Alliance is committed to maintaining the provider rates previously paid by Sandhills Center. Providers serving Harnett members will continue to receive the same Medicaid rates that were in place prior to consolidation with Alliance Health.

Alliance has been analyzing the rates between Alliance and Sandhills and will be publishing an updated Medicaid and State fee schedule in the next few days. We strongly encourage providers to review the Alliance fee schedule and benefit plan to best understand procedure codes/rates and benefit limits as there may be some small differences that could affect your billing. Any questions that you have regarding this please reach out to your Provider Network Relations Specialist and they will assist you with any questions.

Alliance is committed to reimbursement consistency for our entire catchment area. To providers serving members in Cumberland, Durham, Johnston, Mecklenburg, Orange and Wake Counties, Alliance will publish rate changes by February 16th for services provided March 1, 2024 and after. These changes will include increases to the majority of services offered to our members. This will include Medicaid and State services.

Contracts have been sent out to Sandhill providers that served Harnett County members. More than 60% of the identified providers were already contracted with Alliance for the same sites and services and no additional contracting was required. If there were sites and/or services that needed to be added to your existing Alliance contract, you should have received a contract amendment. If you have served a Harnett County member in the past year and have not heard from Alliance please email us at [email protected] and please include the Agency name, NPI, Address and Service Code(s) that you would like Alliance to review to be considered. You may be asked to submit your Sandhills contract and/or billing Remittance Advice to demonstrate your eligibility.

Thank you for working with us and your members during this transition.

Sandhills is providing the following information to Trillium, Alliance, Vaya and Partners:
• List of CFAC members impacted by the transition and their contact information
• List of CFAC current initiatives underway in transitioning areas
• Plan for transitioning county CFAC and Governing Board representation

DMHDDSUS staff will use information received and work with all LME/MCOs and affected CFACs to develop and implement a transition plan. After February 1, 2024, Trillium or receiving LME/MCOs will act as the responsible party for maintaining ongoing engagement with local Consumer and Family Advisory Committees.

To streamline the provider contracting process and ensure continuity of services, Sandhills will offer the following supports:

PROVIDER SERVICE LINE

Before February 1, 2024
▪ Providers can continue using the LME/MCO service lines for each member’s/recipient’s existing LME/MCO until January 31, 2024.
▪ For existing LME/MCO contact information, please reference the following:
▪ Alliance Health: 800-510-9132
▪ Eastpointe: 800-913-6109
▪ Partners Health Management: 888-235-4673
▪ Sandhills Center: 800-256-2452
▪ Trillium Health Resources: 877-685-2415
▪ Vaya Health: 800-962-9003

After February 1, 2024

For issues regarding members/recipients who are transitioning to Trillium:
▪ A single phone number for the provider service line will be selected.
▪ Calls made using the number that was not selected will be forwarded to Trillium for two months following consolidation go-live.
▪ After 60 calendar days post consolidation go-live, provider lines will be updated with a new IVR message that directs providers to the Trillium provider line for one month before being shut off.
For issues regarding members/recipients who are transitioning to Alliance, Partners, and Vaya
▪ Transitioning Sandhills members/recipients will begin receiving services under their new LME/MCO starting February 1, 2024. Questions regarding the provisioning of new services can be directed to Alliance, Partners, or Vaya depending on the members’/recipients’ assignment. Contact information for all LME/MCOs is listed above.
▪ For questions regarding services provided to Sandhills members/recipients with a date of service prior to February 1, 2024, providers will be able to contact Trillium for support.

MEMBER/RECIPIENT SERVICE LINES

Before February 1, 2024
▪ Members/recipients can continue using their current LME/MCO’s service lines through February 1, 2024.
▪ For existing LME/MCO contact information, please reference LME/MCO website links and numbers above.

After February 1, 2024
▪ A single phone number for member/recipient line will be selected as part of the consolidation.
▪ The member/recipientlines not selected will be updated with voice message for 60 calendar days post-consolidation go-live prompting members/recipients to call their new LME/MCO.

To streamline the provider contracting process and ensure continuity of services, Sandhills will provide the remaining LME/MCOs a list of state-funded providers that are contracted to provide block grant, county, grant, and other pass-through funding. DMH/DD/SUS will review the populations moving to new LME/MCOs, as well as specific programs with unique funding, and will communicate with the LME/MCOs about how these dollars will transition as we get closer to consolidation go-live.

