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Supported Employment services aid with choosing, acquiring, and maintaining a job for individuals for whom Competitive Integrated Employment (CIE) has not been achieved and /or has been interrupted or intermittent. Job finding should be exploring options for CIE and is not based on placement from a pool of jobs that are available or set aside specifically for individuals with disabilities. The intent of Supported Employment services is to assist individuals with developing skills to seek, obtain and maintain CIE or develop and operate a micro-enterprise. Employment positions are found based on individual preferences, strengths, and experiences.

Pre-employment Phase (PEP): This phase includes but is not limited to activities that should occur prior to obtaining CIE, such as benefits counseling referral, career exploration, discovery, job readiness skills, and job development activities. The goal of this phase is to have the individual work ready and to assist the individual to obtain employment. Detailed documentation should reflect how the provider is preparing an individual for employment.

Authorization Guidelines

• 1. TAR: Prior authorization required
• 2. VR Documentation: Member must have completed the application process with VR and the Eligibility Decision outcome be documented noting ineligibility or closure for VR Services prior to receiving this service
• 3. NC-SNAP/ SIS/ TBI Assessment/ Employment Evaluation: Required, completed by Vocational Rehabilitation (VR)
• 4. Psychological, Neuropsychological, or Psychiatric Assessment: Required, must demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) or a TBI as defined by G.S. 122-C-3(38a) OR Physician Assessment: Required, to demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) without accompanying intellectual disabilities
• 5. PCP/ ISP: Required, incorporating the Career Development Plan with the Career Development & Planning Assessment attached. Must include evidence that the member is interested in learning about or obtaining CIE.
• 6. Service Order: Required, completed by a QP, MD/DO, LP, PA, or NP
• 7. Submission of all records that support the individual has met the medical necessity criteria.

Reauthorization Guidelines

• 1. TAR: Prior authorization required
• 2. VR Documentation: Member must have completed the application process with VR and the Eligibility Decision outcome be documented noting ineligibility or closure for VR Services prior to receiving this service
• 3. Current NC-SNAP/ SIS/ TBI Assessment/ Employment Evaluation: Required, completed by Vocational Rehabilitation
• 4. Psychological, Neuropsychological, or Psychiatric Assessment: Required, must demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) or a TBI as defined by G.S. 122-C-3(38a) OR Physician Assessment: Required, to demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) without accompanying intellectual disabilities
• 5. Updated PCP/ ISP: Required, incorporating the Career Development Plan with the Career Development & Planning Assessment attached. Updated goals showing a progression in skill acquisition or a documented need for ongoing training and/or support is required. PCP/ISP must include: Member’s employment integration feedback and employer’s ADA accommodations. Must include evidence that the member is interested in learning about or obtaining CIE.
• 6. Evidence of Need: Evidence that continued job development activities are needed to obtain CIE when the 6-month phase timeframe has passed.
• 7. Submission of all records that support the individual has met the medical necessity criteria.

NOTE: Member meets criteria for discharge if there is insufficient documented evidence to support the need for continued services.

Unit Value

One unit = 15 minutes

Limits

• 1. Provider must complete ongoing education to the employer regarding ADA accommodations to ensure the transition from the ESP to the Long-Term Supported Employment Phase is successful and the individual’s needs are met.
• 2. Transportation included (exclusions apply). The ESP should not continue solely as a means of transportation.
• 3. Service does not cover: a) incentive payments made to an employer; b) payments that are passed through to the member; c) payments for non-Supported Employment training
• 4. Cannot be used to employ and provide services to the same individual at the provider agency location.
• 5. Service is not available at the same time of day as any other state funded service, Medicaid waiver service or one of the State Plan Medicaid services that works directly with the Individual.
• 6. Family members or legally responsible person(s) cannot provide the service tp the member.
• 7. Member cannot be a HCBS Waiver members or eligible for or receiving Medicaid funded employment services (i.e., Supported Employment in Innovations Waiver & TBI Waiver, 1915(i) and 1915(b)(3) inclusive of Medicaid ICF-IID In Lieu of Services (ILOS) with employment component).
• 8. Member can receive service from only one provider during an active auth period.

Length of Stay

• 1. The PEP does not exceed six months in a typical situation.
• 2. If an individual exceeds the timeframe of the pre-employment phase, an exception request should be made. The request should include the nature of the issue that caused the timeframe not to be met and the steps to prevent the issue from recurring.
• 3. After one exception for the Pre-employment Phase has occurred, technical assistance may be needed to reassess employment goals.

Age Group Details

Adolescents & Adults (age 16 or older)

Place of Service

A Competitive Integrated Employment HCBC setting. Cannot occur in licensed community facilities, inclusive of day programs.

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

• 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

Supported Employment services aid with choosing, acquiring, and maintaining a job for individuals for whom Competitive Integrated Employment (CIE) has not been achieved and /or has been interrupted or intermittent. Job finding should be exploring options for CIE and is not based on placement from a pool of jobs that are available or set aside specifically for individuals with disabilities. The intent of Supported Employment services is to assist individuals with developing skills to seek, obtain and maintain CIE or develop and operate a micro-enterprise. Employment positions are found based on individual preferences, strengths, and experiences.

Authorization Guidelines

• 1. TAR: Prior authorization required
• 2. VR Documentation: Member must have completed the application process with VR and the Eligibility Decision outcome be documented noting ineligibility or closure for VR Services prior to receiving this service
• 3. NC-SNAP/ SIS/ TBI Assessment/ Employment Evaluation: Required, completed by Vocational Rehabilitation (VR)
• 4. Psychological, Neuropsychological, or Psychiatric Assessment: Required, must demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) or a TBI as defined by G.S. 122-C-3(38a) OR Physician Assessment: Required, to demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) without accompanying intellectual disabilities
• 5. PCP/ ISP: Required, incorporating the Career Development Plan with the Career Development & Planning Assessment attached. Must include evidence the member is interested in and needs service to maintain CIE or to obtain a change in employment conditions.
• 6. Service Order: Required, completed by a QP, MD/DO, LP, PA, or NP
• 7. Wage Info: Required upon initiation of the ESP, at the initiation of each plan year, and at the end of the 6th month of the plan year.
• 8. Evidence of Discharge Planning: to include a fade out plan, technology utilization, documentation of exhausted efforts to maximize on the job and natural supports and attempts to ensure the job fits the individual’s abilities.
• 9. Submission of all records that support the individual has met the medical necessity criteria.

