• Ability-to-Pay Determination
    The amount a consumer is obligated to pay for services. The ability to pay is calculated based on the consumer’s income, and number of dependents. The Federal Government Poverty Guidelines are used to determine the consumer’s payment amount.Web Reference: www.cms.hhs.gov/medicaid/eligibiity/default.asp.
  • Abuse and Waste
    Incidents or practices that are inconsistent with sound fiscal, business, or medical practices that could result in an unnecessary cost to Alliance, the State or Federal government, or another organization. It could also result in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program. (42 CFR 455.2)
  • Access and Information Center
    The toll-free call system established by Alliance to receive all inquiries, respond to crisis situations, and provide quick linkages to qualified Providers in the Network. This will include information, access to care, emergency and Network Provider assistance. The 1-800 call system will rely on information systems management software to assist in tracking and responding to calls.
  • Add On
    Services that are not part of the Base Budget. These services may be used based on the service definition and your needs. They must be included in your Individual Support Plan and approved by the Utilization Management Department. The total of Base Budget and non-Base Budget services may not exceed the annual waiver limit of $135,000 per year.
  • Adjudicate
    A determination to pay or reject a claim.
  • Administrative Review
    A review of documentation to determine whether Alliance procedures were followed, and if any additional information provided warrants a change in a previous determination.
  • Advance Directive
    A communication given by a competent adult which gives directions or appoints another individual to make decisions concerning a consumer's care, custody or medical treatment in the event that the consumer is unable to participate in medical treatment decisions.
  • Alternative Family Living
    An out-of-home setting where the participant receives 24-hour care and lives in a private home environment with a family (or individual) where the services are provided to address the care and rehabilitation needs of the participant. Any AFL providing services to a child/children or two or more adults requires a license (as defined by NC General Statues 122C-3 27G .5600F). Waiver funding may not be utilized as payment for room and board costs.
  • Anxiety
    Anxiety is a part of life. Some anxiety is useful – it can make you more alert or careful, but it usually ends soon after you are out of the situation that caused it. But for millions of people in the United States, anxiety does not go away and actually gets worse over time. These people have anxiety disorders, which can include panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder (PTSD) and generalized anxiety disorder. People with anxiety disorders may have chest pains or nightmares, and may even be afraid to leave home. Treatment for anxiety disorders generally involves medication, therapy or both.
  • Appeal
    A request for review of an action, as “action” is defined in section IV-L.
  • Appellant
    An individual filing an appeal.
  • Assessment
    A procedure for determining the nature and extent of need for which the individual is seeking services.
  • Authorized Service
    Medically necessary services pre-approved by the LME/MCO.
  • Base Budget Category
    Base Budget Services include Community Networking Services Day Supports In-Home Skill Building In-Home Intensive Supports Personal Care Residential Supports Respite
  • Basic Augmented Services
    The Basic Augmented Benefit package includes those services that will be made available to Medicaid-entitled individuals and, to the extent the resources are available, to non-Medicaid individuals meeting Priority population criteria. A consumer requiring this level of benefit is in need of more than the automatically authorized eight (8) or twelve (12) visits in order to maintain or improve his/her level of functioning. An authorization for the services available in this level will need to be requested through the LME/MCO’s Utilization Management Unit. Authorization is based on the consumer’s need and medical necessity criteria for the services requested.
  • Basic Benefit Plan
    The Basic Benefit package includes those services that will be made available to Medicaid-entitled individuals and, to the extent resources are available, to non- Medicaid individuals according to local business plans. These services are intended to provide brief interventions for individuals with acute needs. The Basic Benefit package is accessed through a simple referral from the Local Management Entity, through its screening, triage and referral system. Once the referral is made, there are no prior authorization requirements for these services. Referred individuals can access up to eight (8) visits for adults ages twenty-one (21) and up and sixteen (16) visits for children and adolescents below age twenty-one (21) from the Basic Benefit package from any Provider enrolled in the LME/MCO’s Provider network.
  • Benchmark
    A standard by which something can be measured, judged or compared.
  • Best Practices
    Recommended practices, including evidenced-based practices that consist of those clinical and administrative practices that have been proved to consistently produce specific, intended results, as well as emerging practices for which there is preliminary evidence of effectiveness of treatment.
  • Bipolar Disorder (Manic-Depressive Illness)
    Bipolar disorder is a serious mental illness marked by unusual mood changes. They go from very happy, “up,” and active (mania) to very sad and hopeless, “down,” and inactive (depression), and then back again, broken up by normal moods in between. The causes of bipolar disorder aren’t always clear, although it can run in families. Bipolar disorder often starts in the late teen or early adult years. But young children and older adults can have bipolar disorder too. Bipolar disorder usually lasts a lifetime and, if not treated, can lead to damaged relationships, poor job or school performance, and even suicide. However, medicine and talk therapy are effective treatments to control symptoms. A combination usually works best.