For all services provided to members/recipients who have transitioned from Sandhills, providers should follow these rules:

• Prior to consolidation go-live on February 1, 2024, all LME/MCOs will continue to process their own claims and encounters.
• For Sandhills and Eastpointe claims submitted after consolidation go-live (on or after February 1, 2024) that have a date of service prior to consolidation go-live (up to January 31, 2024), providers will continue to submit claims through LME/MCO legacy systems within timely filing and adjustment timeframe restrictions.
• For claims with a date of service on or after consolidation go-live (on or after February 1, 2024), providers will submit their claims to the LME/MCO that the member/recipient is assigned to for coverage.
• Providers are expected to file claims within the timely filing requirements in their contracts, however the LME/MCOs are encouraged to work with providers to reduce unnecessary denials during the transition.

To ease beneficiary confusion and provider administrative burden, the Department and LME/MCOs will enact transition of care (TOC) flexibilities for a 120-day TOC period, detailed below.

Relax Medical Prior Authorization (PA) Requirements
• To alleviate burden to providers during the transition period, LME/MCOs are required to relax medical PA requirements for Medicaid-funded behavioral health and I/DD services for a duration of 120 days beginning February 1, 2024 through May 31, 2024.
• The Department has provided LME/MCOs with several recommendations on how this flexibility can be implemented. Providers should contact LME/MCOs they are contracted with to learn how this will be applied.
• Per the Department’s Transition of Care policy, LME/MCOs will also honor exisiting Medicaid behavioral health and I/DD prior authorizations.
• To alleviate burden to providers and ensure continuity of care during the transition period, LME/MCOs will be required to relax any existing prior authorization (PA) requirements for state-funded mental health, substance use disorder, I/DD and TBI services for a duration of 120 days beginning February 1, 2024 through May 31, 2024.

Out-of-Network Providers Paid at In-Network Provider Rates
• Between February 1, 2024 and May 31, 2024, medically necessary behavioral health and/or I/DD services will be reimbursed at the same rate for both in- and out-of-network providers.
• Out-of-network providers must still be enrolled in NC Medicaid to be reimbursed by the LME/MCO.
• Receiving LME/MCOs are strongly encouraged to do the same for medically necessary state-funded services.

Out-of-Network Providers Follow In-Network PA Rules
• Between February 1, 2024 and August 31, 2024, LME/MCOs receiving new counties may not require any additional requirements (i.e., PA and/or referral requirements) for out-of-network behavioral health and/or I/DD providers to provide services to transitioning LME/MCO members.

TCM Flexibilities
• For a duration of 120 days, beginning February 1, 2024, members will be able to continue to see their current TCM provider, regardless of contracting status with their new LME/MCO, for the TOC period.
• Members who are assigned to a provider-based TCM entity will not be reassigned as long as their current TCM provider completes a contract with the member’s new LME/MCO by the contracting deadline of April 30, 2024.

The LME/MCOs that will remain operational following consolidation have been encouraged to execute provider contracts prior to Feb. 1, 2024 to ensure members/recipients are able to more seamlessly access services during the transition.

Medicaid behavioral health, I/DD, TBI and TCM providers who are serving impacted counties but are not contracted with the LME/MCO that will assume area authority are encouraged to complete contracting activities as soon as possible to limit any disruption in services for members.

State-funded providers who are serving impacted counties but not contracted with the LME/MCO that will assume Tailored Plan authority under the new LME/MCO realignment are encouraged to complete contracting activities as soon as possible to limit any disruption in services for recipients.

Yes, members will continue to have access to state-plan and waiver behavioral health, I/DD and traumatic brain injury (TBI) services. Additionally, the Department and LME/MCOs are reviewing Medicaid In-lieu of Services (ILOS) and State Funded Alternative Services offered by Sandhills to ensure a successful transition of those services.

Per the Department’s Transition of Care policy, LME/MCOs shall permit transitioning members to continue seeing their provider, regardless of network status following a transition between LME/MCOs and when the member is in an ongoing course of treatment.

For State-Funded Services, recipients will continue to have access to state-funded mental health, substance use disorder, I/DD and TBI services without interruption during the transition. This includes any Cross Area Service Program (CASP) services.

