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Our glossary contains relevant commonly used terms for our industry in general, and for North Carolina in particular.

Common Managed Care Terms

This glossary is provided to assist members in understanding common terms used in managed care, like the care that is provided by Alliance Health or other medical providers.

Appeal: A review by the plan of an adverse benefit determination.

Co-Payment: Also known as a “copay” is a fixed amount paid by the member for certain covered health care services. The copay amount may vary by service or provider. Example: A member cost of $1.00 for a generic prescription.

Emergency Medical Condition: A medical condition in which the symptoms appear quickly and are severe enough that a person with average knowledge of health and medicine would expect that, in the absence of immediate medical attention, the health or life of the person experiencing the symptoms is in jeopardy or they are at risk of serious damage to a bodily function, organ, or part.

Emergency Medical Transportation: Medically necessary ambulance transportation to the nearest appropriate facility where prompt medical services are provided in an emergency such as accident, acute illness or injury.

Emergency Room Care: Care given for a medical emergency, in a part of the hospital where emergency diagnosis and treatment of illness or injury is provided, when it is believed that one’s health is in danger and every second counts.

Emergency Services: Inpatient and outpatient services by a qualified provider needed to evaluate or stabilize an emergency medical condition.

Excluded Services: Services that are not covered by the PHP.

Grievance: An expression of dissatisfaction about any matter other than an adverse benefit determination. Grievances may include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the member’s rights regardless of whether remedial action is requested. Grievance includes the member’s right to dispute an extension of time proposed by the PHP to make an authorization decision.

Habilitation Services and Devices: Health care services that help a member keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient or outpatient settings.

Health Insurance: A type of insurance coverage that pays for your health and medical costs. Your Medicaid coverage is a type of insurance.

Home Health Care: Certain medically necessary services provided to members in any setting in which normal life activities take place other than a hospital, nursing facility, or intermediate care facility. Services include skilled nursing, physical therapy, speech-language pathology, and occupational therapy, home health aide services, and medical supplies.

Hospitalization: Care in a hospital that requires admission as an inpatient for a duration lasting more than twenty-four (24) hours. An overnight stay for observation could be outpatient care.

Hospital Outpatient Care: Care for a member in a hospital, or distinct part of a hospital, for professional services of a duration less than a 24-hour period regardless of the hour of admission, whether or not a bed is used, or whether or not the patient remains in the facility past midnight.

Medically Necessary: Those covered services that are within generally accepted standards of medical care in the community and not experimental.

Network: A group of doctors, hospitals, pharmacies, and other health care experts contracted by the PHP to provide health care services.

Non-participating Provider: Non-par or non-participating providers are physicians or other health care providers that have not entered into an agreement with the PHP and are not part of the network, unlike participating providers. They may also be called out-of-network providers.

Participating Provider: Par or participating providers are physicians or other health care providers that have an agreement with the PHP and are part of its network. These agreements outline the terms and conditions of participation for both the payer and the provider.

Physician Services: Health care services a licensed medical physician, or physician extender such as a nurse practitioner or physician assistant, provides, orders, or coordinates.

Plan (or Health Plan): The company providing you with health insurance.

Preauthorization: The approval needed from your plan before you can get certain health care services or medicines.

Premium: The amount paid for health insurance monthly. In addition to a premium, other costs for health care, including a deductible, copayments, and coinsurance may also be required.

Prepaid Health Plan or PHP:  A prepaid health plan that is under a capitated contract with the department for the delivery of Medicaid and NC Health Choice services, or a local management entity/managed care organization that is under a capitated contract with the department to operate a Behavioral Health I/DD Tailored Plan.

Prescription Drug Coverage: Refers to how the PHP helps pay for its members’ prescription drugs and medications.

Prescription Drugs: Also known as prescription medication or prescription medicine, is a pharmaceutical drug that legally requires a medical prescription to be dispensed.

Primary Care Physician: A licensed medical doctor (MD) or doctor of osteopathy (DO) that provides and coordinates patient needs and initiates and monitors referrals for specialized services when required. See primary care provider.

Primary Care Provider (PCP): The participating physician, physician extender (e.g. physician assistant, nurse practitioner, certified nurse midwife) or group practice/center selected by or assigned to the member to provide and coordinate the member’s health care needs and to initiate and monitor referrals for specialized services when required. Includes family practitioners, pediatricians, obstetricians, and internal medicine physicians.

Provider: A health care professional or a facility that delivers health care services, like a doctor, hospital, or pharmacy.

Rehabilitation Services and Devices: Health care services and equipment that help keep, get back, or improve skills and functioning for daily living that have been lost or impaired due to sickness, injury, or disablement. These services may include physical and occupational therapy, speech language pathology, and psychiatric rehabilitation services in a variety of inpatient or outpatient settings.

