP: Overall Level of Eligible Support of 3 or higher OR SIS: Level D or higher OR TBI Assessment requiring a moderate to high level of supervision and support in most settings.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Supported Living Periodic (IDD & TBI)
The service enables an individual to live in their own home with support from an agency that provides individualized assistance in a home that is under the control and responsibility of the individual. The service includes direct assistance as needed with activities of daily living, household chores essential to the health and safety of the individual, budget mngmnt, attending appointments, and interpersonal and social skill building to enable the individual to live in a home in the community. Expected outcomes include increasing the Individual’s life skills and independent living skills, maximizing self-sufficiency, increasing self-determination, and ensuring the individual’s opportunity to have full membership in their community as defined within the PCP and ISP goals.
Authorization Guidelines
- 1. TAR: Prior authorization required
- 2. NC SNAP/ SIS/ TBI Assessment: Required
- 3. Assessment: Psychological, neuropsych, or psychiatric assessment w/ the appropriate testing using validated tools showing the recipient has a developmental disability according to GS 122C-3 (12a) or TBI as defined in G.S. 122-C- 3(38a), including evidence of an IDD diagnosis prior to the age of 22. For those w/ DD but no intellectual disability, a physician assessment w/ a definitive dx and assoc, functional limitations is acceptable.
- 4. PCP or ISP: Required. An integrated plan inclusive of all providers/ services is required. Should include an expressed desire to obtain the service.
- 5. Service Order: Required.
- 6. Submission of all records that support the recipient has met the medical necessity criteria.
Reauthorization Guidelines
- 1. TAR: Prior authorization required
- 2. NC SNAP/ SIS/ TBI Assessment: Required
- 3. PCP or ISP: recently reviewed detailing the recipient’s progress with the service. An integrated plan inclusive of all providers/ services is required. Should include an expressed desire to maintain the service.
- 4. Evidence of IDD Eligibility: Meets IDD eligibility according to GS 122C-3 (12a), including evidence of an IDD dx before age of 22 or a TBI dx per G.S. 122C-3(38a).
- 5. Submission of all records that support the recipient has met the medical necessity criteria.
Unit Value
One unit = 15 minutes
Limits
- 1. May not receive state-funded CL&S, Residential Supports, DT, Personal Care Services, State Plan Personal Care or PA. Respite can only be provided to those residing in an AFL.
- 2. Shall not be provided in a home where an individual lives with family recipients unless such family recipients are an individual receiving Supported Living, a spouse, or a minor child.
- 3. Relatives, and Relatives who own provider agencies, may not provide the service to family recipients.
- 5. Provider shall not own the home or have any authority to require the individual to move if the individual changes service providers.
- 6. No more than 3 people can live or receive Supported Living Periodic service in the same household. Lease requirements apply.
Length of Stay
- 1. May not exceed 28 hours (112 units) per week
- 2. Request can be for up to 12 months.
Age Group Details
Adults (age 18 or older)
Level of Care
NC SNAP Overall Level of Eligible Support of 2or lower OR SIS: Level B or lower OR TBI Assessment requiring a low level of supervision and support in most settings.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
- State Funded Residential Supports (I/DD & TBI) Service Definition
- Records Management and Documentation Manual
- https://www.ncdhhs.gov/documents/files/joint-communication-bulletin-j325-idd-eligibility-state
- https://www.trilliumhealthresources.org/provider-communication-bulletins
- https://www.ncdhhs.gov/joint-communication-bulletin-j408-state-funded-residential-supports-and-supported-living-periodic
State-Funded Respite Services
Respite services provide periodic support and relief to the primary caregiver(s) from the responsibility and stress of caring for the recipient. This service enables the primary caregiver(s), when other natural supports are unavailable, to assist with caregiving, to meet or participate in periodic, planned or emergency events, and to have planned breaks in caregiving. Respite may include in and out-of-home services, inclusive of overnight, weekend care, or emergency care (caregiver emergency based).
This service is a periodic service. Primary caregiver must maintain their primary residence at the same address as the recipient.