Reauthorization Guidelines

• 1. TAR: Prior authorization required
• 2. VR Documentation: Member must have completed the application process with VR and the Eligibility Decision outcome be documented noting ineligibility or closure for VR Services prior to receiving this service
• 3. Current NC-SNAP/ SIS/ TBI Assessment/ Employment Evaluation: Required, completed by Vocational Rehabilitation
• 4. Psychological, Neuropsychological, or Psychiatric Assessment: Required, must demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) or a TBI as defined by G.S. 122-C-3(38a) OR Physician Assessment: Required, to demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) without accompanying intellectual disabilities
• 5. Updated PCP/ ISP: Required, incorporating the Career Development Plan with the Career Development & Planning Assessment attached. Updated goals showing a progression in skill acquisition or a documented need for ongoing training and/or support is required. PCP/ISP must include: Member’s employment integration feedback and employer’s ADA accommodations. Must include evidence the member is interested in and needs service to maintain CIE or to obtain a change in employment conditions.
• 6. Wage Info: Required upon initiation of the ESP, at the initiation of each plan year, and at the end of the 6th month of the plan year.
• 7. Evidence of Discharge Planning: to include a fade out plan, technology utilization, documentation of exhausted efforts to maximize on the job and natural supports and attempts to ensure the job fits the individual’s abilities.
• 8. Evidence of Need: Evidence that continued employment supports are needed to maintain CIE or to obtain a change in job opportunities when the 1-year phase timeframe has passed.
• 9. Submission of all records that support the individual has met the medical necessity criteria.

NOTE: Member meets criteria for discharge if there is insufficient documented evidence to support the need for continued services.

Unit Value

One unit = 15 minutes

Limits

• 1. Provider must complete ongoing education to the employer regarding ADA accommodations to ensure the transition from the ESP to the Long-Term Supported Employment Phase is successful and the individual’s needs are met.
• 2. Transportation included (exclusions apply). The ESP should not continue solely as a means of transportation.
• 3. Service does not cover: a) incentive payments made to an employer; b) payments that are passed through to the member; c) payments for non-Supported Employment training
• 4. Cannot be used to employ and provide services to the same individual at the provider agency location.
• 5. Service is not available at the same time of day as any other state funded service, Medicaid waiver service or one of the State Plan Medicaid services that works directly with the Individual.
• 6. Family members or legally responsible person(s) cannot provide the service tp the member.
• 7. Member cannot be a HCBS Waiver members or eligible for or receiving Medicaid funded employment services (i.e., Supported Employment in Innovations Waiver & TBI Waiver, 1915(i) and 1915(b)(3) inclusive of Medicaid ICF-IID In Lieu of Services (ILOS) with employment component).
• 8. Member can receive service from only one provider during an active auth period.

Length of Stay

• 1. The ESP should end once the member has achieved satisfactory work performance or work task meets employers’ expectations. The ESP does not typically exceed one calendar year.
• 2. If an individual exceeds the timeframe of the employment phase, an exception request should be made. The request should include the nature of the issue that caused the timeframe not to be met and the steps to prevent the issue from recurring.
• 3. After one exception for the ESP has occurred, technical assistance may be needed to reassess employment goals.

Age Group Details

Adolescents & Adults (age 16 or older)

Place of Service

A Competitive Integrated Employment HCBC setting. Cannot occur in licensed community facilities, inclusive of day programs.

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

• 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/documents/files/joint-communication-bulletin-j325-idd-eligibility-state

Supported Employment services aid with choosing, acquiring, and maintaining a job for individuals for whom Competitive Integrated Employment (CIE) has not been achieved and /or has been interrupted or intermittent. Job finding should be exploring options for CIE and is not based on placement from a pool of jobs that are available or set aside specifically for individuals with disabilities. The intent of Supported Employment services is to assist individuals with developing skills to seek, obtain and maintain CIE or develop and operate a micro-enterprise. Employment positions are found based on individual preferences, strengths, and experiences.

Long-Term Supported Employment (LTSE) Phase: This phase includes the various activities designed to continue to support the individual in maintaining CIE. The goal of this phase is to enable an individual to work as independently as possible and prepare for reduced level of staff support. In this phase the assessment of long- term support needs will occur, which support ongoing retention, prevent job loss, or make recommendations for discharge. Detailed documentation of goals specific to long-term support needs should reflect how the services being received is preparing the individual for working as independently as possible.

Authorization Guidelines

Initial Requests (if the service was not initiated in an earlier phase):

• 1. TAR: Prior authorization required
• 2. VR Documentation: Member must have completed the application process with VR and the Eligibility Decision outcome be documented noting ineligibility or closure for VR Services prior to receiving this service
• 3. NC-SNAP/ SIS/ TBI Assessment/ Employment Evaluation: Required, completed by Vocational Rehabilitation (VR)
• 4. Psychological, Neuropsychological, or Psychiatric Assessment: Required, must demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) or a TBI as defined by G.S. 122-C-3(38a) OR Physician Assessment: Required, to demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) without accompanying intellectual disabilities
• 5. PCP/ ISP: Required, incorporating the Career Development Plan with the Career Development & Planning Assessment attached. Must include evidence the member is interested in and needs service to maintain CIE or to obtain a change in employment conditions. LTSE related to medical/ behavioral/physical support needs requires medical or behavioral records and accompanying documentation in the PCP/ISP supporting the need for individual services as the most appropriate and viable option.
• 6. Service Order: Required, completed by a QP, MD/DO, LP, PA, or NP
• 7. Wage Info: Required upon initiation of the ESP, at the initiation of each plan year, and at the end of the 6th month of the plan year.
• 8. Evidence of Discharge Planning: to include a fade out plan, technology utilization, documentation of exhausted efforts to maximize on the job and natural supports and attempts to ensure the job fits the individual’s abilities.
• 9. Submission of all records that support the individual has met the medical necessity criteria.

