Yes, some OTC products are covered including nicotine replacement products for smoking, stomach acid reducers (PPIs), non-sedating antihistamines, diabetes supplies, and some laxatives, but all require a prescription or standing order from DHHS. OTC vitamins, cough and cold medications, analgesics, topicals, and other products are not covered. Access the policy for OTC coverage.

NC Medicaid has determined it is the responsibility of the Innovations Financial Support Service Provider to development and implement an auto-calculator tool to be used by the EORs the FSS Provider supports.

Call or visit your local DSS office to report these changes so you donā€™t miss important Medicaid information. Also notify Alliance Member and Recipient Services at 800-510-9132 Monday through Saturday, 7 a.m. to 6:00 (Relay 711 or toll-free 800-735-2962, Option 1). (updated 10/13)

The NC Medicaid Ombudsman provides education, advocacy and issue resolution for Medicaid beneficiaries in NC Medicaid Managed Care and NC Medicaid Direct. You can use the NC Medicaid Ombudsman resource when you cannot resolve issues with your health plan or your PCP. Go to ncmedicaidombudsman.org or call 1-877-201-3750, Monday through Friday from 8 a.m. to 5 p.m. The call is toll-free. (updated 10/13)

Go to ncmedicaidplans.gov. You can also use the ā€œchatā€ tool on the website or call NCDHHS at 833-870-5500 (TTY: 711 or RelayNC.com) from 7:00 a.m. to 5:00 p.m., Monday through Saturday. The call is toll-free. Please have your Medicaid ID number when you call or go to the website.

You can get the information at ncmedicaidplans.gov in print. To ask for a free copy, call toll-free at 833-870-5500 (TTY: 711 or RelayNC.com or use the ā€œchatā€ tool on the website. We will send this information within 5 business days.

You can also call Alliance Member Recipient Services at 800-510-9132 (Relay 711 or toll-free 800-735-2962, Option 1) Monday through Saturday, 7:00 a.m. to 6:00 p.m. (updated 10/13)

If you are on the Innovations waiver or TBI waiver, you will receive TCM. You can choose your current care coordinator as your TCM provider or choose a different TCM provider. You can call Alliance Member and Recipient Services at 800-510-9132 (Relay 711 or toll-free 800-735-2962, Option 1) to choose a TCM provider or one will be assigned to you. (updated 10/13)

If you are eligible for TCM, you will have a single care manager who will:

  • Coordinate services for physical health,Ā pharmacy benefits, long-term services and supports, behavioral health, traumatic brain injury (TBI) and I/DD-related needs
  • Address unmet health-related needs (such as housing, food, transportation, personal safety, employment) by connecting you to local programs and services
  • Provide person-centered planning that focuses on your needs and goals

If you are eligible for TCM you will receive a letter with more information in the coming weeks. (updated 10/13)

The delayed start of Tailored Plans allows Local Management Entity/Managed Care Organizations, which will operate the Tailored Plans, more time to contract with additional providers to ensure a smooth transition for people using the plans and their care providers. Until the Tailored Plans launch, people who will be covered by the Tailored Plans will continue to receive care through their existing plans. (updated 2/27/2023)

 

Members who select GT for their FSS do have the choice of selecting a different approved agency to provide their community navigator Services. The information in theĀ  IFDS provider training presentation has been updated to make this clear. Access the updated presentation.

All searches begin with a location. To start, please enter a city, county, or zip code and select the most appropriate option from the dropdown. All results will be displayed based on their distance from this location.

Alliance will assign members for Tailored Care Management to CMAs and AMH+ā€™s. Alliance is currently developing the assignment logic based on the stateā€™s guidance and this will be discussed in a future CMA Learning Collaborative. Refer to the document entitled ā€œStaffing, Caseload, and Financial Modelingā€ for methods organizations can use to project the number of Tailored Care Management members that will be assigned to them.

Member choice is the primary factor in determining how/where a member will be assigned. Members will receive a letter notifying them of the options available to them and if they indicate a preference for a Tailored Care Management provider, the member will be assigned to that provider. A workflow is being developed to clarify this process.