Specialist: A provider that focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions.

Urgent Care: Care for a health condition that needs prompt medical attention but is not an emergency medical condition. You can get urgent care in a walk-in clinic for a non-life-threatening injury (like the flu or sprained ankle).

Glossary of Common Terms and Acronyms

A, B, C | D, E, F | G, H I | J, K, L | M, N, O | P, Q, R, S | T, U, V | W, X, Y, Z

Ability-to-Pay Determination: The amount a consumer is obligated to pay for services. The ability to pay is calculated based on the consumer’s income, and the number of dependents. The federal government poverty guidelines are used to determine the consumer’s payment amount. Learn more about Medicaid eligibility.

Abuse and Waste: Incidents or practices that are inconsistent with sound fiscal, business, or medical practices could result in an unnecessary cost to Alliance, the state or federal government, or another organization. It could also result in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary costs to the Medicaid program. (42 CFR 455.2)

Access and Information Center:  The toll-free call system established by Alliance to receive all inquiries, respond to crisis situations, and provide quick linkages to qualified providers in the network. This will include information, access to care, emergency and network provider assistance. The 1-800 call system will rely on information systems management software to assist in tracking and responding to calls.

Add On: Services that are not part of the Base Budget. These services may be used based on the service definition and your needs. They must be included in your Individual Support Plan and approved by the Utilization Management Department. The total of Base Budget and non-Base Budget services may not exceed the annual waiver limit of $135,000 per year.

Adjudicate: A determination to pay or reject a claim.

Administrative Review: A review of documentation to determine whether Alliance procedures were followed and if any additional information provided warrants a change in a previous determination.

Advance Directive: A communication given by a competent adult which gives directions or appoints another individual to make decisions concerning a consumer’s care, custody, or medical treatment in the event that the consumer is unable to participate in medical treatment decisions.

Alternative Family Living: An out-of-home setting where the participant receives 24-hour care and lives in a private home environment with a family (or individual) where the services are provided to address the care and rehabilitation needs of the participant. Any AFL providing services to a child/children or two or more adults requires a license (as defined by NC General Statues 122C-3 27G .5600F). Waiver funding may not be utilized as payment for room and board costs.

Anxiety: Anxiety is a part of life. Some anxiety is useful – it can make you more alert or careful, but it usually ends soon after you are out of the situation that caused it. But for millions of people in the United States, anxiety does not go away and actually gets worse over time. These people have anxiety disorders, which can include panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder (PTSD), and generalized anxiety disorder. People with anxiety disorders may have chest pains or nightmares, and may even be afraid to leave home. Treatment for anxiety disorders generally involves medication, therapy or both.

Appeal: A request for review of the action, as “action” is defined in section IV-L.

Appellant: An individual filing an appeal.

Assessment: A procedure for determining the nature and extent of the need for which the individual is seeking services.

Authorized Service: Medically necessary services pre-approved by the LME/MCO.

Base Budget Category: Base Budget services include community networking services, day supports, in-home skill building, in-home intensive supports, personal care, residential supports, and respite.

Basic Augmented Services: The Basic Augmented Benefit package includes those services that will be made available to Medicaid-entitled individuals and, to the extent the resources are available, to non-Medicaid individuals meeting priority population criteria. A consumer requiring this level of benefit is in need of more than the automatically authorized eight or 12 visits in order to maintain or improve his/her level of functioning. Authorization for the services available at this level will need to be requested through the LME/MCO’s Utilization Management department. Authorization is based on the consumer’s need and medical necessity criteria for the services requested.

Basic Benefit Plan: The Basic Benefit package includes those services that will be made available to Medicaid-entitled individuals and, to the extent resources are available, to non- Medicaid individuals according to local business plans. These services are intended to provide brief interventions for individuals with acute needs. The Basic Benefit package is accessed through a simple referral from the Local Management Entity, through its screening, triage, and referral system. Once the referral is made, there are no prior authorization requirements for these services. Referred individuals can access up to eight visits for adults ages 21 and up and 16 visits for children and adolescents below age twenty-one from the Basic Benefit package from any Provider enrolled in the LME/MCO’s Provider network.

Benchmark: A standard by which something can be measured, judged, or compared.

Best Practices: Recommended practices, including evidence-based practices that consist of those clinical and administrative practices that have been proved to consistently produce specific, intended results, as well as emerging practices for which there is preliminary evidence of the effectiveness of treatment.

