- 1 Availability of Non-Medicaid Funded Services
- 2 Medicaid and Non-Medicaid Benefit Plans
- 3 Inpatient Hospitalization at State Psychiatric Hospitals
- 4 Psychiatric Residential Treatment Facilities (PRTFs)
- 5 Level III and IV Residential Services for Children/Adolescents
- 6 Non-Covered Services (EPSDT)
- 7 Service Frequency Billing Parameters
Alliance Health authorizes an array of Medicaid and non-Medicaid (State-funded) services for individuals with mental illness, substance use disorders, and intellectual and developmental disabilities who reside in Durham, Wake, Cumberland and Johnston counties.
For access to specific authorization information, benefit plans and other resources, use the Page Contents menu to your right.
All authorization requests from in-network providers must be submitted using the Alpha Provider Portal. To request a login and password for access to the Alpha Provider Portal, complete the Alpha MCS Access Request form. Instructions are provided on the form.
Availability of Non-Medicaid Funded Services
Alliance offers a range of helping services that are available to individuals without Medicaid coverage. Most State-funded services require prior authorization by the Utilization Management Department at Alliance Health. These services can be accessed by contacting the Alliance Access and Information Center. Eligibility for State-funded services is based on member or family level of income in addition to clinical needs. There are some crisis services available to members within the Alliance catchment area that are available regardless of a member’s ability to pay.
Alliance has a limited amount of State funds to pay for treatment services. Therefore, service entry requirements and benefit maximums may be different than the Medicaid requirements for the same service. Members seeking state-funded services may be placed on waiting list when:
Demand for service exceeds available resources (non-Medicaid funds only), or
Service capacity is reached as evidenced by no available provider for the State-funded service.
Alliance Health is notified when providers report openings in service capacity, or funding for services becomes available. Alliance then works with providers to identify potential consumers from their waiting list. The provider and Alliance staff will consider the following factors when selecting waiting list consumers for services:
- Service need (member meets medical necessity for service).
- Risk factors such as health and/or safety issues.
- Risk of hospitalization or a higher level of care if the need is not addressed.
- Whether the resources identified are adequate to meet the member’s need.
- If other funding sources are available to meet the member’s need.
- Length of time the member has been waiting.
Medicaid and Non-Medicaid Benefit Plans
Inpatient Hospitalization at State Psychiatric Hospitals
The Diversion Law (SB 859) prohibits the admission of consumers with intellectual and developmental disabilities, or suspected intellectual and developmental disabilities, and a co-occurring mental illness, to state psychiatric hospitals with limited exceptions. The exceptions must be determined by the Director of the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (MH/DD/SAS) or his designee(s). The information you submit on this worksheet will be used to document that the requirements of SB 859 have been met and to support the development of rational and effective solutions to problems that may arise in the implementation of this law.
Psychiatric Residential Treatment Facilities (PRTFs)
Psychiatric Residential Treatment Facilities (PRTFs) provide non-acute care for NC Medicaid beneficiaries under 21 years of age who have a mental health or a substance use disorder and need 24-hour supervision and specialized interventions.
NC DMA provides Clinical Coverage Policy 8D-1 for PRTF level of care, which outlines Description of the Service, Eligibility Requirements, Entrance, Continued Stay, and Discharge Criteria, Prior Approval Requirements, and other requirements for PRTF level of care.
Under Clinical Coverage Policy 8D-1, in Section 5.3.1, it is noted that Federal Regulations require a Certificate of Need (CON) be completed on or prior to admission to a PRTF facility when the beneficiary is Medicaid eligible or Medicaid is pending.
The Federal Regulations citing the need for the CON and outlining the requirements for the CON can be found in the Code of Federal Regulations (CFR) Subpart D-Inpatient Psychiatric Services for Individuals Under Age 21 in Psychiatric Facilities or Programs.
The Certificate of Need form can be found on the NC DMA/DHHS PRTF Services page.
Level III and IV Residential Services for Children/Adolescents
New Utilization Review Guidelines for Residential Behavioral Health Providers were published via the September 2011 Medicaid Bulletin issued by NC DMA/DHHS. Access archived Medicaid Bulletins 2010-2013.
