Prior Authorization Services

Brief Service Description: This service provides 24-hour access to continuous intensive evaluation and treatment delivered in an Institute for Mental Disease (IMD) for acute and subacute inpatient psychiatric disorders. Delivery of service is provided by nursing and medical professionals under the supervision of a psychiatrist. Providers must follow the requirements for inpatient level of care outlined in Clinical Coverage Policy (CCP) 8-B, Inpatient Behavioral Health Services.

Auth Submission Requirements/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for the first 72 hours of service.

Initial Requests (after pass-through):
1. TAR: prior authorization required within the first 72 hours of service initiation.  
2. CCA or DA: Required. See CCP Section 7.5 for additional requirements. An H&P/ Initial Psychiatric Evaluation may satisfy this requirement.
3. Service Order: Required, signed by a physician, LP, PA, or NP. A signed H&P/ Initial Psychiatric Eval meets this requirement.
4. Service Plan: Required
5. Submission of all records that support the individual has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required. 
2. Updated Service Plan: Required
3. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Length of Stay: 
1. Members receiving tx for MH diagnoses are limited to no more than 15 authorized days each calendar month. For admissions spanning two consecutive months, the total length of stay may exceed 15 days, but no more than 15 days may be authorized in each month. There is not a day limit for members receiving SU services.
2. For State ADATC’s, the initial authorization will be for at least 7 days.
3. 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.  
4. Retrospective auths due to late submissions is not permitted.

Units: Per diem based on the midnight bed count
Age Group: Adults aged 21-64
Place of Service: Institute for Mental Disease (IMD)

Service Specifics, Limitations/ Exclusions (not all inclusive): 
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. Discharge Planning shall begin upon admission to this service.
4. Prior authorization is not required for MCD BH Services rendered to Medicare/Medicaid dual eligible members or members with 3rd-party insurance because MCD is the payer of last resort.  When MCD becomes the primary payer, a primary payer auth denial/ exhaustion of benefits letter is submitted with the MCD TAR.
5. 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.

• Clinical Coverage Policy No. 8-B, Inpatient Behavioral Health Services
• July 2012 MCD Bulletin: Authorization Requests by Psychiatric Inpatient Acute C…
• JCB #J277: Authorization Requests for Services When a Third-Party Payer is Prim…
• JCB #J265: Clarification of Services in an IMD
• JCB #J348: SUD IMD Clarification
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: This is an organized service that provides intensive evaluation and treatment delivered in an acute care inpatient setting by medical and nursing professionals. This service focuses on reducing acute psychiatric symptoms through in-person, structured group and individual treatment.

Auth Submission Requirements/ Documentation Requirements
Initial Requests:
1. TAR: Required  
2. I/DD Exception Form: Required per Diversion Law, if applicable.
3. CCA or DA: Required. See CCP Section 7.5 for additional requirements. An H&P/ Initial Psychiatric Evaluation may meet this requirement.
4. Service Order: Required, signed by a physician, LP, PA, or NP. A signed H&P/ Initial Psychiatric Eval meets this requirement.
5. Service Plan: Required
6. Submission of all records that support the member has met the medical necessity criteria. The state facility shall provide Trillium with all necessary clinical information needed for the utilization management process.

Reauthorization Requests:
Not applicable
 

Authorization Parameters
Length of Stay: 
1. Provider must submit a TAR covering the member’s length of stay on the next business day following the Individual’s discharge.
2. Member’s that present directly to the facility as an emergency commitment or as a self-referral, the facility shall submit a TAR by the next business day.
3. Members receiving tx for MH diagnoses are limited to no more than 15 authorized days each calendar month. For admissions spanning two consecutive months, the total length of stay may exceed 15 days, but no more than 15 days may be authorized in each month. There is not a day limit for members receiving SU services.

Units: 1 unit per day for up to 15 days per month.
Age Group: Adults aged 21-64
Place of Service: Institute for Mental Disease (IMD)

Service Specifics, Limitations/ Exclusions (not all inclusive): 
1. Trillium will issue an auth decision within 14 days after receipt of the TAR.
2. 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.
3. Medicaid eligibility must be verified each time a service is rendered.
4. Discharge Planning shall begin upon admission to this service.
5. Prior authorization is not required for MCD BH Services rendered to Medicare/Medicaid dual eligible members or members with 3rd-party insurance because MCD is the payer of last resort.  When MCD becomes the primary payer, a primary payer auth denial/ exhaustion of benefits letter is submitted with the MCD TAR.

• Clinical Coverage Policy No. 8-B, Inpatient Behavioral Health Services
• July 2012 MCD Bulletin: Authorization Requests by Psychiatric Inpatient Acute C…
• JCB #J277: Authorization Requests for Services When a Third-Party Payer is Prim…
• JCB #J265: Clarification of Services in an IMD
• JCB #J348: SUD IMD Clarification
• APSM 45-2 Records Management and Documentation Manual

Limited funding. Not an entitlement. Only available to legacy Eastpointe and Sandhills recipients.

Brief Service Description: 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..

Auth Submission Requirements/ Documentation Requirements
Initial & Reauthorization Requests:
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 Requests:
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.

Authorization Parameters
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)

Units: One unit = 15 minutes

Age Group: Adolescents & Adults (age 16 or older)

Level of Care: NC SNAP Overall Level of Eligible Support of 1 or higher

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Only available to legacy Eastpointe and Sandhills recipients

• State Funded MH/DD/SA Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual
• NCDHHS NC Support Needs Assessment Profile website
• JCB #325: I/DD Eligibility for State-Funded Services
• Competitive, Integrated Employment Memo

Limited funding. Not an entitlement.

Brief Service Description: 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.

Auth Submission Requirements
All Requests: 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.

Authorization Parameters
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.

Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
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.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: This service is an organized outpatient service that provides medically supervised evaluation, withdrawal management, and referral in a licensed facility. Services are provided in regularly scheduled sessions to be delivered under a defined set of policies and procedures or medical protocols. This is a service for a beneficiary who is assessed to be at minimal risk of severe withdrawal, free of severe physical and psychiatric complications, and can be safely managed at this level.

Auth Submission Requirements/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. CCA: completed within three calendar days of the admission
2. Service Plan: Required, detailing the members’ progress with the service
3. Service Order: Required, signed by a physician, PA, or NP.
4. Discharge Planning: Step-down discharge ASAM LOC must be determined as part of the CCA
5. Submission of applicable records that support the member has met the medical necessity criteria.

All services are subject to post-payment review.

Authorization Parameters
Units: 1 unit = 15 minutes

Age Group: Adolescents & Adults (Aged 18 and older)

Level of Care: ASAM Level 1-WM. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions.

Population Served: Primary Substance Use Diagnosis only

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Provider shall verify each Medicaid beneficiary’s eligibility each time a service is rendered
2. Facility must operate a minimum of 8 hours per day, all 5 weekdays (Monday through Friday), and a minimum of 4 hours daily on the weekend (Saturday and Sunday). The hours of operation must be extended based on beneficiary need. This service must be available for admission seven days per week.
3. Services may not be provided on the same day as Substance Use Disorder Withdrawal Management or Residential Services, except on day of admission or discharge.
4. Clinical and administrative supervision is covered as an indirect cost and part of the rate

• Clinical Coverage Policy No 8A-8: Ambulatory Withdrawal Management (WM) with Ex…
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: This service is an organized outpatient service that provides medically supervised evaluation, withdrawal management, and referral in a licensed facility. This service is for a beneficiary who is assessed to be at moderate risk of severe withdrawal, free of severe physical and psychiatric complications and would safely respond to several hours of monitoring, medication, and treatment. These services are designed to treat the beneficiary’s level of clinical severity and to achieve safe and comfortable withdrawal from alcohol and other substances to effectively facilitate the beneficiary’s transition into ongoing treatment and recovery.

Auth Submission Requirements/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. CCA: completed within three calendar days of the admission
2. Service Plan: Required, detailing the members’ progress with the service
3. Service Order: Required, signed by a physician, PA, or NP.
4. Discharge Planning: Step-down discharge ASAM LOC must be determined as part of the CCA
5. Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) score(s): Required
6. Discharge Planning: Step-down discharge ASAM LOC must be determined as part of the CCA

All services are subject to post-payment review.

Authorization Parameters
Units: 1 unit = 15 minutes

Age Group: Adolescents & Adults (Aged 18 and older)

Level of Care: ASAM Level 2-WM. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions.

Population Served: Primary Substance Use Diagnosis only

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Provider shall verify each Medicaid beneficiary’s eligibility each time a service is rendered
2. Facility must operate a minimum of 8 hours per day, all 5 weekdays (Monday through Friday), and a minimum of 4 hours daily on the weekend (Saturday and Sunday). The hours of operation must be extended based on beneficiary need. This service must be available for admission seven days per week.
3. Services may not be provided on the same day as Substance Use Disorder Withdrawal Management or Residential Services, except on day of admission or discharge.
4. Clinical and administrative supervision is covered as an indirect cost and part of the rate

• Clinical Coverage Policy No 8A-8: Ambulatory Withdrawal Management (WM) with Ex…
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Limited funding. Not an entitlement.

Brief Service Description: This is a service for an individual who is assessed to be at minimal risk of severe withdrawal, free of severe physical and psychiatric complications, and can be safely managed at this level. These services are designed to treat the individual’s level of clinical severity and to achieve safe and comfortable withdrawal from alcohol and other substances to effectively facilitate the individual’s transition into ongoing treatment and recovery.

Auth Submission Requirements/ Documentation Requirements
Pass-Through Period: Prior authorization is not required through the first 3 calendar days of services.

Initial Requests (after pass-through):
1. TAR: Required within the first 3 calendar days of service initiation
2. Initial Abbreviated Assessment or CCA / DA: A comprehensive clinical assessment must be completed by a licensed professional to determine an ASAM level of care for discharge planning w/in 3 days of admission.
3. Service Order: Required, signed by a physician, PA, or NP
4. CIWA-Ar score, or other comparable standardized scoring system: Required, supporting this LOC
5. Submission of applicable records that support the recipient has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: Prior approval required
2. CIWA-Ar score, or other comparable standardized scoring system: Required, supporting this LOC
3. Updated Service Plan: recently reviewed detailing the recipient’s progress with the service
4. Submission of all records that support the recipient has met the medical necessity criteria.

Authorization Parameters
Units: One unit = 15 minutes

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1-WM. The ASAM Criteria, Third Edition uses six dimensions to create a holistic, biopsychosocial assessment to be used for service planning and treatment. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions.

Population Served: Primary Substance Use Diagnosis only

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Service may not be provided on the same day as Substance Use Disorder Withdrawal Management or Residential Services, except on day of admission or discharge
2. This facility must be in operation a minimum of 8 hours per day, all 5 weekdays (Monday through Friday), and a minimum of 4 hours daily on the weekend (Saturday and Sunday). The hours of operation must be extended based on an individual’s need.  This service must be available for admission seven days per week.
3. Discharge planning beginning at admission
4. Provider(s) shall verify eligibility each time a service is rendered
5. State funds shall not cover clinical and administrative supervision of Level 1 WM staff, which is covered as an indirect cost and part of the rate

• State-Funded Ambulatory Withdrawal Management Without Extended On-Site Monitori…
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: An ACT team assists a member in advancing toward personal goals with a focus on enhancing community integration and regaining valued roles (example: worker, daughter, resident, spouse, tenant, or friend). A fundamental charge of ACT is to be the first line (and generally sole provider) of all the services that an ACT member needs. A member who is appropriate for ACT does not benefit from receiving services across multiple, disconnected providers, and may become at greater risk of hospitalization, homelessness, substance use, victimization, and incarceration.

Auth Submission Requirements/ Documentation Requirements
Pass-Through Period:
Prior authorization is not required for this service.

Maintained in the Record (not all inclusive): 
1. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable
2. Complete PCP: Required, to include all required signatures and 3-page crisis plan. Specific interventions, duration, and frequency of ACTT must be detailed in the Plan. PCP interventions must address the role of all team members working with the individual. 
3. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
4. Submission of applicable records that support the member has met the medical necessity criteria.

All services are subject to post-payment review.

Authorization Parameters
Units:
1. One unit = 1 event 
2. Trillium has agreed to billing a weekly case rate up to 2 units per week with up to 4 units per calendar month (instead of the prescribed 1 unit per week). A shadow claim should be billed every time an encounter occurs.
3. The expectation is most ACT members will receive more than 4 contacts per month, with most seeing at least 3 team members in a given month.

Age Group: Adults (age 18 and older)

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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Members with a primary dx of a SU, IDD, TBI, borderline personality disorder, or an autism spectrum disorder are not the intended member group for ACT and should not be referred if they do not have a co-occurring psychiatric disorder. 
2. ACT cannot be provided concurrently w/: Outpatient therapy, Med Management, or Psych Services; Mobile Crisis; PSR (after a 30-day transition period); CST; Partial Hospitalization; Tenancy Support Services; Nursing home facility, or IPS-Supported Employment or LTVS.

• Clinical Coverage Policy 8A-1: Assertive Community Treatment (ACT) Program
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manuals

Brief Service Description: An ACT team assists a member in advancing toward personal goals with a focus on enhancing community integration and regaining valued roles (example: worker, daughter, resident, spouse, tenant, or friend). A fundamental charge of ACT is to be the first line (and generally sole provider) of all the services that an ACT member needs. A member who is appropriate for ACT does not benefit from receiving services across multiple, disconnected providers, and may become at greater risk of hospitalization, homelessness, substance use, victimization, and incarceration.

Auth Submission Requirements/ Documentation Requirements
Pass-Through Period:
Prior authorization is not required for this service.

Maintained in the Record (not all inclusive): 
1. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable
2. Complete PCP: Required, to include all required signatures and 3-page crisis plan. Specific interventions, duration, and frequency of ACTT must be detailed in the Plan. PCP interventions must address the role of all team members working with the individual. 
3. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
4. Submission of applicable records that support the member has met the medical necessity criteria.

All services are subject to post-payment review.

Authorization Parameters
Units:
1. One unit = 1 event 
2. Trillium has agreed to billing a weekly case rate up to 2 units per week with up to 4 units per calendar month (instead of the prescribed 1 unit per week). A shadow claim should be billed every time an encounter occurs.
3. The expectation is most ACT members will receive more than 4 contacts per month, with most seeing at least 3 team members in a given month.

Age Group: Adults (age 18 and older)

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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Members with a primary dx of a SU, IDD, TBI, borderline personality disorder, or an autism spectrum disorder are not the intended member group for ACT and should not be referred if they do not have a co-occurring psychiatric disorder. 
2. ACT cannot be provided concurrently w/: Outpatient therapy, Med Management, or Psych Services; Mobile Crisis; PSR (after a 30-day transition period); CST; Partial Hospitalization; Tenancy Support Services; Nursing home facility, or IPS-Supported Employment or LTVS.

• Clinical Coverage Policy 8A-1: Assertive Community Treatment (ACT) Program
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manuals

Brief Service Description: An Assertive Community Treatment (ACT) team consists of a community-based group of medical, behavioral health, and rehabilitation professionals who use a team approach to meet the needs of an individual with severe and persistent mental illness. An individual who is appropriate for ACT does not benefit from receiving services across multiple, disconnected providers, and may become at greater risk of hospitalization, homelessness, substance use, victimization, and incarceration.

Auth Submission Requirements/ Documentation Requirements
Initial Requests:
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. Complete PCP: Required, to include all required signatures and 3-page crisis plan. Specific interventions, duration, and frequency of ACTT must be detailed in the Plan. PCP interventions must address the role of all team members working with the individual. 
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Submission of all records that support the individual has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP (including above detailed requirements): 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 all records that support the individual has met the medical necessity criteria.

Authorization Parameters
Length of Stay: 
1. Up to 30 days for all authorization requests.
2. No more than 5 months in a rolling year will be authorized.
3. Team must see individuals, on average, 1.5 times per week for at least 60 minutes per week. It is expected that additional face-to-face and phone contacts are made with individuals, their natural supports, and other providers on their behalf.

Units: 
1. One unit = 1 event.  
2. Trillium has agreed to billing a weekly case rate up to 2 units per week with up to 4 units per calendar month (instead of the prescribed 1 unit per week). A shadow claim should be billed every time an encounter occurs.
3. The expectation is most ACT individuals will receive more than 4 contacts per month, with most seeing at least 3 team individuals in a given month.

Age Group: Adults (age 18 and older)

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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. ACT cannot be provided concurrently with: Individual, Group, or Family Outpatient; OPT Med Management; Outpatient Psychiatric Services; d. Mobile Crisis Management; PSR or CST (after a 30-day transition period; Partial Hospitalization; Tenancy Support Services; Nursing home facility, IPS-SE or LTVS.
2. State funds will not cover services provided to individuals with a primary dx of a SU disorder, IDD, ASD, personality disorders, or TBI.

• State-Funded Assertive Community Treatment Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manuals

Brief Service Description: An Assertive Community Treatment (ACT) team consists of a community-based group of medical, behavioral health, and rehabilitation professionals who use a team approach to meet the needs of an individual with severe and persistent mental illness. An individual who is appropriate for ACT does not benefit from receiving services across multiple, disconnected providers, and may become at greater risk of hospitalization, homelessness, substance use, victimization, and incarceration.

Auth Submission Requirements/ Documentation Requirements
Initial Requests:
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. Complete PCP: Required, to include all required signatures and 3-page crisis plan. Specific interventions, duration, and frequency of ACTT must be detailed in the Plan. PCP interventions must address the role of all team members working with the individual. 
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Submission of all records that support the individual has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP (including above detailed requirements): 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 all records that support the individual has met the medical necessity criteria.

Authorization Parameters
Length of Stay: 
1. Up to 30 days for all authorization requests.
2. No more than 5 months in a rolling year will be authorized.
3. Team must see individuals, on average, 1.5 times per week for at least 60 minutes per week. It is expected that additional face-to-face and phone contacts are made with individuals, their natural supports, and other providers on their behalf.