Authorization Guidelines
- 1. TAR: Prior auth required; TAR must be completed by a QP
- 2. Assessment: Psychological, neuropsych, or psychiatric eval w/ appropriate testing indicating the recipient meets ICF/IID criteria for IDD services, including evidence of an IDD dx before age of 22. For TBI, an exam noting a TBI dx per G.S. 122C-3(38a). For those w/ DD but no intellectual disability, a physician assessment w/ a definitive dx and assoc, functional limitations is acceptable.
- 3. NC SNAP/ SIS: Either the NC-SNAP or the SIS is required for all individuals with intellectual or developmental disabilities.
- 4. Documentation that the primary caregiver(s) need periodic support and relief from the responsibility and stress of caregiving OR the individual needs periodic support and relief from the primary caregiver.
- 5. Documentation that there are no other natural resources or support available to the primary caregiver to provide the necessary relief of substitute care.
- 6. Service Order: Signed by a MD/ DO, LP, PA, or NP. For the I/DD population also a QP.
- 7. Complete PCP: Required
- 8. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
- 9. Submission of all records that support the recipient has met the medical necessity criteria.
Reauthorization Guidelines
- 1. TAR: Prior auth required; TAR must be completed by a QP
- 2. Evidence of IDD Eligibility: Meets IDD eligibility according to GS 122C-3 (12a), including evidence of an IDD dx before age of 22 or TBI.
- 3. Documentation that the primary caregiver(s) need periodic support and relief from the responsibility and stress of caregiving OR the individual needs periodic support and relief from the primary caregiver.
- 4. Documentation that there are no other natural resources or support available to the primary caregiver to provide the necessary relief of substitute care.
- 5. Complete PCP: Required
- 6. Medicaid Application: Evidence of individual applying for Medicaid or update on application status.
- 7. Submission of all records that support the recipient has met the medical necessity criteria.
Unit Value
One unit = 15 minutes
Length of Stay
No more than 1536 units (384 hours) per fiscal year 1. In an urgent or emergent situation requiring a verbal auth, up to 192 units (48 hours) of service for an initial 2 calendar day pass-through is permitted.
- 2. Written auth required after this pass-through.
- 3. This pass-through is available only once per state fiscal year.
Exclusions
- 1. Respite may not be provided by relatives, legal guardians, or individuals if they live in the same home.
- 2. Individual must live in a non-licensed setting, with a non-paid caregiver(s), except for those residing in an AFL (respite cannot be billed on the same day as Residential Supports if utilized for more than 8 hours per day).
- 3. The following are not covered: Formal habilitation goals; Services provided to teach academics/ education substitutes; Payment for room and board.
Diagnosis Requirements
Evidence of IDD or TBI
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
State-Funded Respite Services
Respite services provide periodic support and relief to the primary caregiver(s) from the responsibility and stress of caring for the recipient. This service enables the primary caregiver(s), when other natural supports are unavailable, to assist with caregiving, to meet or participate in periodic, planned or emergency events, and to have planned breaks in caregiving. Respite may include in and out-of-home services, inclusive of overnight, weekend care, or emergency care (caregiver emergency based).
This service is a periodic service. Primary caregiver must maintain their primary residence at the same address as the recipient.
Authorization Guidelines
- 1. TAR: Prior auth required; TAR must be completed by a QP
- 2. Assessment: Psychological, neuropsych, or psychiatric eval w/ appropriate testing indicating the recipient meets ICF/IID criteria for IDD services, including evidence of an IDD dx before age of 22. For TBI, an exam noting a TBI dx per G.S. 122C-3(38a). For those w/ DD but no intellectual disability, a physician assessment w/ a definitive dx and assoc, functional limitations is acceptable.
- 3. NC SNAP/ SIS: Either the NC-SNAP or the SIS is required for all individuals with intellectual or developmental disabilities.
- 4. Documentation that the primary caregiver(s) need periodic support and relief from the responsibility and stress of caregiving OR the individual needs periodic support and relief from the primary caregiver.
