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UM Resources – I/DD

NC Innovations Service Requests

All NC Innovations beneficiaries have a Care Coordinator who works for Alliance. The Care Coordinator submits requests for authorization of services to the Utilization Management Department. More information about NC Innovations services is available on the NC Division of Medical Assistance website as well as on the Alliance Innovations webpage.

Annually an Individual Support Plan (ISP) is developed by the individual/legally-responsible person and their planning team and is submitted by the Care Coordinator to be effective the first day of the month following the beneficiary’s birth month and must be submitted with the following forms:

  • Level of Care (LOC)
  • Risk Supports Needs Assessment
  • NC-SNAP/Supports Intensity Scale (SIS)
  • Individual Budget
  • Signature page

Note that some services or interventions require additional forms, such as a behavioral plan or additional assessments, to be submitted with the ISP.

Requests to add, increase or reduce services can be submitted as a plan revision any time throughout the year that the beneficiary’s needs change and must include the following forms:

  • Update to ISP
  • Signature page
  • Individual Budget

Note that updated assessments, along with other additional forms, may be required based on the services requested.

Change in provider(s) can be made anytime throughout the plan year for services that are authorized and the following forms must be submitted:

  • Alliance NC Innovations Provider Change request form signed by beneficiary/legally-responsible person
  • Updated Individual Budget

Additional Services available through Alliance Health for Innovation Wavier Recipients (Members must meet Medical Necessity):

Innovations Criteria and Waiver

ICF-I/ID Requests for Authorizations

For initial requests, the following information is required and is submitted through the Alpha portal:

  • Level of Care signed by a medical doctor
  • Medical evaluation form
  • Psychological assessment

Requests for 180-day reauthorization require the following forms to be submitted through the Alpha Portal:

  • Level of Care signed by medical doctor
  • Medical Evaluation form
  • Service Authorization Request (SAR) completed in the Alpha Provider Portal

Effective October 1, 2017 the additional authorization submission requirement will be to include the member’s Individual Program Plan (IPP) in addition to the LOC Form to the Service Authorization Request. Alliance Utilization Management will review the IPP in addition to the Utilization Review Committee’s LOC recertification that the member continues to meet the ICF/IDD criteria to determine medical necessity for continued stay for authorization up to the 180 day benefit.

Access the DMA policy for ICF-I/ID.

IDD Non-Innovations Clinical Coverage Policies/Service Definitions

IPRS and B3 services are requested by the provider. The benefit plan for IPRS and B3 services is available online here. Please review the benefit plan prior to requesting services for availability by county, required documents and service limitations.

Service and CodeMedicaidState
ADVP (YP620)N/AState Funded MH/DD/SA Service Definitions
Clinical Assessment (90791, 90792)N/AClinical Coverage Policy 8C
Community Guide-B3 (T2041 U4)B3 Service DefinitionN/A
Community Respite (YP730)N/AState Funded MH/DD/SA Service Definitions
Community Transition (One Time Transitional Costs) T2038 U4B3 Service DefinitionN/A
Comprehensive Screening and Community Connection (YA377)N/AAlternative Service Definition
Day Activity (YP660)N/AState Funded MH/DD/SA Service Definitions
Developmental Day-Child Only (YP610)N/A

State Funded MH/DD/SA Service Definitions
Developmental Therapy Paraprofessional (H2014 HM)N/AState Funded Developmental Therapy Service
Developmental Therapy Professional (H2014)N/AState Funded Developmental Therapy Service
Facility Based Crisis Services (S9484)
N/AAdult: 2017 State Funded Enhanced MH/SA Services

Child: State Funded Facility Based Crisis
Group Living (Low YP760, Moderate YP770)N/AState Funded MH/DD/SA Service Definitions
Hourly Respite (YP010, YP213)N/AState Funded MH/DD/SA Service Definitions
ICF-IDD (RC100)Clinical Coverage Policy 8EN/A
ICF-IDD Therapeutic Leave (0183)Clinical Coverage Policy 8EN/A
Mobile Crisis Management (H2011)
N/AState-Funded Enhanced MH/DD/SA Service Definitions
Personal Assistance (YP020)N/AState Funded MH/DD/SA Service Definitions
Psychological Testing (96130, 96131, 96136, 96137, 96146)

N/AClinical Coverage Policy 8C
Respite B3 (Individual-H0045 U4, Group-H0045 HQ U4)B3 Service DefinitionN/A
Short Term Residential Stabilization (T2016 TFU5)In Lieu of ServiceN/A
Supervised Living 1-6 (YM811-YM816)N/AState Funded MH/DD/SA Service Definitions
Supervised Living Low (YP710)N/AState Funded MH/DD/SA Service Definitions
Supported Employment Group (Medicaid – H2023 HQ U4, State – YP640)
B3 Service DefinitionState Funded MH/DD/SA Service Definitions
Supported Employment Individual (B3 Medicaid H2023 U4, H2026 U4; State YA390)B3 Service DefinitionState Funded MH/DD/SA Service Definitions
Supported Employment Long Term Follow Up-Long Term Vocational (YA389)N/AState Funded MH/DD/SA Service Definitions
Case Support (COVID)State Funded Alternative Service Definition
This page was last reviewed for accuracy on 10/13/2021