Units: 
1. One unit = 1 event.  
2. Trillium has agreed to billing a weekly case rate up to 2 units per week with up to 4 units per calendar month (instead of the prescribed 1 unit per week). A shadow claim should be billed every time an encounter occurs.
3. The expectation is most ACT individuals will receive more than 4 contacts per month, with most seeing at least 3 team individuals in a given month.

Age Group: Adults (age 18 and older)

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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. ACT cannot be provided concurrently with: Individual, Group, or Family Outpatient; OPT Med Management; Outpatient Psychiatric Services; d. Mobile Crisis Management; PSR or CST (after a 30-day transition period; Partial Hospitalization; Tenancy Support Services; Nursing home facility, IPS-SE or LTVS.
2. State funds will not cover services provided to individuals with a primary dx of a SU disorder, IDD, ASD, personality disorders, or TBI.

• State-Funded Assertive Community Treatment Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manuals

Brief Service Description: Assistive Technology, Equipment and Supplies (ATES) are necessary for the proper functioning of items and systems, whether acquired commercially, modified, or customized, that are used to increase, maintain, or improve functional capabilities of individuals. This service covers purchases, leasing, trial periods and shipping costs, and as necessary, repair/modification of equipment required to enable individuals to increase, maintain or improve their functional capacity to perform daily life tasks that would not be possible otherwise. Cost of Monthly monitoring, connectivity, and internet charges may be covered when it is required for the functioning of the item and system.

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. for each plan year.
2. SIS
3. Individual Budget: shipping costs must be itemized. Taxes are not coverable.
4. Care Management Comprehensive Assessment 
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures, e) a plan for training the individual, the natural support system, and paid caregivers on the use of the requested equipment and supplies, f) Long-range outcomes related to training needs associated with the member’s or family’s utilization and procurement of the requested equipment or adaptations. See CCP 8P, section 5.3, for all general ISP requirements.
6. Assessment or Written Recommendation:  by an appropriate professional identifying:
a. the equipment and supplies being requested in the amounts needed
b. Must be less than one calendar year old from requested date.
7. Certificate of Medical Necessity/Prescription: completed by the physician, PA, or NP. MN must be documented for every item requested.
8. MN Letter: written & signed by an MD/ DO, PA, NP, or applicable professional for every item requested. This meets the prescription requirement when created by an MD/ DO, PA, or NP.
9. When an assessment is completed by another professional recommending the MN of specific items, then an MD/ DO, PA, or NP must write a letter of MN OR sign off on the letter of MN prepared by professional AND write a prescription.
10. The estimated life of the equipment and the length of time the member is expected to benefit from the equipment.
11. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
For Assistive Technology Equipment 
1. Training Plan: how the person and family will be trained on the use of the equipment
2. Two quotes for the requested item(s)

For Supplies
1. Statement of Medical Necessity: completed by an appropriate professional, to include the amount and type of item(s) 
2. Supplies that continue to be needed at the time of the Annual Plan must be recommended by an annual re-assessment. The assessment or recommendation must be updated if the amount needs change.
3. Two quotes for the requested item(s)

For Adaptive Car Seats
1. A documented chronic health condition or DD which requires the use of an adaptive car seat for positioning. 
2. The following information in the assessment must be included:
a. Member’s weight;
b. Weight limits of the car seat currently used to transport;
c. Measurements showing the member has a seat to crown height that is longer than the back height of the largest child car safety seat if the member weighs less than the upper weight limit of the current car seat;
d. Reasons why the member cannot be safely transported in a car seat belt or convertible or booster seat for individual weighing 30 pounds and up; 
e. Two quotes for the requested item(s)

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    Limited to expenditures of $50,000 (ATES and Home Modifications) over the life of the waiver (excluding nutritional supplements and monthly alert monitoring / connectivity system charges).
2.    Assistive Technology and Supplies can be requested when the item will belong to the individual.
3.    Excluded Items include:
a.    Recreational items normally purchased by a family
b.    Non-Adaptive Computer desks and other furniture items.
c.    Service, maintenance contracts and extended warranties
d.    Equipment or supplies purchased for exclusive use at the school/home school
e.    Computer hardware solely to improve socialization or educational skills, to provide recreation or diversion activities, or to be used by any person other than the member.
f.    Hot tubs, Jacuzzis, and pools.
g.    Items utilized as restraints.
h.    Items that are coverable under the Medicaid DME benefit should not be covered by NC Innovations ATES.
4.    Remote support technology may only be used with consent of the individual and guardian, indicated in the ISP (including preference for the location of any monitoring equipment)
5.    Service contracts and extended warranties may be covered for a one-year time frame.
6.    All items must meet applicable standards of manufacture, design, and installation.
7.    Car seats are not approved for behavioral restraint.
8.    See the CCP for all covered items and categories
9.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
10.    See the CCP for all applicable exclusions, limitations & exceptions

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

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

Auth Submission Requirements/ Documentation Requirements
Initial & Concurrent Requests: No prior authorization is required for this service.

Other: 
1. Tier IV BHUC holds IVC designation and completes IVC First Evaluations.
2. Within a BHUC setting, law enforcement is available on site to maintain custody and facilitate drop off by community first responders or other law enforcement in instances where a petition has been filed or an IVC has been initiated.
3. This BH-CAI service is comprised of four elements. Central to it is the clinical assessment by a licensed clinician. Without that component the service is not billable. Other core elements include a triage determination, crisis intervention and disposition planning.
4. BHUC services are either Tier III or Tier IV. A Tier III BHUC operates at least 12 hours per day 7 days a week, 365 days a year w/ at least 6 hours occurring after 4:00 PM each day. A Tier IV BHUC is open 24 hours a day, 7 days a week, 365 days a year. This service is designed to be completed during the defined business hours.
5. For community discharges, it is expected the consumer will receive a copy of the crisis plan and follow up instructions at the time of release.

Authorization Parameters
Length of Stay & Units: One unit = 1 event with a clinical assessment by a licensed clinician (required for billing).  Individuals receiving this service will be evaluated, then stabilized and/or referred to the most appropriate level of care.

Place of Service: Behavioral Health Urgent Care (BHUC)

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

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

Service Specifics, Limitations/ Exclusions (not all inclusive): None noted
 

• In-Lieu Of Behavioral Health Crisis Assessment and Intervention Service Definit…
• APSM 45-2 Records Management and Documentation Manual

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

Auth Submission Requirements/ Documentation Requirements
Initial & Concurrent Requests: No prior authorization is required for this service.

Other: 
1. Tier IV BHUC holds IVC designation and completes IVC First Evaluations.
2. Within a BHUC setting, law enforcement is available on site to maintain custody and facilitate drop off by community first responders or other law enforcement in instances where a petition has been filed or an IVC has been initiated.
3. This BH-CAI service is comprised of four elements. Central to it is the clinical assessment by a licensed clinician. Without that component the service is not billable. Other core elements include a triage determination, crisis intervention and disposition planning.
4. BHUC services are either Tier III or Tier IV. A Tier III BHUC operates at least 12 hours per day 7 days a week, 365 days a year w/ at least 6 hours occurring after 4:00 PM each day. A Tier IV BHUC is open 24 hours a day, 7 days a week, 365 days a year. This service is designed to be completed during the defined business hours.
5. For community discharges, it is expected the consumer will receive a copy of the crisis plan and follow up instructions at the time of release.

Authorization Parameters
Length of Stay & Units: One unit = 1 event with a clinical assessment by a licensed clinician (required for billing).  Individuals receiving this service will be evaluated, then stabilized and/or referred to the most appropriate level of care.

Place of Service: Behavioral Health Urgent Care (BHUC)

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

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

Service Specifics, Limitations/ Exclusions (not all inclusive): None noted

• In-Lieu Of Behavioral Health Crisis Assessment and Intervention Service Definit…
• APSM 45-2 Records Management and Documentation Manual

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

Auth Submission Requirements/ Documentation Requirements
Initial & Concurrent Requests: No prior approval is required.

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

Authorization Parameters
Length of Stay & Units: One unit = 1 event.  Individuals receiving this service will be evaluated, then stabilized and/or referred to the most appropriate level of care.

Age Group: Children, Adolescents & Adults (aged 4 and older)
Population Served: All Behavioral Health Diagnosis
Place of Service: Office and clinics as clinically indicated

Service Specifics, Limitations/ Exclusions (not all inclusive): 
1. Not a step-down service for inpatient/FBC discharge
2. Not for routine follow up for med management and cannot administer routine injectable meds
3. Not to replace first responder services
4. Not to replace MCM nor to be used as a diversion from MCM
5. Not to be billed at the same time as other services.

• State-Funded Behavioral Health Urgent Care Service Definition
• APSM 45-2 Records Management and Documentation Manual

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

Auth Submission Requirements/ Documentation Requirements
Initial & Concurrent Requests: No prior approval is required.

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

Authorization Parameters
Length of Stay & Units: One unit = 1 event.  Individuals receiving this service will be evaluated, then stabilized and/or referred to the most appropriate level of care.

Age Group: Children, Adolescents & Adults (aged 4 and older)
Population Served: All Behavioral Health Diagnosis
Place of Service: Office and clinics as clinically indicated

Service Specifics, Limitations/ Exclusions (not all inclusive): 
1. Not a step-down service for inpatient/FBC discharge
2. Not for routine follow up for med management and cannot administer routine injectable meds
3. Not to replace first responder services
4. Not to replace MCM nor to be used as a diversion from MCM
5. Not to be billed at the same time as other services.

• State-Funded Behavioral Health Urgent Care Service Definition
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: This is a structured tx service in a licensed facility for youth and their families that builds on strengths and addresses identified needs. This service is designed to serve children who, as a result of their mental health or substance use disorder tx needs, are unable to benefit from participation in academic or vocational services at a developmentally appropriate level in a traditional school or work setting. The provider implements therapeutic interventions that are coordinated with the member’s academic or vocational services available through enrollment in an educational setting.

Auth Submission Requirements/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
3. Complete PCP, reviewed as applicable.  
4. Service Order, signed by an MD, DO, PA, NP, or a Licensed Psychologist.
5. Child/Adolescent Discharge/Transition Plan
6. IEP/ 504 Plan
7. Behavioral Plan
8. School Suspension Records

All services are subject to post-payment review.

Authorization Parameters
Length of Stay: This service should be titrated based on the transition plan.

Units: One unit =1 hour
Age Group: Children & Adolescents (Age 5 through 20)

Level of Care: ASAM Level of 2.1 (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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. CADT services cannot be provided during the same auth period as: IIH; MST; Individual, Group and Family therapy; SAIOP; Child Residential Tx: Level II Program Type through Level IV; PRTF; Substance Abuse Residential Services, or; Inpatient Hospitalization.
2. CADT programs may not operate as simply an after-school program.  
3. CADT programs may not operate as simply an after-school program.  
4. Transition and discharge planning begin at admission and must be documented in the PCP.

• Clinical Coverage Policy 8A: Enhanced Mental Health and Substance Abuse Service…
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: A structured tx service in a licensed facility for children or adolescents and their families that builds on strengths and addresses identified needs. This service is designed to serve children who, as a result of their MH or SU disorder tx needs, are unable to benefit from participation in academic or vocational services at a developmentally appropriate level in a traditional school or work setting. The provider implements therapeutic interventions that are coordinated with the individual’s academic or vocational services available through enrollment in an educational setting. Each CADT provider must follow a clearly identified clinical model(s) or evidence-based tx(s) consistent with best practice. Day Treatment provides case management services.

Auth Submission Requirements/ Documentation Requirements
Initial Requests:
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. Complete PCP: Required  
4. Service Order: Required
5. Child/Adolescent Discharge/Transition Plan
6. IEP/ 504 Plan: Required
7. Behavioral Plan: Required
8. School Suspension Records: Required
9. Submission of all records that support the recipient has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: Prior authorization is required
2. Complete PCP: 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 all records that support the individual has met the medical necessity criteria.

Authorization Parameters
Length of Stay: 
1. This is a time limited service, and services should be titrated based on the transition plan in the PCP.  
2. This is a day or night service that shall be available year-round for a minimum of three hours a day during all days of operation.
3. Up to 60 days for the initial and reauth period.  

Units:
1.  One unit = 1 hour.  
2. Up to 258 units per 60 days.  

Age Group: Children & Adolescents (Ages 5 through 17)

Level of Care: ASAM Level of 2.1 (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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. CADT services may not be provided during the same auth period as: IIH; MST; Individual, group, and family therapy; SAIOP; Child Residential Treatment services–Levels II through IV; PRTF; Substance abuse residential services; or Inpatient hospitalization.
2. CADT programs may not operate as simply an after-school program.  

• State-Funded Enhanced Mental Health and Substance Abuse Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Child First is an intensive, early childhood, two-generation, home visiting intervention that works with the most vulnerable young children (prenatal through age five years) and their families. The goal is to heal and protect children from trauma and adversity. This service requires prior approval through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) process. To request a service under EPSDT, submit a TAR and upload the EPSDT non-covered form as part of the clinical documents for review. 

• EPSDT Non-Covered Form

Child First is an intensive, early childhood, two-generation, home visiting intervention that works with the most vulnerable young children (prenatal through age five years) and their families. The goal is to heal and protect children from trauma and adversity. This service requires prior approval through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) process. To request a service under EPSDT, submit a TAR and upload the EPSDT non-covered form as part of the clinical documents for review. 

• EPSDT Non-Covered Form

All services are subject to post-payment review.

Brief Service Description: The member’s functional limitations necessitate a safe and stable living environment to develop and demonstrate sufficient recovery skills. This level of care is designed to prevent immediate relapse or continued use in an imminently dangerous manner upon transfer to a lower, less intensive level of care. An adult member meeting this level of care may have significant mental health support needs along with psychological and self-management functional limitations. The member may have a history of physical, sexual, or emotional trauma; a history of, or current involvement with, the justice system; limited education or work history; inadequate anger management skills; and extreme impulsiveness.  The service has protocols in place for the management of medical and behavioral health emergencies. Programs are staffed by clinicians and professional staff who have training and experience working with adults diagnosed with primary substance use disorders and co-occurring mental health conditions. Clinicians and professional staff are available 24 hours a day.

Auth Submission/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. An initial abbreviated assessment must be completed by clinical staff

2. CCA or DA: completed within 7 days of admission

3. PCP: Required, documenting the ASAM dimensions 2 - 6, development of tx goals, measurable tx objectives, and activities designed to meet those objectives.  Must detail the amount, duration, and intensity of the service, along with the relevant diagnostic information

4. Service Order: Required, completed by a physician, PA, NP, or LP

5. Discharge and transfer planning beginning at admission.

Authorization Parameters
Units: One unit= 1 Day

Age Group: Adults (aged 18+) 

Level of Care: ASAM Level 3.5. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and document the determination for continued stay, discharge, or transfer to another LOC.

Place of Service: Must be provided in a facility licensed under 10A NCAC 27G.5600. Refer to Tribal & Urban Indian Health Centers | HRSA when the service is provided by IHS.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Provider must have agreements in place with IPS providers and DVR offices to facilitate the direct referral of a member to these services for support in employment and education-related goals.

2. Provider must coordinate with housing providers and a member’s care coordinator to support member having safe/ stable housing to transition to at time of discharge.

3. Provider shall verify each Medicaid member’s eligibility each time a service is rendered.

4. A minimum of 2 staff shall be on-site when a member is present.

5. Provider must notify the member’s care coordinator on the first day of admission to the service to coordinate services.

6. Must not be provided or billed on the same day (except day of admission or discharge) as other residential levels of care; Withdrawal management services; SAIOP; SACOT; PSR; PSS; Partial Hospitalization; Facility Based Crisis; PRTF; ACT; CST

• Clinical Coverage Policy 8D-5: Clinically Managed High-Intensity Residential Se…
• APSM 45-2 Records Management and Documentation Manual
• PCP Guidance Documents & Templates

Limited funding. Not an entitlement.

All services are subject to post-payment review.

Brief Service Description: This LOC is for an adult member with a primary SUD whose functional limitations necessitate a safe and stable living environment to develop and demonstrate sufficient recovery skills. This LOC is designed to prevent immediate relapse or continued use in an imminently dangerous manner upon transfer to a lower, less intensive LOC. An adult member meeting this LOC may have significant mental health support needs along with psychological and self-management functional limitations. The member may have a history of physical, sexual, or emotional trauma; a history of, or current involvement with, the justice system; limited education or work history; inadequate anger management skills; and extreme impulsivity.  The program has protocols in place for the management of medical and behavioral health emergencies and is staffed by clinicians and professional staff who have training and experience working with adults diagnosed with primary substance use disorders and co-occurring mental health conditions.

Auth Submission/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. An initial abbreviated assessment must be completed by clinical staff

2. CCA or DA: completed within 7 days of admission

3. PCP: Required, documenting the ASAM dimensions 2 - 6, development of tx goals, measurable tx objectives, and activities designed to meet those objectives.  Must detail the amount, duration, and intensity of the service, along with the relevant diagnostic information

4. Service Order: Required, completed by a physician, PA, NP, or LP

5. Medicaid Application: Required w/in the 30 days of authorization.  Evidence of individual applying for Medicaid or update on application status.

6. Discharge and transfer planning beginning at admission.

Authorization Parameters
Units: One unit= 1 Day

Age Group: Adults (aged 18+) 

Level of Care: ASAM Level 3.5. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and document the determination for continued stay, discharge, or transfer to another LOC.

Place of Service: Must be provided in a facility licensed under 10A NCAC 27G.5600.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. A minimum of 2 staff must be on-site when a member is present.

2. Provider must have the availability of specialized medical consultation; the ability to arrange for medical procedures, including indicated laboratory and toxicology testing; the ability to arrange for medical and psychiatric treatment through consultation, referral to offsite concurrent treatment services, or transfer to another level of care; and direct affiliations with other levels of care to effectively facilitate the member’s transition into ongoing treatment and recovery.