Reauthorization Guidelines

• 1. TAR: Prior authorization required
• 2. VR Documentation: Member must have completed the application process with VR and the Eligibility Decision outcome be documented noting ineligibility or closure for VR Services prior to receiving this service
• 3. Current NC-SNAP/ SIS/ TBI Assessment/ Employment Evaluation: Required, completed by Vocational Rehabilitation
• 4. Psychological, Neuropsychological, or Psychiatric Assessment: Required, must demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) or a TBI as defined by G.S. 122-C-3(38a) OR Physician Assessment: Required, to demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) without accompanying intellectual disabilities
• 5. Updated PCP/ ISP: Required, incorporating the Career Development Plan with the Career Development & Planning Assessment attached. Updated goals showing a progression in skill acquisition or a documented need for ongoing training and/or support is required. PCP/ISP must include: Member’s employment integration feedback and employer’s ADA accommodations.
• 6. Wage Info: Required upon initiation of the ESP, at the initiation of each plan year, and at the end of the 6th month of the plan year.
• 7. Evidence of Discharge Planning: to include a fade out plan, technology utilization, documentation of exhausted efforts to maximize on the job and natural supports and attempts to ensure the job fits the individual’s abilities.
• 8. Evidence of Need: Evidence that continued employment supports are needed to maintain CIE or to prevent an unfavorable change in employment.
• 9. Submission of all records that support the individual has met the medical necessity criteria.

NOTE: Member meets criteria for discharge if there is insufficient documented evidence to support the need for continued services.

Unit Value

One unit = 15 minutes

Limits

• 1. Provider must complete ongoing education to the employer regarding ADA accommodations to ensure the transition from the ESP to the Long-Term Supported Employment Phase is successful and the individual’s needs are met.
• 2. Transportation included (exclusions apply). The ESP should not continue solely as a means of transportation.
• 3. Service does not cover: a) incentive payments made to an employer; b) payments that are passed through to the member; c) payments for non-Supported Employment training
• 4. Cannot be used to employ and provide services to the same individual at the provider agency location.
• 5. Service is not available at the same time of day as any other state funded service, Medicaid waiver service or one of the State Plan Medicaid services that works directly with the Individual.
• 6. Family members or legally responsible person(s) cannot provide the service to the member.
• 7. Member cannot be a HCBS Waiver members or eligible for or receiving Medicaid funded employment services (i.e., Supported Employment in Innovations Waiver & TBI Waiver, 1915(i) and 1915(b)(3) inclusive of Medicaid ICF-IID In Lieu of Services (ILOS) with employment component).
• 8. Member can receive service from only one provider during an active auth period.

Length of Stay

LTSE may be used on a regular basis to meet specific and detailed documented needs.

Age Group Details

Adolescents & Adults (age 16 or older)

Place of Service

A Competitive Integrated Employment HCBC setting. Cannot occur in licensed community facilities, inclusive of day programs.

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

• 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/documents/files/joint-communication-bulletin-j325-idd-eligibility-state

Supported Employment services aid with choosing, acquiring, and maintaining a job for individuals for whom Competitive Integrated Employment (CIE) has not been achieved and /or has been interrupted or intermittent. Job finding should be exploring options for CIE and is not based on placement from a pool of jobs that are available or set aside specifically for individuals with disabilities. The intent of Supported Employment services is to assist individuals with developing skills to seek, obtain and maintain CIE or develop and operate a micro-enterprise. Employment positions are found based on individual preferences, strengths, and experiences.

Authorization Guidelines

• 1. TAR: Prior authorization required
• 2. VR Documentation: Member must have completed the application process with VR and the Eligibility Decision outcome be documented noting ineligibility or closure for VR Services prior to receiving this service
• 3. NC-SNAP/ SIS/ TBI Assessment/ Employment Evaluation: Required, completed by Vocational Rehabilitation (VR)
• 4. Psychological, Neuropsychological, or Psychiatric Assessment: Required, must demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) or a TBI as defined by G.S. 122-C-3(38a) OR Physician Assessment: Required, to demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) without accompanying intellectual disabilities
• 5. PCP/ ISP: Required, incorporating the Career Development Plan with the Career Development & Planning Assessment attached. Must include evidence the member is interested in and needs service to maintain CIE or to obtain a change in employment conditions.
• 6. Service Order: Required, completed by a QP, MD/DO, LP, PA, or NP
• 7. Wage Info: Required upon initiation of the ESP, at the initiation of each plan year, and at the end of the 6th month of the plan year.
• 8. Evidence of Discharge Planning: to include a fade out plan, technology utilization, documentation of exhausted efforts to maximize on the job and natural supports and attempts to ensure the job fits the individual’s abilities.
• 9. Submission of all records that support the individual has met the medical necessity criteria.

Reauthorization Guidelines

• 1. TAR: Prior authorization required
• 2. VR Documentation: Member must have completed the application process with VR and the Eligibility Decision outcome be documented noting ineligibility or closure for VR Services prior to receiving this service
• 3. Current NC-SNAP/ SIS/ TBI Assessment/ Employment Evaluation: Required, completed by Vocational Rehabilitation
• 4. Psychological, Neuropsychological, or Psychiatric Assessment: Required, must demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) or a TBI as defined by G.S. 122-C-3(38a) OR Physician Assessment: Required, to demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) without accompanying intellectual disabilities
• 5. Updated PCP/ ISP: Required, incorporating the Career Development Plan with the Career Development & Planning Assessment attached. Updated goals showing a progression in skill acquisition or a documented need for ongoing training and/or support is required. PCP/ISP must include: Member’s employment integration feedback and employer’s ADA accommodations. Must include evidence the member is interested in and needs service to maintain CIE or to obtain a change in employment conditions.
• 6. Wage Info: Required upon initiation of the ESP, at the initiation of each plan year, and at the end of the 6th month of the plan year.
• 7. Evidence of Discharge Planning: to include a fade out plan, technology utilization, documentation of exhausted efforts to maximize on the job and natural supports and attempts to ensure the job fits the individual’s abilities.
• 8. Evidence of Need: Evidence that continued employment supports are needed to maintain CIE or to obtain a change in job opportunities when the 1-year phase timeframe has passed.
• 9. Submission of all records that support the individual has met the medical necessity criteria.