  • Business Associate
    A person or organization that performs a function or activity on behalf of a covered entity but is not part of the covered entity’s work force. A business associate can also be a covered entity in its own right (see the HIPAA definition as it appears in 45 CFR 160.103).
  • Care Coordination Department
    A division of Alliance that provides outreach and Treatment Planning Case Management functions for special, high-impact population of consumers.
  • Care Coordinator
    A qualified developmental disability professional at Alliance who assists by developing the person-centered Individual Support Plan (ISP), coordinating services, and monitoring to assure quality services are being delivered and that health and safety needs are addressed.
  • Care Management
    Care Management is non-face-to face monitoring of an individual consumers care and services, including follow-up activities, as well as, assistance to consumers in accessing care on non-plan services, including referrals to Providers and other community agencies.
  • Care Manager
    Care Managers do Utilization Management (authorization of services) for Alliance Care Managers monitor progress on goals in the Individual Support Plan, make recommendations, and refer for additional or different services and amounts of services, and supports based on their findings.  
  • Catchment Area
    Geographic Service Area with a defined grouping of counties. Alliance’s catchment area includes Cumberland, Durham, Johnston and Wake counties.
  • Centers for Medicare and Medicaid Services
    The unit of the Federal Department of Health and Human Services that administers the Medicare and Medicaid programs.
  • Child and Adolescent Level of Care Utilization System
    A standardized tool that measures level of care needs for children and adolescents. Note: LOCUS is used to assess adults.
  • Children with Severe Emotional Disturbances
    Describes consumers who: Are age seventeen (17) or under Have mental, behavioral, or emotional disturbance severe enough to substantially interfere with or limit the minor's role or function in family, school, or community activities Score less than sixty (60) on the Global Assessment Scale (GAF).
  • Claim
    A request for reimbursement under a benefit plan for services.
  • Clean Claim
    A claim that can be processed without obtaining additional information from the Provider of the services or a third party. It does not include a claim under review for medical necessity, or a claim from a Provider that is under investigation by a governmental agency for fraud or abuse.
  • Client
    As defined in the General Statutes 122C-3 (6).
  • Community Supports
    Organizations that provide support to a person. Community Supports may include advocacy organizations, community service organizations, faith-based organizations, civic organizations, and/or educational organizations.
  • Concurrent Review
    A review conducted by the LME/MCO during a course of treatment to determine whether services continue to meet medical necessity and quality standards and whether services should continue as prescribed or should be terminated, changed or altered.
  • Consumer
    A person that needs services for treatment of a mental health, intellectual and/or developmental disability, or substance use/addiction condition.
  • Consumer and Family Advisory Committee
    A formalized group of consumers and family members appointed in accordance with the requirements of NCGS 122-C-170. The purpose of CFAC is to ensure meaningful participation by consumers and families in shaping the development and delivery of public mental health, developmental disabilities, and substance abuse services in the four-county region serviced by Alliance.
  • Cost Limit
    The maximum amount of all waiver services (Base Budget plus other NC Innovations services) that an individual may receive annually while participating in the NC Innovations Waiver. For NC Innovations this is $135,000 per waiver year.  
  • Covered Services
    The service which the LME/MCO agrees to provide, or arranges to provide to consumers.
  • Credentialing
    The review process to approve the credentials and/or eligibility of a Provider who has applied to participate in the LME/MCO Network of Providers.
  • Crisis Intervention
    Unscheduled assessment and treatment for the purpose of resolving an urgent/emergent situation requiring immediate attention.
  • Crisis Plan
    An individualized, written plan developed in conjunction with the consumer and treatment team. The Plan contains clear directives information to assist in de-escalating a crisis, for consumer supports, as well as crisis response clinicians or others involved. Crisis plans are developed for consumers at-risk for inpatient treatment, incarceration, or out-of-home placement.
  • Critical Access Behavioral Healthcare Agency Providers
    A Provider who delivers a comprehensive array of mental health and substance abuse services. This does not include intellectual/developmental disability services, although some CABHAs may provide I/DD services. The role of a CABHA is to ensure that critical services are delivered by a clinically-competent organization with appropriate medical oversight and the ability to deliver a robust array of services. CABHAs ensure consumer care is based upon a comprehensive clinical assessment and appropriate array of services for the population served. A CABHA is required to offer the following Core Services: Comprehensive Clinical Assessment, Medication Management and Outpatient Therapy.
  • Cultural Competency
    The understanding of the social, linguistic, ethnic and behavioral characteristics of a community or population and the ability to translate systematically that knowledge into practices in the delivery of behavioral health services. Such understanding may be reflected, for example, in the ability to identify and value differences; acknowledge the interactive dynamics of cultural differences, continuously expand cultural knowledge and resources with regard to populations served, collaborate with the community regarding service provisions and delivery, and commit to cross-cultural training of staff and develop policies to provide relevant, effective programs for the diversity of people served.