AHEC will be facilitating trainings on most of the topics included under Tailored Care Management in the RFA and the Provider Manual. Alliance is working on a gap analysis to determine any gaps in the trainings offered by AHEC, and Alliance will provide the required trainings that are identified through that process.Ā  A training schedule will be addressed in future CMA Collaborative meetings.

You, your support team, and the CIPM team will work together to follow up on the CIPM action plan. The community inclusion planning coordinator or member inclusion and outreach specialist assigned to the team will follow up with the member or guardian and referral source at 21, 60, 90, 180, and 365 days (one year) after a CIPM to check on the progress of the CIPM action plan.

CIPMs can be held in-person or virtually.

As we work hard to include representatives/individuals from various community agencies, please extend the courtesy of notifying us within 5 days (or as soon as you are aware) if you are not able to attend. To schedule a CIPM, please complete the referral form and submit it to [email protected].

Each person in attendance is responsible for ensuring the action plan can be carried out through assigned support and tasks. This is a collaborative effort and each person has responsibility in ensuring successful outcomes. If there are barriers/challenges with tasks being completed, whoever is responsible for that task will contact another individual in the community who can assist with support for this task (while ensuring confidentiality). If this is not successful, contact a Community Inclusion Planning Coordinator by sending an email to [email protected].

Everyone will introduce themselves and their role at the meeting. The member and/or referral source should be prepared to present information goals. A CIPM action plan will be developed and reviewed at the conclusion of the meeting. The member and anyone the member wishes will receive a copy of the CIPM action plan.

The CIPM team represents the member/family needing support, natural supports (friend, family, people the member/family trusts) and various agencies and organizations in the community.

While CIPM teams represent their organizations, they are expected not to advocate for the interest of their organizations, but rather to focus on the interest of the member. The individuals selected for the team are invited by the community inclusion planning coordinator. Members are welcome to bring whomever they want.

Community Inclusion Planning Meetings use a System of Care approach by being strength-based, community-based and member-driven. CIPM action plans are built around what members do well and fit their beliefs. Community Inclusion Planning Meetings are in place to help a person or family meet with community and agency representatives to discuss their needs and desires across multiple areas and put a plan in place to meet those needs and desires. These areas may include mental and physical health, housing, transportation, employment, social activities, and legal, financial, educational and spiritual needs.

The Community Inclusion Planning (CIP) team will help with brainstorming and creating a CIPM action plan with the member or family to access community resources and provide support throughout the process. The member or family leads this process and should be informed and willing to participate in the CIPM for the meeting to take place. It is the responsibility of the person completing the application with the member to explain the purpose of CIPMs to ensure they are interested in participating.

A CIPM is a time for members to meet with their CIP teams to express their needs and wishes across multiple areas including behavioral health, physical health, housing, transportation, and legal, financial, educational, vocational, social and spiritual needs.

Community inclusion planning teams can:

  • Support timely access to services to members transitioning from treatment facilities and incarceration
  • Support service coordination
  • Develop ideas and provide connections to community resources to enhance the members quality of life

Community inclusion planning teams cannot:

  • Provide a clinical recommendation for a particular treatment service or level of care (such a recommendation is the product of a comprehensive clinical assessment)
  • Overturn decisions made by Allianceā€™s Utilization Management Department with regard to the denial or reduction of authorizations of MH/DD/SA services
  • Guarantee a particular MH/DD/SA service will be approved by Allianceā€™s Utilization Management Department as meeting medical necessity
  • Approve or guarantee housing funds, such as Independent Living Initiative (ILI) funding
  • Determine eligibility for funding sources (Medicaid or state-funding)

Alliance Health is a North Carolina organization that contracts with the Division of Medical Assistance (DMA) to administer specialty medical plans for TBI survivors in Wake, Durham, Johnston, and Cumberland Counties. Alliance manages a group of healthcare providers to provide services and coordinates the care of survivors participating in the TBI Waiver Program. This includes identifying appropriate community resources, developing support plans, and coordinating benefits.

