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NC Medicaid Behavioral Health and Intellectual/Developmental Disabilities Tailored Plans (Tailored Plans) will launch July 1, 2024.

Effective February 1, 2024, citizens of Harnett County are being served by Alliance Health. Access more information for health plan participants or for providers.

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Alliance Clinical Guidelines

Alliance’s approved Clinical Practice Guidelines and Psychological Testing Guidelines document what is known and what is not known about a condition or disorder for the treatment of patients with the ultimate goal of improving care.

Clinical Practice Guidelines have been developed nationally and internationally by a variety of expert sources including the American Psychiatric Association (APA), American Academy of Child and Adolescent Psychiatry (AACAP), American Society of Addiction Medicine (ASAM), Substance Abuse and Mental Health Services Administration (SAMHSA) and other national and international societies, government/VA/DoD, and other care delivery systems such as Magellan and Managed Care organizations (MCOs).

When national guidelines are unavailable, work groups comprised of Alliance staff, providers and consultants who are experts in their fields have developed clinical guidelines. All of these guidelines have been reviewed and adopted by the Alliance Clinical Advisory Committee to assist providers and consumers alike in the clinical decision making process for a variety of mental health and substance use disorders with the goal of improved patient management and enhanced quality of care. As a result of this explosion of knowledge, concerns about the quality of care, access and cost and to determine “appropriate” or “reimbursable” care, it is necessary to describe the range of treatments available for patients with Mental Illness, Behavioral Disorders and/or Substance Use Disorders.

Clinical Practice Guidelines clearly and concisely document what is known and what is not known about a condition or disorder for the treatment of patients with the ultimate goal of improving care. These guidelines reflect evidence based treatment, but are not intended to be service definitions, or medical necessity criteria, though they may overlap. Additionally, guidelines should enhance individualized care, sound clinical practice and good judgment. Guidelines also do not supersede federal and/or state regulations. Alliance will continue to review, revise and update its approved clinical practice guidelines. Your comments and suggestions are welcome.

Approved Alliance Guidelines

Clinical Guidelines-Adult

Clinical Guidelines-Adult
Adult Mental HealthDiagnosisGuideline LinkDeveloper/Source (year)Notes/Additional Links
Antipsychotic MedicationMetabolic Monitoring Guidelines(ADA/APA/AACE/N. American Assoc. for Study of Obesity, 2004)
Benzodiazepines Prescribing Benzodiazepines Prescribing GuidelinesInternal, Alliance Health Provider Quality Subcommittee (2017)
Bipolar Disorder in AdultsF31Systematic Review: Evidence SummaryAHRQ (2018)APA Practice Guideline for the Treatment of Patients with Bipolar Disorder

2005 Guideline Watch-Practice Guideline For The Treatment of Patients With Bipolar Disorder, 2nd Edition

VA/DoD Clinical Practice Guidelines for the Management of Bipolar Disorder

NICE Guideline (2020)

Guidelines for the recognition and management of mixed depression (2017)
DementiaF02APA Practice Guideline for the Treatment of Patients with Alzheimers and other Dementia Disorders

2014 Guideline Watch-Alzheimers Disease and other Dementias

APA Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients with Dementia
APA (2007)



2014 Guideline Watch (2014)


APA (2007)
Eating DisordersF50APA Practice Guideline for the Treatment of Patients With Eating Disorders, Fourth Edition (2023)

APA Pocket Guide for the Treatment of Patients With Eating Disorders (2023)

APA August 2012 Guideline Watch : Practice Guideline for the Treatment of Patients with Eating Disorders, Third Edition

Quick Reference Guide : Treating Eating Disorders 2006
APA (2006)



APA (2023)


APA Guideline Watch (2012)



APA (2006)
Joint Commission Residential and Outpatient Program Requirements (2016)

NICE Guideline: Eating disorders: recognition and treatment (2017)
Generalized Anxiety Disorder (GAD)F41.1Treatment of Panic Disorder, Social Anxiety Disorder and GAD

Evidence-Based Pharmacological Treatment
Royal Australian and New Zealand College of Psychiatrists (2018)
British Association for Psychopharmacology (2014)
Major Depressive DisorderF32, F33VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder

VA/DOD PocketCard
VA/DOD (2016)


VA/DOD (2016)
APA Practice Guideline For the Treatment of Patients with Major Depressive Disorder

Accompanying Quick Reference Guide
Obsessive-Compulsive Disorders in AdultsF42APA Practice Guideline for the Treatment of Patients with Obsessive-Compulsive Disorder