  • Days
    Except as otherwise noted, refers to calendar days. Working day or business day means day on which the LME/MCO is officially open to conduct its affairs.
  • Denial of Service
    A determination made by the LME/MCO in response to a Network Provider’s request for approval to provide in-plan services of a specific duration and scope which: ∙ Disapproves the request completely; or ∙ Approves provision of the requested service(s), but for a lesser scope or duration than requested by the Provider; (an approval of a requested services which includes a requirement for a concurrent review by the LME/MCO during the authorized period does not constitute a denial); or ∙ Disapproves provision of the requested service(s), but approves provision of an alternative service(s).
  • Department of Health and Human Services
    The state agency that includes both the Division of Medical Assistance and the Division of Mental Health/Developmental Disabilities/Substance Abuse Services.  The website for North Carolina’s DHHS is www.ncdhhs.gov/.  
  • Department of Social Services
    The local (county) public agency that is responsible for determining eligibility for Medicaid benefits and for other assistance programs.
  • Description of Consumer Clinical Issues
    A statement of need for services.
  • Developmental Center
     A state operated ICF-IID facility (institution) that provides health and habilitation services to individuals with intellectual and/or other developmental disabilities. The Developmental Center for the Alliance catchment area is The Murdoch Center located in Butner, NC. Referrals to Developmental Centers can be made only by the Managed Care Organization (Alliance). NC Innovations funding cannot be used while in a Developmental Center.
  • Dispute Resolution Process
    Alliance process to address administrative actions or sanctions taken against Providers in a consistent manner.
  • Division of Medical Assistance (for the State of North Carolina)
    The state agency responsible for Medicaid-funded services and the administration of the NC Innovations and NC MH/DD/SAS Health Plan.  The website for North Carolina’s Division of Medical Assistance is www.ncdhhs.gov/dma/index.htm.
  • Division of Mental Health, Developmental Disabilities and Substance Abuse Services
    The state agency that works with DMA in the administration of the NC Innovations and NC MH/DD/SAS Health Plan. The website for North Carolina’s DMH/DD/SAS is www.ncdhhs.gov/mhddsas/.
  • Early and Periodic Screening, Diagnosis and Treatment
    Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is the Federal Medicaid benefit that says Medicaid must provide all necessary health care services to Medicaid eligible children under twenty-one (21) years of age. Even if the service is not covered under the NC Medicaid State Plan, it can be covered for recipients under 21 years of age if the service is listed at 1905 (a) of the Social Security Act and if all EPSDT criteria are met.
  • Eligibility
    The determination that an individual meets the requirements to receive services as defined by the payor.
  • Emergency Medical Condition
    A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
  • Emergency Services
    Covered inpatient and outpatient emergency services are: ∙ Furnished by a Provider that is qualified to furnish such services, and ∙ Needed to evaluate or stabilize an emergency medical condition as defined above.
  • Emergent Need Mental Health
    A life threatening condition in which a person is suicidal, homicidal, actively psychotic, displaying disorganized thinking, or reporting hallucinations and delusions that may result in self harm or harm to others, and/or vegetative signs and is unable to care for self.
  • Emergent Need Substance Abuse
    A life threatening condition in which the person is by virtue of their use of alcohol or other drugs, suicidal, homicidal, actively psychotic, displaying disorganized thinking or reporting hallucinations and delusions which may result in self-harm or harm to others, and/or is unable to adequately care for self without supervision due to the effects of chronic substance abuse or dependence.
  • Enhanced Benefit Plan
    Includes those services, which will be made available to Medicaid- entitled individuals and non-Medicaid individuals meeting priority population criteria. Enhanced Benefit services are accessed through a person-centered planning process. Enhanced Benefit services are intended to provide a range of services and supports, which are more appropriate for individuals seeking to recover from more severe forms of mental illness and substance abuse and with more complex service and support needs as identified in the person-centered planning process.
  • Enrollment
    Action taken by the Division of Medical Assistance (DMA) to add a Medicaid recipient’s name to the monthly enrollment report.
  • Enrollment Period
    The time span during which a recipient in enrolled with the LME/MCO as a Medicaid waiver-eligible recipient.
  • Facility
    Any person at one location whose primary purpose is to provide services for the care, treatment, habilitation, or rehabilitation of the mentally ill, the developmentally disabled, or substance abusers, and includes: ∙ Licensed facilities are any 24-hour residential facilities required to be licensed under Chapter 122C of the North Carolina General Statutes, such as Psychiatric Residential Treatment Facilities (PRTFs), Intermediate Care Facilities for the Developmentally Disabled (ICF-DDs), Supervised Living Facilities, Residential Treatment/Rehabilitation Facilities for Individuals with Substance Abuse Disorders, Outpatient Opioid Treatment Facilities, .5600 group homes or other licensed MH/IDD/SA facilities. These facilities may require a Certificate of Need or Letter of Support and must meet all applicable state licensure laws and rules, including but not limited to NCG.S. §122C-3 and Title 10A, Subchapter 27C, 27D, 27E, 27F,27G, 26B and 26C. ∙ A State facility, which is a facility that is operated by the Secretary. ∙ A Veterans Administration facility or part thereof that provides services for the care, treatment, habilitation or rehabilitation of the mentally ill, the developmentally disabled, or substance abusers.