Support for survivors may include (but are not limited to):

  • Staff supports to enable you to live independently or in a group-living situation
  • Personal care services
  • Life-skills training
  • Cognitive rehabilitation
  • Home and/or vehicle modification
  • Technology supports
  • Occupational, physical and speech therapy
  • Activities to do during the day or help in finding a job
  • Family/caregiver support

View theĀ TBI Waiver Services flyer.

Alliance Health is the managed care organization for publicly-funded behavioral health care services for the people of North Carolina’s Cumberland, Durham, Johnston, Mecklenburg, Orange and Wake counties.

A TBI is defined as an injury to the brain caused by an external force that can result in impairments to cognition (thinking) and physical, behavioral and emotional functioning. Such an injury may have been caused by a motor vehicle accident, fall, gunshot wound, occupational/recreational injury, abuse or military action.

If you have cognitive, behavioral and physical support needs, your TBI occurred on or after your 22ndĀ birthday, you need specialty hospital care or skilled nursing care, and you meet certain financial eligibility, you may be eligible to participate in this program.

If you have questions about eligibility call Allianceā€™s 24-hourĀ Access and Information line atĀ (800) 510-9132 and request information about the TBI Waiver.Ā Callers should expect to experience a brief crisis screening initially.

If you or someone you care about has a traumatic brain injury (TBI), the TBI Waiver Program is designed to provide community-based rehabilitative services and support to help with your recovery. This is a pilot program managed by Alliance Health in four North Carolina counties (Durham, Wake, Cumberland and Johnston). The services are provided in your own home and community, or in a group living setting ā€“ giving you choices and promoting your independence. Under this three-year pilot, 49 individuals will have the opportunity to participate in the TBI waiver the first year, 99 in the second and 107 in the third year.

Each service should be billed where the intervention was performed. Mostly commonly used is the office or home. For more information about place of service exceptions, see the ā€œAlliance POS Mappingā€ located on our website under Finance and Claims Resources

As a Alliance Health provider, you’re helping ensure care to our members with complex needs. Our core values shine through our providers’ work and permeate everything they do. Alliance is committed to ensuring that metwork providers are aware of the information necessary to provide care to individuals served by Alliance and are able to comply with Allianceā€™s requirements. Alliance is committed to communicate through a variety of means in an effort to keep the community of network providers well informed of state and federal changes, new information, trainings, requests for proposals and opportunities for collaboration. For any and all Provider questions, we have a dedicated provider network line through our telephonic helpdesk, 919-651-8500, as well as a dedicated provider network email address ([email protected]). Through the helpdesk and dedicated email, providers are able to receive real-time assistance during normal business hours, and 24/7/365 assistance is available through Allianceā€™s Access and Information Center (call center).

In order to be added to the Registry of Unmet Needs (RUN) for the NC Innovations Waiver, you or your family should call Allianceā€™s Access and Information Center at 800-510-9132. You will be asked to provide confirmation of your intellectual and/or developmental disability to be added to the RUN. At the time that you are working with Alliance staff to be added to the registry, you will also be informed of other state-funded or Medicaid-funded services available to you.

At this time there is no RUN for TBI Waiver services because slots are available. In the future, a TBI Waiver RUN may be necessary when the demand for services exceeds available funding.

Alliance has standardized procedures for evaluating the needs of individuals seeking services under the NC Innovations Waiver or the NC TBI Waiver. You must meet the diagnostic and financial criteria for the appropriate waiver. Please reference the NC Innovations Waiver or theĀ NC TBI Waiver as appropriate.

Expedited requests are reserved for individuals currently experiencing life-threatening situations due to their current symptoms or behaviors. Requests that are marked expedited should include clinical justification to support the need for an expedited review.

Pursuant to 42 C.F.R. Ā§438.210, an expedited request is one which ā€œa provider indicates, or the MCOā€¦ determines, that following the standard timeframe could seriously jeopardize the enrolleeā€™s life or health or ability to attain, maintain, or regain maximum function.ā€ An expedited authorization decision must be made as expeditiously as the enrollee’s health condition requires and no later than 72 hours after receipt of the request for service.