Bipolar Disorder (Manic-Depressive Illness): Bipolar disorder is a serious mental illness marked by unusual mood changes. They go from very happy, “up,” and active (mania) to very sad and hopeless, “down,” and inactive (depression), and then back again, broken up by normal moods in between. The causes of bipolar disorder aren’t always clear, although it can run in families. Bipolar disorder often starts in the late teen or early adult years, but young children and older adults can have bipolar disorder too. Bipolar disorder usually lasts a lifetime and, if not treated, can lead to damaged relationships, poor job or school performance, and even suicide. However, medicine and talk therapy are effective treatments to control symptoms. A combination usually works best.

Business Associate: A person or organization that performs a function or activity on behalf of a covered entity but is not part of the covered entity’s workforce. A business associate can also be a covered entity in its own right (see the HIPAA definition as it appears in 45 CFR 160.103).

Care Coordination Department: A division of Alliance that provides outreach and treatment planning case management functions for a special, high-impact population of consumers.

Care Coordinator: A qualified developmental disability professional at Alliance who assists by developing the person-centered Individual Support Plan (ISP), coordinating services, and monitoring to assure quality services are being delivered and that health and safety needs are addressed.

Care Management: Care management is non-face-to-face monitoring of an individual consumer’s care and services, including follow-up activities, as well as, assistance to consumers in accessing care on non-plan services, including referrals to providers and other community agencies.

Care Manager: Care managers do utilization management (authorization of services) for Alliance care managers monitor progress on goals in the Individual Support Plan, make recommendations, and refer for additional or different services and amounts of services, and supports based on their findings.

Catchment Area: Geographic service area with a defined grouping of counties. Alliance’s catchment area includes Cumberland, Durham, Johnston, and Wake counties.

Centers for Medicare and Medicaid Services: The unit of the federal Department of Health and Human Services administers the Medicare and Medicaid programs.

Child and Adolescent Level of Care Utilization System: A standardized tool that measures the level of care needs for children and adolescents. Note: LOCUS is used to assess adults.

Children with Severe Emotional Disturbances: Describes consumers who: are age seventeen (17) or under; have mental, behavioral, or emotional disturbance severe enough to substantially interfere with or limit the minor’s role or function in family, school, or community activities; and Sscore less than sixty (60) on the Global Assessment Scale (GAF).

Claim: A request for reimbursement under a benefit plan for services.

Clean Claim: A claim that can be processed without obtaining additional information from the provider of the services or a third party. It does not include a claim under review for medical necessity, or a claim from a provider that is under investigation by a governmental agency for fraud or abuse.

Client: As defined in the General Statutes 122C-3 (6).

Community Supports: Organizations that provide support to a person. Community supports may include advocacy organizations, community service organizations, faith-based organizations, civic organizations, and/or educational organizations.

Concurrent Review: A review conducted by the LME/MCO during a course of treatment to determine whether services continue to meet medical necessity and quality standards and whether services should continue as prescribed or should be terminated, changed, or altered.

Consumer: A person that needs services for treatment of mental health, intellectual and/or developmental disability, or substance use/addiction condition.

Consumer and Family Advisory Committee: A formalized group of consumers and family members appointed in accordance with the requirements of NCGS 122-C-170. The purpose of CFAC is to ensure meaningful participation by consumers and families in shaping the development and delivery of public mental health, developmental disabilities, and substance abuse services in the four-county region serviced by Alliance.

Cost Limit: The maximum amount of all waiver services (Base Budget plus other NC Innovations services) that an individual may receive annually while participating in the NC Innovations Waiver. For NC Innovations this is $135,000 per waiver year.

Covered Services: The service which the LME/MCO agrees to provide, or arranges to provide to consumers.

Credentialing: The review process to approve the credentials and/or eligibility of a Provider who has applied to participate in the LME/MCO network of providers.

Crisis Intervention: Unscheduled assessment and treatment for the purpose of resolving an urgent/emergent situation requiring immediate attention.

Crisis Plan: An individualized, written plan developed in conjunction with the consumer and treatment team. The plan contains clear directives information to assist in de-escalating a crisis, for consumer supports, as well as crisis response clinicians or others involved. Crisis plans are developed for consumers at-risk for inpatient treatment, incarceration, or out-of-home placement.

Critical Access Behavioral Healthcare Agency Provider (CABHA): A provider who delivers a comprehensive array of mental health and substance abuse services. This does not include intellectual/developmental disability services, although some CABHAs may provide I/DD services. The role of a CABHA is to ensure that critical services are delivered by a clinically competent organization with appropriate medical oversight and the ability to deliver a robust array of services. CABHAs ensure consumer care is based upon a comprehensive clinical assessment and appropriate array of services for the population served. A CABHA is required to offer the following core services: comprehensive clinical assessment, medication management, and outpatient therapy.