3. Provider must have agreements in place with IPS providers and DVR offices to facilitate the direct referral of a member to these services for support in employment and education-related goals.

4. Providers must coordinate with housing providers and a member’s care coordinator to support the member having safe/ stable housing to transition to after discharge.

5. Service can be received from only one provider during any active episode of care.

6. Service must not be billed on the same day (except day of admission or discharge) as Other residential levels of care; Withdrawal management services; SAIOP; SACOT; PSR; PSS; Partial Hospitalization; Facility Based Crisis; PRTF; ACT; CST

• State-Funded Clinically Managed Residential Services Service Definition
• APSM 45-2 Records Management and Documentation Manual
• PCP Guidance Documents & Templates

All services are subject to post-payment review.

Brief Service Description: This level of care is for a member with substance use, or co-occurring mental health issues, who would benefit from a structured, residential level of care. This level of service provides supports to strengthen the parent-child dyad. Services must be designed to provide a safe and healthy environment for parents and their children. A member meeting this level of care can benefit from targeted substance use interventions that increase the incidence of prenatal visits, improve birth outcomes, lower overall health costs, and improve health outcomes for the member, infant, and other children. It is critical that the member has an environment and interventions that support the learning and use of positive parenting skills that include trauma-informed parenting supports, how to establish and maintain recovery while parenting, developing, and improving basic understanding of child development, and how to support healthy child development.

Auth Submission/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. An initial abbreviated assessment must be completed by clinical staff

2. CCA or DA: completed within 7 days of admission

3. PCP: Required, documenting the ASAM dimensions 2 through 6, development of tx goals, measurable tx objectives, and activities designed to meet those objectives.  Must detail the amount, duration, and intensity of the service, along with the relevant diagnostic information

4. Service Order: Required, completed by a physician, PA, NP, or LP

5. Discharge and transfer planning beginning at admission.

Authorization Parameters
Units: One unit= 1 Day

Age Group: Adults (aged 18+) 

Level of Care: ASAM Level 3.5. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and document the determination for continued stay, discharge, or transfer to another LOC.

Place of Service: Must be provided in a facility licensed under 10A NCAC 27G Section .4100. Refer to Tribal & Urban Indian Health Centers | HRSA when the service is provided by IHS.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Providers must ensure that children receive age and developmentally appropriate screening and assessments, and evidence-based tx, and therapies based on MN needs.

2. Service must directly link to medical care (prenatal, postpartum, pediatric, and primary) to support both the member and the infant and other children.

3. Service must directly link to education services for children and adolescents residing in the program. Education services must be provided according to local regulations.

4. Provider must coordinate with the local DSS office when working with a member who has DSS involvement.

5. Provider must coordinate with housing providers and a member’s care coordinator to support the member in having safe/ stable housing to transition to after discharge.

6. Provider shall verify each Medicaid member’s eligibility each time a service is rendered.

7. A minimum of 2 staff shall be on-site at all times when a member is present.

8. Provider must notify the member’s care coordinator on the first day of admission to the service to coordinate services.

9. Must not be provided or billed on the same day (except day of admission or discharge) as other residential levels of care; Withdrawal management services; SAIOP; SACOT; PSR; PSS; Partial Hospitalization; Facility Based Crisis; PRTF; ACT; CST

• Clinical Coverage Policy 8D-5: Clinically Managed High-Intensity Residential Se…
• APSM 45-2 Records Management and Documentation Manual
• PCP Guidance Documents & Templates

Limited funding. Not an entitlement.

All services are subject to post-payment review.

Brief Service Description: This LOC is for a member with substance use, or co-occurring mental health issues, who would benefit from a structured, residential LOC providing support to strengthen the parent-child dyad. Services must be designed to provide a safe and healthy environment for parents and their children. A member meeting this LOC can benefit from targeted SU interventions that increase the incidence of prenatal visits; improve birth outcomes, lower overall health costs; and improve health outcomes for the member, infant, and other children.

Auth Submission/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. An initial abbreviated assessment must be completed by clinical staff

2. CCA or DA: completed within 7 days of admission

3. PCP: Required, documenting the ASAM dimensions 2 - 6, development of tx goals, measurable tx objectives, and activities designed to meet those objectives.  Must detail the amount, duration, and intensity of the service, along with the relevant diagnostic information

4. Service Order: Required, completed by a physician, PA, NP, or LP

5. Medicaid Application: Required w/in the 30 days of authorization.  Evidence of individual applying for Medicaid or update on application status.

6. Discharge and transfer planning beginning at admission.

Authorization Parameters
Units: One unit= 1 Day

Age Group: Adolescent or Adult (aged 12+) 

Level of Care: ASAM Level 3.5. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and document the determination for continued stay, discharge, or transfer to another LOC.

Place of Service: Must be provided in a facility licensed under 10A NCAC 27G .4100.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. A minimum of 2 staff must be on-site when a member is present.

2. Providers must ensure that children receive age and developmentally appropriate screening and assessments, and evidence-based tx, and therapies based on MN needs.

3. Providers must directly link to education services for children and adolescents residing in the program. Education services must be provided according to local regulations.

4. Providers must coordinate with the local DSS office when working with a member who has DSS involvement.

5. Provider must coordinate with housing providers and a member’s care coordinator to support the member in having safe/ stable housing to transition to after discharge.

6. Service can be received from only one provider during any active episode of care.

7. Service must not be billed on the same day (except day of admission or discharge) as Other residential levels of care; Withdrawal management services; SAIOP; SACOT; PSR; PSS; Partial Hospitalization; Facility Based Crisis; PRTF; ACT; CST.

• State-Funded Clinically Managed Residential Services Service Definition
• APSM 45-2 Records Management and Documentation Manual
• PCP Guidance Documents & Templates

All services are subject to post-payment review.

Brief Service Description: This service is provided 24-hour, seven days a week in a community based residential setting providing clinical and recovery services. This service is designed to treat members experiencing problems in the application of recovery skills, self-efficacy, and a lack of connection to the community systems of work, education, or family life.  This service provides the member the opportunity to develop and practice interpersonal and group living skills, strengthen their recovery skills, reintegrate into the community and family settings, and experience employment or academic pursuits.  Services are characterized by individual, group, and family therapy, medication management, and psychoeducation. The service must provide crisis response 24 hours-a-day, 7 days a week.

Auth Submission/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. CCA or DA: completed prior to admission. Must confirm the member meets ASAM Criteria Level 3.1

2. Physical Exam: Completed no more than 90 days prior to admission. If no prior physical exam was conducted, a physical exam must be completed within 45 days of admission.

3. Person-Centered Plan: Required, including the amount, duration, and intensity of the service. Must document the problems identified in the ASAM dimensions 2 – 6, development of tx goals, measurable tx objectives, and activities designed to meet those objectives, needs, strengths, skills, and priority formulation of short-term goals and preferences, and activities designed to achieve those goals.

4. Service Order: Required, signed by a physician, PA, or NP. A service order is valid for the episode of care. MN must be revisited, and service must be ordered based on episode of care, if multiple episodes of care are required within a twelve (12) consecutive month period

5. Discharge & Transfer Planning: Beginning at admission.

Authorization Parameters
Units: One unit= 1 Day

Age Group: Adult (aged 18) 

Level of Care: ASAM Level 3.1. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions.

Place of Service: Must be provided in a facility licensed under 10A NCAC 27G.5600. Refer to Tribal & Urban Indian Health Centers | HRSA when the service is provided by IHS.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Provider shall verify each Medicaid member’s eligibility each time a service is rendered

2. Service must provide a minimum of at least 5 hours of clinically directed program activities per week.

3. Service must support a member prescribed medications to address their SU or MH diagnosis. Coordination of care with the prescribing physician or physician extender is required.

4. Care coordination/ management for linkage and referrals for counseling, as well as medical, psychiatric, and continuing care is required.

5. Service can only be provided by one provider during any active episode of care. Services must not be provided and billed on the same day (except day of admission or discharge) as: Clinically managed residential services, Clinically Managed Residential Withdrawal Management, Medically Monitored Inpatient Withdrawal Management, Clinically Managed Population-Specific High-Intensity Residential Programs, Clinically Managed High-Intensity Residential Services, Medically Monitored Intensive Inpatient Services, SACOT, ACT, or CST.

• CCP 8D-3: Clinically Managed Low-Intensity Residential Treatment Services
• APSM 45-2 Records Management and Documentation Manual
• PCP Guidance Documents & Templates

Limited funding. Not an entitlement.

All services are subject to post-payment review.

Brief Service Description: This service is provided in a 24-hour, 7 day a week community-based residential setting and is designed to tx a member experiencing functional limitations due to their SUD. Functional limitations include problems in the application of recovery skills; self-efficacy; and lack of connection to the community systems of work, education, or family life. This service provides the member the opportunity to develop and practice interpersonal and group living skills; strengthen their recovery skills; reintegrate into the community and family settings; and experience employment or academic pursuits. Clinical and recovery services are characterized by individual, group and family therapy, medication management, and psychoeducation.

Auth Submission/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. CCA or DA: Required, completed prior admission. 

2. Physical Exam: required, completed no earlier than 90 days prior to admission or w/in the first 45 days of admission.

3. PCP: Required, documenting the ASAM dimensions 2 - 6, development of tx goals, measurable tx objectives, and activities designed to meet those objectives.  Must detail the amount, duration, and intensity of the service, along with the relevant diagnostic information.

4. Service Order: Required, signed by a physician, PA, NP, or LP. 

5. Medicaid Application: Evidence of individual applying for Medicaid or update on application status.

6. Discharge and transfer planning beginning at admission.

Authorization Parameters
Units: One unit= 1 Day

Level of Care: ASAM Level 3.1. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and documented the determination for continued stay, discharge, or transfer to another LOC.

Place of Service: Must be provided in a facility licensed under 10A NCAC 27G.5600. 

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Provider must provide crisis response 24 hours-a-day, 7 days a week to a member who is receiving services.

2. Service can be received from only one provider during any active episode of care.

3. Service must not be billed on the same day (except day of admission or discharge) as Clinically managed residential services; Clinically Managed Residential Withdrawal Management; Medically Monitored Inpatient Withdrawal Management; Clinically Managed Population-Specific High-Intensity Residential Programs; Clinically Managed High-Intensity Residential Services; Medically Monitored Intensive Inpatient Services; SACOT; ACT; CST.

• State-Funded Clinically Managed Low-Intensity Residential Treatment Services Se…
• APSM 45-2 Records Management and Documentation Manual
• PCP Guidance Documents & Templates

All services are subject to post-payment review.

Brief Service Description: This level of care is for an adolescent experiencing impaired functioning that includes disruptive behaviors, delinquency, juvenile justice involvement, educational difficulties, family conflicts, developmental immaturity, and impaired psychological functioning. This level of care frequently works with adolescents who are impulsive, displaying severe conduct problems, and struggling with interpersonal relationships, hostility, and aggression. This service operates under protocols for the management of medical or behavioral health emergencies. Programs are staffed by clinicians and professional staff who have training and experience working with adolescents diagnosed with SUD and co-occurring mental health conditions. Clinicians and professional staff shall be available 24 hours a day.

Auth Submission/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. An initial abbreviated assessment must be completed by clinical staff

2. CCA or DA: completed within 7 days of admission

3. PCP: Required, documenting the ASAM dimensions 2 - 6, development of tx goals, measurable tx objectives, and activities designed to meet those objectives.  Must detail the amount, duration, and intensity of the service, along with the relevant diagnostic information

4. Service Order: Required, completed by a physician, PA, NP, or LP

5. Discharge and transfer planning beginning at admission.

Authorization Parameters
Units: One unit= 1 Day

Age Group: Adolescents (aged 12-17) 

Level of Care: ASAM Level 3.5. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and document the determination for continued stay, discharge, or transfer to another LOC.

Population Served: Must have a primary SUD. 

Place of Service: Must be provided in a facility licensed under 10A NCAC 27G.5600. Refer to Tribal & Urban Indian Health Centers | HRSA when the service is provided by IHS. 

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Programs are expected to coordinate with other agencies and entities involved in the member’s care such as social services, local school districts, juvenile justice, and medical providers.

2. Provider shall verify each Medicaid member’s eligibility each time a service is rendered.

3. A minimum of 2 awake staff must be onsite when a member is present.

4. Provider must notify the member’s care coordinator on the first day of admission to the service to coordinate services.

5. Must not be provided or billed on the same day (except day of admission or discharge) as other residential levels of care; Withdrawal management services; SAIOP; SACOT; PSR; PSS; Partial Hospitalization; Facility Based Crisis; PRTF; ACT; CST.

• Clinical Coverage Policy 8D-5: Clinically Managed Residential Services
• APSM 45-2 Records Management and Documentation Manual
• PCP Guidance Documents & Templates

Limited funding. Not an entitlement.

All services are subject to post-payment review.

Brief Service Description: This LOC is for an adolescent experiencing impaired functioning across a broad range of psychosocial domains, including disruptive behaviors; delinquency; juvenile justice involvement; educational difficulties; family conflicts; developmental immaturity; and impaired psychological functioning. This LOC frequently works with adolescents who are impulsive, displaying severe conduct problems, and struggling with interpersonal relationships, hostility, and aggression. This program operates under protocols for the management of medical or behavioral health emergencies and is staffed by clinicians and professional staff who have training and experience working with an adolescent diagnosed with SUD and co-occurring mental health conditions.

Auth Submission/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. An initial abbreviated assessment must be completed by clinical staff

2. CCA or DA: completed within 7 days of admission

3. PCP: Required, documenting the ASAM dimensions 2 - 6, development of tx goals, measurable tx objectives, and activities designed to meet those objectives.  Must detail the amount, duration, and intensity of the service, along with the relevant diagnostic information

4. Service Order: Required, completed by a physician, PA, NP, or LP

5. Medicaid Application: Required w/in the 30 days of authorization.  Evidence of individual applying for Medicaid or update on application status.

6. Discharge and transfer planning beginning at admission.

Authorization Parameters
Units: One unit= 1 Day

Age Group: Adolescents (aged 12-17) 

Level of Care: ASAM Level 3.5. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and document the determination for continued stay, discharge, or transfer to another LOC.

Population Served: Must have a primary SUD. 

Place of Service: Must be provided in a facility licensed under 10A NCAC 27G.5600. 

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. A minimum of 2 awake staff must be onsite when a member is present.

2. This service must have the availability of specialized medical consultation; the ability to arrange for medical procedures, including indicated laboratory and toxicology testing; the ability to arrange for medical and psychiatric treatment through consultation; the ability to refer to off-site, concurrent treatment services or transfer to another level of care; and direct affiliations with other levels of care to effectively facilitate the member’s transition into ongoing treatment and recovery.

3. Programs are expected to coordinate with other agencies and entities involved in the member’s care such as social services, local school districts, juvenile justice, and medical providers.

4. Providers must provide or directly link to educational services that are provided according to local regulations, designed to maintain the educational and intellectual development of the member and, when indicated, provide opportunities to remedy deficits in the educational level of a member who has fallen behind because of their involvement with alcohol and other substances

5. Service can be received from only one provider during any active episode of care.

6. Service must not be billed on the same day (except day of admission or discharge) as Other residential levels of care; Withdrawal management services; SAIOP; SACOT; PSR; PSS; Partial Hospitalization; Facility Based Crisis; PRTF; ACT; CST.

• State-Funded Clinically Managed Residential Services Service Definition
• APSM 45-2 Records Management and Documentation Manual
• PCP Guidance Documents & Templates

All services are subject to post-payment review.

Brief Service Description: This service provides a 24-hour structured recovery environment in combination with high-intensity clinical services. This service is for a member with both a substance use disorder (SUD) and traumatic brain injury (TBI). It is designed to meet the functional and cognitive limitations of a member and to support recovery from substance use disorders. The effects of the substance use disorder combined with the cognitive limitations are such that outpatient or other levels of residential care are not feasible or effective. This tx service focuses on overcoming a lack of awareness or ambivalence about the effects of addiction and preventing relapse. The service also focuses on promoting reintegration into the community.

Auth Submission/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. An initial abbreviated assessment conducted by a physician as a part of the admission process

2. Medical records that confirm a diagnosis of TBI

3. AOD Nursing Assessment: Required, completed by an RN at admission

4. CCA or DA: completed by a licensed professional to determine an ASAM level of care for discharge planning.  Must contain observational information obtained during the first 7 days of tx in the program and must be updated as new strengths and barriers are observed in the residential setting

5. NC TBI Waiver Risk Support Needs Assessment

6. NC TBI Waiver Wellness Assessment

7. PCP: completed within 30 calendar days, which contains the problem identification in ASAM dimensions two through six, development of tx goals, measurable tx objectives, and activities designed to meet those objectives,

8. Service Order: Required, signed by a physician, PA, NP, or LP. A service order is valid for the episode of care. MN must be revisited, and service must be ordered based on episode of care, if multiple episodes of care are required within a twelve (12) consecutive month period.

Authorization Parameters
Units: One unit= 1 Day

Age Group: Adults (aged 18+) 

Level of Care: ASAM Level 3.3. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions.

Population Served: Must have both a substance use disorder and TBI diagnosis. 

Place of Service: Must be provided in a facility licensed under 10A NCAC 27G.5600. Refer to Tribal & Urban Indian Health Centers | HRSA when the service is provided by IHS. 

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Provider shall verify each Medicaid member’s eligibility each time a service is rendered

2. A minimum of 2 staff shall be on-site at all times when a member is present.

3. Must be staffed to screen and accept admissions a minimum of eight (8) hours a day, five (5) days a week.

4. Must not be provided and billed on the same day (except day of admission or discharge) as: Other residential levels of care, Withdrawal management services, Outpatient treatment services, SAIOP, SACOT, ACT, CST, Supported Employment, PSR, PSS, Partial Hospitalization, Facility Based Crisis (Adult), or TBI State-funded program services.