Both the waiver ā€œHard Limits-Benchmarks for providers and familiesā€ and ā€œAuthorization Guidelinesā€ can be found on the Alliance Health website under the provider resources. If you have specific questions, call the Provider Network line at 919-651-8500 or email [email protected].

All members with suspected TBI are encouraged to call Alliance Access and Information Line. When members call Alliance access and information line, they are asked 2 questions; ā€œHave you ever been hit on the head or been knocked unconscious?ā€ If the answer is YES to at least one question, the member is then asked if they would like to complete a basic TBI Phone Screening. The member is then transferred to an Alliance IDD/TBI Access Clinician who completes the Ohio Screening ( TBI screening) with the member. Based on the memberā€™s responses, the access clinician will provide basic TBI Resources and or discuss TBI supports and services. Alliance Access Dept. is responsible for collecting TBI Data Monthly. Alliance is responsible for submitting TBI Screening Data to the state on a quarterly basis.

The TBI screening is for any provider who treats a member with TBI. The form is assessable on our external website under Provider Resources in the ā€œProvider Resource Formsā€ section. Should the TBI Ohio screening result in a positive screening or suspected TBI,Ā  the memberĀ  then should be encouraged to contact Alliance Health Access and Information line.Ā  They should access to speak with an Access Clinician about about potential TBI services and Resources.

UM reviews requests as timely as possibly but as all Innovations annual plan requests are submitted on the first of the month, this can require up to the allowed time frames to complete all reviews. This is why ISPs are submitted a month in advance of the effective dates and updates should be submitted at least to 15 days in advance. For urgent situations, the Care Coordinator would work with UM to prioritize. For any concerns, the provider should discuss with the Care Coordinator.

The NC Innovations Waiver allows individuals with intellectual and developmental disabilities to receive services and supports in their own community. This helps people live as independently as possible, rather than in an institution like a developmental center.

Alliance Health manages the NC Innovations Waiver program in Cumberland, Durham, Johnston, Mecklenburg, Orange and Wake counties. There is currently a waitlist for these services called the Registry of Unmet Needs.

To learn more about the NC Innovations Waiver or the Registry of Unmet Needs, call Allianceā€™s Access and Information Center at 800-510-9132.

The Registry of Unmet Needs is a first-come, first-served list maintained by Alliance Health to keep track of people waiting for the NC Innovations Waiver in Wake, Durham, Johnston, and Cumberland counties. Since services from the NC Innovations Waiver may not be immediately accessible, we do strongly encourage parents of children who have an intellectual and/or developmental disability who may need these services in the future to contact us to add your child to the Registry of Unmet Needs now. To learn more about the IDD eligibility review process or the Registry of Unmet Needs, call Allianceā€™s Access and Information Center at (800) 510-9132.

If you are the relative or legal guardian of an adult (age 18 and older) who participates in the NC Innovations Waiver, you may qualify to become a Relative/Legal Guardian as Direct Support Employee (RDSE). The only service you may provide in this role is Community Living and Support. To serve in this manner, you must meet certain standards for employment. Read tips for RDSE members.

The LME/MCO Level Appeal must be completed within thirty (30) days after the request is filed. Alliance will schedule a review with a health care professional who has no prior involvement in the case. This person will review the information used in making our decision, in addition to any other information that the individual/guardian wishes to submit. Additional information must be sent to us within ten (10) days of filing this LME/MCO Level Appeal request form. We will mail a decision within thirty (30) days.

A provider may help the individual with completing the form and filing the appeal if the individual gives them written permission. There is a space on the form for the individual to identify someone who is going to help them with their appeal.

Individuals may call (919) 651-8545 if they want to make a
request by phone. If an individual needs assistance, they can also contact Alliance
at (800) 510-9132Ā  and someone will provide guidance.