  • Fee-For-Service
    A payment methodology that associates a unit of service with a specific reimbursement amount.
  • Fidelity
    Adheres to the guidelines as specified in the evidenced based best practice
  • Financial Audit
    Audit generally performed by a CPA in accordance with Generally Accepted Accounting Principles to obtain reasonable assurance about whether the general purpose financial statements are free of material misstatement. An audit includes examining, on a test basis evidence supporting the amounts and disclosures in the financial statements. Audits also include assessing the accounting principles used and significant estimates made by management, as well as evaluating the overall general purpose financial statement presentation.
  • First Responder
    A person or personnel of an agency designated as the primary Provider by the person-centered plan/crisis plan who will have access to the individual’s crisis plan at all times and be knowledgeable of the local crisis response system.
  • Fiscal Agent
    An agency that processes and audits Provider claims for payment and performs certain other related functions as an agent of DMA and DMH.
  • Fiscal Audit
    Audit performed by the Financial Department of the LME/MCO which includes a review of the contractor’s evaluation of a consumer’s income, consumer’s determined ability to pay, third party insurance verification, first and third party billing, receipts and denials. A review of COB information will also be conducted to verify support of claimed amounts submitted to LME/MCO.
  • Fraud
    The misrepresentation or concealment of a material fact made by a person that could result in some unauthorized benefit to self, some other person, or organization. It includes any act that constitutes fraud under applicable Federal or State law.
  • Freedom of Choice
    The right afforded an individual who is determined to be likely to require a level of care specified in a waiver to choose either institutional or home and community-based services.
  • Grievance
    An expression of dissatisfaction about any matter other than an action, as action is defined in this section. The term is also used to refer to the overall system that includes grievances and appeals handled at the LME/MCO level and access to the State fair hearing process. Possible subjects for grievances include, but are not limited to, the quality of care or services provided, aspects of interpersonal relationships such as rudeness of a Provider or employee, and failure to respect the consumer’s rights.
  • Grievance Procedure
    The written procedure pursuant to which consumers may express dissatisfaction with the provision of services by the LME/MCO and the methods for resolution of consumer’s grievance by the LME/MCO.
  • Habilitation Service
    A service that assists an individual in learning or improving skills, including self-help, socialization, and other adaptive skills directed at maximizing an individual’s independent functioning.
  • HCBS Waivers
    Home and Community Based Services Waivers that allow states that participate in Medicaid to develop alternatives for individuals who would otherwise require care in institutions. NC Innovations is one of North Carolina’s HCBS waivers.
  • Health Insurance Portability and Accountability Act
    Health Insurance Portability and Accountability Act of 1996.
  • In-Home Services
    In NC Innovations this includes In-Home Skill Building, In-Home Intensive Support, Respite and Personal Care.
  • Incident
    An unusual occurrence as defined in APSM 30-1. Incidents are reported as Level I, II, or III as defined in APSM 30-1.
  • Initial Authorization
    The initial or first approval by Alliance’s Utilization Management Department of a medically necessary service(s) at a given level of care prior to services being rendered.
  • Institution
    For purposes of NC Innovations, an institution is defined as a residential facility that is licensed and funded as an ICF-IID (Intermediate Care Facility/Mental Retardation). NC Innovations funding cannot be used in an institution, including ICFs-MR, hospitals, Skilled Nursing Facilities, or State Developmental Centers.
  • Intellectual/Developmental Disabilities
    Characterized by the following: Impairment of general intellectual functioning and adaptive behavior that occurs before age twenty-two (22) which: Limits one (1) or more major life functions. IQ of sixty-nine (69) or below. Impairment has continued since its origination or can be expected to continue indefinitely.
  • Intermediate Care Facility for Individuals with Intellectual Disabilities
    A licensed facility that provides care and active treatment for individuals with intellectual disability and certain other developmental disabilities. This is the institutional placement that is "waived" when the NC Innovations Waiver is chosen instead. ICF-IID facilities have four or more beds (most have six, some more than 100) and must provide active treatment to residents.
  • Least Restrictive Environment
    The least restrictive/intensive setting of care sufficient to effectively and safely support an individual. Supporting an individual in the environment that is least restrictive is considered best practice.
  • Legal Guardian or Legally-Responsible Person
    A person who has been appointed by a court of law to act as decision-maker for an individual deemed unable to make decisions on their own behalf. . Parents of children under 18 are their children’s legally responsible person, unless those rights have been taken away by the court. Once a person turns 18, they legally become their own guardian unless the court deems otherwise and appoints a guardian representative (most often a family member or friend unless there is no one available in which case a public employee is appointed).