• Clinical Coverage Policy 8D-4: Clinically Managed Population Specific High-Inte…
• APSM 45-2 Records Management and Documentation Manual
• PCP Guidance Documents & Templates

Limited funding. Not an entitlement.

All services are subject to post-payment review.

Brief Service Description: This is a therapeutic rehabilitation service delivered by trained and experienced medical and nursing professionals, as well as clinical and support staff for a member with both SUD and TBI. This service provides a 24-hour structured recovery environment in combination with high-intensity clinical services, designed to meet the functional and cognitive limitations of a member and to support recovery from substance use disorders. This tx service focuses on overcoming a lack of awareness or ambivalence about the effects of addiction and preventing relapse. The service also focuses on promoting reintegration into the community.

Auth Submission/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. Initial abbreviated assessment consisting of an addiction focused history and physical examination completed at admission by the physician along with the completion of a traumatic brain injury assessment.

2. AOD Nursing Assessment: Required, completed by an RN at admission.

3. Service Order: Required, signed by a physician, PA, NP, or LP.

4. CCA or DA: Required, completed within 7 calendar days of admission.

5. NC TBI Waiver Risk Support Needs Assessment

6. NC TBI Waiver Wellness Assessment

7. PCP: Required, completed within 30 calendar days, which contains the problem identification in ASAM dimensions 2-6, development of tx goals, measurable tx objectives, and activities designed to meet those objectives.

8. Medical records that confirm a dx of TBI or the NC TBI Physician Referral Form to confirm a dx of TBI

9. Medicaid Application: Evidence of individual applying for Medicaid or update on application status.

Authorization Parameters
Units: One unit= 1 Day

Level of Care: ASAM Level 3.3. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and document the determination for continued stay, discharge, or transfer to another LOC.

Population Served: Must have both a substance use disorder and TBI diagnosis. 

Place of Service: Must be provided in a facility licensed under 10A NCAC 27G.5600. 

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. A minimum of 2 staff shall be on-site at all times when a member is present.

2. Must be staffed to screen and accept admissions a minimum of eight (8) hours a day, five (5) days a week.

3. Service can be received from only one provider during any active episode of care.

4. Service must not be billed on the same day (except day of admission or discharge) as Residential levels of care; Other residential levels of care; Withdrawal management services; Outpatient treatment services; SAIOP; SACOT; ACT; CST; Supported Employment; PSR; PSS; Partial Hospitalization; Facility Based Crisis; or TBI State-funded program services.

• State-Funded Clinically Managed Residential Withdrawal Management Service Defin…
• APSM 45-2 Records Management and Documentation Manual
• PCP Guidance Documents & Templates

All services are subject to post-payment review.

Brief Service Description: This service is an organized facility-based service that is delivered by trained staff who provide 24-hour supervision, observation, and support for a member who is intoxicated or experiencing withdrawal. This service is intended for a member who is not at risk of severe withdrawal symptoms or severe physical and psychiatric complications. Moderate withdrawal symptoms can be safely managed at this LOC.  This service emphasizes the utilization of peer and social supports to safely assist a member through withdrawal. Programs must have established clinical protocols developed and supported by a physician who is available 24 hours a day. Support systems must include direct coordination with other levels of care. This service is designed to achieve safe and comfortable withdrawal from alcohol and other substances to effectively facilitate the member’s transition into ongoing treatment and recovery.

Auth Submission/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. A CCA or DA within 3 calendar days of admission

2. An initial abbreviated assessment at admission

3. Individualized service plan, including problem identification in ASAM dimensions 2 - 6, development of tx goals, measurable tx objectives, and activities designed to meet those objectives

4. The member’s CIWA-Ar score(s)

5. Service Order: Required, completed by a physician, PA, NP, or LP

6. Discharge and transfer planning beginning at admission.

Authorization Parameters
Units: One unit= 1 Day

Age Group: Adults (aged 18+) 

Level of Care: ASAM Level 3.2 WM. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and document the determination for continued stay, discharge, or transfer to another LOC.

Population Served: An adult w/ an SUD in need of withdrawal management services who is not at risk of severe withdrawal symptoms or severe physical and psychiatric complications. 

Place of Service: Must be provided in a facility licensed under 10A NCAC 27G Section .3200. Refer to Tribal & Urban Indian Health Centers | HRSA when the service is provided by IHS. 

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Providers must have staff to screen and accept admissions a minimum of 12 hours a day, 7 days a week. At least 5 of these 12 hours must occur during second shift.

2. Provider shall verify each Medicaid member’s eligibility each time a service is rendered.

3. A minimum of 2 staff shall be on-site at all times and the staffing ratio must be at least 1 staff to 9 members.

4. The service must not be billed on the same day (except day of admission or discharge) as Residential levels of care; Other withdrawal management services; Outpatient treatment services; SAIOP; SACOT; ACT; CST; Supported Employment; Psychiatric Rehabilitation; PSS, Mobile Crisis, Partial Hospitalization; and Facility Based Crisis.

• Clinical Coverage Policy 8A-10: Clinically Managed Residential Withdrawal Manag…
• APSM 45-2 Records Management and Documentation Manual
• PCP Guidance Documents & Templates

Limited funding. Not an entitlement.

All services are subject to post-payment review.

Brief Service Description: This is a facility-based service delivered by trained staff who provide 24-hour supervision, observation, and support for a member who is intoxicated or experiencing withdrawal, intended for a member who is not at risk of severe withdrawal symptoms or severe physical and psychiatric complications. Moderate withdrawal symptoms can be safely managed at this LOC. This service emphasizes the utilization of peer and social supports to safely assist a member through withdrawal. Programs must have established clinical protocols developed and supported by a physician who is available 24 hours a day. Support systems must include direct coordination with other LOC. This service is designed to achieve safe and comfortable withdrawal from alcohol and other substances to effectively facilitate the member’s transition into ongoing tx and recovery.

Auth Submission/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive):
1. CCA or DA: Required within 3 calendar days of admission.

2. An initial abbreviated assessment at admission.

3. A physical examination, to be completed by a physician or physician extender, when clinically indicated.

4. Individualized service plan, including problem identification in ASAM dimensions 2 - 6, development of tx goals, measurable tx objectives, and activities designed to meet those objectives.

5. The members’ CIWA-Ar score(s) (or other comparable standardized scoring system)

6. Service Order: Required, signed by a physician or physician extender

7. Discharge and transfer planning, beginning at admission.

8. Medicaid Application: Evidence of individual applying for Medicaid or update on application status.

Authorization Parameters
Units: One unit= 1 Day

Age Group: Adults (aged 18+) 

Level of Care: ASAM Level 3.2 WM. The ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions. Each of the six ASAM dimensions must be reviewed and document the determination for continued stay, discharge, or transfer to another LOC.

Population Served: Primary Substance Use Diagnosis only. 

Place of Service: Must be provided in a facility licensed under 10A NCAC 27G Section .3200. 

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. A minimum of 2 staff must be on-site at all times, and the staffing ratio must be at least 1 staff to 9 members.

2. Program must have staff to screen and accept admissions a minimum of 12 hours a day, 7 days a week. At least 5 of these 12 hours must occur during second shift.

3. Service can be received from only one provider during any active episode of care.

4. Service must not be billed on the same day (except day of admission or discharge) as Residential levels of care; Other withdrawal management services; Outpatient treatment services; SAIOP; SACOT; ACT; CST; Supported Employment; Psychiatric Rehabilitation; PSS; Mobile Crisis; Partial Hospitalization; and Facility Based Crisis.

• State-Funded Clinically Managed Residential Withdrawal Management Service Defin…
• APSM 45-2 Records Management and Documentation Manual
• PCP Guidance Documents & Templates

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

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures, e) if applicable, member agrees with the employment of the relative and has been given the opportunity to consider employment of non-related staff. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Timeframes:
1. Requests up to 12 hours daily may be auth’d for the entire plan year.
2. Requests up to 16 hours daily may be auth’d for 6 months within the plan year.
3. Requests for more than 16 hours daily are auth’d for up to a 90-days within the plan year.

Units: One unit = 15 minutes

Other:
1. For services provided in the home of a direct service employee, the Provider Agency, Employer of Record or Agency With Choice is required to complete the Health and Safety Checklist and Justification for Services form prior to the delivery of service in that home and every 6 months afterwards. The member or legally responsible person must sign this checklist.

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

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

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

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures, e) if applicable, member agrees with the employment of the relative and has been given the opportunity to consider employment of non-related staff. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Timeframes:
1. Requests up to 12 hours daily may be auth’d for the entire plan year.
2. Requests up to 16 hours daily may be auth’d for 6 months within the plan year.
3. Requests for more than 16 hours daily are auth’d for up to a 90-days within the plan year.

Units: One unit = 15 minutes

Other:
1. For services provided in the home of a direct service employee, the Provider Agency, Employer of Record or Agency With Choice is required to complete the Health and Safety Checklist and Justification for Services form prior to the delivery of service in that home and every 6 months afterwards. The member or legally responsible person must sign this checklist.

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

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

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

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures, e) if applicable, member agrees with the employment of the relative and has been given the opportunity to consider employment of non-related staff. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Timeframes:
1. Requests up to 12 hours daily may be auth’d for the entire plan year.
2. Requests up to 16 hours daily may be auth’d for 6 months within the plan year.
3. Requests for more than 16 hours daily are auth’d for up to a 90-days within the plan year.

Units: One unit = 15 minutes

Other:
1. For services provided in the home of a direct service employee, the Provider Agency, Employer of Record or Agency With Choice is required to complete the Health and Safety Checklist and Justification for Services form prior to the delivery of service in that home and every 6 months afterwards. The member or legally responsible person must sign this checklist.

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

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

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

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures, e) if applicable, member agrees with the employment of the relative and has been given the opportunity to consider employment of non-related staff. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Timeframes:
1. Requests up to 12 hours daily may be auth’d for the entire plan year.
2. Requests up to 16 hours daily may be auth’d for 6 months within the plan year.
3. Requests for more than 16 hours daily are auth’d for up to a 90-days within the plan year.

Units: One unit = 15 minutes

Other:
1. For services provided in the home of a direct service employee, the Provider Agency, Employer of Record or Agency With Choice is required to complete the Health and Safety Checklist and Justification for Services form prior to the delivery of service in that home and every 6 months afterwards. The member or legally responsible person must sign this checklist.

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

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

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

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures, e) if applicable, member agrees with the employment of the relative and has been given the opportunity to consider employment of non-related staff. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Timeframes:
1. Requests up to 12 hours daily may be auth’d for the entire plan year.
2. Requests up to 16 hours daily may be auth’d for 6 months within the plan year.
3. Requests for more than 16 hours daily are auth’d for up to a 90-days within the plan year.

Units: One unit = 15 minutes

Other:
1. For services provided in the home of a direct service employee, the Provider Agency, Employer of Record or Agency With Choice is required to complete the Health and Safety Checklist and Justification for Services form prior to the delivery of service in that home and every 6 months afterwards. The member or legally responsible person must sign this checklist.

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

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

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

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

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures, e) if applicable, member agrees with the employment of the relative and has been given the opportunity to consider employment of non-related staff. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Timeframes:
1. Requests up to 12 hours daily may be auth’d for the entire plan year.
2. Requests up to 16 hours daily may be auth’d for 6 months within the plan year.
3. Requests for more than 16 hours daily are auth’d for up to a 90-days within the plan year.

Units: One unit = 15 minutes

Other:
1. For services provided in the home of a direct service employee, the Provider Agency, Employer of Record or Agency With Choice is required to complete the Health and Safety Checklist and Justification for Services form prior to the delivery of service in that home and every 6 months afterwards. The member or legally responsible person must sign this checklist.

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

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

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

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures, e) if applicable, member agrees with the employment of the relative and has been given the opportunity to consider employment of non-related staff. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Timeframes:
1. Requests up to 12 hours daily may be auth’d for the entire plan year.
2. Requests up to 16 hours daily may be auth’d for 6 months within the plan year.
3. Requests for more than 16 hours daily are auth’d for up to a 90-days within the plan year.

Units: One unit = 15 minutes

Other:
1. For services provided in the home of a direct service employee, the Provider Agency, Employer of Record or Agency With Choice is required to complete the Health and Safety Checklist and Justification for Services form prior to the delivery of service in that home and every 6 months afterwards. The member or legally responsible person must sign this checklist.

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

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

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

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

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures, e) if applicable, member agrees with the employment of the relative and has been given the opportunity to consider employment of non-related staff. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Timeframes:
1. Requests up to 12 hours daily may be auth’d for the entire plan year.
2. Requests up to 16 hours daily may be auth’d for 6 months within the plan year.
3. Requests for more than 16 hours daily are auth’d for up to a 90-days within the plan year.

Units: One unit = 15 minutes

Other:
1. For services provided in the home of a direct service employee, the Provider Agency, Employer of Record or Agency With Choice is required to complete the Health and Safety Checklist and Justification for Services form prior to the delivery of service in that home and every 6 months afterwards. The member or legally responsible person must sign this checklist.

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

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

Limited funding. Not an entitlement. No New Admissions.

Brief Service Description: 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.

Auth Submission Requirements/ Documentation Requirements
Initial Requests:
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 Requests:
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.

Authorization Parameters
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).

Units: One unit = 15 minutes

Age Group: Children/ Adolescents & Adults

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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
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.

• State-Funded Community Living & Support
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual
• NCDHHS NC Support Needs Assessment Profile website
• JCB #325: I/DD Eligibility for State-Funded Services

Limited funding. Not an entitlement. No New Admissions.

Brief Service Description: 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.

Auth Submission Requirements/ Documentation Requirements
Initial Requests:
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 Requests:
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.

Authorization Parameters
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).

Units: One unit = 15 minutes

Age Group: Children/ Adolescents & Adults

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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
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.

• State-Funded Community Living & Support
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual
• NCDHHS NC Support Needs Assessment Profile website
• JCB #325: I/DD Eligibility for State-Funded Services

Limited funding. Not an entitlement. No New Admissions.

Brief Service Description: 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.

Auth Submission Requirements/ Documentation Requirements
Initial Requests:
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 Requests:
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.

Authorization Parameters
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).

Units: One unit = 15 minutes

Age Group: Children/ Adolescents & Adults

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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
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.

• State-Funded Community Living & Support
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual
• NCDHHS NC Support Needs Assessment Profile website
• JCB #325: I/DD Eligibility for State-Funded Services

Limited funding. Not an entitlement. No New Admissions.

Brief Service Description: 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.

Auth Submission Requirements/ Documentation Requirements
Initial Requests:
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 Requests:
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.

Authorization Parameters
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).

Units: One unit = 15 minutes

Age Group: Children/ Adolescents & Adults

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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
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.

• State-Funded Community Living & Support
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual
• NCDHHS NC Support Needs Assessment Profile website
• JCB #325: I/DD Eligibility for State-Funded Services

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

Auth Submission Requirements
Initial Requests:
1. Prior approval required. The request must be by the TCM.
2. Independent Assessment: Required, completed by a TCM or the CIHA for Tribal members that indicates the Member would benefit from CL&S
3. Independent Evaluation: Required, completed by DHB/ Carelon to determine eligibility for 1915(i) 
4. Evidence of IDD or TBI: Required, as defined by the CCP.
5. Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
6. Service Order: Required, completed by QP, Licensed BH clinician, Licensed Psychologist, MD/ DO, NP, PA
7. Submission of applicable records that support the member has met the medical necessity criteria

Reauthorization Requests:
1. Prior approval required. The request must be by the TCM.
2. Updated Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
3. Submission of applicable records that support the member has met the medical necessity criteria

Authorization Parameters
Length of Stay: 
1. School-aged Members (through age 21 unless proof of graduation is provided): Up to 15 hours (60 units) a week when school is in session and up to 28 hours (112 units) a week when school is not in session 
2. Members aged 22 and up (or graduated, with proof of graduation): Up to 28 hours (or 112 units) a week
3. Proof of Graduation: includes graduation with a degree in a standard or occupational course of study, a GED, a Certificate of Completion, or proof of the exhaustion of their educational course of study)

Units: One unit = 15 minutes  
Age Group: Children/ Adolescents & Adults
Level of Care: Members must meet the IDD or TBI eligibility criteria as defined by the CCP.

Service Specifics, Limitations, & Exclusions (not all inclusive): 

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

• Clinical Coverage Policy No. 8H-5: Community Living and Supports
• Tailored Care Management Provider Manual (Section 4.4. Care Plans and Individua…
• PCP Guidance Documents & Templates
• North Carolina’s Transition of 1915(b)(3) Benefits to 1915(i) Fact Sheet
• APSM 45-2 Records Management and Documentation Manual

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

Auth Submission Requirements
Initial Requests:
1. Prior approval required. The request must be by the TCM.
2. Independent Assessment: Required, completed by a TCM or the CIHA for Tribal members that indicates the Member would benefit from CL&S
3. Independent Evaluation: Required, completed by DHB/ Carelon to determine eligibility for 1915(i) 
4. Evidence of IDD or TBI: Required, as defined by the CCP.
5. Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
6. Service Order: Required, completed by QP, Licensed BH clinician, Licensed Psychologist, MD/ DO, NP, PA
7. Submission of applicable records that support the member has met the medical necessity criteria

Reauthorization Requests:
1. Prior approval required. The request must be by the TCM.
2. Updated Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
3. Submission of applicable records that support the member has met the medical necessity criteria

Authorization Parameters
Length of Stay: 
1. School-aged Members (through age 21 unless proof of graduation is provided): Up to 15 hours (60 units) a week when school is in session and up to 28 hours (112 units) a week when school is not in session 
2. Members aged 22 and up (or graduated, with proof of graduation): Up to 28 hours (or 112 units) a week
3. Proof of Graduation: includes graduation with a degree in a standard or occupational course of study, a GED, a Certificate of Completion, or proof of the exhaustion of their educational course of study)

Units: One unit = 15 minutes  
Age Group: Children/ Adolescents & Adults
Level of Care: Members must meet the IDD or TBI eligibility criteria as defined by the CCP.