To request a LME/MCO Level Appeal, the appellant can call (919) 651-8545 and/or complete the appeal form included with the Notice of Adverse Benefit Determination. The request form can be faxed, emailed, mailed or hand delivered to Alliance at:
Fax: (919) 651-8682
Email: [email protected]
Mail or Hand Delivery: Alliance Health, Attention: Appeals Coordinator 5200 W. Paramount Parkway, Suite 200, Morrisville, NC 27560

Ā 

What if I have a question about specific claims? Utilize the standard Claims Research spreadsheet as a tool to communicate with your assigned Claims Research Analyst. Complete the spreadsheet, email it to your assigned Claims Research Analyst, and you will receive a prompt response.

Cutoff for claims to be processed is every Tuesday at 5:00 pm. Claims will adjudicate every evening and the status of most claims will be available to view the next day. *Please note: processing time can be impacted by ACS updates. If the system is updating, claims may not process until the update is complete (sometimes not until the next day).

The best resolution is 1360Ɨ765 screen resolution. If that is not an option try holding down the Ctrl button on the left bottom part of your keyboard and rolling the ball on your mouse if using Internet Explorer. If that doesnā€™t work, please contact your IT department for additional help.

For all IPRS services billed you will only use the CMS-1500. For Medicaid claims, professional services must be billed on a CMS-1500. Services such as ICF, inpatient, and ED claims are billed on a UB04.

Navigate to the authorization module in ACS.

Click “Filter.”

Enter patient ID (if known).

Click “Search” at the bottom

If patient ID is not known, click “Search” next to the patient ID box.

Enter last name, first name.

Click “Search.”

Click on the correct line to highlight patient’s name.

Click “Select Patient.”

Patient ID will now populate.

Click “Search” at bottom.

Click on line to expand

Click “Print” to print the auth report.

Click “Details” to view additional details of auth. (After clicking on details, click on line to expand and view details.)

Medicaid abuse occurs when a member or provider engages in activity that results in unnecessary cost, including services that are not necessary or services that do not meet the standards of care.

Medicaid fraud occurs when a member or provider knowingly cheats or is dishonest, resulting in a benefit such as payment or coverage that would not have been provided.

NC START does not replace mobile crisis management or first responder. Although the NC START clinical teams are available for assistance/support/consultation at any time during a crisis response, the first responder and mobile crisis teams retain their roles and responsibilities, NC START clinical teams are intended to support not replace these functions. An eligible individual will continue to access mobile crisis management via the established DMH/DD/SAS crisis service protocol. Eligible individuals will still be required to go through their clinical homes/first responders (if applicable) prior to accessing mobile crisis management. Once an eligible individual is seen by a mobile crisis management team member, that team member should contact the regional NC START program for a potential referral and telephonic/on-site assistance (if indicated). For individuals previously known to an NC START region, their clinical home providers and/or natural supports may contact NC START at any time for information, consultation and assistance deescalating individuals experiencing minor difficulties and/or crises. This assistance/availability of NC START clinical team staff is intended to help deescalate situations before the level of need becomes emergent necessitating a mobile crisis intervention.

Each NC START region has a central access number for information and referral. Referrals to NC START for eligible individuals can be made by anyone known to the individual with an understanding of the individualā€™s current status and treatment, support and behavioral history and the applicable legal consent for referral. Referral sources often include the following individuals/groups: Individuals themselves, parents and other natural supports, legal guardians, LME staff, Case Management provider staff, Mobile Crisis Management team staff, Clinical home provider staff, Hospital staff, Community Mental Health provider staff, etc. Referrals for eligible individuals not experiencing crises at the time of referral should be made during business hours (8:00 AM ā€“ 5:00 PM EST) to appropriate NC START team access number. Referrals for eligible individuals experiencing crises at the time of referral may be made at any time of day/night (24/7/365) to the appropriate NC START team access number.

If the individual loses the appeal, Alliance is allowed to recover the cost of the Medicaid services received during the appeal process. We cannot recover these costs from the parents or guardians of individuals over 18 or from providers.