Guideline Watch (March 2013): Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder
APA (2007)


APA Guideline Watch (2013)
Panic Disorder in AdultsF41.0Practice Guideline for the Treatment of Patients with Panic Disorder
APA (2009)
Post-Traumatic Stress Disorder in AdultsF43.1PTSD and Acute Stress Reaction Guidelines

Pocketcard Treatment of PTSD
VA (2017)

APA (2017)
Schizophrenia in AdultsF20-F29Treatment of Patients With Schizophrenia
APA (2020)
Social Anxiety Disorder (Social Phobia)F40.10Treatment of Panic Disorder, Social Anxiety Disorder and GAD

Evidence-Based Pharmacological Treatment
Royal Australian and New Zealand College of Psychiatrists (2018)
British Association for Psychopharmacology (2014)
SuicideClinical Guideline for Assessment and Managements of Patients at Risk for SuicideInternal, 2019 Provider Quality Subcommittee approved excerpts from 2013 VA Guideline 2019 VA Guidelines

Clinical Guidelines-Children and Adolescents

Clinical Guidelines-Children and Adolescents
Child/Adolescent Mental HealthDiagnosisGuideline LinkDeveloper/Source (Year)Notes/Additional Links
Antipsychotic MedicationUse of Antipsychotics in Children

Metabolic Monitoring Guidelines
AACAP 2011

ADA/APA/AACE/N. American Assoc. for Study of Obesity (2004)
Attention Deficit Hyperactivity Disorder in Children and AdolescentsF90Assessment and Treatment of Children and Adolescents with Attention Deficit/Hyperactivity DisorderAACAP (2007)
Bipolar Disorder in Children and AdolescentsF31
Assessment and Treatment of Children and Adolescents with Bipolar DisorderAACAP (2006)
Eating DisordersF50APA Practice Guideline for the Treatment of Patients With Eating Disorders, Fourth Edition (2023)

Assessment and Treatment of Children and Adolescents with Eating Disorders
APA (2006)



AACAP (2015)
AAP Review (2014)

Residential and Outpatient Program Requirements (2016)
Generalized Anxiety Disorder in Children and AdolescentsF41.1Assessment and Treatment of Children and Adolescents with Anxiety DisordersAACAP (2006)
Major Depressive Disorder in Children F32, F33Assessment and Treatment of Children and Adolescents with Depressive DisordersAACAP (2007)
Obsessive-Compulsive Disorder in Children and AdolescentsF42Assessment and Treatment of Children and Adolescents with Anxiety Disorders

Assessment and Treatment of Children and Adolescents with Obsessive-Compulsive Disorder
AACAP (2006)


AACAP (2012)
Oppositional Defiant DisorderF91.3Assessment and Treatment of Children and Adolescents with Oppositional Defiant DisorderAACAP (2006)
Panic Disorder in Children and AdolescentsF41, F93 Assessment and Treatment of Children and Adolescents with Anxiety DisordersAACAP (2006)
Post-Traumatic Stress Disorder in Children and AdolescentsF43Assessment and Treatment of Children and Adolescents with Post-Traumatic Stress DisorderAACAP (2010)
Schizophrenia in Children and AdolescentsF20, F25, F29Assessment and Treatment of Children and Adolescents with SchizophreniaAACAP (2013)
Sexualized Behavior in AdolescentsClinical Practice Guideline for Intervention with Adolescents with Sexualized Behavior ProblemsInternal, Clinical Advisory Committee, 9/28/15

Clinical Guidelines-SUD

Clinical Guidelines-SUD
Substance Use DisorderDiagnosisGuideline LinkDeveloper/Source (Year)Notes/Additional Links
SUD (Adult)F10, F11, F12, F13, F14, F15, F18Management of Substance Use Disorders

Pocket Card (see pocket card errata)
VA/DoD (2015)
Alcohol Use DisorderF10Withdrawal Management

Pharmacological Treatment
ASAM (2020)

APA (2018)
Nicotine Use Disorder (Adult)F17US PSTF (2021)United States Preventive Service Task Force (2015)You Quit Two Quit

QuitlineNC

Smoking, Mental Illness and Public Health

Implementing Tobacco Cessation Programs in SUD Treatment Settings (SAMHSA)

Implementing Tobacco Cessation Treatment for Individuals with SMI: A Quick Guide for Program Directors and Clinicians (SAMHSA)