Cultural Competency: The understanding of the social, linguistic, ethnic, and behavioral characteristics of a community or population and the ability to translate systematically that knowledge into practices in the delivery of behavioral health services. Such understanding may be reflected, for example, in the ability to identify and value differences; acknowledge the interactive dynamics of cultural differences, continuously expand cultural knowledge and resources with regard to populations served, collaborate with the community regarding service provisions and delivery, and commit to cross-cultural training of staff and develop policies to provide relevant, effective programs for the diversity of people served.

Days: Except as otherwise noted, refers to calendar days. Working day or business day means a day on which the LME/MCO is officially open to conduct its affairs.

Denial of Service: A determination made by the LME/MCO in response to a network provider’s request for approval to provide in-plan services of a specific duration and scope which: disapproves the request completely; or approves provision of the requested service(s), but for a lesser scope or duration than requested by the provider (approval of a requested service which includes a requirement for a concurrent review by the LME/MCO during the authorized period does not constitute a denial); or disapproves provision of the requested service(s), but approves provision of alternative service(s).

Department of Health and Human Services: The state agency that includes both the Division of Medical Assistance and the Division of Mental Health/Developmental Disabilities/Substance Abuse Services. The website for North Carolina’s DHHS is

Department of Social Services: The local (county) public agency that is responsible for determining eligibility for Medicaid benefits and for other assistance programs.

Description of Consumer Clinical Issues: A statement of need for services.

Developmental Center: A state-operated ICF-IID facility (institution) that provides health and habilitation services to individuals with intellectual and/or other developmental disabilities. The developmental center for the Alliance catchment area is The Murdoch Center located in Butner, NC. Referrals to developmental centers can be made only by the managed care organization (Alliance). NC Innovations funding cannot be used while in a developmental center.

Dispute Resolution Process: Alliance process to address administrative actions or sanctions taken against providers in a consistent manner.

Division of Medical Assistance (for the State of North Carolina): The state agency responsible for Medicaid-funded services and the administration of the NC Innovations and NC MH/DD/SAS health plan. The website for North Carolina’s Division of Medical Assistance is

Division of Mental Health, Developmental Disabilities and Substance Abuse Services: The state agency that works with DMA in the administration of the NC Innovations and NC MH/DD/SAS Health Plan. The website for North Carolina’s DMH/DD/SAS is

Early and Periodic Screening, Diagnosis, and Treatment: Early and periodic screening, diagnosis, and treatment (EPSDT) is the federal Medicaid benefit that says Medicaid must provide all necessary health care services to Medicaid eligible children under 21 years of age. Even if the service is not covered under the NC Medicaid state plan, it can be covered for recipients under 21 years of age if the service is listed at 1905 (a) of the Social Security Act and if all EPSDT criteria are met.

Eligibility: The determination that an individual meets the requirements to receive services as defined by the payor.

Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

Emergency Services: Covered inpatient and outpatient emergency services are:

  • Furnished by a provider that is qualified to furnish such services.
  • Needed to evaluate or stabilize an emergency medical condition as defined above.

Emergent Need Mental Health: A life-threatening condition in which a person is suicidal, homicidal, actively psychotic, displaying disorganized thinking, or reporting hallucinations and delusions that may result in self-harm or harm to others, and/or vegetative signs and is unable to care for self.

Emergent Need Substance Abuse: A life-threatening condition in which the person is by virtue of their use of alcohol or other drugs, suicidal, homicidal, actively psychotic, displaying disorganized thinking or reporting hallucinations and delusions which may result in self-harm or harm to others, and/or is unable to adequately care for self without supervision due to the effects of chronic substance abuse or dependence.

Enhanced Benefit Plan: Includes those services which will be made available to Medicaid-entitled individuals and non-Medicaid individuals meeting priority population criteria. Enhanced benefit services are accessed through a person-centered planning process. Enhanced benefit services are intended to provide a range of services and supports, which are more appropriate for individuals seeking to recover from more severe forms of mental illness and substance abuse and with more complex service and support needs as identified in the person-centered planning process.

Enrollment: Action taken by the Division of Medical Assistance (DMA) to add a Medicaid recipient’s name to the monthly enrollment report.

Enrollment Period: The time span during which a recipient is enrolled with the LME/MCO as a Medicaid waiver-eligible recipient.

Facility: Any person at one location whose primary purpose is to provide services for the care, treatment, habilitation, or rehabilitation of the mentally ill, the developmentally disabled, or substance abusers, and includes:

  • Licensed facilities are any 24-hour residential facilities required to be licensed under Chapter 122C of the North Carolina General Statutes, such as Psychiatric Residential Treatment Facilities (PRTFs), Intermediate Care Facilities for the Developmentally Disabled (ICF-DDs), Supervised Living Facilities, Residential Treatment/Rehabilitation Facilities for Individuals with Substance Abuse Disorders, Outpatient Opioid Treatment Facilities, .5600 group homes or other licensed MH/IDD/SA facilities. These facilities may require a Certificate of Need or Letter of Support and must meet all applicable state licensure laws and rules, including but not limited to NCG.S. §122C-3 and Title 10A, Subchapter 27C, 27D, 27E, 27F,27G, 26B and 26C.
  • A state facility, which is a facility that is operated by the secretary.
  •  A Veterans Administration facility or part thereof that provides services for the care, treatment, habilitation or rehabilitation of the mentally ill, the developmentally disabled, or substance abusers.