- 5. Documentation that there are no other natural resources or support available to the primary caregiver to provide the necessary relief of substitute care.
- 6. Service Order: Signed by a MD/ DO, LP, PA, or NP. For the I/DD population also a QP.
- 7. Complete PCP: Required
- 8. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
- 9. Submission of all records that support the recipient has met the medical necessity criteria.
Reauthorization Guidelines
- 1. TAR: Prior auth required; TAR must be completed by a QP
- 2. Evidence of IDD Eligibility: Meets IDD eligibility according to GS 122C-3 (12a), including evidence of an IDD dx before age of 22 or TBI.
- 3. Documentation that the primary caregiver(s) need periodic support and relief from the responsibility and stress of caregiving OR the individual needs periodic support and relief from the primary caregiver.
- 4. Documentation that there are no other natural resources or support available to the primary caregiver to provide the necessary relief of substitute care.
- 5. Complete PCP: Required
- 6. Medicaid Application: Evidence of individual applying for Medicaid or update on application status.
- 7. Submission of all records that support the recipient has met the medical necessity criteria.
Unit Value
One unit = 15 minutes
Length of Stay
No more than 1536 units (384 hours) per fiscal year 1. In an urgent or emergent situation requiring a verbal auth, up to 192 units (48 hours) of service for an initial 2 calendar day pass-through is permitted.
- 2. Written auth required after this pass-through.
- 3. This pass-through is available only once per state fiscal year.
Exclusions
- 1. Respite may not be provided by relatives, legal guardians, or individuals if they live in the same home.
- 2. Individual must live in a non-licensed setting, with a non-paid caregiver(s), except for those residing in an AFL (respite cannot be billed on the same day as Residential Supports if utilized for more than 8 hours per day).
- 3. The following are not covered: Formal habilitation goals; Services provided to teach academics/ education substitutes; Payment for room and board.
Diagnosis Requirements
Evidence of IDD or TBI
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
State-Funded Respite Services Child
Respite services provide periodic support and relief to the primary caregiver(s) from the responsibility and stress of caring for the recipient. This service enables the primary caregiver(s), when other natural supports are unavailable, to assist with caregiving, to meet or participate in periodic, planned or emergency events, and to have planned breaks in caregiving. Respite may include in and out-of-home services, inclusive of overnight, weekend care, or emergency care (caregiver emergency based). This service is a periodic service. Primary caregiver must maintain their primary residence at the same address as the recipient.
Authorization Guidelines
- 1. TAR: Prior auth required; TAR must be completed by a QP
- 2. Assessment: detailing serious emotional disturbance (SED) or a moderate or severe substance use disorders (SUD)
- 3. Documentation that the primary caregiver(s) need periodic support and relief from the responsibility and stress of caregiving OR the individual needs periodic support and relief from the primary caregiver.
- 4. Documentation that there are no other natural resources or support available to the primary caregiver to provide the necessary relief of substitute care.
- 5. Service Order: Signed by a MD/ DO, LP, PA, or NP.
- 6. Complete PCP: Required
- 7. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
- 8. Submission of all records that support the recipient has met the medical necessity criteria.
Reauthorization Guidelines
- 1. TAR: Prior auth required; TAR must be completed by a QP
- 2. Assessment: detailing serious emotional disturbance (SED) or a moderate or severe substance use disorders (SUD)
- 3. Documentation that the primary caregiver(s) need periodic support and relief from the responsibility and stress of caregiving OR the individual needs periodic support and relief from the primary caregiver.
- 4. Documentation that there are no other natural resources or support available to the primary caregiver to provide the necessary relief of substitute care.
- 5. Complete PCP: Required
- 6. Medicaid Application: Evidence of individual applying for Medicaid or update on application status.
- 7. Submission of all records that support the recipient has met the medical necessity criteria.
Unit Value
One unit = 15 minutes
Limits
- 1. Respite may not be provided by relatives, legal guardians, or individuals if they live in the same home.