  • Level of Care Utilization System
    A standardized tool for measuring the level of care needs for adult consumers. CALOCUS is used with children and adolescents.
  • Licensed Independent Practitioner
    Medical Doctors (M.D.), Practicing Psychologists (Ph.D.) Psychologist Associates (Master’ Level Psychologist [LPA]), Master’ Level Social Workers (LCSW), Licensed Marriage and Family Therapists (LMFT), Licensed Professional Counselors (LPC), Licensed Clinical Addictions Specialists (LCAS), Advanced Practice Psychiatric Clinical Nurse Specialists, Psychiatric Nurse Practitioners, and Licensed Physician Assistants who are eligible to bill under their own license.
  • Limits on Sets of Services
    A maximum amount of a designated group of services that an individual can receive under a waiver.
  • Local Management Entity
    A local political subdivision of the state of North Carolina as established under General Statute 122C.
  • Local Management Entity-Managed Care Organization
    An LME that is under contract with the Department to operate the combined Medicaid Waiver program authorized under Section 1915(b) and Section 1915(c) of the Social Security Act.
  • Managed Benefit
    Services that require authorization from Utilization Management.
  • Material Change
    A material change in any written instrument is one which changes its legal meaning and effect.
  • Mediation
    The process of bringing individuals or agencies in conflict together with a neutral third person who assists them in reaching a mutually agreeable solution
  • Medicaid
    The joint federal and state program to assist states in furnishing medical assistance (health insurance) to financially eligible individuals. Federal law concerning the Medicaid program is located in Title XIX of the Act. NC Innovations services are provided under the Medicaid program. All NC Innovations participants have Medicaid coverage.
  • Medicaid Consumer Registration
    Form used to register Medicaid consumers with Alliance while in unmanaged basic benefit services, or while accessing hospital beds, and for the release of information regarding eligibility for services.
  • Medicaid for Infants and Children
    A program for medical assistance for children under the age of nineteen (19) whose countable income falls under a specific percentage of the Federal Poverty Limit and who are not already eligible for Medicaid in another category.
  • Medicaid for Pregnant Women
    A program for medical assistance for pregnant women whose income falls under a specified percentage of the Federal Poverty Limit and who are not already eligible in another category.
  • Medicaid Identification Card
    The Medical Assistance Eligibility Certification card issued monthly by DMA to Medicaid recipients.
  • Medical Assistance (Medicaid) Program
    DMA's program to provide medical assistance to eligible citizens of the State of North Carolina, established pursuant to Chapter 58, Articles 67 and 68 of the North Carolina General Statutes and Title XIX of the Social Security Act, 42 U.S.C. 1396 et. se.
  • Medical Record
    A single complete record, maintained by the Provider of services, which documents all of the treatment plans developed for and behavioral health services received by the consumer.
  • Medically Necessary Services
    A range of procedures or interventions that is appropriate and necessary for the diagnosis, treatment, or support in response to an assessment of a consumer’s condition or need. Medically necessary means services and supplies that are: ∙ Provided for the diagnosis, secondary or tertiary prevention, amelioration, intervention, rehabilitation, or care and treatment of a mental health, developmental disability or substance abuse condition, and ∙ Necessary for and appropriate to the conditions, symptoms, intervention, diagnosis, or treatment of a mental health, developmental disability or substance abuse condition, and ∙ Within generally accepted standards of medical practice, and ∙ Not primarily for the convenience of an Consumer, and ∙ Performed in the least costly setting and manner appropriate to treat the Consumer’s mental health, developmental disability or substance abuse condition.
  • Medically Necessary Treatment
    In order for NC Innovations to cover (pay for) treatment (services) those services must be deemed “medically necessary.” This means treatment and services must be:   Necessary and appropriate for the prevention, diagnosis, palliative, curative, or restorative treatment of a mental health or substance abuse condition. Consistent with Medicaid policies and National or evidence based standards, North Carolina DHHS defined standards or verified by independent clinical experts at the time the procedures, products and services are provided. Provided in the most cost effective, least restrictive environment that is consistent with clinical standards of care. Not provided solely for the convenience of the individual, family members, custodian or provider. Not for experimental, investigational, unproven or solely cosmetic purposes. Furnished by or under the supervision of a licensed professional (as relevant) under State law in the specialty for which they are providing service and in accordance with Title 42 of the Code of Federal Regulations, the Medicaid State Plan, the North Carolina Administrative Code, Medicaid medical coverage policies, and other applicable Federal and state directives; Sufficient in amount, duration and scope to reasonably achieve their purpose, and Reasonably related to the diagnosis for which they are prescribed regarding type, intensity, and duration of service and setting of treatment. Within the scope of the above guidelines, medically-necessary treatment shall be designed to: Be provided in accordance with the person-centered Individual Service Plan which is based upon a comprehensive assessment, and developed in partnership with the person receiving services (or in the case of a child, the child and the child’s family or legal guardian) and the community team; Conform with any advanced medical or mental health directives that  have been prepared; Respond to the unique needs of linguistic and cultural minorities and furnished in a culturally relevant manner; and Prevent the need for involuntary treatment or institutionalization.