CDC Health Advisory on Severe Pulmonary Disease Associated with Using E-Cigarettes (August 30, 2019)
Nicotine Use Disorder (Child/Adolescent)F17US PSTF (2013)United States Preventive Service Task Force (2013)CDC: Youth and Tobacco Use
Opioid Use DisorderF11TIP 63: Medications for OUD - Executive Summary

SAMHSA (2021)TIP 63: Medications for OUD - Full Document (SAMHSA 2021)

ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use (2015)


Practice-Based Guidelines: Buprenorphine in the Age of Fentanyl (PCSS Guidance, May 2023)

Opioid Use Disorder in Pregnant and Parenting WomenNational Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use
Part 8, Special Populations: Pregnant Women, pages 39-43
ASAM (2015)Clinical Guidance on Treatment of Pregnant/Parenting Women w/OUD
Opioid Treatment Programs (OTPs)Federal Guidelines for OTPsSAMHSA (2015)Management of Benzodiazepines in MOUD (IRETA 2013)

Guidelines for Addressing Benzodiazepine Use In OTPS (American Association for the Treatment of Opioid Dependence, website accessed 11/26/18)

SUD (Adolescents)F10, F11, F12, F13, F14, F15, F16, F18Assessment and Treatment of Children and Adolescents with SUDsAACAP (2005 )
NIDA resources:

Preventing Drug Use in Children and Adolescents (2003)

Clinical Guidelines-I/DD

Clinical Guidelines-I/DD
Intellectual / Developmental DisabilityDiagnosisGuideline LinkDeveloper/Source (Year)Notes/Additional Links
TBI (In NC individuals qualify for ID services if the traumatic brain occurred before their 22nd birthday)Management of Concussion and Mild TBI : Clinician Summary


Rehabilitation of Adults with Moderate to Severe TBI - website link
VA/DoD, 2015




Ontario Neurotrauma Foundation, 2018
Management of Concussion and Mild TBI (full guidelines) and Patient Guide and Pocket Card
Genetic SyndromesGenetic Syndrome Websites

Health Watch Tables for Selected Developmental and Related Disabilities- website link
AssessmentAssessment of and Intervention With Persons With Disabilities
(Geared toward psychologists & testing, focuses broadly on disabilities.)
Developmental DisabilitiesF70-F73Integrated Mental Health Treatment GuidelinesSTART (2021)
ASDF84Assessment and Treatment of Children and Adolescents With Autism Spectrum DisorderAACAP (2014)
Trauma
Dual DiagnosisUnderstanding and Serving People with Intellectual Disabilities and Mental, Emotional, and Behavioral DisordersFlorida Disabilities Council (2009)Diagnostic Manual- Intellectual Disability (DM-ID2): A Textbook of Diagnosis of Mental Disorders in Persons with Intellectual Disability, second edition
Texas/Algorithm ProjectDetermination of Intellectual Disability
(For children, sections 1-7 helpful in determining ID, testing guidelines, types of assessments and report writing)
Primary CarePrimary Care of Adults with IDDDevelopmental Disabilities Primary Care Initiative (2018)

Additional Information

Psychological Testing

Psychological testing involves the use of formal procedures using reliable and valid instruments to measure the areas of intellectual, cognitive, adaptive, emotional and behavioral functioning along with personality styles, interpersonal skills and psychopathology. Prior to administering a battery of tests, it is important for the evaluator to gather (or review) updated clinical information. Relevant clinical information should be considered from the Comprehensive Clinical Assessment and/or most recent medical, psychiatric, and/or educational evaluations. The evaluator should consider historical clinical information, identify specific questions to be addressed by the evaluation, and determine that the clinical questions cannot be addressed through a diagnostic interview with a skilled clinician.

The evaluator should inquire about and review any prior psycho-educational, psychological, developmental and neuropsychological testing that may have been administered and request copies for review prior to conducting a new battery. If prior testing cannot be reviewed, the provider should document their attempts to access the information and offer an explanation pertaining to the clear medical necessity for a new assessment. Attempts should be made to determine when tests were previously administered to ensure that test exposure is not a factor in the outcome of the evaluation.

The evaluator should take note on the dates of administration and whether questions presented for testing have been addressed in a prior evaluation. The evaluator should be conscious of factors that may interfere with the validity of outcomes including recent exposure to a standardized test, active substance use/abuse, vision or hearing impairments, health and/or medication related concerns. Testing related to the treatment of pain or as a component of a pre-surgical evaluation may be considered medically necessary if consistent with the expectations per policy.