- 2. Individual must live in a non-licensed setting, with a non-paid caregiver(s), except for those residing in an AFL (respite cannot be billed on the same day as Residential Supports if utilized for more than 8 hours per day).
- 3. The following are not covered: Formal habilitation goals; Services provided to teach academics/ education substitutes; Payment for room and board.
- 4. Individuals eligible for MCD Respite (including exhausted MCD Respite) are not eligible for State-funded Respite.
Length of Stay
No more than 1536 units (384 hours) per fiscal year
Age Group Details
Children & Adolescents (ages 3-17 with SED or moderate or severe SUD or age 3-18 with IDD or TBI)
Level of Care
Evidence of SED, moderate or severe SUD, or IDD or TBI
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
State-Funded Respite Services
Respite services provide periodic support and relief to the primary caregiver(s) from the responsibility and stress of caring for the recipient. This service enables the primary caregiver(s), when other natural supports are unavailable, to assist with caregiving, to meet or participate in periodic, planned or emergency events, and to have planned breaks in caregiving. Respite may include in and out-of-home services, inclusive of overnight, weekend care, or emergency care (caregiver emergency based).
This service is a periodic service. Primary caregiver must maintain their primary residence at the same address as the recipient.
Authorization Guidelines
- 1. TAR: Prior auth required; TAR must be completed by a QP
- 2. Assessment: Psychological, neuropsych, or psychiatric eval w/ appropriate testing indicating the recipient meets ICF/IID criteria for IDD services, including evidence of an IDD dx before age of 22. For TBI, an exam noting a TBI dx per G.S. 122C-3(38a). For those w/ DD but no intellectual disability, a physician assessment w/ a definitive dx and assoc, functional limitations is acceptable.
- 3. NC SNAP/ SIS: Either the NC-SNAP or the SIS is required for all individuals with intellectual or developmental disabilities.
- 4. Documentation that the primary caregiver(s) need periodic support and relief from the responsibility and stress of caregiving OR the individual needs periodic support and relief from the primary caregiver.
- 5. Documentation that there are no other natural resources or support available to the primary caregiver to provide the necessary relief of substitute care.
- 6. Service Order: Signed by a MD/ DO, LP, PA, or NP. For the I/DD population also a QP.
- 7. Complete PCP: Required
- 8. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
- 9. Submission of all records that support the recipient has met the medical necessity criteria.
Reauthorization Guidelines
- 1. TAR: Prior auth required; TAR must be completed by a QP
- 2. Evidence of IDD Eligibility: Meets IDD eligibility according to GS 122C-3 (12a), including evidence of an IDD dx before age of 22 or TBI.
- 3. Documentation that the primary caregiver(s) need periodic support and relief from the responsibility and stress of caregiving OR the individual needs periodic support and relief from the primary caregiver.
- 4. Documentation that there are no other natural resources or support available to the primary caregiver to provide the necessary relief of substitute care.
- 5. Complete PCP: Required
- 6. Medicaid Application: Evidence of individual applying for Medicaid or update on application status.
- 7. Submission of all records that support the recipient has met the medical necessity criteria.
Unit Value
One unit = 15 minutes
Length of Stay
No more than 1536 units (384 hours) per fiscal year 1. In an urgent or emergent situation requiring a verbal auth, up to 192 units (48 hours) of service for an initial 2 calendar day pass-through is permitted.
- 2. Written auth required after this pass-through.
- 3. This pass-through is available only once per state fiscal year.
Exclusions
- 1. Respite may not be provided by relatives, legal guardians, or individuals if they live in the same home.
- 2. Individual must live in a non-licensed setting, with a non-paid caregiver(s), except for those residing in an AFL (respite cannot be billed on the same day as Residential Supports if utilized for more than 8 hours per day).
- 3. The following are not covered: Formal habilitation goals; Services provided to teach academics/ education substitutes; Payment for room and board.