Service Specifics, Limitations, & Exclusions (not all inclusive): 

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

• Clinical Coverage Policy No. 8H-5: Community Living and Supports
• Tailored Care Management Provider Manual (Section 4.4. Care Plans and Individua…
• PCP Guidance Documents & Templates
• North Carolina’s Transition of 1915(b)(3) Benefits to 1915(i) Fact Sheet
• APSM 45-2 Records Management and Documentation Manual

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

Auth Submission Requirements
Initial Requests:
1. Prior approval required. The request must be by the TCM.
2. Independent Assessment: Required, completed by a TCM or the CIHA for Tribal members that indicates the Member would benefit from CL&S
3. Independent Evaluation: Required, completed by DHB/ Carelon to determine eligibility for 1915(i) 
4. Evidence of IDD or TBI: Required, as defined by the CCP.
5. Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
6. Service Order: Required, completed by QP, Licensed BH clinician, Licensed Psychologist, MD/ DO, NP, PA
7. Submission of applicable records that support the member has met the medical necessity criteria

Reauthorization Requests:
1. Prior approval required. The request must be by the TCM.
2. Updated Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
3. Submission of applicable records that support the member has met the medical necessity criteria

Authorization Parameters
Length of Stay: 
1. School-aged Members (through age 21 unless proof of graduation is provided): Up to 15 hours (60 units) a week when school is in session and up to 28 hours (112 units) a week when school is not in session 
2. Members aged 22 and up (or graduated, with proof of graduation): Up to 28 hours (or 112 units) a week
3. Proof of Graduation: includes graduation with a degree in a standard or occupational course of study, a GED, a Certificate of Completion, or proof of the exhaustion of their educational course of study)

Units: One unit = 15 minutes  
Age Group: Children/ Adolescents & Adults
Level of Care: Members must meet the IDD or TBI eligibility criteria as defined by the CCP.

Service Specifics, Limitations, & Exclusions (not all inclusive): 

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

• Clinical Coverage Policy No. 8H-5: Community Living and Supports
• Tailored Care Management Provider Manual (Section 4.4. Care Plans and Individua…
• PCP Guidance Documents & Templates
• North Carolina’s Transition of 1915(b)(3) Benefits to 1915(i) Fact Sheet
• APSM 45-2 Records Management and Documentation Manual

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

Auth Submission Requirements
Initial Requests:
1. Prior approval required. The request must be by the TCM.
2. Independent Assessment: Required, completed by a TCM or the CIHA for Tribal members that indicates the Member would benefit from CL&S
3. Independent Evaluation: Required, completed by DHB/ Carelon to determine eligibility for 1915(i) 
4. Evidence of IDD or TBI: Required, as defined by the CCP.
5. Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
6. Service Order: Required, completed by QP, Licensed BH clinician, Licensed Psychologist, MD/ DO, NP, PA
7. Submission of applicable records that support the member has met the medical necessity criteria

Reauthorization Requests:
1. Prior approval required. The request must be by the TCM.
2. Updated Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
3. Submission of applicable records that support the member has met the medical necessity criteria

Authorization Parameters
Length of Stay: 
1. School-aged Members (through age 21 unless proof of graduation is provided): Up to 15 hours (60 units) a week when school is in session and up to 28 hours (112 units) a week when school is not in session 
2. Members aged 22 and up (or graduated, with proof of graduation): Up to 28 hours (or 112 units) a week
3. Proof of Graduation: includes graduation with a degree in a standard or occupational course of study, a GED, a Certificate of Completion, or proof of the exhaustion of their educational course of study)

Units: One unit = 15 minutes  
Age Group: Children/ Adolescents & Adults
Level of Care: Members must meet the IDD or TBI eligibility criteria as defined by the CCP.

Service Specifics, Limitations, & Exclusions (not all inclusive): 

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

• Clinical Coverage Policy No. 8H-5: Community Living and Supports
• Tailored Care Management Provider Manual (Section 4.4. Care Plans and Individua…
• PCP Guidance Documents & Templates
• North Carolina’s Transition of 1915(b)(3) Benefits to 1915(i) Fact Sheet
• APSM 45-2 Records Management and Documentation Manual

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

Auth Submission Requirements
Initial Requests:
1. Prior approval required. The request must be by the TCM.
2. Independent Assessment: Required, completed by a TCM or the CIHA for Tribal members that indicates the Member would benefit from CL&S
3. Independent Evaluation: Required, completed by DHB/ Carelon to determine eligibility for 1915(i) 
4. Evidence of IDD or TBI: Required, as defined by the CCP.
5. Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
6. Service Order: Required, completed by QP, Licensed BH clinician, Licensed Psychologist, MD/ DO, NP, PA
7. Submission of applicable records that support the member has met the medical necessity criteria

Reauthorization Requests:
1. Prior approval required. The request must be by the TCM.
2. Updated Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
3. Submission of applicable records that support the member has met the medical necessity criteria

Authorization Parameters
Length of Stay: 
1. School-aged Members (through age 21 unless proof of graduation is provided): Up to 15 hours (60 units) a week when school is in session and up to 28 hours (112 units) a week when school is not in session 
2. Members aged 22 and up (or graduated, with proof of graduation): Up to 28 hours (or 112 units) a week
3. Proof of Graduation: includes graduation with a degree in a standard or occupational course of study, a GED, a Certificate of Completion, or proof of the exhaustion of their educational course of study)

Units: One unit = 15 minutes  
Age Group: Children/ Adolescents & Adults
Level of Care: Members must meet the IDD or TBI eligibility criteria as defined by the CCP.

Service Specifics, Limitations, & Exclusions (not all inclusive): 

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

• Clinical Coverage Policy No. 8H-5: Community Living and Supports
• Tailored Care Management Provider Manual (Section 4.4. Care Plans and Individua…
• PCP Guidance Documents & Templates
• North Carolina’s Transition of 1915(b)(3) Benefits to 1915(i) Fact Sheet
• APSM 45-2 Records Management and Documentation Manual

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

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

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

Authorization Parameters
Length of Stay: Up to 6 months for all requests.

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

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

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

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

• Community Living Facilities and Support (CLFS) ILO Service Definition
• NCDHHS NC Support Needs Assessment Profile website
• CCP No 8E: Intermediate Care Facilities for Individuals with Intellectual Disab…
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

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

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

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

Authorization Parameters
Length of Stay: Up to 6 months for all requests.

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

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

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

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

• Community Living Facilities and Support (CLFS) ILO Service Definition
• NCDHHS NC Support Needs Assessment Profile website
• CCP No 8E: Intermediate Care Facilities for Individuals with Intellectual Disab…
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

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

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

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

Authorization Parameters
Length of Stay: Up to 6 months for all requests.

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

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

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

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

• Community Living Facilities and Support (CLFS) ILO Service Definition
• NCDHHS NC Support Needs Assessment Profile website
• CCP No 8E: Intermediate Care Facilities for Individuals with Intellectual Disab…
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

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

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

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

Authorization Parameters
Authorization Parameters
Length of Stay: Up to 6 months for all requests.

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

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

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

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

• Community Living Facilities and Support (CLFS) ILO Service Definition
• NCDHHS NC Support Needs Assessment Profile website
• CCP No 8E: Intermediate Care Facilities for Individuals with Intellectual Disab…
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

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

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

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

Authorization Parameters
Length of Stay: Up to 6 months for all requests.

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

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

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

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

• Community Living Facilities and Support (CLFS) ILO Service Definition
• NCDHHS NC Support Needs Assessment Profile website
• CCP No 8E: Intermediate Care Facilities for Individuals with Intellectual Disab…
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: The purpose of Community Navigator Services is to promote self-determination, support the member in making life choices, provide advocacy and identify opportunities to become a part of their community. Community Navigator provides support to the member and planning teams in developing social networks and connections within local communities. Community Navigator Services emphasizes, promotes, and coordinates the use of generic resources to address the members needs in addition to paid services. Community Navigator provides an annual informational session on Self-Determination and Self Direction. The member and legally responsible person may choose to opt out of this annual informational session.

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: One unit = 1 month

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    Community Navigation services are used to support members self-directing waiver services; therefore, it is only available for individuals participating in self-direction. Community Navigation service is only available if the member is self-directing one or more of their services through the Agency with Choice or Employer of Record Model.
2.    Community Navigator is mandatory for all Employers of Record until competence in directing service is demonstrated.
3.    This service does not duplicate Care Coordination. Care coordination under managed care includes the development of the ISP, completing or gathering evaluations inclusive of the re-evaluation of the level of care, monitoring the implementation of the ISP, choosing service providers, coordination of benefits and monitoring the health and safety of the member consistent with 42 CFR 438.208(c).
4.    The creation and the facilitation of the Individual Support Plan is the responsibility of the Care Coordinator. The Community Navigator can assist the member with preparing for the Individual Support Plan.
5.    If a provider does not provide Agency with Choice Services, the only other service that they may provide to the same member, in addition to Community Navigator Services, is Community Transition.
6.    An agency may provide both Community Navigator Services and Agency with Choice Services to the same individual, in addition to Community Transition, Financial Support Services, Individual Goods and Services, and Primary Crisis Response Services.
7.    The Community Navigator Self-Directed activities can only to be used to provide support to the individual under Individual and Family Directed Supports: Employer of Record and Agency with Choice Models, as approved in this Waiver.
8.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
9.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

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

Brief Service Description: The purpose of Community Navigator Services is to promote self-determination, support the member in making life choices, provide advocacy and identify opportunities to become a part of their community. Community Navigator provides support to the member and planning teams in developing social networks and connections within local communities. Community Navigator Services emphasizes, promotes, and coordinates the use of generic resources to address the members needs in addition to paid services. Community Navigator provides an annual informational session on Self-Determination and Self Direction. The member and legally responsible person may choose to opt out of this annual informational session.

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: One unit = 1 month

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    Community Navigation services are used to support members self-directing waiver services; therefore, it is only available for individuals participating in self-direction. Community Navigation service is only available if the member is self-directing one or more of their services through the Agency with Choice or Employer of Record Model.
2.    Community Navigator is mandatory for all Employers of Record until competence in directing service is demonstrated.
3.    This service does not duplicate Care Coordination. Care coordination under managed care includes the development of the ISP, completing or gathering evaluations inclusive of the re-evaluation of the level of care, monitoring the implementation of the ISP, choosing service providers, coordination of benefits and monitoring the health and safety of the member consistent with 42 CFR 438.208(c).
4.    The creation and the facilitation of the Individual Support Plan is the responsibility of the Care Coordinator. The Community Navigator can assist the member with preparing for the Individual Support Plan.
5.    If a provider does not provide Agency with Choice Services, the only other service that they may provide to the same member, in addition to Community Navigator Services, is Community Transition.
6.    An agency may provide both Community Navigator Services and Agency with Choice Services to the same individual, in addition to Community Transition, Financial Support Services, Individual Goods and Services, and Primary Crisis Response Services.
7.    The Community Navigator Self-Directed activities can only to be used to provide support to the individual under Individual and Family Directed Supports: Employer of Record and Agency with Choice Models, as approved in this Waiver.
8.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
9.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: The purpose of Community Navigator Services is to promote self-determination, support the member in making life choices, provide advocacy and identify opportunities to become a part of their community. Community Navigator provides support to the member and planning teams in developing social networks and connections within local communities. Community Navigator Services emphasizes, promotes, and coordinates the use of generic resources to address the members needs in addition to paid services. Community Navigator provides an annual informational session on Self-Determination and Self Direction. The member and legally responsible person may choose to opt out of this annual informational session.

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: One unit = 15 minutes

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    Community Navigation services are used to support members self-directing waiver services; therefore, it is only available for individuals participating in self-direction. Community Navigation service is only available if the member is self-directing one or more of their services through the Agency with Choice or Employer of Record Model.
2.    Community Navigator is mandatory for all Employers of Record until competence in directing service is demonstrated.
3.    This service does not duplicate Care Coordination. Care coordination under managed care includes the development of the ISP, completing or gathering evaluations inclusive of the re-evaluation of the level of care, monitoring the implementation of the ISP, choosing service providers, coordination of benefits and monitoring the health and safety of the member consistent with 42 CFR 438.208(c).
4.    The creation and the facilitation of the Individual Support Plan is the responsibility of the Care Coordinator. The Community Navigator can assist the member with preparing for the Individual Support Plan.
5.    If a provider does not provide Agency with Choice Services, the only other service that they may provide to the same member, in addition to Community Navigator Services, is Community Transition.
6.    An agency may provide both Community Navigator Services and Agency with Choice Services to the same individual, in addition to Community Transition, Financial Support Services, Individual Goods and Services, and Primary Crisis Response Services.
7.    The Community Navigator Self-Directed activities can only to be used to provide support to the individual under Individual and Family Directed Supports: Employer of Record and Agency with Choice Models, as approved in this Waiver.
8.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
9.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

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

Brief Service Description: The purpose of Community Navigator Services is to promote self-determination, support the member in making life choices, provide advocacy and identify opportunities to become a part of their community. Community Navigator provides support to the member and planning teams in developing social networks and connections within local communities. Community Navigator Services emphasizes, promotes, and coordinates the use of generic resources to address the members needs in addition to paid services. Community Navigator provides an annual informational session on Self-Determination and Self Direction. The member and legally responsible person may choose to opt out of this annual informational session.

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: One unit = 15 minutes

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    Community Navigation services are used to support members self-directing waiver services; therefore, it is only available for individuals participating in self-direction. Community Navigation service is only available if the member is self-directing one or more of their services through the Agency with Choice or Employer of Record Model.
2.    Community Navigator is mandatory for all Employers of Record until competence in directing service is demonstrated.
3.    This service does not duplicate Care Coordination. Care coordination under managed care includes the development of the ISP, completing or gathering evaluations inclusive of the re-evaluation of the level of care, monitoring the implementation of the ISP, choosing service providers, coordination of benefits and monitoring the health and safety of the member consistent with 42 CFR 438.208(c).
4.    The creation and the facilitation of the Individual Support Plan is the responsibility of the Care Coordinator. The Community Navigator can assist the member with preparing for the Individual Support Plan.
5.    If a provider does not provide Agency with Choice Services, the only other service that they may provide to the same member, in addition to Community Navigator Services, is Community Transition.
6.    An agency may provide both Community Navigator Services and Agency with Choice Services to the same individual, in addition to Community Transition, Financial Support Services, Individual Goods and Services, and Primary Crisis Response Services.
7.    The Community Navigator Self-Directed activities can only to be used to provide support to the individual under Individual and Family Directed Supports: Employer of Record and Agency with Choice Models, as approved in this Waiver.
8.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
9.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Community Networking services provide individualized day activities that support the member’s definition of a meaningful day in an integrated community setting, with persons who are not disabled. If the member requires paid supports to participate / engage once connected with the activity, Community Networking can be used to refer and link the member. Services are designed to promote maximum participation in community life while developing natural supports within integrated settings. Community Networking services enable the member to increase or maintain their capacity for independence and develop social roles valued by non-disabled members of the community. As the member gains skills and increase community connections, service hours may fade.

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: One unit = 15 minutes

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    Payment for attendance at classes and conferences cannot exceed $1,000/ per member plan year. The amount of community networking services is subject to the “Limits on Sets of Services.”
2.    This service is provided separate and apart from the member’s primary private residence, other residential living arrangement, and/or the home of a service provider. These services do not take place in licensed facilities and are intended to offer the member the opportunity to develop meaningful community relationships with non-disabled individuals.
3.    Service does not cover the cost of hotels, meals, materials or transportation while attending conferences.
4.    Service does not cover activities that would normally be a component of a member’s home/residential life or services.
5.    Service does not pay day care fees or fees for other childcare related activities.
6.    The waiver member may not volunteer for the Community Networking service provider.
7.    Volunteering may not be done at locations that would not typically have volunteers (that is, hair salon or florist) or in positions that would be paid positions if performed by an individual that was not on the waiver.
8.    This service may not duplicate or be furnished/claimed at the same time of day as Day Supports, Community Living and Support, Residential Supports, Respite, Supported Employment or one of the State Plan Medicaid services that works directly with the member.
9.    For a member who is eligible for educational services under the Individuals With Disability Educational Act, Community Networking does not cover transportation to/from school settings. (Transportation to/from member’s home or any community location where the member may be receiving services before/after school is covered for this service.)
10.    This service does not pay for overnight programs of any kind. 
11.    Classes that offer one-to-one instruction are not covered.
12.    Classes that are in a nonintegrated community setting are not covered.
13.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
14.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

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

Brief Service Description: Community Networking services provide individualized day activities that support the member’s definition of a meaningful day in an integrated community setting, with persons who are not disabled. If the member requires paid supports to participate / engage once connected with the activity, Community Networking can be used to refer and link the member. Services are designed to promote maximum participation in community life while developing natural supports within integrated settings. Community Networking services enable the member to increase or maintain their capacity for independence and develop social roles valued by non-disabled members of the community. As the member gains skills and increase community connections, service hours may fade.

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: One unit = 15 minutes

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    Payment for attendance at classes and conferences cannot exceed $1,000/ per member plan year. The amount of community networking services is subject to the “Limits on Sets of Services.”
2.    This service is provided separate and apart from the member’s primary private residence, other residential living arrangement, and/or the home of a service provider. These services do not take place in licensed facilities and are intended to offer the member the opportunity to develop meaningful community relationships with non-disabled individuals.
3.    Service does not cover the cost of hotels, meals, materials or transportation while attending conferences.
4.    Service does not cover activities that would normally be a component of a member’s home/residential life or services.
5.    Service does not pay day care fees or fees for other childcare related activities.
6.    The waiver member may not volunteer for the Community Networking service provider.
7.    Volunteering may not be done at locations that would not typically have volunteers (that is, hair salon or florist) or in positions that would be paid positions if performed by an individual that was not on the waiver.
8.    This service may not duplicate or be furnished/claimed at the same time of day as Day Supports, Community Living and Support, Residential Supports, Respite, Supported Employment or one of the State Plan Medicaid services that works directly with the member.
9.    For a member who is eligible for educational services under the Individuals With Disability Educational Act, Community Networking does not cover transportation to/from school settings. (Transportation to/from member’s home or any community location where the member may be receiving services before/after school is covered for this service.)
10.    This service does not pay for overnight programs of any kind. 
11.    Classes that offer one-to-one instruction are not covered.
12.    Classes that are in a nonintegrated community setting are not covered.
13.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
14.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Community Networking services provide individualized day activities that support the member’s definition of a meaningful day in an integrated community setting, with persons who are not disabled. If the member requires paid supports to participate / engage once connected with the activity, Community Networking can be used to refer and link the member. Services are designed to promote maximum participation in community life while developing natural supports within integrated settings. Community Networking services enable the member to increase or maintain their capacity for independence and develop social roles valued by non-disabled members of the community. As the member gains skills and increase community connections, service hours may fade.