NOTE: Member meets criteria for discharge if there is insufficient documented evidence to support the need for continued services.

Unit Value

One unit = 15 minutes

Limits

• 1. Provider must complete ongoing education to the employer regarding ADA accommodations to ensure the transition from the ESP to the Long-Term Supported Employment Phase is successful and the individual’s needs are met.
• 2. Transportation included (exclusions apply). The ESP should not continue solely as a means of transportation.
• 3. Service does not cover: a) incentive payments made to an employer; b) payments that are passed through to the member; c) payments for non-Supported Employment training
• 4. Cannot be used to employ and provide services to the same individual at the provider agency location.
• 5. Service is not available at the same time of day as any other state funded service, Medicaid waiver service or one of the State Plan Medicaid services that works directly with the Individual.
• 6. Family members or legally responsible person(s) cannot provide the service tp the member.
• 7. Member cannot be a HCBS Waiver members or eligible for or receiving Medicaid funded employment services (i.e., Supported Employment in Innovations Waiver & TBI Waiver, 1915(i) and 1915(b)(3) inclusive of Medicaid ICF-IID In Lieu of Services (ILOS) with employment component).
• 8. Member can receive service from only one provider during an active auth period.

Length of Stay

• 1. The ESP should end once the member has achieved satisfactory work performance or work task meets employers’ expectations. The ESP does not typically exceed one calendar year.
• 2. If an individual exceeds the timeframe of the employment phase, an exception request should be made. The request should include the nature of the issue that caused the timeframe not to be met and the steps to prevent the issue from recurring.
• 3. After one exception for the ESP has occurred, technical assistance may be needed to reassess employment goals.

Age Group Details

Adolescents & Adults (age 16 or older)

Place of Service

A Competitive Integrated Employment HCBC setting. Cannot occur in licensed community facilities, inclusive of day programs.

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

• 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/documents/files/joint-communication-bulletin-j325-idd-eligibility-state

Supported Employment services aid with choosing, acquiring, and maintaining a job for individuals for whom Competitive Integrated Employment (CIE) has not been achieved and /or has been interrupted or intermittent. Job finding should be exploring options for CIE and is not based on placement from a pool of jobs that are available or set aside specifically for individuals with disabilities. The intent of Supported Employment services is to assist individuals with developing skills to seek, obtain and maintain CIE or develop and operate a micro-enterprise. Employment positions are found based on individual preferences, strengths, and experiences.

Long-Term Supported Employment (LTSE) Phase: This phase includes the various activities designed to continue to support the individual in maintaining CIE. The goal of this phase is to enable an individual to work as independently as possible and prepare for reduced level of staff support. In this phase the assessment of long- term support needs will occur, which support ongoing retention, prevent job loss, or make recommendations for discharge. Detailed documentation of goals specific to long-term support needs should reflect how the services being received is preparing the individual for working as independently as possible.

Authorization Guidelines

Initial Requests (if the service was not initiated in an earlier phase):

• 1. TAR: Prior authorization required
• 2. VR Documentation: Member must have completed the application process with VR and the Eligibility Decision outcome be documented noting ineligibility or closure for VR Services prior to receiving this service
• 3. NC-SNAP/ SIS/ TBI Assessment/ Employment Evaluation: Required, completed by Vocational Rehabilitation (VR)
• 4. Psychological, Neuropsychological, or Psychiatric Assessment: Required, must demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) or a TBI as defined by G.S. 122-C-3(38a) OR Physician Assessment: Required, to demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) without accompanying intellectual disabilities
• 5. PCP/ ISP: Required, incorporating the Career Development Plan with the Career Development & Planning Assessment attached. Must include evidence the member is interested in and needs service to maintain CIE or to obtain a change in employment conditions. LTSE related to medical/ behavioral/physical support needs requires medical or behavioral records and accompanying documentation in the PCP/ISP supporting the need for individual services as the most appropriate and viable option.
• 6. Service Order: Required, completed by a QP, MD/DO, LP, PA, or NP
• 7. Wage Info: Required upon initiation of the ESP, at the initiation of each plan year, and at the end of the 6th month of the plan year.
• 8. Evidence of Discharge Planning: to include a fade out plan, technology utilization, documentation of exhausted efforts to maximize on the job and natural supports and attempts to ensure the job fits the individual’s abilities.
• 9. Submission of all records that support the individual has met the medical necessity criteria.

Reauthorization Guidelines

• 1. TAR: Prior authorization required
• 2. VR Documentation: Member must have completed the application process with VR and the Eligibility Decision outcome be documented noting ineligibility or closure for VR Services prior to receiving this service
• 3. Current NC-SNAP/ SIS/ TBI Assessment/ Employment Evaluation: Required, completed by Vocational Rehabilitation
• 4. Psychological, Neuropsychological, or Psychiatric Assessment: Required, must demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) or a TBI as defined by G.S. 122-C-3(38a) OR Physician Assessment: Required, to demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) without accompanying intellectual disabilities
• 5. Updated PCP/ ISP: Required, incorporating the Career Development Plan with the Career Development & Planning Assessment attached. Updated goals showing a progression in skill acquisition or a documented need for ongoing training and/or support is required. PCP/ISP must include: Member’s employment integration feedback and employer’s ADA accommodations.
• 6. Wage Info: Required upon initiation of the ESP, at the initiation of each plan year, and at the end of the 6th month of the plan year.
• 7. Evidence of Discharge Planning: to include a fade out plan, technology utilization, documentation of exhausted efforts to maximize on the job and natural supports and attempts to ensure the job fits the individual’s abilities.
• 8. Evidence of Need: Evidence that continued employment supports are needed to maintain CIE or to prevent an unfavorable change in employment.
• 9. Submission of all records that support the individual has met the medical necessity criteria.