From February 1, 2024 through May 30, 2024, members receiving Tailored Care Management provided by community-based TCM providers, will be able to keep their current providers. Community-based TCM providers will need to contract with the member’s new LME/MCO by April 30, 2024, to keep providing services and not have members reassigned to a new TCM provider.

Members receiving TCM provided by Sandhills Center care managers will be assigned a new TCM provider. If members prefer to get TCM from a certain provider, they should call their new LME/MCO and make the assignment request.

High needs members will be identified by the Department and prioritized by Sandhills and the LME/MCO assuming care to determine when warm handoffs (care manager to care manager live discussion regarding the key summary details and needs for each member) may be required.

The following populations will be included in this process:
o Members receiving in-home long-term services and supports (LTSS)
o Members authorized for transplantation
o Members who require complex treatment circumstances or multiple service interventions
o Members authorized for out-of-state services
o Members enrolled in Care Management for At-Risk Children (CMARC)
o Members in foster care who have been identified as Tailored Plan eligible
o Transition to community living (TCL) participants
o Other high need members or group of members identified by the Department or the health plan.
o Innovations waiver members (validated through Supplemental Questions (SQ) process for exceptional support needs or assigned an individual budget tool level of F or G).

Members can continue to see their primary care provider (PCP) and other NC Medicaid Direct providers for physical health services.

Members will receive a package of educational materials and resources to help them navigate services with their new LME/MCO, including:

• An LME/MCO assignment letter from the NC Medicaid Enrollment Broker two to three weeks prior to consolidation go-live.
• New member welcome packets and Tailored Care Management (TCM) inserts (as appropriate) for their new LME/MCO, including the Prepaid Inpatient Health Plan (PIHP) welcome letter and member/handbook, to impacted members prior to consolidation go-live.
• Within one week of consolidation go live, new Medicaid ID cards will be issued with the name of their new LME/MCO. Note that members can keep using their old Medicaid ID cards until their new card is received.

Work to implement the necessary changes for LME/MCO Consolidation is already underway. Below are key dates that providers should be aware of in advance of consolidation.

• November 2023 – Ongoing: The four remaining LME/MCOs begin contracting with providers in their new assigned counties, if not already contracted.
• January 8, 2024 – January 18, 2024: Welcome packet sent to members/recipients from new LME/MCO.
• January 8, 2024 – January 20, 2024 Enrollment Broker sends new LME/MCO assignment letter to members
• January 15, 2024 – February 9, 2024: LME/MCOs perform warm handoff process for high needs members to newly assigned LME/MCOs.
• February 1, 2024: Consolidation go-live (effective date of coverage under the new LME/MCO for each impacted member/recipient.

Sandhills is providing the following information to Alliance:

  • List of CFAC beneficiaries impacted by the transition and their contact information
  • List of CFAC current initiatives underway in transitioning areas
  • Plan for transitioning county CFAC and Governing Board representation

DMH/DD/SUS will use the information to work with all LME/MCOs and their CFACs to create and carry out a transition plan that ensures a represented voice for all members, regardless of LME/MCO serving them. After February 1, 2024, Alliance will have ongoing engagement with the Harnett County CFAC.

Yes. From February 1, 2024 through May 30, 2024, members receiving Tailored Care Management provided by community-based TCM providers will be able to keep their current providers. Community-based TCM providers will need to contract with the member’s new LME/MCO by April 30, 2024 to keep providing services and not have members reassigned to a new TCM provider.

Members receiving TCM provided by Sandhills Center care managers may be assigned a new TCM provider. If members prefer to get TCM from a certain provider they should call their new LME/MCO and make the assignment request.

Members and recipients do not need to take any action with the LME/MCO changes and will continue to receive the same type of services as they do today.

For members with Medicaid, LME/MCO assignment will continue to be based on the member’s administrative county (the county that manages the member’s Medicaid case). Members should refer to the county that manages their case if it is different from the county they live in. County contacts can be found in the local DSS directory.

For recipients who do not have Medicaid and are currently receiving services through an LME/MCO, they should continue to receive services based on the county where they live.
The NC Medicaid Enrollment Broker will send a letter to members getting a new LME/MCO in January 2024.