It is expected that the request for testing may include information regarding prior screening and assessment, prior intervention for the given diagnosis, an explanation pertaining to why the clinical evaluation was inconclusive, and a statement regarding the need for psychological testing to clarify the diagnosis. Tests must be standardized and validated measures recognized by the scientific and professional community as a national standard for professional practice. Practitioners administering psychological batteries should practice within their scope and be credentialed in a manner consistent with the expectations of the North Carolina Psychology Board.

Developmental Testing

Developmental testing involves the use of standardized and validated measures to explore developmental concerns for individuals who may have been identified through the use of screening tools. Tests included in a developmental battery focus on cognitive, language, motor, and socio-emotional development. The findings of these evaluations can assist in identifying children who may have developmental delays and developing targeted intervention plans to support them in making gains. The evaluator should be conscious of factors that may interfere with the validity of outcomes including: recent exposure to a standardized test, vision or hearing impairments, health and/or other related concerns.

Prior to administering a battery of tests, it is important for the evaluator to gather (or review) relevant information. Relevant clinical information should be considered from the Comprehensive Clinical Assessment and/or most recent medical, psychiatric, and/or educational evaluations. The evaluator should consider historical clinical information, identify specific questions to be addressed by the evaluation, and determine that the clinical questions cannot be addressed through a diagnostic interview with a skilled clinician.

The evaluator should inquire about and review any prior psycho-educational, psychological, developmental, and neuropsychological testing that may have been administered and request copies for review prior to conducting a new battery. If prior testing cannot be reviewed, the provider should document their attempts to access the information and offer an explanation pertaining to the clear medical necessity for a new assessment.  Attempts should be made to determine when tests were previously administered to ensure that test exposure is not a factor in the outcome of the evaluation. The evaluator should take note on the dates of administration and whether questions presented for testing have been addressed in a prior evaluation.

It is expected that the request for testing may include information regarding prior screening and assessment, any prior intervention, an explanation pertaining to why the clinical evaluation was inconclusive, and a statement regarding the need for developmental testing to clarify the diagnosis. Tests must be standardized and validated measures recognized by the scientific and professional community as a national standard for professional practice. Practitioners administering psychological tests (within developmental batteries) should practice within their scope and be credentialed in a manner consistent with the expectations of the North Carolina Psychology Board.

Neuropsychological Testing

Neuropsychological testing involves the use of formal procedures using reliable and valid instruments to detect the existence of brain damage, dysfunction, injury, and/or functional deficits associated with the deterioration of brain function related to a condition or medical disease process. Prior to administering a battery of tests, it is important for the evaluator to gather (or review) updated clinical information. Relevant clinical information should be considered from the Comprehensive Clinical Assessment and/or most recent medical, psychiatric and/or educational evaluations. The evaluator should consider historical clinical information, identify specific questions to be addressed by the evaluation, and determine that the clinical questions cannot be addressed through a diagnostic interview with a skilled clinician.

The evaluator should inquire about and review any prior psycho-educational, psychological, developmental and neuropsychological testing that may have been administered and request copies for review prior to conducting a new battery. If prior testing cannot be reviewed, the provider should document their attempts to access the information and offer an explanation pertaining to the clear medical necessity for a new assessment. Attempts should be made to determine when tests were previously administered to ensure that test exposure is not a factor in the outcome of the evaluation. The evaluator should take note on the dates of administration and whether questions presented for testing have been addressed in a prior evaluation.

Testing related to the treatment of pain or as a component of a pre-surgical evaluation may be considered medically necessary if consistent with the expectations per policy. Prior to a neuropsychological evaluation, a clinical evaluation should have been completed and found to be inconclusive. Physicians may refer patients with suspected or known cognitive deficits for neuropsychological testing to quantify their cognitive and behavioral capabilities. Common measures used in neuropsychological batteries include tests of cognitive functioning, attention, language, motor, achievement and personality.

Neuropsychological tests are used to clarify the patient’s diagnosis in instances where the patient presents with atypical symptoms, a behavioral health condition or a medical condition. The tests are also used to establish a baseline of neurocognitive functioning, monitor changes from baseline in functioning, and to assist with treatment, placement, and/or discharge planning. Neuropsychological testing may be considered medically necessary for patients diagnosed with ADHD when medical screenings (including the use of screening tools used by an MD) support further assessment of specific neurocognitive behavioral deficits.