NOTE: Member meets criteria for discharge if there is insufficient documented evidence to support the need for continued services.

Unit Value

One unit = 15 minutes

Limits

• 1. Provider must complete ongoing education to the employer regarding ADA accommodations to ensure the transition from the ESP to the Long-Term Supported Employment Phase is successful and the individual’s needs are met.
• 2. Transportation included (exclusions apply). The ESP should not continue solely as a means of transportation.
• 3. Service does not cover: a) incentive payments made to an employer; b) payments that are passed through to the member; c) payments for non-Supported Employment training
• 4. Cannot be used to employ and provide services to the same individual at the provider agency location.
• 5. Service is not available at the same time of day as any other state funded service, Medicaid waiver service or one of the State Plan Medicaid services that works directly with the Individual.
• 6. Family members or legally responsible person(s) cannot provide the service to the member.
• 7. Member cannot be a HCBS Waiver members or eligible for or receiving Medicaid funded employment services (i.e., Supported Employment in Innovations Waiver & TBI Waiver, 1915(i) and 1915(b)(3) inclusive of Medicaid ICF-IID In Lieu of Services (ILOS) with employment component).
• 8. Member can receive service from only one provider during an active auth period.

Length of Stay

LTSE may be used on a regular basis to meet specific and detailed documented needs.

Age Group Details

Adolescents & Adults (age 16 or older)

Place of Service

A Competitive Integrated Employment HCBC setting. Cannot occur in licensed community facilities, inclusive of day programs.

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

• 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

Supported Supported Employment services aid with choosing, acquiring, and maintaining a job for individuals for whom Competitive Integrated Employment (CIE) has not been achieved and /or has been interrupted or intermittent. Job finding should be exploring options for CIE and is not based on placement from a pool of jobs that are available or set aside specifically for individuals with disabilities. The intent of Supported Employment services is to assist individuals with developing skills to seek, obtain and maintain CIE or develop and operate a micro-enterprise. Employment positions are found based on individual preferences, strengths, and experiences.

Pre-employment Phase (PEP): This phase includes but is not limited to activities that should occur prior to obtaining CIE, such as benefits counseling referral, career exploration, discovery, job readiness skills, and job development activities. The goal of this phase is to have the individual work ready and to assist the individual to obtain employment. Detailed documentation should reflect how the provider is preparing an individual for employment. Employment services aid with choosing, acquiring, and maintaining a job for individuals for whom Competitive Integrated Employment (CIE) has not been achieved and /or has been interrupted or intermittent. Job finding should be exploring options for CIE and is not based on placement from a pool of jobs that are available or set aside specifically for individuals with disabilities. The intent of Supported Employment services is to assist individuals with developing skills to seek, obtain and maintain CIE or develop and operate a micro-enterprise. Employment positions are found based on individual preferences, strengths, and experiences.

Long-Term Supported Employment (LTSE) Phase: This phase includes the various activities designed to continue to support the individual in maintaining CIE. The goal of this phase is to enable an individual to work as independently as possible and prepare for reduced level of staff support. In this phase the assessment of long- term support needs will occur, which support ongoing retention, prevent job loss, or make recommendations for discharge. Detailed documentation of goals specific to long-term support needs should reflect how the services being received is preparing the individual for working as independently as possible.

Authorization Guidelines

• 1. TAR: Prior authorization required
• 2. VR Documentation: Member must have completed the application process with VR and the Eligibility Decision outcome be documented noting ineligibility or closure for VR Services prior to receiving this service
• 3. NC-SNAP/ SIS/ TBI Assessment/ Employment Evaluation: Required, completed by Vocational Rehabilitation (VR)
• 4. Psychological, Neuropsychological, or Psychiatric Assessment: Required, must demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) or a TBI as defined by G.S. 122-C-3(38a) OR Physician Assessment: Required, to demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) without accompanying intellectual disabilities
• 5. PCP/ ISP: Required, incorporating the Career Development Plan with the Career Development & Planning Assessment attached. Must include evidence that the member is interested in learning about or obtaining CIE.
• 6. Service Order: Required, completed by a QP, MD/DO, LP, PA, or NP
• 7. Submission of all records that support the individual has met the medical necessity criteria.

Reauthorization Guidelines

• 1. TAR: Prior authorization required
• 2. VR Documentation: Member must have completed the application process with VR and the Eligibility Decision outcome be documented noting ineligibility or closure for VR Services prior to receiving this service
• 3. Current NC-SNAP/ SIS/ TBI Assessment/ Employment Evaluation: Required, completed by Vocational Rehabilitation
• 4. Psychological, Neuropsychological, or Psychiatric Assessment: Required, must demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) or a TBI as defined by G.S. 122-C-3(38a) OR Physician Assessment: Required, to demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) without accompanying intellectual disabilities
• 5. Updated PCP/ ISP: Required, incorporating the Career Development Plan with the Career Development & Planning Assessment attached. Updated goals showing a progression in skill acquisition or a documented need for ongoing training and/or support is required. PCP/ISP must include: Member’s employment integration feedback and employer’s ADA accommodations. Must include evidence that the member is interested in learning about or obtaining CIE.
• 6. Evidence of Need: Evidence that continued job development activities are needed to obtain CIE when the 6-month phase timeframe has passed.
• 7. Submission of all records that support the individual has met the medical necessity criteria.

NOTE: Member meets criteria for discharge if there is insufficient documented evidence to support the need for continued services.