The member’s new LME/MCO will send a welcome packet and Tailored Care Management (TCM) assignment letters (if needed). Welcome packets include member handbooks and other important information about the LME/MCO.

Medicaid ID cards for members with a new LME/MCO will be mailed in early February 2024. Members can use their current Medicaid ID card until they get their new one. Medicaid ID cards will be mailed by NC Medicaid. Members can contact their local DSS administrative office for questions about cards.

Call your newly assigned LME/MCO if you did not get your welcome packet or have questions about your benefits and services. Call Alliance Member and Recipient Services at 800-510-9132 if you have questions before or after February 1, 2024.

LME/MCOs coordinate services for mental health and substance use disorders, I/DD, and TBI. People who get services from an LME/MCO are enrolled in NC Medicaid Direct or may be uninsured/underinsured. More information on NC Medicaid Direct services can be found at NC Medicaid Direct.

LME/MCOs also provide a variety of State-Funded services. General information about those services can be found on the Division of Mental Health, Developmental Disablitiles and Substance Use Services (DMH/DD/SUS) website.

LME/MCOs and providers support Tailored Care Management (TCM) for eligible Medicaid members. TCM launched December 1, 2022, to give extra support to help beneficiaries assess their needs and meet their health goals.

To learn more about the Tailored Care Management model, its benefits and certified TCM providers go to the NCDHHS TCM webpage.

Verify if the practitioner is enrolled in NCTracks. If not, submit an enrollment packet to NCTracks.

Practitioners that are joining or are associated with currently contracted behavioral health provider entities or physical health providers that will be contracted for the Tailored Plan,  do not need to send in any additional information.  Alliance uses daily files from the NCTracks system to auto populate into our Alliance Claims System (ASC).  This information includes  practitioner provider association and other data needed for billing, Provider Directory etc.  Please ensure that your NCTracks information is up to date in order to ensure current status.

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 don’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 “chat” 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 “chat” 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, 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 the  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+’s. Alliance is currently developing the assignment logic based on the state’s guidance and this will be discussed in a future CMA Learning Collaborative. Refer to the document entitled “Staffing, Caseload, and Financial Modeling” 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.  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 Alliance’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 Alliance’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 the 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, Harnett, 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 22nd 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 Alliance’s 24-hour Access and Information line at (800) 510-9132 and request information about the TBI Waiver. 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, Orange, Mecklenburg and Johnston). The services are provided in your own home and community, or in a group living setting – 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.

Both the waiver “Hard Limits-Benchmarks for providers and families” and “Authorization Guidelines” 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].

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. §438.210, an expedited request is one which “a provider indicates, or the MCO… determines, that following the standard timeframe could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function.” 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.

In order to be added to the Registry of Unmet Needs (RUN) for the NC Innovations Waiver, you or your family should call Alliance’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 the NC TBI Waiver as appropriate.

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 Alliance’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 Alliance’s Access and Information Center (call center).

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 “Alliance POS Mapping” located on our website under Finance and Claims Resources

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; “Have you ever been hit on the head or been knocked unconscious?” 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 member’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 “Provider Resource Forms” section. Should the TBI Ohio screening result in a positive screening or suspected TBI,  the member  then should be encouraged to contact Alliance Health Access and Information line.  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.

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 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 Cumberland, Durham, Harnett, Johnston, Orange, Mecklenburg and Wake 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 Alliance’s Access and Information Center at (800) 510-9132.

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, Harnett, Johnston, Orange, Mecklenburg 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 Alliance’s Access and Information Center at 800-510-9132.

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.

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.

The best resolution is 1360×765 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 doesn’t work, please contact your IT department for additional help.

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.

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.)

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.

As of September 28, 2023, Alliance’s Enrollment Department no longer processes “Request to Add” forms. All rendering clinicians need to be enrolled in NCTracks and affiliated with each organization and site where they will be providing services. Alliance will receive an electronic transmission (provider eligibility file) from NCTracks daily to update ACS with all provider information found in NCTracks, including but not limited to provider name, NPI, taxonomy, address, and associated clinicians.

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

 

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 individual’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 – 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.

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.

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.

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 individual’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. § 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.

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.

An individual/guardian may ask for an expedited Reconsideration Review if waiting thirty days might seriously jeopardize the individual’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.