  • Medicare
    Medicare is health insurance for people age 65 or older, under age 65 with certain disabilities, and any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant). While NC Innovations services are not provided under the Medicare program, some NC Innovations participants may have Medicare coverage in addition to Medicaid coverage.
  • Most Integrated Environment
    The least restrictive setting of care sufficient to effectively treat a participant. An integrated environment is one in which a person with a disability participates in the same activities and settings as non-disabled peers.  
  • National Council of Quality Assurance
    National Council of Quality Assurance is an independent, 501(c)(3) non-profit organization whose mission is to improve health care quality through accreditation and recognition programs with a rigorous review of key clinical and administrative processes, through the Health Plan Employer Data and Information Set (HEIDS®), a tool used to measure performance in key areas, and through a comprehensive member satisfaction survey.
  • Natural Resource Linking
    Processes that maximize the use of family and community support systems to optimize functioning.
  • Natural Supports
    People who provide support, care, and assistance to a person with a disability without payment for that support. Natural Supports may include parents, siblings, extended family members, neighbors, church members, and/or co-workers, etc..
  • NC Innovations
    A 1915(c) Home and Community-Based Wavier for individuals with Intellectual and/or Developmental Disabilities. This is a waiver of institutional level of care. Funds that could be used to serve a person in an Intermediate Care Facility may be used to serve people in the community.
  • NC Innovations Level of Care
    The document used in the NC Innovations Waiver that records the specification of the minimum amount of assistance an individual must require in order to receive services in an institutional setting under the State Medicaid Plan. For the NC Innovations Waiver the institutional level of care setting that corresponds to the level of care that must be met for NC Innovations participants is the Intermediate Level of Care for individuals with Intellectual Disability and related conditions.
  • NC Innovations Waiver
    The NC Innovations Waiver is a means of funding services and supports for individuals with intellectual disabilities and other related developmental disabilities who are at risk for institutional care in an Intermediate Care Facility for Individuals with Mental Retardation (ICF-IID) but who chose instead to remain in their own home and community. NC Innovations is authorized by a Medicaid Home and Community-Based Services (HCBS) Waiver granted by the Centers for Medicare and Medicaid Services (CMS) under Section 1915 (c) of the Social Security Act. Federal, State and Local dollars fund Medicaid Waivers. The NC DD/MH/SAS Health Plan functions as a Prepaid Inpatient Health Plan (PIHP) through which all mental health, substance abuse and developmental disabilities services are authorized for Medicaid participants in the Durham, Wake, Cumberland and Johnston Counties.   CMS approves the services provided under NC Innovations, the number of individuals that may participate each year, and other aspects of the program. The waiver can be amended with the approval of CMS. CMS may exercise its authority to terminate the waiver whenever it believes the waiver is not being managed by the MCO properly The Division of Medical Assistance (DMA), the State Medicaid agency, operates the NC Innovations Waiver. DMA contracts with Alliance Health Care to arrange for and manage the delivery of services, and perform other waiver operational functions under the concurrent 1915 (b)/(c) waivers. DMA directly oversees the NC Innovations Waiver, approves all policies and procedures governing waiver operations and ensures that the NC Innovations Wavier assurances are met.
  • NC MH/DD/SAS Health Plan
    A 1915(b) Medicaid Managed Care Waiver for Mental Health and Substance Abuse allowing for a waiver of freedom of choice of Providers so that the LME/MCO can determine the size and scope of the Provider network. This also allows for use of Medicaid funds for alternative services.
  • NC Treatment Outcomes and Program Performance System
    The NC Treatment Outcomes and Program Performance System is a Division web-based system for gathering outcome and performance data on behalf of mental health and substance abuse consumers in North Carolina’s public system of services. The NC-TOPPS system provides reliable information that is used to measure the impact of treatment and to improve service and manage quality throughout the service system.
  • NCTracks
    The new multi-payer Medicaid Management Information System for the NC Department of Health and Human Services.
  • Network Provider
    An appropriately-credentialed Provider of MH/IDD/SA services that has entered into a contract for participation in the Alliance Network.
  • Out-of-Network Provider
    A practice or agency who has been approved as an Out-of Network Provider and has executed a Single Case Agreement with Alliance. The Out- of-Network Provider is not offered as a choice of referral to Alliance consumers.
  • Out-of-Plan Services
    Health care services, which the Plan is not required to provide under the terms of this contract. The services are Medicaid covered services reimbursed on a fee-for-service basis.
  • Participant
    The person who is approved to receive services under the NC Innovations Waiver.