• 2. VR Documentation: Member must have completed the application process with VR and the Eligibility Decision outcome be documented noting ineligibility or closure for VR Services prior to receiving this service
• 3. Current NC-SNAP/ SIS/ TBI Assessment/ Employment Evaluation: Required, completed by Vocational Rehabilitation
• 4. Psychological, Neuropsychological, or Psychiatric Assessment: Required, must demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) or a TBI as defined by G.S. 122-C-3(38a) OR Physician Assessment: Required, to demonstrate an individual has a developmental disability as defined by G.S. 122-C-3(12a) without accompanying intellectual disabilities
• 5. Updated PCP/ ISP: Required, incorporating the Career Development Plan with the Career Development & Planning Assessment attached. Updated goals showing a progression in skill acquisition or a documented need for ongoing training and/or support is required. PCP/ISP must include: Member’s employment integration feedback and employer’s ADA accommodations.
• 6. Wage Info: Required upon initiation of the ESP, at the initiation of each plan year, and at the end of the 6th month of the plan year.
• 7. Evidence of Discharge Planning: to include a fade out plan, technology utilization, documentation of exhausted efforts to maximize on the job and natural supports and attempts to ensure the job fits the individual’s abilities.
• 8. Evidence of Need: Evidence that continued employment supports are needed to maintain CIE or to prevent an unfavorable change in employment.
• 9. Submission of all records that support the individual has met the medical necessity criteria.

NOTE: Member meets criteria for discharge if there is insufficient documented evidence to support the need for continued services.

Unit Value

One unit = 15 minutes

Limits

• 1. Provider must complete ongoing education to the employer regarding ADA accommodations to ensure the transition from the ESP to the Long-Term Supported Employment Phase is successful and the individual’s needs are met.
• 2. Transportation included (exclusions apply). The ESP should not continue solely as a means of transportation.
• 3. Service does not cover: a) incentive payments made to an employer; b) payments that are passed through to the member; c) payments for non-Supported Employment training
• 4. Cannot be used to employ and provide services to the same individual at the provider agency location.
• 5. Service is not available at the same time of day as any other state funded service, Medicaid waiver service or one of the State Plan Medicaid services that works directly with the Individual.
• 6. Family members or legally responsible person(s) cannot provide the service tp the member.
• 7. Member cannot be a HCBS Waiver members or eligible for or receiving Medicaid funded employment services (i.e., Supported Employment in Innovations Waiver & TBI Waiver, 1915(i) and 1915(b)(3) inclusive of Medicaid ICF-IID In Lieu of Services (ILOS) with employment component).
• 8. Member can receive service from only one provider during an active auth period.

Length of Stay

• 1. The PEP does not exceed six months in a typical situation.
• 2. If an individual exceeds the timeframe of the pre-employment phase, an exception request should be made. The request should include the nature of the issue that caused the timeframe not to be met and the steps to prevent the issue from recurring.
• 3. After one exception for the Pre-employment Phase has occurred, technical assistance may be needed to reassess employment goals.

Age Group Details

Adolescents & Adults (age 16 or older)

Place of Service

A Competitive Integrated Employment HCBC setting. Cannot occur in licensed community facilities, inclusive of day programs.

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

• 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

Low Intensity: Service is typically provided in individual apartments, sometimes clustered in small developments that may or may not have an apartment manager on site during regularly scheduled hours. This is the least restrictive residential service which includes room and periodic support care. These apartments are the individual's home, not licensed facilities. No BH services are attached to the apartment. The individual may receive periodic MH services such as outpatient tx, structured day programming, etc., independent of the "supervised living" apartment. Community based MH services such as ACTT may be provided to the individual in the home, but the service is not programmatically linked to the home.

Authorization Guidelines

• 1. TAR: Prior approval is required.
• 2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
• 3. NC SNAP or SIS: Required, if applicable
• 4. Service/ Tx Plan: Required

Reauthorization Guidelines

• 1. TAR: Prior authorization required
• 2. Service/ Tx Plan: recently reviewed detailing the recipient’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.

Unit Value

One unit = 1 day

Limits

• 1. No new admissions effective 10/5/23
• 2. If an individual is temporarily in a respite or other 24-hour placement, staff are to assure that there is no double billing.
• 3. Therapeutic leave does not apply to this service.

Length of Stay

Up to a 6-month per authorization.

Level of Care

While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

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

• State-Funded Supervised Living Low
• Records Management and Documentation Manual
• DMHDDSUS Bulletins

Moderate Intensity: Service is typically in an apartment which includes periodic support care to one or more individuals who do not need 24-hour supervision; or, for whom care in a group setting is considered inappropriate. Supervision includes routine or spontaneous visits, on-call support, and sometimes more intense one-on-one contact for several consecutive hours. It includes assistance in daily living skills, supportive counseling, and monitoring of the client's well-being. It may also include the employment of an individual to live with the client(s) to provide the appropriate level of supervision.

Authorization Guidelines

• 1. TAR: Prior approval is required.
• 2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
• 3. NC SNAP or SIS: Required, if applicable
• 4. Service/ Tx Plan: Required

Reauthorization Guidelines

• 1. TAR: Prior authorization required
• 2. Service/ Tx Plan: recently reviewed detailing the recipient’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.

Unit Value

One unit = 1 day

Limits

• 1. No new admissions effective 10/5/23
• 2. If an individual is temporarily in a respite or other 24-hour placement, staff are to assure that there is no double billing.
• 3. Therapeutic leave does not apply to this service.

Length of Stay

Up to a 6-month per authorization.

Level of Care

While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

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

• State-Funded Supervised Living Moderate Intensity
• Records Management and Documentation Manual
• DMHDDSUS Bulletins

Low Intensity: A residential service which includes room and board and provides "family style" supervision and monitoring of daily activities. Individuals live with a family who act as providers of supportive services. The service providers are supported by the professional staff of the area program or the contract agency with ongoing consultation and education to the service providers in their own homes.

Moderate Intensity: A 24-hour service (including room and board) which provides professionally trained parent-substitutes who work intensively with individuals in providing for their basic living, socialization, therapeutic, and skill-learning needs. The parent-substitutes receive substantial training and receive close supervision and support from the area program or its contract agencies. Recipients receiving this service may utilize periodic or day program services from the area program; but such services should be accounted for and reported separately.