The content of that bulletin is provided here:
Attention: Residential Behavioral Health Providers New Utilization Review Guidelines for Residential Behavioral Health Providers
As per legislation, Session Law, House Bill 200 on page 126 –127:
- Effective November 1, 2011, a comprehensive clinical assessment (CCA) completed and signed by a licensed mental health professional within 30 days of the requested admission date must be submitted with the ITR for initial reviews to assure the appropriateness of placement. Requests for transfer from one Level III or Level IV facility to another do not require a new CCA completed if the transfer is for the same level of care. Please see Implementation Update #36 for more information regarding comprehensive clinical assessments.
- Effective November 1, 2011, a psychiatric or psychological assessment is required for authorization requests past the 180-day mark, to be completed by a psychiatrist (MD/DO) or psychologist (PhD) within 60 days of the requested start date of the requested re-authorization period. This psychiatric or psychological assessment must be completed by an independent practitioner who is not associated with the residential services provider if the provider is not a Critical Access Behavioral Health Agency (CABHA). If the residential services provider is a certified CABHA the assessment may be completed by a professional associated with the CABHA. The UR vendor will require a statement from the independent evaluator who completes the CCA for the non-CABHA attesting that he or she is independent from, and not employed by or under contract with, the residential provider seeking prior authorization for services. When prior authorization is being requested by a CABHA, the UR Vendor will require a statement signed by the CABHA Clinical Director that the person completing the assessment is employed by or under contract with the CABHA.
- Documentation in the request for an extension past the 180 day mark must support that a Child and Family Team has reviewed goals and treatment progress and that the child or adolescent’s family or discharge setting is involvement in treatment planning and engaged in the treatment interventions.
- Independent assessments for extensions on Level III and Level IV past the 120-day mark are no longer required for requests for prior authorization.
- Providers will continue to submit an updated discharge summary but it will no longer need to be signed by the System of Care coordinator at the time of submission.
An updated and signed Child/Adolescent Discharge/Transition form is required with each submission of request for Level 3 and Level 4 Residential Services. Access the Child/Adolescent Discharge/Transition Plan form.
Non-Covered Services (EPSDT)
The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit entitles Medicaid beneficiaries under the age of 21 to medically necessary screening, diagnostic and treatment services within the scope of Social Security Act that are needed to “correct or ameliorate defects and physical and mental illnesses and conditions,” regardless of whether the requested service is covered in the NC State Plan for Medical Assistance. This means that children under 21 years of age can receive services in excess of benefit limits or even if the service is no longer covered under the State Plan. To request a service that is not covered by the State Plan that is covered under 1905(a) of the Social Security Act please email the Non-Covered State Medicaid Plan Services Request Form for Recipients Under the Age of 21 to the Alliance Utilization Management Department at [email protected].
According to CMS, “ameliorate” means to improve or maintain the beneficiary’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. Basic EPSDT criteria are that the service must be covered under 1905(a) of the Social Security Act, and that it must be safe, effective, generally recognized as an accepted method of medical practice or treatment, and cannot be experimental or investigational (which means that most clinical trials cannot be covered).
Requests for MH/IDD/SUD services for Medicaid-eligible children under the age of 21 will be reviewed using EPSDT criteria. Requests for NC Innovations Waiver services will be reviewed under EPSDT if the request is both a waiver and an EPSDT service. Most NC Innovations Waiver services are not covered under the Social Security Act (i.e. respite, home modifications and all habilitative services).
NC DHHS provides information and links regarding EPSDT on their website.
Service Frequency Billing Parameters
The Alpha system contains daily, weekly, monthly and annual benefit limits for services that are available to consumers within the Alliance region. The benefit limits in Alpha are designed to help ensure that services are provided within the guidelines and limitations set forth on the Medicaid services and non-Medicaid (IPRS) services Benefit Plans. It should be noted that nothing within the Alpha system is designed to increase or override the service limits listed on our Benefit Plans.
To allow flexibility in the delivery of services, a service with an annual limit in a Benefit Plan might indicate the maximum benefit is 100 units. However, the Alpha benefit grids below may allow the same limit within a month. This does not mean that 1200 units are then available annually. It simply means that if needed the entire benefit could be provided within a month. With prior approval from UM certain benefit limits may be overridden through the authorization process.