  • Penetration Rate
    The degree to which a defined population is served
  • Person Centered Plan
    The document that includes important information about the participant, their life goals, and the steps that they and the planning team need to take to get there. It also identifies support needs, and includes a combination of paid, natural supports from family and friends, and community supports.
  • Person-Centered Planning
    A process for planning and supporting the individual receiving services that builds upon the individual's capacity to engage in activities that promote community life and that honor the individual's preferences, choices and abilities. The person-centered planning process involves families, friends and professionals as the individual desires or requires. The resulting treatment document is the Person-Centered Plan (PCP) or Individual Service Plan (ISP).
  • Persons with Severe and Persistent Mental Illness
    Describes consumers who: Are age eighteen (18) or older; Have a substantial disorder of thought or mood that significantly impairs judgment, behavior, capacity to recognize reality, or the ability to cope with the ordinary demands of life; Score less than or equal to thirty (30) on the Global Assessment Scale (GAF) AND Have had three (3) or more psychiatric hospitalizations or crisis home admissions in the last year. Includes all persons diagnosed with: Bipolar Disorders 296.00-296.96. Schizophrenia 295.20-295.90. Major Depressive Disorders 296.20-296.36.
  • Persons with Severe Mental Illness
    Describes consumers who: Are age eighteen (18) or older; Have substantial disorder of thought or mood that significantly impairs judgment, behavior, capacity to recognize reality, or the ability to cope with the ordinary demands of life; Score less than or equal to fifty (50) on the Global Assessment Scale (GAF), or Have had one (1) or more psychiatric hospitalizations or crisis home admissions in the last year.
  • Post-Payment Review
    A review conducted by Alliance to assess the presence of appropriate documentation to support claims submitted for payment by Alliance.
  • Pre-Authorization
    The initial or first approval by Alliance’s Utilization Department of a medically necessary service(s) at a given level of care prior to service delivery.
  • Prepaid Inpatient Health Plan
    Alliance Health, as do all NC Managed Care Organizations (MCOs), functions as a Prepaid Inpatient Health Plan (PIHP) through which all mental health, substance use and developmental disabilities services are managed and authorized for Medicaid participants in the Durham, Wake, Cumberland, and Johnston counties.
  • Primary Clinician
    A professional assigned after the initial intake that is ultimately responsible for implementation/coordination of the Treatment Plan/Person-Centered Plan or treatment plan.
  • Primary Diagnosis
    The most important or significant condition of an individual at any time during the course of treatment in terms of its implications for the individual’s health, medical care and need for services.
  • Prior Authorization
    The act of authorizing specific services before they are rendered.
  • Priority Populations
    People with the most severe type of mental illness, severe emotional disturbances, as well as, substance abuse disorders with complicating life circumstances conditions, and/or situations which impact the person’s capacity to function, often resulting in high-risk behaviors.
  • Private Home
    The home that an individual owns or rents in his or her own right or the home where a waiver participant resides with other family members or friends. A living arrangement (house or apartment) that is owned or leased by a service provider is not a private residence.
  • Prompt Payment Guidelines
    State-mandated timelines that LME/MCOs must follow when adjudicating and paying claims.
  • Protected Health Information
    Under the U.S. Health Insurance Portability and Accountability Act (HIPPA), any information about health status, provision of healthcare, or payment for healthcare that can be linked to a specific individual.
  • Provider Network
    The agencies or professionals under contract with Alliance Behavioral Healthcare to provide authorized services to eligible individuals.
  • Qualified Professional
    Any individual with appropriate training or experience as specified by the North Carolina General Statues or by rule of the North Carolina Commission on Mental Health, Developmental Disabilities, and Substance Abuse Services in the field of mental health or intellectual/developmental disabilities, or substance abuse treatments or habilitation, including physicians, psychologists, psychological associates, educators, social workers, registered nurses, certified fee- based practicing pastoral counselors and certified counselors (NC General Statute 122C-3).
  • Recipient
    A person who is receiving services
  • Reconsideration Review
    A review of a previous finding or decision by Alliance based on the Provider’s Reconsideration Request and any additional materials presented by the Provider.
  • Recredentialing
    The review process to determine if a Provider continues to meet the criteria for inclusion as a LME/MCO Network Provider.
  • Registry of Unmet Needs
    A registry that contains a list of individuals who are waiting for NC Innovations funding for identified needs.
  • Risk Support Needs Assessment
    An assessment of factors that, if unaddressed, might pose a high threat to an individual’s health and welfare. These include: health risk (medical conditions that require continuing care and treatment); behavioral risk (behaviors or conditions that might cause harm to the person or others); and personal safety risk, (e. g., ability to make safe evacuation independently).
  • Routine Need – Mental Health
    A condition in which the person describes signs and symptoms which are resulting in impairment and functioning of life tasks; impact the person’s ability to participate in daily living; and/or have markedly decreased the person’s quality of life.