Authorization Guidelines

• 1. TAR: Prior authorization is required
• 2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable..
• 3. NC SNAP or SIS: Required, if applicable
• 4. Service/ Tx Plan: Required

Reauthorization Guidelines

• 1. TAR: prior approval required
• 2. Service/ Tx Plan: recently reviewed detailing the recipient’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.

Unit Value

One unit = 1 day

Limits

• 1. No new admissions effective 10/5/2023.

Length of Stay

Request length of stay can be for up to one fiscal year or the end of the PCP (whichever comes first).

Level of Care

While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

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

• Family Living Low Intensity
• Records Management and Documentation Manual
• Person Centered Planning

Low Intensity: A residential service which includes room and board and provides "family style" supervision and monitoring of daily activities. Individuals live with a family who act as providers of supportive services. The service providers are supported by the professional staff of the area program or the contract agency with ongoing consultation and education to the service providers in their own homes.

Moderate Intensity: A 24-hour service (including room and board) which provides professionally trained parent-substitutes who work intensively with individuals in providing for their basic living, socialization, therapeutic, and skill-learning needs. The parent-substitutes receive substantial training and receive close supervision and support from the area program or its contract agencies. Recipients receiving this service may utilize periodic or day program services from the area program; but such services should be accounted for and reported separately.

Authorization Guidelines

• 1. TAR: Prior authorization is required
• 2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable..
• 3. NC SNAP or SIS: Required, if applicable
• 4. Service/ Tx Plan: Required

Reauthorization Guidelines

• 1. TAR: prior approval required
• 2. Service/ Tx Plan: recently reviewed detailing the recipient’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.

Unit Value

One unit = 1 day

Limits

• 1. No new admissions effective 10/5/2023.

Length of Stay

Request length of stay can be for up to one fiscal year or the end of the PCP (whichever comes first).

Level of Care

While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

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

• Family Living Moderate Intensity
• Records Management and Documentation Manual
• Person Centered Planning

The determining factor as to whether a particular group living arrangement is to be considered low-moderate-high is the intensity of the individual tx/ habilitation provided and the integration between day and 24-hour tx/ habilitation programming.

Low Intensity: Care (room & board included) provided in a home-like environment to 5 or more individuals. Supervision and therapeutic intervention are limited to sleeping time, home living skills and leisure time activities. Primary tx and rehab services are provided off-site and are accounted for where appropriate (i.e., Outpatient Treatment/ Habilitation, ADVP). Group Living-Low Intensity must be provided in a licensed facility.

Moderate Intensity: A 24-Hour service that includes a greater degree of supervision and therapeutic intervention for the residents because of the degree of their dependence or the severity of their disability. The care (including room and board), that is provided, includes individualized therapeutic or rehabilitative programming designed to supplement day tx services which are provided in another setting. This level of group living is often provided because the individual's removal from his/her regular living arrangement is necessary in order to facilitate tx.

High Intensity: A 24-Hour service (including room and board) that includes a significant amount of individualized therapeutic or rehabilitative programming as a part of the residential placement. The individuals can receive day treatment services either on-site or off-site; but the day and residential programming is highly integrated. The individuals who receive this level of 24-Hour care are significantly disabled and dependent and would need to be served in an institutional setting. Staff are trained and receive regular professional support and supervision. The costs related to day programming are often a part of the day rate for this service. If the day service cost is reported separately, Group Living-Moderate Intensity should be considered as an alternative for this type of service.

Authorization Guidelines

No prior authorization is required for those admitted to PORT’s Adolescent SU Tx Program or those admitted to the Robeson Village Perinatal Program. (some contract variations).

• 1. TAR: Prior authorization required
• 2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable.
• 3. Service/ Tx Plan: Required
• 4. NC SNAP/ SIS: Required, if applicable

Reauthorization Guidelines

• 1. TAR: Prior authorization required
• 2. Service/ Tx Plan: 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.

Unit Value

One unit = 1 day, to be counted in a midnight occupied bed count. Allowance will be made for Therapeutic Leave.

Limits

• 1. No new admissions effective 10/5/23
• 2. When available, new admissions are only open to individuals stepping down from long term care (2 yrs or more) in a state operated facility.

Length of Stay

Up to a 6-month auth period per request.

Level of Care

NC SNAP OR Supports Intensity Scale OR ASAM Level 3.1 (for Low Intensity), ASAM Level 3.5 (for Moderate Intensity, and ASAM Level 3.7 (for High Intensity). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

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

• State-Funded Group Living Low Intensity
• Records Management and Documentation Manual
• Person Centered Planning

The determining factor as to whether a particular group living arrangement is to be considered low-moderate-high is the intensity of the individual tx/ habilitation provided and the integration between day and 24-hour tx/ habilitation programming.

Low Intensity: Care (room & board included) provided in a home-like environment to 5 or more individuals. Supervision and therapeutic intervention are limited to sleeping time, home living skills and leisure time activities. Primary tx and rehab services are provided off-site and are accounted for where appropriate (i.e., Outpatient Treatment/ Habilitation, ADVP). Group Living-Low Intensity must be provided in a licensed facility.

Moderate Intensity: A 24-Hour service that includes a greater degree of supervision and therapeutic intervention for the residents because of the degree of their dependence or the severity of their disability. The care (including room and board), that is provided, includes individualized therapeutic or rehabilitative programming designed to supplement day tx services which are provided in another setting. This level of group living is often provided because the individual's removal from his/her regular living arrangement is necessary in order to facilitate tx.

High Intensity: A 24-Hour service (including room and board) that includes a significant amount of individualized therapeutic or rehabilitative programming as a part of the residential placement. The individuals can receive day treatment services either on-site or off-site; but the day and residential programming is highly integrated. The individuals who receive this level of 24-Hour care are significantly disabled and dependent and would need to be served in an institutional setting. Staff are trained and receive regular professional support and supervision. The costs related to day programming are often a part of the day rate for this service. If the day service cost is reported separately, Group Living-Moderate Intensity should be considered as an alternative for this type of service.