Fee-For-Service: A payment methodology that associates a unit of service with a specific reimbursement amount.

Fidelity: Adheres to the guidelines as specified in the evidenced-based best practice

Financial Audit: Audit generally performed by a CPA in accordance with generally accepted accounting principles to obtain reasonable assurance about whether the general purpose financial statements are free of material misstatement. An audit includes examining, on a test basis, evidence supporting the amounts and disclosures in the financial statements. Audits also include assessing the accounting principles used and significant estimates made by management, as well as evaluating the overall general purpose financial statement presentation.

First Responder: A person or personnel of an agency designated as the primary provider by the person-centered plan/crisis plan who will have access to the individual’s crisis plan at all times and be knowledgeable of the local crisis response system.

Fiscal Agent: An agency that processes and audits provider claims for payment and performs certain other related functions as an agent of DMA and DMH.

Fiscal Audit: Audit performed by the financial department of the LME/MCO which includes a review of the contractor’s evaluation of a consumer’s income, a consumer’s determined ability to pay, third party insurance verification, first and third-party billing, receipts, and denials. A review of COB information will also be conducted to verify support of claimed amounts submitted to LME/MCO.

Fraud: The misrepresentation or concealment of a material fact made by a person that could result in some unauthorized benefit to self, some other person, or organization. It includes any act that constitutes fraud under applicable federal or state law.

Freedom of Choice: The right afforded an individual who is determined to be likely to require a level of care specified in a waiver to choose either institutional or home and community-based services.

Grievance: An expression of dissatisfaction about any matter other than an action, as action is defined in this section. The term is also used to refer to the overall system that includes grievances and appeals handled at the LME/MCO level and access to the state fair hearing process. Possible subjects for grievances include, but are not limited to, the quality of care or services provided, aspects of interpersonal relationships such as rudeness of a provider or employee, and failure to respect the consumer’s rights.

Grievance Procedure: The written procedure pursuant to which consumers may express dissatisfaction with the provision of services by the LME/MCO and the methods for resolution of consumer’s grievance by the LME/MCO.

Habilitation Service: A service that assists an individual in learning or improving skills, including self-help, socialization, and other adaptive skills directed at maximizing an individual’s independent functioning.

HCBS Waivers: Home and community-based services (HCBS) waivers allow states that participate in Medicaid to develop alternatives for individuals who would otherwise require care in institutions. NC Innovations is one of North Carolina’s HCBS waivers.

Health Insurance Portability and Accountability Act: Health Insurance Portability and Accountability Act of 1996.

In-Home Services: In NC Innovations this includes in-home skill building, in-home intensive support, respite and personal care.

Incident: An unusual occurrence as defined in APSM 30-1. Incidents are reported as level I, II, or III as defined in APSM 30-1.

Initial Authorization: The initial or first approval by Alliance’s Utilization Management department of a medically necessary service(s) at a given level of care prior to services being rendered.

Institution: For purposes of NC Innovations, an institution is defined as a residential facility that is licensed and funded as an ICF-IID (intermediate care facility/mental retardation). NC Innovations funding cannot be used in an institution, including ICFs-MR, hospitals, skilled nursing facilities, or state developmental centers.

Intellectual/Developmental Disabilities: Characterized by impairment of general intellectual functioning and adaptive behavior that occurs before age 22 which limits one or more major life functions. IQ of 69 or below. Impairment has continued since its origination or can be expected to continue indefinitely.

Intermediate Care Facility for Individuals with Intellectual Disabilities: A licensed facility that provides care and active treatment for individuals with intellectual disability and certain other developmental disabilities. This is the institutional placement that is “waived” when the NC Innovations Waiver is chosen instead. ICF-IID facilities have four or more beds (most have six, some more than 100) and must provide active treatment to residents.

Least Restrictive Environment: The least restrictive/intensive setting of care sufficient to effectively and safely support an individual. Supporting an individual in an environment that is least restrictive is considered best practice.

Legal Guardian or Legally-Responsible Person: A person who has been appointed by a court of law to act as decision-maker for an individual deemed unable to make decisions on their own behalf. Parents of children under 18 are their children’s legally responsible person unless those rights have been taken away by the court. Once a person turns 18, they legally become their own guardian unless the court deems otherwise and appoints a guardian representative (most often a family member or friend unless there is no one available in which case a public employee is appointed).