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: One unit = 15 minutes

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    Payment for attendance at classes and conferences cannot exceed $1,000/ per member plan year. The amount of community networking services is subject to the “Limits on Sets of Services.”
2.    This service is provided separate and apart from the member’s primary private residence, other residential living arrangement, and/or the home of a service provider. These services do not take place in licensed facilities and are intended to offer the member the opportunity to develop meaningful community relationships with non-disabled individuals.
3.    Service does not cover the cost of hotels, meals, materials or transportation while attending conferences.
4.    Service does not cover activities that would normally be a component of a member’s home/residential life or services.
5.    Service does not pay day care fees or fees for other childcare related activities.
6.    The waiver member may not volunteer for the Community Networking service provider.
7.    Volunteering may not be done at locations that would not typically have volunteers (that is, hair salon or florist) or in positions that would be paid positions if performed by an individual that was not on the waiver.
8.    This service may not duplicate or be furnished/claimed at the same time of day as Day Supports, Community Living and Support, Residential Supports, Respite, Supported Employment or one of the State Plan Medicaid services that works directly with the member.
9.    For a member who is eligible for educational services under the Individuals With Disability Educational Act, Community Networking does not cover transportation to/from school settings. (Transportation to/from member’s home or any community location where the member may be receiving services before/after school is covered for this service.)
10.    This service does not pay for overnight programs of any kind. 
11.    Classes that offer one-to-one instruction are not covered.
12.    Classes that are in a nonintegrated community setting are not covered.
13.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
14.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

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

Brief Service Description: Community Networking services provide individualized day activities that support the member’s definition of a meaningful day in an integrated community setting, with persons who are not disabled. If the member requires paid supports to participate / engage once connected with the activity, Community Networking can be used to refer and link the member. Services are designed to promote maximum participation in community life while developing natural supports within integrated settings. Community Networking services enable the member to increase or maintain their capacity for independence and develop social roles valued by non-disabled members of the community. As the member gains skills and increase community connections, service hours may fade.

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: One unit = 15 minutes

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    Payment for attendance at classes and conferences cannot exceed $1,000/ per member plan year. The amount of community networking services is subject to the “Limits on Sets of Services.”
2.    This service is provided separate and apart from the member’s primary private residence, other residential living arrangement, and/or the home of a service provider. These services do not take place in licensed facilities and are intended to offer the member the opportunity to develop meaningful community relationships with non-disabled individuals.
3.    Service does not cover the cost of hotels, meals, materials or transportation while attending conferences.
4.    Service does not cover activities that would normally be a component of a member’s home/residential life or services.
5.    Service does not pay day care fees or fees for other childcare related activities.
6.    The waiver member may not volunteer for the Community Networking service provider.
7.    Volunteering may not be done at locations that would not typically have volunteers (that is, hair salon or florist) or in positions that would be paid positions if performed by an individual that was not on the waiver.
8.    This service may not duplicate or be furnished/claimed at the same time of day as Day Supports, Community Living and Support, Residential Supports, Respite, Supported Employment or one of the State Plan Medicaid services that works directly with the member.
9.    For a member who is eligible for educational services under the Individuals With Disability Educational Act, Community Networking does not cover transportation to/from school settings. (Transportation to/from member’s home or any community location where the member may be receiving services before/after school is covered for this service.)
10.    This service does not pay for overnight programs of any kind. 
11.    Classes that offer one-to-one instruction are not covered.
12.    Classes that are in a nonintegrated community setting are not covered.
13.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
14.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Community Networking services provide individualized day activities that support the member’s definition of a meaningful day in an integrated community setting, with persons who are not disabled. If the member requires paid supports to participate / engage once connected with the activity, Community Networking can be used to refer and link the member. Services are designed to promote maximum participation in community life while developing natural supports within integrated settings. Community Networking services enable the member to increase or maintain their capacity for independence and develop social roles valued by non-disabled members of the community. As the member gains skills and increase community connections, service hours may fade.

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: One unit = 15 minutes

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    Payment for attendance at classes and conferences cannot exceed $1,000/ per member plan year. The amount of community networking services is subject to the “Limits on Sets of Services.”
2.    This service is provided separate and apart from the member’s primary private residence, other residential living arrangement, and/or the home of a service provider. These services do not take place in licensed facilities and are intended to offer the member the opportunity to develop meaningful community relationships with non-disabled individuals.
3.    Service does not cover the cost of hotels, meals, materials or transportation while attending conferences.
4.    Service does not cover activities that would normally be a component of a member’s home/residential life or services.
5.    Service does not pay day care fees or fees for other childcare related activities.
6.    The waiver member may not volunteer for the Community Networking service provider.
7.    Volunteering may not be done at locations that would not typically have volunteers (that is, hair salon or florist) or in positions that would be paid positions if performed by an individual that was not on the waiver.
8.    This service may not duplicate or be furnished/claimed at the same time of day as Day Supports, Community Living and Support, Residential Supports, Respite, Supported Employment or one of the State Plan Medicaid services that works directly with the member.
9.    For a member who is eligible for educational services under the Individuals With Disability Educational Act, Community Networking does not cover transportation to/from school settings. (Transportation to/from member’s home or any community location where the member may be receiving services before/after school is covered for this service.)
10.    This service does not pay for overnight programs of any kind. 
11.    Classes that offer one-to-one instruction are not covered.
12.    Classes that are in a nonintegrated community setting are not covered.
13.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
14.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Community Networking services provide individualized day activities that support the member’s definition of a meaningful day in an integrated community setting, with persons who are not disabled. If the member requires paid supports to participate / engage once connected with the activity, Community Networking can be used to refer and link the member. Services are designed to promote maximum participation in community life while developing natural supports within integrated settings. Community Networking services enable the member to increase or maintain their capacity for independence and develop social roles valued by non-disabled members of the community. As the member gains skills and increase community connections, service hours may fade.

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
Units: One unit = 15 minutes

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    Payment for attendance at classes and conferences cannot exceed $1,000/ per member plan year. The amount of community networking services is subject to the “Limits on Sets of Services.”
2.    This service is provided separate and apart from the member’s primary private residence, other residential living arrangement, and/or the home of a service provider. These services do not take place in licensed facilities and are intended to offer the member the opportunity to develop meaningful community relationships with non-disabled individuals.
3.    Service does not cover the cost of hotels, meals, materials or transportation while attending conferences.
4.    Service does not cover activities that would normally be a component of a member’s home/residential life or services.
5.    Service does not pay day care fees or fees for other childcare related activities.
6.    The waiver member may not volunteer for the Community Networking service provider.
7.    Volunteering may not be done at locations that would not typically have volunteers (that is, hair salon or florist) or in positions that would be paid positions if performed by an individual that was not on the waiver.
8.    This service may not duplicate or be furnished/claimed at the same time of day as Day Supports, Community Living and Support, Residential Supports, Respite, Supported Employment or one of the State Plan Medicaid services that works directly with the member.
9.    For a member who is eligible for educational services under the Individuals With Disability Educational Act, Community Networking does not cover transportation to/from school settings. (Transportation to/from member’s home or any community location where the member may be receiving services before/after school is covered for this service.)
10.    This service does not pay for overnight programs of any kind. 
11.    Classes that offer one-to-one instruction are not covered.
12.    Classes that are in a nonintegrated community setting are not covered.
13.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
14.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a MH, SU, or co-morbid disorder and who have complex and extensive treatment needs. Consists of community-based MH and SU services, and structured rehab interventions intended to increase and restore a member’s ability to live successfully in the community. The team approach involves structured, face-to-face therapeutic interventions that assist in reestablishing the members community roles related to life domains..

Auth Submission Requirements/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive): 
1. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable. For services lasting more than six months, a new CCA or an addendum must be completed.
2. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
3. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
4. Transition/ Stepdown Plan: Encouraged
5. Submission of applicable records that support the member has met the medical necessity criteria.

All services are subject to post-payment review.

Authorization Parameters
Units and Length of Stay: 
1. One unit = 15 minutes
2. It is expected that service intensity titrates down as the member demonstrates improvement.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. When helping a member transition to and from a service, CST services may be provided for a max of eight units for the first and last 30-day period for members transitioning to: ACTT, SAIOP, SACOT.
2. May not be provided in conjunction with ACTT or during the same episode period as any other State Plan service that contains duplicative service components. This includes PSS, as CCP 8G states that PSS must not be provided during the same auth period as CST, as a member who needs CST and peer support will be offered by peer support by the CST providers.

• Clinical Coverage Policy No 8A-6: Community Support Team
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a MH, SU, or co-morbid disorder and who have complex and extensive treatment needs. Consists of community-based MH and SU services, and structured rehab interventions intended to increase and restore a member’s ability to live successfully in the community. The team approach involves structured, face-to-face therapeutic interventions that assist in reestablishing the members community roles related to life domains..

Auth Submission Requirements/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive): 
1. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable. For services lasting more than six months, a new CCA or an addendum must be completed.
2. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
3. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
4. Transition/ Stepdown Plan: Encouraged
5. Submission of applicable records that support the member has met the medical necessity criteria.

All services are subject to post-payment review.

Authorization Parameters
Units and Length of Stay: 
1. One unit = 15 minutes
2. It is expected that service intensity titrates down as the member demonstrates improvement.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. When helping a member transition to and from a service, CST services may be provided for a max of eight units for the first and last 30-day period for members transitioning to: ACTT, SAIOP, SACOT.
2. May not be provided in conjunction with ACTT or during the same episode period as any other State Plan service that contains duplicative service components. This includes PSS, as CCP 8G states that PSS must not be provided during the same auth period as CST, as a member who needs CST and peer support will be offered by peer support by the CST providers.

• Clinical Coverage Policy No 8A-6: Community Support Team
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a MH, SU, or co-morbid disorder and who have complex and extensive treatment needs. Consists of community-based MH and SU services, and structured rehab interventions intended to increase and restore a member’s ability to live successfully in the community. The team approach involves structured, face-to-face therapeutic interventions that assist in reestablishing the members community roles related to life domains..

Auth Submission Requirements/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive): 
1. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable. For services lasting more than six months, a new CCA or an addendum must be completed.
2. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
3. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
4. Transition/ Stepdown Plan: Encouraged
5. Submission of applicable records that support the member has met the medical necessity criteria.

All services are subject to post-payment review.

Authorization Parameters
Units and Length of Stay: 
1. One unit = 15 minutes
2. It is expected that service intensity titrates down as the member demonstrates improvement.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. When helping a member transition to and from a service, CST services may be provided for a max of eight units for the first and last 30-day period for members transitioning to: ACTT, SAIOP, SACOT.
2. May not be provided in conjunction with ACTT or during the same episode period as any other State Plan service that contains duplicative service components. This includes PSS, as CCP 8G states that PSS must not be provided during the same auth period as CST, as a member who needs CST and peer support will be offered by peer support by the CST providers.

• Clinical Coverage Policy No 8A-6: Community Support Team
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a MH, SU, or co-morbid disorder and who have complex and extensive treatment needs. Consists of community-based MH and SU services, and structured rehab interventions intended to increase and restore a member’s ability to live successfully in the community. The team approach involves structured, face-to-face therapeutic interventions that assist in reestablishing the members community roles related to life domains..

Auth Submission Requirements/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive): 
1. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable. For services lasting more than six months, a new CCA or an addendum must be completed.
2. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
3. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
4. Transition/ Stepdown Plan: Encouraged
5. Submission of applicable records that support the member has met the medical necessity criteria.

All services are subject to post-payment review.

Authorization Parameters
Units and Length of Stay: 
1. One unit = 15 minutes
2. It is expected that service intensity titrates down as the member demonstrates improvement.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. When helping a member transition to and from a service, CST services may be provided for a max of eight units for the first and last 30-day period for members transitioning to: ACTT, SAIOP, SACOT.
2. May not be provided in conjunction with ACTT or during the same episode period as any other State Plan service that contains duplicative service components. This includes PSS, as CCP 8G states that PSS must not be provided during the same auth period as CST, as a member who needs CST and peer support will be offered by peer support by the CST providers.

• Clinical Coverage Policy No 8A-6: Community Support Team
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a MH, SU, or co-morbid disorder and who have complex and extensive treatment needs. Consists of community-based MH and SU services, and structured rehab interventions intended to increase and restore a member’s ability to live successfully in the community. The team approach involves structured, face-to-face therapeutic interventions that assist in reestablishing the members community roles related to life domains..

Auth Submission Requirements/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Maintained in the Record (not all inclusive): 
1. CCA: Required, to include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions if applicable. For services lasting more than six months, a new CCA or an addendum must be completed.
2. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
3. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
4. Transition/ Stepdown Plan: Encouraged
5. Submission of applicable records that support the member has met the medical necessity criteria.

All services are subject to post-payment review.

Authorization Parameters
Units and Length of Stay: 
1. One unit = 15 minutes
2. It is expected that service intensity titrates down as the member demonstrates improvement.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. When helping a member transition to and from a service, CST services may be provided for a max of eight units for the first and last 30-day period for members transitioning to: ACTT, SAIOP, SACOT.
2. May not be provided in conjunction with ACTT or during the same episode period as any other State Plan service that contains duplicative service components. This includes PSS, as CCP 8G states that PSS must not be provided during the same auth period as CST, as a member who needs CST and peer support will be offered by peer support by the CST providers.

• Clinical Coverage Policy No 8A-6: Community Support Team
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a dx of MH, SU, or comorbid disorder and who have complex and extensive tx needs. This is an intensive community-based rehab team service that provides direct tx and restorative interventions as well as case management.  This service consists of community-based MH and SU services, and structured rehabilitative interventions intended to increase and restore a individuals ability to live successfully in the community. The team approach involves assistance in re-est. the individuals community roles related to the following life domains: emotional, behavioral, social, safety, housing, medical and health, educational, vocational, and legal.

Auth Submission Requirements/ Documentation Requirements
Initial Requests:
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. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Submission of applicable records that support the individual has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP: recently reviewed detailing the individual’s progress with the service to include all required signatures and the 3-page crisis plan.
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.

Authorization Parameters
Length of Stay: 
1. Up to a 60-day auth period per request.
2. No more than 3 months in a rolling year will be authorized.

Units:
1. One unit = 15 minutes
2. Up to 128 units for 60 calendar days. For those searching for stable housing and requiring permanent supportive housing interventions, up to 420 units for the initial authorization period. These additional units have a 3-month max limit per rolling year.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. CST must not be provided in conjunction with ACT; during the same auth period as any other service that contains duplicative service components (to include TMS or PSS); to individuals residing in Institutions for Mental Disease (IMD), and; Family individuals or LRPs of the individual may not provide this service.  
2. To help w/ transition, CST services may be provided for a max of 8 units for the first and last 30-day period for individuals who transitioning to or from: ACTT, SAIOP or SACOT.

• State-Funded Community Support Team Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a dx of MH, SU, or comorbid disorder and who have complex and extensive tx needs. This is an intensive community-based rehab team service that provides direct tx and restorative interventions as well as case management.  This service consists of community-based MH and SU services, and structured rehabilitative interventions intended to increase and restore a individuals ability to live successfully in the community. The team approach involves assistance in re-est. the individuals community roles related to the following life domains: emotional, behavioral, social, safety, housing, medical and health, educational, vocational, and legal.

Auth Submission Requirements/ Documentation Requirements
Initial Requests:
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. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Submission of applicable records that support the individual has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP: recently reviewed detailing the individual’s progress with the service to include all required signatures and the 3-page crisis plan.
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.

Authorization Parameters
Length of Stay: 
1. Up to a 60-day auth period per request.
2. No more than 3 months in a rolling year will be authorized.

Units:
1. One unit = 15 minutes
2. Up to 128 units for 60 calendar days. For those searching for stable housing and requiring permanent supportive housing interventions, up to 420 units for the initial authorization period. These additional units have a 3-month max limit per rolling year.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. CST must not be provided in conjunction with ACT; during the same auth period as any other service that contains duplicative service components (to include TMS or PSS); to individuals residing in Institutions for Mental Disease (IMD), and; Family individuals or LRPs of the individual may not provide this service.  
2. To help w/ transition, CST services may be provided for a max of 8 units for the first and last 30-day period for individuals who transitioning to or from: ACTT, SAIOP or SACOT.

• State-Funded Community Support Team Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a dx of MH, SU, or comorbid disorder and who have complex and extensive tx needs. This is an intensive community-based rehab team service that provides direct tx and restorative interventions as well as case management.  This service consists of community-based MH and SU services, and structured rehabilitative interventions intended to increase and restore a individuals ability to live successfully in the community. The team approach involves assistance in re-est. the individuals community roles related to the following life domains: emotional, behavioral, social, safety, housing, medical and health, educational, vocational, and legal.

Auth Submission Requirements/ Documentation Requirements
Initial Requests:
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. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Submission of applicable records that support the individual has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP: recently reviewed detailing the individual’s progress with the service to include all required signatures and the 3-page crisis plan.
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.

Authorization Parameters
Length of Stay: 
1. Up to a 60-day auth period per request.
2. No more than 3 months in a rolling year will be authorized.