Diagnosis Requirements
Evidence of IDD or TBI
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
State-Funded Respite Services Child Group
Respite services provide periodic support and relief to the primary caregiver(s) from the responsibility and stress of caring for the recipient. This service enables the primary caregiver(s), when other natural supports are unavailable, to assist with caregiving, to meet or participate in periodic, planned or emergency events, and to have planned breaks in caregiving. Respite may include in and out-of-home services, inclusive of overnight, weekend care, or emergency care (caregiver emergency based). This service is a periodic service. Primary caregiver must maintain their primary residence at the same address as the recipient.
Authorization Guidelines
- 1. TAR: Prior auth required; TAR must be completed by a QP
- 2. Assessment: detailing serious emotional disturbance (SED) or a moderate or severe substance use disorders (SUD)
- 3. Documentation that the primary caregiver(s) need periodic support and relief from the responsibility and stress of caregiving OR the individual needs periodic support and relief from the primary caregiver.
- 4. Documentation that there are no other natural resources or support available to the primary caregiver to provide the necessary relief of substitute care.
- 5. Service Order: Signed by a MD/ DO, LP, PA, or NP.
- 6. Complete PCP: Required
- 7. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
- 8. Submission of all records that support the recipient has met the medical necessity criteria.
Reauthorization Guidelines
- 1. TAR: Prior auth required; TAR must be completed by a QP
- 2. Assessment: detailing serious emotional disturbance (SED) or a moderate or severe substance use disorders (SUD)
- 3. Documentation that the primary caregiver(s) need periodic support and relief from the responsibility and stress of caregiving OR the individual needs periodic support and relief from the primary caregiver.
- 4. Documentation that there are no other natural resources or support available to the primary caregiver to provide the necessary relief of substitute care.
- 5. Complete PCP: Required
- 6. Medicaid Application: Evidence of individual applying for Medicaid or update on application status.
- 7. Submission of all records that support the recipient has met the medical necessity criteria.
Unit Value
One unit = 15 minutes
Limits
- 1. Respite may not be provided by relatives, legal guardians, or individuals if they live in the same home.
- 2. Individual must live in a non-licensed setting, with a non-paid caregiver(s), except for those residing in an AFL (respite cannot be billed on the same day as Residential Supports if utilized for more than 8 hours per day).
- 3. The following are not covered: Formal habilitation goals; Services provided to teach academics/ education substitutes; Payment for room and board.
- 4. Individuals eligible for MCD Respite (including exhausted MCD Respite) are not eligible for State-funded Respite.
Length of Stay
No more than 1536 units (384 hours) per fiscal year
Age Group Details
Children & Adolescents (ages 3-17 with SED or moderate or severe SUD or age 3-18 with IDD or TBI)
Level of Care
Evidence of SED, moderate or severe SUD, or IDD or TBI
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
State-Funded Respite Services
Respite services provide periodic support and relief to the primary caregiver(s) from the responsibility and stress of caring for the recipient. This service enables the primary caregiver(s), when other natural supports are unavailable, to assist with caregiving, to meet or participate in periodic, planned or emergency events, and to have planned breaks in caregiving. Respite may include in and out-of-home services, inclusive of overnight, weekend care, or emergency care (caregiver emergency based).
This service is a periodic service. Primary caregiver must maintain their primary residence at the same address as the recipient.
Authorization Guidelines
- 1. TAR: Prior auth required; TAR must be completed by a QP
- 2. Assessment: Psychological, neuropsych, or psychiatric eval w/ appropriate testing indicating the recipient meets ICF/IID criteria for IDD services, including evidence of an IDD dx before age of 22. For TBI, an exam noting a TBI dx per G.S. 122C-3(38a). For those w/ DD but no intellectual disability, a physician assessment w/ a definitive dx and assoc, functional limitations is acceptable.
- 3. NC SNAP/ SIS: Either the NC-SNAP or the SIS is required for all individuals with intellectual or developmental disabilities.
- 4. Documentation that the primary caregiver(s) need periodic support and relief from the responsibility and stress of caregiving OR the individual needs periodic support and relief from the primary caregiver.