Level of Care Utilization System: A standardized tool for measuring the level of care needs for adult consumers. CALOCUS is used with children and adolescents.

Licensed Independent Practitioner: medical doctors (MD), practicing psychologists (PhD), psychologist associates (master’s level psychologist [LPA]), master’s level social workers (LCSW), licensed marriage and family therapists (LMFT), licensed professional counselors(LPC), licensed clinical addictions specialists (LCAS), advanced practice psychiatric clinical nurse specialists, psychiatric nurse practitioners, and licensed physician assistants who are eligible to bill under their own license.

Limits on Sets of Services: A maximum amount of a designated group of services that an individual can receive under a waiver.

Local Management Entity: A local political subdivision of the state of North Carolina as established under General Statute 122C.

Local Management Entity-Managed Care Organization: An LME that is under contract with the department to operate the combined Medicaid Waiver program authorized under Section 1915(b) and Section 1915(c) of the Social Security Act.

Managed Benefit: Services that require authorization from Utilization Management.

Material Change: A material change in any written instrument is one that changes its legal meaning and effect.

Mediation: The process of bringing individuals or agencies in conflict together with a neutral third person who assists them in reaching a mutually agreeable solution

Medicaid: The joint federal and state program to assist states in furnishing medical assistance (health insurance) to financially eligible individuals. Federal law concerning the Medicaid program is located in Title XIX of the Act. NC Innovations services are provided under the Medicaid program. All NC Innovations participants have Medicaid coverage.

Medicaid Consumer Registration: Form used to register Medicaid consumers with Alliance while in unmanaged basic benefit services, or while accessing hospital beds, and for the release of information regarding eligibility for services.

Medicaid for Infants and Children: A program for medical assistance for children under the age of nineteen whose countable income falls under a specific percentage of the federal poverty limit and who are not already eligible for Medicaid in another category.

Medicaid for Pregnant Women: A program for medical assistance for pregnant women whose income falls under a specified percentage of the federal poverty limit and who are not already eligible in another category.

Medicaid Identification Card: The medical assistance eligibility certification card issued monthly by DMA to Medicaid recipients.

Medical Assistance (Medicaid) Program: DMA’s program to provide medical assistance to eligible citizens of the State of North Carolina, established pursuant to Chapter 58, Articles 67 and 68 of the North Carolina General Statutes and Title XIX of the Social Security Act, 42 U.S.C. 1396 et. se.

Medical Record: A single complete record, maintained by the provider of services, which documents all of the treatment plans developed for and behavioral health services received by the consumer.

Medically Necessary Services: A range of procedures or interventions that is appropriate and necessary for the diagnosis, treatment, or support in response to an assessment of a consumer’s condition or need. Medically necessary means services and supplies that are:

  • Provided for the diagnosis, secondary or tertiary prevention, amelioration, intervention, rehabilitation, or care and treatment of mental health, developmental disability, or substance abuse condition.
  • Necessary for and appropriate to the conditions, symptoms, intervention, diagnosis, or treatment of mental health, developmental disability, or substance abuse condition
  • Within generally accepted standards of medical practice.
  • Not primarily for the convenience of a Consumer.
  • Performed in the least costly setting and manner appropriate to treat the Consumer’s mental health, developmental disability, or substance abuse condition.

Medically Necessary Treatment: In order for NC Innovations to cover (pay for) treatment (services) those services must be deemed “medically necessary.” This means treatment and services must be:

  • Necessary and appropriate for the prevention, diagnosis, palliative, curative, or restorative treatment of a mental health or substance abuse condition. Consistent with Medicaid policies and National or evidence-based standards, North Carolina DHHS defined standards or verified by independent clinical experts at the time the procedures, products, and services are provided.
  • Provided in the most cost-effective, least restrictive environment that is consistent with clinical standards of care. Not provided solely for the convenience of the individual, family members, custodian, or provider.
  • Not for experimental, investigational, unproven, or solely cosmetic purposes.
  • Furnished by or under the supervision of a licensed professional (as relevant) under State law in the specialty for which they are providing service and in accordance with Title 42 of the Code of Federal Regulations, the Medicaid State Plan, the North Carolina Administrative Code, Medicaid medical coverage policies, and other applicable Federal and state directives.
  • Sufficient in amount, duration, and scope to reasonably achieve their purpose.
  • Reasonably related to the diagnosis for which they are prescribed regarding the type, intensity, and duration of service, and setting of treatment.