The evaluator should be conscious of factors that may interfere with the validity of outcomes including: recent exposure to a standardized test, active substance use/abuse, vision or hearing impairments, and health and/or medication-related concerns. It is expected that the request for testing may include information regarding prior medical screening and assessment, prior intervention for the given diagnosis, an explanation pertaining to why the clinical evaluation was inconclusive, and a statement regarding the need for neuropsychological testing to clarify the diagnosis. Tests must be standardized and validated measures recognized by the scientific and professional community as a national standard for professional practice. Practitioners administering neuropsychological batteries should practice within their scope and be credentialed in a matter consistent with the expectations of the North Carolina Psychology Board.

Psychological/Developmental/Neuropsychological Testing

Providers should be prepared to provide Alliance with the following information when requesting psychological, developmental and/or neuropsychological testing:

  • The reason testing is medically necessary (e.g. differential diagnosis, atypical symptomatology, prior/current mental health treatment is ineffective). Information should be provided to explain why a clinical evaluation was inconclusive and why testing is needed to clarify the diagnosis.
  • Clinical information relevant to the referral for testing and source of referral.
  • The specific names of the standardized, validated tests planned for the evaluation (Clinical Coverage Policy 8 C).
  • Information regarding prior mental health treatment and other interventions.
  • Information pertaining to prior testing/evaluation (tests, dates, results).
  • Justification for the medical necessity of further testing if prior testing has been completed.

Medical Necessity

Medical necessity for testing may be met in the following cases:

  • Best practice clinical intervention has not been effective.
  • Differential diagnosis is indicated to develop a more effective treatment plan.
  • The individual has a medical or neurological condition and has been referred by a physician for further assessment after being evaluated by the MD.
  • An individual presents with concerns regarding possible Intellectual/Developmental Disability and testing is needed for specialized services (Innovations).
  • Testing related to the treatment of pain or as a component of a pre-surgical evaluation may be considered medically necessary if consistent with the expectations per policy.
Psychological, developmental and neuropsychological testing requests may not meet medical necessity if:
  • Service is not considered consistent with generally accepted standards of practice or supported by credible research demonstrating the service will have a measurable and beneficial health outcome for the enrollee.
  • Tests are not standardized, valid measures nationally recognized by licensed practitioners in the field.
  • Requests are for educational placement/services (e.g., IEP), career/vocational, sports, camp, marriage, adoption, or insurance purposes.
  • Requests are for judicial or legal proceedings such as Guardianship (Clerk of the Court and/or the NC Division of Aging and Adult Services) or parental competency (Department of Social Services (DSS) and/or the court system).
  • The evaluation is for Disability as these evaluations are adjudicated through North Carolina Disability Determination Services (DDS)
  • The enrollee has not had a diagnostic evaluation by a licensed mental health practitioner.
  • The enrollee presents with symptoms of ADHD and has not had a thorough evaluation by a psychiatrist or prior screening using questionnaires or rating scales.  Requests for testing for ADHD should include an explanation of the reason the initial evaluation (e.g., by a licensed mental health practitioner and/or physician) was insufficient.
  • Testing for the primary purpose of titrating medications.
  • Routine/periodic testing without clinical justification will not meet medical necessity.  Exemption: It is noted that children/adolescents with I/DD diagnoses will need updated testing every 3 years to determine I/DD eligibility, and adults entering waiver services must have evaluations within the past 5 years.
  • The enrollee is actively abusing substances, in acute withdrawal, or recently entered recovery as the testing results may not be valid.
  • If mental health symptoms are causing significant impairment (e.g., enrollee is actively psychotic, manic, aggressive, etc.) such that the testing results may not be valid.
  • Testing has been previously completed and there is no clinical justification for further testing (e.g., TBI, medical condition, developmental changes, or other factors that render the previous evaluation inaccurate).
  • There is no indication based on Clinical Coverage Policy/Service Definition that testing is required to access the covered service.

Psychological Testing vs. Neuropsychological Testing

Providers requesting neuropsychological testing/evaluations should provide statements explaining why neuropsychological testing is necessary for the purpose of exploring questions related to the enrollee’s diagnosis and for treatment recommendations.  Neuropsychological testing is considered medically necessary for the assessment of cognitive impairment due to medical or psychiatric conditions. Psychological testing should be summarized in a report reflecting psychological testing has been completed (“Psychological Evaluation”).  Neuropsychological testing should be summarized in a report reflecting neuropsychological testing has been completed (“Neuropsychological Evaluation”). Neuropsychological testing should not be requested when the clinical questions can be addressed through a psychological evaluation.

References:
North Carolina Psychology Practice Act
Clinical Coverage Policy 8C

This page was last reviewed for accuracy on 09/24/2020