- 5. Documentation that there are no other natural resources or support available to the primary caregiver to provide the necessary relief of substitute care.
- 6. Service Order: Signed by a MD/ DO, LP, PA, or NP. For the I/DD population also a QP.
- 7. Complete PCP: Required
- 8. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
- 9. Submission of all records that support the recipient has met the medical necessity criteria.
Reauthorization Guidelines
- 1. TAR: Prior auth required; TAR must be completed by a QP
- 2. Evidence of IDD Eligibility: Meets IDD eligibility according to GS 122C-3 (12a), including evidence of an IDD dx before age of 22 or TBI.
- 3. Documentation that the primary caregiver(s) need periodic support and relief from the responsibility and stress of caregiving OR the individual needs periodic support and relief from the primary caregiver.
- 4. Documentation that there are no other natural resources or support available to the primary caregiver to provide the necessary relief of substitute care.
- 5. Complete PCP: Required
- 6. Medicaid Application: Evidence of individual applying for Medicaid or update on application status.
- 7. Submission of all records that support the recipient has met the medical necessity criteria.
Unit Value
One unit = 15 minutes
Length of Stay
No more than 1536 units (384 hours) per fiscal year 1. In an urgent or emergent situation requiring a verbal auth, up to 192 units (48 hours) of service for an initial 2 calendar day pass-through is permitted.
- 2. Written auth required after this pass-through.
- 3. This pass-through is available only once per state fiscal year.
Exclusions
- 1. Respite may not be provided by relatives, legal guardians, or individuals if they live in the same home.
- 2. Individual must live in a non-licensed setting, with a non-paid caregiver(s), except for those residing in an AFL (respite cannot be billed on the same day as Residential Supports if utilized for more than 8 hours per day).
- 3. The following are not covered: Formal habilitation goals; Services provided to teach academics/ education substitutes; Payment for room and board.
Diagnosis Requirements
Evidence of IDD or TBI
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Adult Developmental Vocational Program (ADVP) Services
A day/night service which provides organized developmental activities for individuals with intellectual/developmental disabilities to prepare the individual to live and work as independently as possible. The activities and services of ADVP are designed to adhere to the principles of normalization and community integration. This service is available for a period of three or more hours per day; although, an individual may attend for fewer than three hours.
Authorization Guidelines
- 1. TAR: Prior authorization required.
- 2. NC SNAP or SIS: Required
- 3. Assessment: Psychological, neuropsych, or psychiatric assessment w/ the appropriate testing using validated tools showing the recipient has a developmental disability according to GS 122C-3 (12a) or TBI as defined in G.S. 122-C- 3(38a), including evidence of an IDD diagnosis prior to the age of 22. For those w/ DD but no intellectual disability, a physician assessment w/ a definitive dx and assoc, functional limitations is acceptable.
- 4. Service/ Tx Plan or ISP: Required
- 5. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
- 6. Submission of applicable records that support the individual has met the medical necessity criteria.
Reauthorization Guidelines
- 1. TAR: prior authorization required.
- 2. Service/ Tx Plan or ISP: recently reviewed detailing the individual’s progress with the service.
- 3. Medicaid Application: Required w/in the 30 days of authorization. Evidence of individual applying for Medicaid or update on application status.
- 4. Submission of applicable records that support the individual has met the medical necessity criteria.
Unit Value
One unit = 15 minutes
Length of Stay
Maximum is up to 8 hours/day (32 units), up to 5 days per week (160 units/wk or 8256 units/yr)
Exclusions
- 1. Only available to legacy Eastpointe and Sandhills recipients
Age Group Details
Adolescents & Adults (age 16 or older)
Level of Care
NC SNAP Overall Level of Eligible Support of 1 or higher
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
- State-Funded Enhanced Mental Health and Substance Abuse Service Definition
- Records Management and Documentation Manual
- https://www.ncdhhs.gov/providers/provider-information/mental-health-development-disabilities-substance-use-services-and-traumatic-brain-injuries/nc-snap-nc-support-needs-assessment-profile
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