Within the scope of the above guidelines, medically necessary treatment shall be designed to:

  • Be provided in accordance with the person-centered Individual Service Plan which is based upon a comprehensive assessment, and developed in partnership with the person receiving services (or in the case of a child, the child, and the child’s family or legal guardian) and the community team
  • Conform with any advanced medical or mental health directives that have been prepared
  • Respond to the unique needs of linguistic and cultural minorities and furnished in a culturally relevant manner
  • Prevent the need for involuntary treatment or institutionalization.

Medicare: Medicare is health insurance for people age 65 or older, under age 65 with certain disabilities, and any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant). While NC Innovations services are not provided under the Medicare program, some NC Innovations participants may have Medicare coverage in addition to Medicaid coverage.

Most Integrated Environment: The least restrictive setting of care sufficient to effectively treat a participant. An integrated environment is one in which a person with a disability participates in the same activities and settings as non-disabled peers.

National Council of Quality Assurance: National Council of Quality Assurance is an independent, 501(c)(3) non-profit organization whose mission is to improve health care quality through accreditation and recognition programs with a rigorous review of key clinical and administrative processes, through the Health Plan Employer Data and Information Set (HEIDS®), a tool used to measure performance in key areas, and through a comprehensive member satisfaction survey.

Natural Resource Linking: Processes that maximize the use of family and community support systems to optimize functioning.

Natural Supports People who provide support, care, and assistance to a person with a disability without payment for that support. Natural Supports may include parents, siblings, extended family members, neighbors, church members, and/or co-workers, etc.

NC Innovations: A 1915(c) Home and Community-Based Wavier for individuals with Intellectual and/or Developmental Disabilities. This is a waiver of the institutional level of care. Funds that could be used to serve a person in an Intermediate Care Facility may be used to serve people in the community.

NC Innovations Level of Care: The document used in the NC Innovations Waiver records the specification of the minimum amount of assistance an individual must require in order to receive services in an institutional setting under the State Medicaid Plan. For the NC Innovations Waiver, the institutional level of care setting that corresponds to the level of care that must be met for NC Innovations participants is the Intermediate Level of Care for Individuals with Intellectual Disability and related conditions.

NC Innovations Waiver: The NC Innovations Waiver is a means of funding services and supports for individuals with intellectual disabilities and other related developmental disabilities who are at risk for institutional care in an Intermediate Care Facility for Individuals with Mental Retardation (ICF-IID) but who chose instead to remain in their own home and community. NC Innovations is authorized by a Medicaid Home and Community-Based Services (HCBS) Waiver granted by the Centers for Medicare and Medicaid Services (CMS) under Section 1915 (c) of the Social Security Act. Federal, State, and Local dollars fund Medicaid Waivers. The NC DD/MH/SAS Health Plan functions as a Prepaid Inpatient Health Plan (PIHP) through which all mental health, substance abuse, and developmental disabilities services are authorized for Medicaid participants in the Cumberland, Durham, Johnston, Mecklenburg, Orange and Wake counties. CMS approves the services provided under NC Innovations, the number of individuals that may participate each year, and other aspects of the program. The waiver can be amended with the approval of CMS. CMS may exercise its authority to terminate the waiver whenever it believes the waiver is not being managed by the MCO properly The Division of Medical Assistance (DMA), the State Medicaid agency, operates the NC Innovations Waiver. DMA contracts with Alliance Health Care to arrange for and manage the delivery of services, and perform other waiver operational functions under the concurrent 1915 (b)/(c) waivers. DMA directly oversees the NC Innovations Waiver, approves all policies and procedures governing waiver operations, and ensures that the NC Innovations Wavier assurances are met.

NC MH/DD/SAS Health Plan: A 1915(b) Medicaid Managed Care Waiver for Mental Health and Substance Abuse allowing for a waiver of freedom of choice of Providers so that the LME/MCO can determine the size and scope of the Provider network. This also allows for use of Medicaid funds for alternative services.

NC Treatment Outcomes and Program Performance System: The NC Treatment Outcomes and Program Performance System is a Division web-based system for gathering outcome and performance data on behalf of mental health and substance abuse consumers in North Carolina’s public system of services. The NC-TOPPS system provides reliable information that is used to measure the impact of treatment and to improve service and manage quality throughout the service system.

NCTracks: The new multi-payer Medicaid Management Information System for the NC Department of Health and Human Services.

Network Provider: An appropriately credentialed Provider of MH/IDD/SA services that has entered into a contract for participation in the Alliance Network.

Out-of-Network Provider: A practice or agency that has been approved as an Out-of-Network Provider and has executed a Single Case Agreement with Alliance. The Out-of-Network Provider is not offered as a choice of referral to Alliance consumers.

Out-of-Plan Services: Health care services, which the Plan is not required to provide under the terms of this contract. The services are Medicaid-covered services reimbursed on a fee-for-service basis.