Authorization Guidelines

No prior authorization is required for those admitted to PORT’s Adolescent SU Tx Program or those admitted to the Robeson Village Perinatal Program. (some contract variations).

• 1. TAR: Prior authorization required
• 2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable.
• 3. Service/ Tx Plan: Required
• 4. NC SNAP/ SIS: Required, if applicable

Reauthorization Guidelines

• 1. TAR: Prior authorization required
• 2. Service/ Tx Plan: 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.

Unit Value

One unit = 1 day, to be counted in a midnight occupied bed count. Allowance will be made for Therapeutic Leave.

Limits

• 1. No new admissions effective 10/5/23
• 2. When available, new admissions are only open to individuals stepping down from long term care (2 yrs or more) in a state operated facility.

Length of Stay

Up to a 6-month auth period per request.

Level of Care

NC SNAP OR Supports Intensity Scale OR ASAM Level 3.1 (for Low Intensity), ASAM Level 3.5 (for Moderate Intensity, and ASAM Level 3.7 (for High Intensity). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

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

• State-Funded Group Living Moderate Intensity
• Records Management and Documentation Manual
• Person Centered Planning

The determining factor as to whether a particular group living arrangement is to be considered low-moderate-high is the intensity of the individual tx/ habilitation provided and the integration between day and 24-hour tx/ habilitation programming.

Low Intensity: Care (room & board included) provided in a home-like environment to 5 or more individuals. Supervision and therapeutic intervention are limited to sleeping time, home living skills and leisure time activities. Primary tx and rehab services are provided off-site and are accounted for where appropriate (i.e., Outpatient Treatment/ Habilitation, ADVP). Group Living-Low Intensity must be provided in a licensed facility.

Moderate Intensity: A 24-Hour service that includes a greater degree of supervision and therapeutic intervention for the residents because of the degree of their dependence or the severity of their disability. The care (including room and board), that is provided, includes individualized therapeutic or rehabilitative programming designed to supplement day tx services which are provided in another setting. This level of group living is often provided because the individual's removal from his/her regular living arrangement is necessary in order to facilitate tx.

High Intensity: A 24-Hour service (including room and board) that includes a significant amount of individualized therapeutic or rehabilitative programming as a part of the residential placement. The individuals can receive day treatment services either on-site or off-site; but the day and residential programming is highly integrated. The individuals who receive this level of 24-Hour care are significantly disabled and dependent and would need to be served in an institutional setting. Staff are trained and receive regular professional support and supervision. The costs related to day programming are often a part of the day rate for this service. If the day service cost is reported separately, Group Living-Moderate Intensity should be considered as an alternative for this type of service.

Authorization Guidelines

No prior authorization is required for those admitted to PORT’s Adolescent SU Tx Program or those admitted to the Robeson Village Perinatal Program. (some contract variations).

• 1. TAR: Prior authorization required
• 2. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable.
• 3. Service/ Tx Plan: Required
• 4. NC SNAP/ SIS: Required, if applicable

Reauthorization Guidelines

• 1. TAR: Prior authorization required
• 2. Service/ Tx Plan: 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.

Unit Value

One unit = 1 day, to be counted in a midnight occupied bed count. Allowance will be made for Therapeutic Leave.

Limits

• 1. No new admissions effective 10/5/23
• 2. When available, new admissions are only open to individuals stepping down from long term care (2 yrs or more) in a state operated facility.

Length of Stay

Up to a 6-month auth period per request.

Level of Care

NC SNAP OR Supports Intensity Scale OR ASAM Level 3.1 (for Low Intensity), ASAM Level 3.5 (for Moderate Intensity, and ASAM Level 3.7 (for High Intensity). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

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

• State-Funded Group Living High Intensity
• Records Management and Documentation Manual
• Person Centered Planning

Service is focused on reducing psychiatric and behavioral symptoms to improve the recipient’s functioning in familial, social, educational, or occupational life domains. The recipient’s needs and preferences determine the treatment goals, frequency, and duration of services, as well as measurable and desirable outcomes.

Authorization Guidelines

Prior authorization is not required. No more than 12 visits for adults & 24 visits for children/ adolescents each fiscal year (July 1st – June 30th) of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Diagnostic Eval.

Unit Value

One service code = 1 unit of service.

Limits

• 1. Maximum benefit of 12 visits for adults & 24 visits for children/ adolescents.
• 2. Service cannot be billed while an individual is authorized to receive ACT, IIH, MST, Day Treatment, SAIOP, or SACOT
• 3. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
• 4. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
• 5. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.

6 For substance use disorders, ASAM level 1 outpatient services are provided for less than nine hours a week for adults and less than six (6) hours a week for adolescents.

• 7. The provider will communicate and coordinate care with other professionals providing care to the recipient.
• 8. Provider must verify individual’s eligibility each time a service is rendered
• 9. If a higher LOC is indicated but unavailable or the individual is refusing the service, outpatient services can be provided until the appropriate level of care is available or to support the individual to participate in that higher LOC
• 10. Enrolled providers must provide, or have a written agreement with another entity, for access to 24-hour coverage for BH emergency services.

Length of Stay

No more than 12 visits for adults & 24 visits for children/ adolescents each fiscal year (July 1st – June 30th) of a combination of Individual Therapy, Family Therapy, Group Therapy, and Psych Diagnostic Eval.

Level of Care

ASAM Level 1 or lower (if applicable). While the LOCUS/ CALOCUS are specifically no longer required, providers are still expected to use a standardized assessment tool when evaluating an individual for treatment services.

Other Information

Modifiers:

GT: Telehealth KX: Telephonic

Telephonic Services (KX) are reserved for when physical or BH status or access issues (transportation, telehealth technology) prevent the recipient from participating in-person or telehealth services.

How to Submit

N/A - No authorization is required

Resources

• State-Funded Outpatient Behavioral Health Services Definition
• Records Management and Documentation Manual