Units:
1. One unit = 15 minutes
2. Up to 128 units for 60 calendar days. For those searching for stable housing and requiring permanent supportive housing interventions, up to 420 units for the initial authorization period. These additional units have a 3-month max limit per rolling year.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. CST must not be provided in conjunction with ACT; during the same auth period as any other service that contains duplicative service components (to include TMS or PSS); to individuals residing in Institutions for Mental Disease (IMD), and; Family individuals or LRPs of the individual may not provide this service.  
2. To help w/ transition, CST services may be provided for a max of 8 units for the first and last 30-day period for individuals who transitioning to or from: ACTT, SAIOP or SACOT.

• State-Funded Community Support Team Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a dx of MH, SU, or comorbid disorder and who have complex and extensive tx needs. This is an intensive community-based rehab team service that provides direct tx and restorative interventions as well as case management.  This service consists of community-based MH and SU services, and structured rehabilitative interventions intended to increase and restore a individuals ability to live successfully in the community. The team approach involves assistance in re-est. the individuals community roles related to the following life domains: emotional, behavioral, social, safety, housing, medical and health, educational, vocational, and legal.

Auth Submission Requirements/ Documentation Requirements
Initial Requests:
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. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Submission of applicable records that support the individual has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP: recently reviewed detailing the individual’s progress with the service to include all required signatures and the 3-page crisis plan.
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.

Authorization Parameters
Length of Stay: 
1. Up to a 60-day auth period per request.
2. No more than 3 months in a rolling year will be authorized.

Units:
1. One unit = 15 minutes
2. Up to 128 units for 60 calendar days. For those searching for stable housing and requiring permanent supportive housing interventions, up to 420 units for the initial authorization period. These additional units have a 3-month max limit per rolling year.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. CST must not be provided in conjunction with ACT; during the same auth period as any other service that contains duplicative service components (to include TMS or PSS); to individuals residing in Institutions for Mental Disease (IMD), and; Family individuals or LRPs of the individual may not provide this service.  
2. To help w/ transition, CST services may be provided for a max of 8 units for the first and last 30-day period for individuals who transitioning to or from: ACTT, SAIOP or SACOT.

• State-Funded Community Support Team Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Provides direct support to adults with a dx of MH, SU, or comorbid disorder and who have complex and extensive tx needs. This is an intensive community-based rehab team service that provides direct tx and restorative interventions as well as case management.  This service consists of community-based MH and SU services, and structured rehabilitative interventions intended to increase and restore a individuals ability to live successfully in the community. The team approach involves assistance in re-est. the individuals community roles related to the following life domains: emotional, behavioral, social, safety, housing, medical and health, educational, vocational, and legal.

Auth Submission Requirements/ Documentation Requirements
Initial Requests:
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. Complete PCP: Required, to include all required signatures and the 3-page crisis plan
4. Service Order: Required, signed by an MD/ DO, NP, PA, or a Licensed Psychologist.
5. Submission of applicable records that support the individual has met the medical necessity criteria.

Reauthorization Requests:
1. TAR: prior authorization required
2. Complete PCP: recently reviewed detailing the individual’s progress with the service to include all required signatures and the 3-page crisis plan.
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.

Authorization Parameters
Length of Stay: 
1. Up to a 60-day auth period per request.
2. No more than 3 months in a rolling year will be authorized.

Units:
1. One unit = 15 minutes
2. Up to 128 units for 60 calendar days. For those searching for stable housing and requiring permanent supportive housing interventions, up to 420 units for the initial authorization period. These additional units have a 3-month max limit per rolling year.

Age Group: Adults (age 18 and older)

Level of Care: ASAM Level 1 (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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. CST must not be provided in conjunction with ACT; during the same auth period as any other service that contains duplicative service components (to include TMS or PSS); to individuals residing in Institutions for Mental Disease (IMD), and; Family individuals or LRPs of the individual may not provide this service.  
2. To help w/ transition, CST services may be provided for a max of 8 units for the first and last 30-day period for individuals who transitioning to or from: ACTT, SAIOP or SACOT.

• State-Funded Community Support Team Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Community Transition provides funding for a one-time initial setup of expenses for a member transitioning from an institutional or other approved setting, into their own private residence where the member is responsible for their own living expenses. Community Transition can support a member being diverted from entry into ACHs or any institutional level of care due to preadmission, screening, and diversion efforts, provided that the member is moving to a living arrangement where they are directly responsible for their own living expenses.
 

Auth Submission Requirements
Initial Requests:
1. Prior approval required. The request must be submitted by TCM.
2. Independent Assessment: Required, completed by a TCM or the CIHA for Tribal members that indicates the Member would benefit from Community Transition
3. Independent Evaluation: Required, completed by DHB/ Carelon to determine eligibility for 1915(i) 
4. Care Plan/ ISP: Must include the information/ requirements detailed in the TCM Provider Manual and federal PCP requirements (see PCP section above).
5. Submission of applicable records that support the member has met the medical necessity criteria
Reauthorization Requests: Not Applicable

Authorization Parameters
Length of Stay: Available up to 3 months in advance of a member’s move to an integrated living arrangement, and up to 90 consecutive days post move in date 
Units: One unit per episode  
Age Group: Adolescents & Adults (18 years of age and older)
Level of Care: A primary diagnosis of IDD, TBI, SMI, SPMI, or severe SUD as defined by the CCP is required.
Miscellaneous:
•    The Community Transition Checklist is to be maintained in the members’ record.

For individuals with IDD/TBI:
1. Providers (non-TCMs/care coordinators) will be responsible for providing Community Transition services.
2. The TCM/care coordinator and the provider must work together to identify the Community Transition needs of the individuals.
3. The TCM/care coordinator completes the care plan/ISP which indicates the request for Community Transition.
4. The tx team then reviews the hours needed to support the individual to access Community Transition.
5. The tx team works with the TCM/care coordinator to update the care plan/goals to address specific hours needed through the Community Living Supports service to support the individual.
 

Service Specifics, Limitations, & Exclusions (not all inclusive): 
 

• Community Transition has a limit of $5,000 per individual during the five-year period.
• Community Transition only covers the actual items purchased, not the time spent assisting the member to purchase them. Providers currently providing a community-based service like CST or ACT to a SMI/SUD members can bill the time spent helping members purchase these items.
• An institutional or other approved setting can include a state developmental center, community Intermediate Care Facility, nursing facility, licensed group home, Alternative Family Living (AFL), foster home, adult care home, State Operated Healthcare Facility, or a Psychiatric Residential Treatment Facility (PRTF).
• May be provided only in a private home or apartment with a lease in the individual’s/ legal guardian’s/ representative’s name or a home owned by the individual.
• May not be provided by family members.
• Services cannot duplicate items that are currently available from a roommate.
• Furnished only to the extent that the member is unable to meet such expense, or when the support cannot be obtained from other sources or services.
• May not be provided to members enrolled in the CAP/C or CAP/DA wavier.
• May not be provided to a member residing in an Institution for Mental Disease (IMD) regardless of the facility type.
• Medicaid will not cover: 1) Monthly rental or mortgage expenses; 2) Repairs to a property; 3) Regular or recurring utility bills or fees associated with lawn care, property facilities, homeowners’ associations, or recurring pest eradication; 4) Household appliances (exception: a microwave); 5) Recreational items such as televisions, gaming systems, cell phones, CD or DVD players and components; 6) Food or groceries; 7) Care management services or activities, and; 8) Maintenance contracts and extended warranties

• Clinical Coverage Policy No. 8H-6: Community Transition
• Tailored Care Management Provider Manual (Section 4.4. Care Plans and Individua…
• PCP Guidance Documents & Templates
• North Carolina’s Transition of 1915(b)(3) Benefits to 1915(i) Fact Sheet
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: The purpose of Community Transition is to provide initial set-up expenses for adults to facilitate their transition from a Developmental Center (institution), community ICF-IID Group Home, nursing facility or another licensed living arrangement (group home, foster home, Psychiatric Residential Treatment Facility, alternative family living arrangement), a family home or one person AFL(Alternative Family Living) to a living arrangement where the individual is directly responsible for his or her own living expenses. This service may be provided only in a private home or apartment with a lease in the member’s, legal guardian’s, representative’s name or a home owned by the member.

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Community Transition Checklist
7. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
These services are available only during the three-month period that commences one calendar month in advance of the member’s move to an integrated living arrangement.

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    The cost of Community Transition has a life of the waiver limit of $5,000.00 per member. Community Transition includes the actual cost of services and does not cover provider overhead charges.
2.    Community Transition does not cover monthly rental or mortgage expense; regular utility charges; and/or household appliances or diversional/recreational items such as televisions, streaming devices, VCR players and components and DVD players and components. Service and maintenance contracts and extended warranties are not covered. 
3.    Community Transition services can be accessed only one time from either the 1915b or 1915c waiver over the life of the waiver.
4.    In situations when a member lives with a roommate, Community Transition cannot duplicate items that are currently available.
5.    Community Transition expenses are furnished only to the extent that the member is unable to meet such expense or when the support cannot be obtained from other sources.
6.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
7.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Crisis consultation is for individuals that have significant, intensive, or challenging behaviors or medical conditions that have resulted or have the potential to result in a crisis. Consultation is provided by staff that meets the minimum staffing requirements of a Qualified Professional and who have crisis experience.

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
1. Following service auth, any needed modifications to the ISP and individual budget will occur within five working days of the date of verbal service authorization.
2. Out-of-Home Crisis services are authorized in increments of up to 30 calendar days.
3. Crisis Intervention & Stabilization Supports may be authorized for periods of up to 14 calendar day increments per event.

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    This service may not duplicate services provided under Specialized Consultation Services.
2.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
3.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

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

Brief Service Description: Crisis consultation is for individuals that have significant, intensive, or challenging behaviors or medical conditions that have resulted or have the potential to result in a crisis. Consultation is provided by staff that meets the minimum staffing requirements of a Qualified Professional and who have crisis experience.

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
1. Following service auth, any needed modifications to the ISP and individual budget will occur within five working days of the date of verbal service authorization.
2. Out-of-Home Crisis services are authorized in increments of up to 30 calendar days.
3. Crisis Intervention & Stabilization Supports may be authorized for periods of up to 14 calendar day increments per event.

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    This service may not duplicate services provided under Specialized Consultation Services.
2.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
3.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Crisis Supports provide intervention and stabilization for a member experiencing a crisis. Crisis Supports are for a member who experiences acute crises and who presents a threat to the member’s health and safety or the health and safety of others. These behaviors may result in the member losing his or her home, job, or access to activities and community involvement. Crisis Supports promote prevention of crises as well as assistance in stabilizing the member when a behavioral crisis occurs. Crisis Supports are an immediate intervention available 24 hours per day, 7 days per week, to support the individual.

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
1. Following service auth, any needed modifications to the ISP and individual budget will occur within five working days of the date of verbal service authorization.
2. Out-of-Home Crisis services are authorized in increments of up to 30 calendar days.
3. Crisis Intervention & Stabilization Supports may be authorized for periods of up to 14 calendar day increments per event.

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    This service may not duplicate services provided under Specialized Consultation Services.
2.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
3.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

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

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
1. Day Supports is billed in 1-hour unit increments.

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    The amount of Day Supports is subject to the Limits on Sets of services.
2.    For individuals who are eligible for educational services under the Individuals with Disability Educational Act, Day Supports is the payer of last resort for Developmental Day.
3.    Day Supports are furnished in a non-residential setting, separate from the home or residential setting where the member resides.
4.    Transportation to/from the member’s home, the day supports facility and travel within the community is included in the payment rate. Transportation to and from the licensed day program is the responsibility of the Day Supports provider.
5.    This service may not duplicate services, nor can they be furnished or billed at the same time of day as services, provided under Community Networking, In-Home Intensive Supports, Community Living and Supports, Supported Living, Residential Supports, Supported Employment and/or one of the State Plan Medicaid Services that works directly with the member.
6.    Waiver funding is not available for vocational services delivered in facility based, sheltered work settings, or Adult Developmental Vocational Program.
7.    Individuals are provided opportunities to seek employment and work in competitive integrated settings, engage in community life and control personal resources.
8.    Each individual’s rights of privacy, dignity, respect and freedom from coercion and restraint are protected.
9.    Settings optimize, but do not regiment, individual initiative, autonomy and independence in making life choices.
10.    Settings facilitate individual choice regarding services and support, and who provides these.
11.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
12.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

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

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

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
1. Day Supports is billed in 1-hour unit increments.

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    The amount of Day Supports is subject to the Limits on Sets of services.
2.    For individuals who are eligible for educational services under the Individuals with Disability Educational Act, Day Supports is the payer of last resort for Developmental Day.
3.    Day Supports are furnished in a non-residential setting, separate from the home or residential setting where the member resides.
4.    Transportation to/from the member’s home, the day supports facility and travel within the community is included in the payment rate. Transportation to and from the licensed day program is the responsibility of the Day Supports provider.
5.    This service may not duplicate services, nor can they be furnished or billed at the same time of day as services, provided under Community Networking, In-Home Intensive Supports, Community Living and Supports, Supported Living, Residential Supports, Supported Employment and/or one of the State Plan Medicaid Services that works directly with the member.
6.    Waiver funding is not available for vocational services delivered in facility based, sheltered work settings, or Adult Developmental Vocational Program.
7.    Individuals are provided opportunities to seek employment and work in competitive integrated settings, engage in community life and control personal resources.
8.    Each individual’s rights of privacy, dignity, respect and freedom from coercion and restraint are protected.
9.    Settings optimize, but do not regiment, individual initiative, autonomy and independence in making life choices.
10.    Settings facilitate individual choice regarding services and support, and who provides these.
11.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
12.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

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

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
1. Day Supports is billed in 1-hour unit increments.

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    The amount of Day Supports is subject to the Limits on Sets of services.
2.    For individuals who are eligible for educational services under the Individuals with Disability Educational Act, Day Supports is the payer of last resort for Developmental Day.
3.    Day Supports are furnished in a non-residential setting, separate from the home or residential setting where the member resides.
4.    Transportation to/from the member’s home, the day supports facility and travel within the community is included in the payment rate. Transportation to and from the licensed day program is the responsibility of the Day Supports provider.
5.    This service may not duplicate services, nor can they be furnished or billed at the same time of day as services, provided under Community Networking, In-Home Intensive Supports, Community Living and Supports, Supported Living, Residential Supports, Supported Employment and/or one of the State Plan Medicaid Services that works directly with the member.
6.    Waiver funding is not available for vocational services delivered in facility based, sheltered work settings, or Adult Developmental Vocational Program.
7.    Individuals are provided opportunities to seek employment and work in competitive integrated settings, engage in community life and control personal resources.
8.    Each individual’s rights of privacy, dignity, respect and freedom from coercion and restraint are protected.
9.    Settings optimize, but do not regiment, individual initiative, autonomy and independence in making life choices.
10.    Settings facilitate individual choice regarding services and support, and who provides these.
11.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
12.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

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

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

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
1. Day Supports is billed in 1-hour unit increments.

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    The amount of Day Supports is subject to the Limits on Sets of services.
2.    For individuals who are eligible for educational services under the Individuals with Disability Educational Act, Day Supports is the payer of last resort for Developmental Day.
3.    Day Supports are furnished in a non-residential setting, separate from the home or residential setting where the member resides.
4.    Transportation to/from the member’s home, the day supports facility and travel within the community is included in the payment rate. Transportation to and from the licensed day program is the responsibility of the Day Supports provider.
5.    This service may not duplicate services, nor can they be furnished or billed at the same time of day as services, provided under Community Networking, In-Home Intensive Supports, Community Living and Supports, Supported Living, Residential Supports, Supported Employment and/or one of the State Plan Medicaid Services that works directly with the member.
6.    Waiver funding is not available for vocational services delivered in facility based, sheltered work settings, or Adult Developmental Vocational Program.
7.    Individuals are provided opportunities to seek employment and work in competitive integrated settings, engage in community life and control personal resources.
8.    Each individual’s rights of privacy, dignity, respect and freedom from coercion and restraint are protected.
9.    Settings optimize, but do not regiment, individual initiative, autonomy and independence in making life choices.
10.    Settings facilitate individual choice regarding services and support, and who provides these.
11.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
12.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

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

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Risk/Support Needs Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Authorization Parameters
1. Day Supports is billed in 1-hour unit increments.

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    The amount of Day Supports is subject to the Limits on Sets of services.
2.    For individuals who are eligible for educational services under the Individuals with Disability Educational Act, Day Supports is the payer of last resort for Developmental Day.
3.    Day Supports are furnished in a non-residential setting, separate from the home or residential setting where the member resides.
4.    Transportation to/from the member’s home, the day supports facility and travel within the community is included in the payment rate. Transportation to and from the licensed day program is the responsibility of the Day Supports provider.
5.    This service may not duplicate services, nor can they be furnished or billed at the same time of day as services, provided under Community Networking, In-Home Intensive Supports, Community Living and Supports, Supported Living, Residential Supports, Supported Employment and/or one of the State Plan Medicaid Services that works directly with the member.
6.    Waiver funding is not available for vocational services delivered in facility based, sheltered work settings, or Adult Developmental Vocational Program.
7.    Individuals are provided opportunities to seek employment and work in competitive integrated settings, engage in community life and control personal resources.
8.    Each individual’s rights of privacy, dignity, respect and freedom from coercion and restraint are protected.
9.    Settings optimize, but do not regiment, individual initiative, autonomy and independence in making life choices.
10.    Settings facilitate individual choice regarding services and support, and who provides these.
11.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
12.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

Limited funding. Not an entitlement.

Brief Service Description: 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.

Auth Submission Requirements/ Documentation Requirements
Initial Requests:
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 Requests:
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.

Authorization Parameters
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.

Units: One unit = 15 minutes
Age Group: 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.

Service Specifics, Limitations, & Exclusions (not all inclusive): 
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.