  • Routine Need – Substance Abuse
    A condition in which the person describes signs and symptoms consequent to substance use resulting in a level of impairment which can likely be diagnosed as a substance use disorder according to the current version of the Diagnostic and Statistical Manual.
  • Service Limit
    The maximum amount of a specific service that can be received under NC Innovations waiver.
  • Service Location
    Any location at which a consumer may obtain any covered service from a Network Provider.
  • Service Records Manual
    The DMH/DD/SAS document that provides the requirements for maintenance of client information, documentation of service provision, and confidentiality requirements.
  • Slots
    The annual allocation of the number of individuals that may be served in NC Innovations. The Center for Medicare & Medicaid Services (CMS) allows North Carolina to serve a given number of individuals on NC Innovations each waiver (calendar) year. This number is the number of ‘slots’ available for that year.
  • SNAP
    Measurement used for level of care for I/DD. This scale will be replaced by the Supports Intensity Scale (SIS).
  • Special Needs Population:
    Population cohorts defined by diagnostic, demographic and behavioral characteristics that are identified in a Managed Care Waiver. The managed care organization responsible for waiver operations must identify and ensure that these individuals receive appropriate assessment and services.
  • Spend Down
    Medicaid term used to indicate the dollar amount of charges a Medicaid consumer must incur before Medicaid coverage begins during a specified period of time.
  • State Plan
    The term that refers to the State Medicaid Plan for Medicaid for the State of North Carolina that is approved by the Center for Medicare & Medicaid Services (CMS).
  • Supplemental Security Income (Social Security)
    Social Security program that pays benefits to disabled adults and children who have limited income and resources.
  • Support Plan
    A component of the Person-Centered Plan that addresses the treatment needs, natural resources, and community resources needed for the consumer to achieve personal goals and to live in the least restrictive setting possible.
  • Support Services
    Services that enable an individual to live in their community. These include services that can provide direct assistance to the individual, and/or services that provide assistance to the individual’s caregivers and/or support staff.
  • Supports Intensity Scale
    A nationally recognized assessment that measures the level of supports required by people with disabilities to lead normal, independent, quality lives in their home community.
  • The Joint Commission
    The national accrediting organization that evaluates and certifies hospitals and other healthcare organizations as meeting certain administrative and operational standards.
  • Third-Party Billing
    Services billed to an insurance company, Medicare or another agency.
  • Treatment Planning Case Management
    A managed care function that ensures that consumers meeting Special Needs Population criteria receive needed assessments and assistance in accessing services. Alliance Care Coordinators carry out this function working with Providers if the consumer is already engaged with Providers, or assists in connecting and engaging the consumer with Providers that will provide the necessary services to meet his/her needs. Activities may include: ∙ Referral for assessment of the eligible individual to determine service needs. ∙ Development of a specific care plan. ∙ Referral and related activities to help the individual obtain needed services. ∙ Monitoring and follow-up.
  • Unmanaged Benefit
    Services that do not require authorization from Utilization Management (UM).
  • URAC
    The national accrediting body under which Alliance Behavioral Healthcare is accredited.
  • Urgent Need Mental Health
    A condition in which a person is not actively suicidal or homicidal, denies having a plan, means or intent for suicide or homicide but expresses feelings of hopelessness, helplessness or rage, has potential to become actively suicidal or homicidal without immediate intervention, a condition which could rapidly deteriorate without immediate intervention, and/or without diversion and intervention will progress to the need for emergent services and care.
  • Urgent Need Substance Abuse
    A condition in which the person is not imminently at risk of harm to self or others or unable to adequately care for self, but by virtue of their substance use is in need of prompt assistance to avoid further deterioration in the person’s condition which could require emergency assistance.
  • Utilization Management Authorization
    The process of evaluating the medical necessity, appropriateness and efficiency of behavioral healthcare services against established guidelines and criteria and to ensure that the client receives necessary, appropriate, high-quality care in a cost-effective manner.
  • Utilization Management Department
    The Alliance department responsible for approving Individual Support Plans and authorizing medically-necessary services. Care Managers work in the UM Department.
  • Utilization Review
    A formal review of the appropriateness and medical necessity of behavioral health services to determine if the service is appropriate, if the goals are being achieved, or if changes need to be made in the Person-Centered Plan or services and supports provided.
  • Utilization Review Manager
    LME/MCO qualified professional who reviews a consumer's clinical data to determine the clinical necessity of care and authorizes services associated with the plan of care.
  • Waiver Year
    The 12-month period that the Center for Medicare & Medicaid Services (CMS) uses to authorize, monitor and control waiver programs and expenditures. The waiver year begins on the effective date of the waiver approval and includes the 12 months following that date. For NC Innovations this is August 1 to July 31.
  • Waste and Abuse
    Incidents or practices that are inconsistent with sound fiscal, business or medical practices that could result in unnecessary costs to Alliance, the State or Federal government, or another organization. Waste could also result in reimbursement for services that are not medically necessary, or services that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary costs to the Medicaid program.