If the individual disagrees with the LME/MCO level appeal decision, they may request a state fair hearing with the North Carolina Office of Administrative Hearings (OAH). Information explaining how to request a state fair hearing with OAH will be enclosed with the LME/MCO Level Appeal decision. The first step in a state fair hearing is the opportunity for mediation. Individuals and providers can learn more about requesting a state fair hearing at the OAH website or by calling 919-431-3000.

Medicaid 1915(b)(3) services enable states to provide health-related services in addition to those in the approved state plan. 1915(b)(3) services are subject to Medicaid due process and appeal rights in the same manner as other Medicaid services provided under the waiver. Medicaid due process and appeal rights must be provided to Medicaid beneficiaries when there is a denial or limited authorization, reduction, suspension, or termination of a previously authorized 1915(b)(3) service based on medical necessity criteria. LME-MCOs receive a separate 1915(b)(3) capitation rate. Total expenditures on 1915(b)(3) services cannot exceed the resources available. 1915(b)(3) services that are denied based on funding exceeding the resources available are subject to the grievance process.

PLEASE NOTE: Individuals must request a LME/MCO level appeal and receive a decision before they can request a state fair hearing.

The NC START (North Carolina Systemic, Therapeutic Assessment, Respite and Treatment) program is exclusively available to serve adults (age 18 and above) that have a primary diagnosis of developmental disability (DD) and challenging behaviors, often with a co-occurring mental illness.

The NC START program is divided into three regions (East, Central and West) and each region consists of two clinical teams and one respite home. The two clinical teams provide 24/7 crisis response and consultation as well as on-going preventative cross-systems crisis planning for eligible individuals. The crisis prevention component of NC START also involves working with the existing DD and mental health systems of care to provide technical assistance, consultation and support when working with individuals eligible for NC START. The NC START clinical teams will continue to work with referred individuals and their service/support system up to one year following a referral. Within that time the NC START team will work with the individual and their system of services and supports to systemically prepare for crises and reduce the frequency of restrictive interventions, hospital admissions and overall crisis events. The NC START regional respite homes each have two beds reserved for eligible individuals in crisis and two beds reserved for planned caregiver respite of eligible individuals* (4 beds total). Access to the respite home will be governed by the regional clinical teams and respite directors.

If Alliance terminates, suspends, or reduces an individualā€™s current Medicaid services before the authorization period ends, they may continue to receive those services if they meet all of the following conditions:

  • The LME/MCO Level Appeal request is filed within 60 days of Alliance mailing the
    Notice of Adverse Benefit Determination.
  • The decision involves the termination, suspension, or reduction of currently
    authorized services.
  • The services were ordered by an authorized provider.
  • The authorization period for the services has not expired.
  • The individual/guardian requests that services continue.

Revised September 16, 2020; effective October 16, 2020.

If all of these conditions are met, the individual will continue to be authorized for current
services unless and until:

  • The individual/guardian withdraws the request for a LME/MCO Level Appeal, or
  • Ten days after we mail the LME/MCO Level Appeal decision, unless the
    individual/guardian requests a State Fair Hearing within those ten (10) days, or
  • The individual/guardian loses the State Fair Hearing, or
  • The authorization period for the services expires or authorization service limits are
    met.

For more details about continuation of benefits, see 42 C.F.R. Ā§ 438.420.

If we deny a request for an expedited LME/MCO level appeal, we will call the individual as soon as possible to tell them that expedited review was not approved, and will send written motivation within 24 hours. An individual can contact 800-510-9132 to file a grievance about our decision to deny expedited review. If the request for expedited review is denied, we will make a decision on your appeal within the standard timeframe (30 calendar days) and there is no need to resubmit appeal request.

An individual/guardian may ask for an expedited Reconsideration Review if waiting thirty days might seriously jeopardize the individualā€™s life, health, or functional abilities. A provider or any other individual may also help with asking for expedited review if they have been authorized in writing to do so by the member/guardian. A written appeal request is not required for expedited appeal requests filed orally. If Alliance approves a request for an expedited Reconsideration Review, we will notify the appellant in writing within 24 hours of the request and provide written notification of the determination within 72 hours of the request.