• State-Funded Day Supports (I/DD & TBI)
• Joint Communication Bulletin # J396: State-Funded Day Supports Service
• State-Funded Day Supports (DS) - I/DD and TBI FAQs
• JCB #325: I/DD Eligibility for State-Funded Services
• NC PCP Guidance Document
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: An in-depth look at a member’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the member, give the member a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Auth Submission Requirements/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: An in-depth look at a member’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the member, give the member a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Auth Submission Requirements/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Limited funding. Not an entitlement.

Brief Service Description: An in-depth look at a recipient’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the recipient, give the recipient a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Auth Submission Requirements
All Requests: TAR: required if the unmanaged units have been exhausted.  Providers may seek prior authorization if they are unsure the recipient has reached their unmanaged visit limit.  To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit.

Authorization Parameters
Units: 
1. The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  
2. Up to 9 unmanaged units of 96110: Developmental Testing - Limited.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Funding will not cover Outpatient Behavioral Health Services when the service duplicates another service approved with another provider.
2. 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.
3. The provider shall communicate and coordinate care with others providing care. When the recipient is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Limited funding. Not an entitlement.

Brief Service Description: An in-depth look at a recipient’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the recipient, give the recipient a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Auth Submission Requirements
All Requests: TAR: required if the unmanaged units have been exhausted.  Providers may seek prior authorization if they are unsure the recipient has reached their unmanaged visit limit.  To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit.

Authorization Parameters
Units: 
1. The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  
2. Up to 9 unmanaged units of 96110: Developmental Testing - Limited.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Funding will not cover Outpatient Behavioral Health Services when the service duplicates another service approved with another provider.
2. 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.
3. The provider shall communicate and coordinate care with others providing care. When the recipient is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: An in-depth look at a member’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the member, give the member a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Auth Submission Requirements/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: An in-depth look at a member’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the member, give the member a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Auth Submission Requirements/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. The provider shall communicate and coordinate care with others providing care. When the member is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Limited funding. Not an entitlement.

Brief Service Description: An in-depth look at a recipient’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the recipient, give the recipient a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Auth Submission Requirements
All Requests: TAR: required if the unmanaged units have been exhausted.  Providers may seek prior authorization if they are unsure the recipient has reached their unmanaged visit limit.  To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit.

Authorization Parameters
Units: 
1. The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  
2. Up to 9 unmanaged units of 96110: Developmental Testing - Limited.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Funding will not cover Outpatient Behavioral Health Services when the service duplicates another service approved with another provider.
2. 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.
3. The provider shall communicate and coordinate care with others providing care. When the recipient is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

Limited funding. Not an entitlement.

Brief Service Description: An in-depth look at a recipient’s development, usually done by a trained specialist, such as a developmental pediatrician, psychologist, speech-language pathologist, occupational therapist, or other specialist. The specialist may observe the recipient, give the recipient a structured test, ask the guardian questions, or ask them to fill out questionnaires.

Auth Submission Requirements
All Requests: TAR: required if the unmanaged units have been exhausted.  Providers may seek prior authorization if they are unsure the recipient has reached their unmanaged visit limit.  To ensure timely prior authorization, requests must be submitted prior to the last unauthorized visit.

Authorization Parameters
Units: 
1. The appropriate procedure code(s) determines the billing unit(s). One CPT code = 1 unit of service.  
2. Up to 9 unmanaged units of 96110: Developmental Testing - Limited.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Funding will not cover Outpatient Behavioral Health Services when the service duplicates another service approved with another provider.
2. 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.
3. The provider shall communicate and coordinate care with others providing care. When the recipient is receiving multiple BH services in addition to this service, a tx plan must be developed, and outpatient behavioral health services are to be incorporated into the tx plan.

• State-Funded Outpatient Behavioral Health Services Service Definition
• PCP Guidance Documents & Templates
• APSM 45-2 Records Management and Documentation Manual

All services are subject to post-payment review.

Brief Service Description: A diagnostic assessment (DA) is an intensive clinical and functional evaluation of a member’s MH, IDD, or SU condition. A DA determines whether the member meets medical necessity and can benefit from BH services based on the member’s diagnosis, presenting problems, and tx and recovery goals.  It evaluates the member’s level of readiness and motivation to engage in tx. This assessment is designed to be delivered in a team approach that results in the issuance of a written report that provides the clinical basis for the development of the member’s treatment or service plan. The written report must be kept in the service record.

Auth Submission/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

DA Elements (the DA must include the following):
1. The presenting problems, including source of distress, precipitating events, & associated problems or symptoms;

2. Chronological general health, past trauma hx & BH history (including both MH & SU including tobacco use) of the beneficiary’s symptoms, tx, & tx response.

3. Current meds for medical, psychiatric, & SU disorder tx. Identify past meds that were ineffective or caused significant side effects or adverse reactions.

4. Review of biological, psychological, familial, social, developmental & environmental dimensions to identify strengths, needs, & risks in each area.

5. Evidence of member & legally responsible person’s (if applicable) participation in the assessment.

6. Analysis & interpretation of the assessment info with an appropriate case formulation including determination of ASAM level of care when a SU disorder is present.

7. Diagnosis, including MH, SU disorders, or IDD, as well as PH conditions & functional impairment.

8. Recommendations for additional assessments, services, supports or tx based on the results of the DA.

9. Must be signed & dated by the licensed professionals completing the assessment & by the MD, DO, PA, NP, or LP (serving as the initial service order included in the PCP).

10. Evidence of an interdisciplinary team service note that documents the team’s review & discussion of the assessment. The involvement of the team in the delivery of the service is very important & is documented in the team note. Particular emphasis is made on the involvement & participation of all members of the team in the formulation of diagnoses & tx recommendations.

Authorization Parameters
Units: One unit = 1 event 

Age Group: Children/ Adolescents & Adults 

Level of Care: N/A. 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.

Place of Service: Can be provided in any location except an IMD (for adults) or in a public institution (jail, detention center).

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Medicaid shall not cover diagnostic assessment if psychological testing or specialized assessments are indicated. The testing or assessments are covered separately using appropriate CPT codes for psychological, developmental, or neuropsychological testing.

2. Results from a DA include an appropriate case formulation, an interpretation of the assessment info including recommendations for services, supports, tx or additional assessments; appropriate case formulation, a service order for immediate needs, and the development of PCP. For a beneficiary with a SU disorder diagnosis, a diagnostic assessment must recommend the ASAM level of care.

3. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.

• Clinical Coverage Policy No. 8A-5, Diagnostic Assessment
• APSM 45-2 Records Management and Documentation Manual
• PCP Guidance Documents & Templates

Limited funding. Not an entitlement.

All services are subject to post-payment review.

Brief Service Description: A diagnostic assessment (DA) is an intensive clinical and functional evaluation of a member’s MH, IDD, or SU condition. A DA determines whether the member meets medical necessity and can benefit from BH services based on the member’s diagnosis, presenting problems, and tx and recovery goals.  It evaluates the member’s level of readiness and motivation to engage in tx. This assessment is designed to be delivered in a team approach that results in the issuance of a written report that provides the clinical basis for the development of the member’s treatment or service plan. The written report must be kept in the service record.

Auth Submission/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service for the first event in a fiscal year. Additional events in the same fiscal year require prior authorization.

DA Elements (the DA must include the following):
1. The presenting problems, including source of distress, precipitating events, & associated problems or symptoms;

2. Chronological general health, past trauma hx & BH history (including both MH & SU including tobacco use) of the beneficiary’s symptoms, tx, & tx response.

3. Current meds for medical, psychiatric, & SU disorder tx. Identify past meds that were ineffective or caused significant side effects or adverse reactions.

4. Review of biological, psychological, familial, social, developmental & environmental dimensions to identify strengths, needs, & risks in each area.

5. Evidence of member & legally responsible person’s (if applicable) participation in the assessment.

6. Analysis & interpretation of the assessment info with an appropriate case formulation including determination of ASAM level of care when a SU disorder is present.

7. Diagnosis, including MH, SU disorders, or IDD, as well as PH conditions & functional impairment.

8. Recommendations for additional assessments, services, supports or tx based on the results of the DA.

9. Must be signed & dated by the licensed professionals completing the assessment & by the MD, DO, PA, NP, or LP (serving as the initial service order included in the PCP).

10. Evidence of an interdisciplinary team service note that documents the team’s review & discussion of the assessment. The involvement of the team in the delivery of the service is very important & is documented in the team note. Particular emphasis is made on the involvement & participation of all members of the team in the formulation of diagnoses & tx recommendations.

Authorization Parameters
Units: One unit = 1 event 

Age Group: Children/ Adolescents & Adults 

Level of Care: N/A. 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.

Place of Service: Can be provided in any location. Substance Abuse Prevention and Treatment Block Grant (SAPTBG) funds may not be used to support an individual who is an inmate in a public correctional institution. 

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. State funds shall not cover a DA on the same day as ACTT, IIH, MST or CST services. 

2. If psychological testing or specialized assessments are indicated, they are covered separately using appropriate CPT codes for psych, developmental, or neuropsych testing.

3. State funds & Community Mental Health Block Grant funds outside of UCR may be used to support those who are an inmate in a public correctional institution. SAPTBG funds may not be used for this purpose. 

4. Results from a DA include an appropriate case formulation, an interpretation of the assessment info including recommendations for services, supports, tx or additional assessments; appropriate case formulation, a service order for immediate needs, & the development of PCP. For a beneficiary with a SU disorder diagnosis, a diagnostic assessment must recommend the ASAM level of care.

• State-Funded Diagnostic Assessment Service Definition
• APSM 45-2 Records Management and Documentation Manual
• PCP Guidance Documents & Templates

All services are subject to post-payment review.

Brief Service Description: A diagnostic assessment (DA) is an intensive clinical and functional evaluation of a member’s MH, IDD, or SU condition. A DA determines whether the member meets medical necessity and can benefit from BH services based on the member’s diagnosis, presenting problems, and tx and recovery goals.  It evaluates the member’s level of readiness and motivation to engage in tx. This assessment is designed to be delivered in a team approach that results in the issuance of a written report that provides the clinical basis for the development of the member’s treatment or service plan. The written report must be kept in the service record.

Auth Submission/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service.

DA Elements (the DA must include the following):
1. The presenting problems, including source of distress, precipitating events, & associated problems or symptoms;

2. Chronological general health, past trauma hx & BH history (including both MH & SU including tobacco use) of the beneficiary’s symptoms, tx, & tx response.

3. Current meds for medical, psychiatric, & SU disorder tx. Identify past meds that were ineffective or caused significant side effects or adverse reactions.

4. Review of biological, psychological, familial, social, developmental & environmental dimensions to identify strengths, needs, & risks in each area.

5. Evidence of member & legally responsible person’s (if applicable) participation in the assessment.

6. Analysis & interpretation of the assessment info with an appropriate case formulation including determination of ASAM level of care when a SU disorder is present.

7. Diagnosis, including MH, SU disorders, or IDD, as well as PH conditions & functional impairment.

8. Recommendations for additional assessments, services, supports or tx based on the results of the DA.

9. Must be signed & dated by the licensed professionals completing the assessment & by the MD, DO, PA, NP, or LP (serving as the initial service order included in the PCP).

10. Evidence of an interdisciplinary team service note that documents the team’s review & discussion of the assessment. The involvement of the team in the delivery of the service is very important & is documented in the team note. Particular emphasis is made on the involvement & participation of all members of the team in the formulation of diagnoses & tx recommendations.

Authorization Parameters
Units: One unit = 1 event 

Age Group: Children/ Adolescents & Adults 

Level of Care: N/A. 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.

Place of Service: Can be provided in any location except an IMD (for adults) or in a public institution (jail, detention center).

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. Medicaid shall not cover diagnostic assessment if psychological testing or specialized assessments are indicated. The testing or assessments are covered separately using appropriate CPT codes for psychological, developmental, or neuropsychological testing.

2. Results from a DA include an appropriate case formulation, an interpretation of the assessment info including recommendations for services, supports, tx or additional assessments; appropriate case formulation, a service order for immediate needs, and the development of PCP. For a beneficiary with a SU disorder diagnosis, a diagnostic assessment must recommend the ASAM level of care.

3. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.

• Clinical Coverage Policy No. 8A-5, Diagnostic Assessment
• APSM 45-2 Records Management and Documentation Manual
• PCP Guidance Documents & Templates

Limited funding. Not an entitlement.

All services are subject to post-payment review.

Brief Service Description: A diagnostic assessment (DA) is an intensive clinical and functional evaluation of a member’s MH, IDD, or SU condition. A DA determines whether the member meets medical necessity and can benefit from BH services based on the member’s diagnosis, presenting problems, and tx and recovery goals.  It evaluates the member’s level of readiness and motivation to engage in tx. This assessment is designed to be delivered in a team approach that results in the issuance of a written report that provides the clinical basis for the development of the member’s treatment or service plan. The written report must be kept in the service record.

Auth Submission/ Documentation Requirements
Pass-Through Period: Prior authorization is not required for this service for the first event in a fiscal year. Additional events in the same fiscal year require prior authorization.

DA Elements (the DA must include the following):
1. The presenting problems, including source of distress, precipitating events, & associated problems or symptoms;

2. Chronological general health, past trauma hx & BH history (including both MH & SU including tobacco use) of the beneficiary’s symptoms, tx, & tx response.

3. Current meds for medical, psychiatric, & SU disorder tx. Identify past meds that were ineffective or caused significant side effects or adverse reactions.

4. Review of biological, psychological, familial, social, developmental & environmental dimensions to identify strengths, needs, & risks in each area.

5. Evidence of member & legally responsible person’s (if applicable) participation in the assessment.

6. Analysis & interpretation of the assessment info with an appropriate case formulation including determination of ASAM level of care when a SU disorder is present.

7. Diagnosis, including MH, SU disorders, or IDD, as well as PH conditions & functional impairment.

8. Recommendations for additional assessments, services, supports or tx based on the results of the DA.

9. Must be signed & dated by the licensed professionals completing the assessment & by the MD, DO, PA, NP, or LP (serving as the initial service order included in the PCP).

10. Evidence of an interdisciplinary team service note that documents the team’s review & discussion of the assessment. The involvement of the team in the delivery of the service is very important & is documented in the team note. Particular emphasis is made on the involvement & participation of all members of the team in the formulation of diagnoses & tx recommendations.

Authorization Parameters
Units: One unit = 1 event 

Age Group: Children/ Adolescents & Adults 

Level of Care: N/A. 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.

Place of Service: Can be provided in any location. Substance Abuse Prevention and Treatment Block Grant (SAPTBG) funds may not be used to support an individual who is an inmate in a public correctional institution. 

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. State funds shall not cover a DA on the same day as ACTT, IIH, MST or CST services. 

2. If psychological testing or specialized assessments are indicated, they are covered separately using appropriate CPT codes for psych, developmental, or neuropsych testing.

3. State funds & Community Mental Health Block Grant funds outside of UCR may be used to support those who are an inmate in a public correctional institution. SAPTBG funds may not be used for this purpose. 

4. Results from a DA include an appropriate case formulation, an interpretation of the assessment info including recommendations for services, supports, tx or additional assessments; appropriate case formulation, a service order for immediate needs, & the development of PCP. For a beneficiary with a SU disorder diagnosis, a diagnostic assessment must recommend the ASAM level of care.

• State-Funded Diagnostic Assessment Service Definition
• APSM 45-2 Records Management and Documentation Manual
• PCP Guidance Documents & Templates

Brief Service Description: Financial Support Services (FSS) is an umbrella service for the continuum of supports offered to NC Innovations individuals who elect the Individual and Family Directed Services Option, Employer of Record Model. Financial Support Services are provided to ensure that funds for self-directed services are managed and distributed as intended. The service also facilitates the employment of support staff by the Employer. A member who chooses to self-direct via the Employer of Record model may require equipment necessary to carry out duties of Employer of Record and may access this service.

Auth Submission Requirements/ Documentation Requirements
1. TAR: Prior approval is required for each plan year. 
2. SIS
3. Individual Budget
4. Care Management Comprehensive Assessment
5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
6. Submission of applicable records that support the member has met the medical necessity criteria.

Service Specifics, Limitations & Exclusions (not all inclusive): 
1.    Items not coverable by Employer Supplies (this is not an all-inclusive list): a) Wireless keyboards; b) Mouse (unless the EOR is purchasing a desktop and the desktop does not include a mouse); c) Computer Protective Cases (outside of one laptop bag for EORs who utilize a laptop); d) Additional Computer Screens (a desktop computer should include one monitor); e) IT help desk service for support to operate the equipment; f) Office/Desk Chair.
2.    The provider of financial support services may only additionally provide Community Navigator services. The financial support service may bill for the following services: community transition services, and individual goods and services under the NC Innovations waiver.
3.    The financial supports agency may be an Agency with Choice and provide Community Navigator. They may bill for community transition and individual goods and services to the same member. Community Transition Services and Individual Goods and Services are not directly provided by the FMS. 
4.    Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
5.    See the CCP for all applicable exclusions, limitations & exceptions.

• Clinical Coverage Policy No 8P: North Carolina Innovations
• NCDHHS NC Innovations Waiver Website
• APSM 45-2 Records Management and Documentation Manual

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist/ MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist/ MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist/ MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist/ MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist/ MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist/ MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist/ MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services

Brief Service Description: Evaluation and Management provided by a Psychiatrist/ MD/ DO or a Psych NP/PA.

Auth Submission Requirements
Prior authorization is not required for this service. E/M codes are not specific to mental health and are not subject to prior authorization.

Authorization Parameters
Units: The appropriate procedure code(s) determines the billing unit(s). One service code = 1 unit of service.  

Age Group: Children/ Adolescents & Adults

Level of Care: N/A

Service Specifics, Limitations, & Exclusions (not all inclusive): 
1. 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.
2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD.  MCD is the payor of last resort.
3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
4. The provider will communicate and coordinate care with other professionals providing care to the member.

• Clinical Coverage Policy No. 8C: Outpatient Behavioral Health Services