Participant: The person who is approved to receive services under the NC Innovations Waiver.

Penetration Rate: The degree to which a defined population is served

Person-Centered Plan: The document that includes important information about the participant, their life goals, and the steps that they and the planning team need to take to get there. It also identifies support needs and includes a combination of paid, natural supports from family and friends, and community supports.

Person-Centered Planning: A process for planning and supporting the individual receiving services that builds upon the individual’s capacity to engage in activities that promote community life and that honor the individual’s preferences, choices, and abilities. The person-centered planning process involves families, friends, and professionals as the individual desires or requires. The resulting treatment document is the Person-Centered Plan (PCP) or Individual Service Plan (ISP).

Persons with Severe and Persistent Mental Illness: Describes consumers who:

  • Are age eighteen or older.
  • Have a substantial disorder of thought or mood that significantly impairs judgment, behavior, capacity to recognize reality, or the ability to cope with the ordinary demands of life.
  •  Score less than or equal to 30 on the Global Assessment Scale (GAF).
  • Have had three or more psychiatric hospitalizations or crisis home admissions in the last year. Includes all persons diagnosed with: bipolar disorders 296.00-296.96, schizophrenia 295.20-295.90, and major depressive disorders 296.20-296.36.

Persons with Severe Mental Illness: Describes consumers who are age eighteen or older; have substantial disorder of thought or mood that significantly impairs judgment, behavior, capacity to recognize reality, or the ability to cope with the ordinary demands of life; score less than or equal to 50 on the Global Assessment Scale (GAF); or have had one or more psychiatric hospitalizations or crisis home admissions in the last year.

Post-Payment Review: A review conducted by Alliance to assess the presence of appropriate documentation to support claims submitted for payment by Alliance.

Pre-Authorization: The initial or first approval by Alliance’s Utilization Department of a medically necessary service(s) at a given level of care prior to service delivery.

Prepaid Inpatient Health Plan: Alliance Health, as do all NC managed care organizations (MCOs), functions as a prepaid inpatient health plan (PIHP) through which all mental health, substance use, and developmental disabilities services are managed and authorized for Medicaid participants in Cumberland, Durham, Johnston, Mecklenburg, Orange and Wake counties.

Primary Clinician: A professional assigned after the initial intake that is ultimately responsible for implementation/coordination of the treatment plan or person-centered plan.

Primary Diagnosis: The most important or significant condition of an individual at any time during the course of treatment in terms of its implications for the individual’s health, medical care, and need for services.

Prior Authorization: The act of authorizing specific services before they are rendered.

Priority Populations: People with the most severe type of mental illness, severe emotional disturbances, as well as, substance abuse disorders with complicating life circumstances conditions, and/or situations that impact the person’s capacity to function, often resulting in high-risk behaviors.

Private Home: The home that an individual owns or rents in his or her own right or the home where a waiver participant resides with other family members or friends. A living arrangement (house or apartment) that is owned or leased by a service provider is not a private residence.

Prompt Payment Guidelines: State-mandated timelines that LME/MCOs must follow when adjudicating and paying claims.

Protected Health Information: Under the U.S. Health Insurance Portability and Accountability Act (HIPPA), any information about health status, provision of healthcare, or payment for healthcare that can be linked to a specific individual.

Provider Network: The agencies or professionals under contract with Alliance Health to provide authorized services to eligible individuals.

Qualified Professional: Any individual with appropriate training or experience as specified by the North Carolina General Statues or by the rule of the North Carolina Commission on Mental Health, Developmental Disabilities, and Substance Abuse Services in the field of mental health or intellectual/developmental disabilities, or substance abuse treatments or habilitation, including physicians, psychologists, psychological associates, educators, social workers, registered nurses, certified fee-based practicing pastoral counselors and certified counselors (NC General Statute 122C-3).

Recipient: A person who is receiving services

Reconsideration Review: A review of a previous finding or decision by Alliance based on the provider’s reconsideration request and any additional materials presented by the provider.

Recredentialing: The review process to determine if a provider continues to meet the criteria for inclusion as an LME/MCO network provider.

Registry of Unmet Needs: A registry that contains a list of individuals who are waiting for NC Innovations funding for identified needs.

Risk Support Needs Assessment: An assessment of factors that, if unaddressed, might pose a high threat to an individual’s health and welfare. These include health risk (medical conditions that require continuing care and treatment); behavioral risk (behaviors or conditions that might cause harm to the person or others); and personal safety risk, (e. g., ability to make safe evacuation independently).

Routine Need – Mental Health: A condition in which the person describes signs and symptoms which are resulting in impairment and functioning of life tasks, impact the person’s ability to participate in daily living, and/or have markedly decreased the person’s quality of life.

Routine Need – Substance Abuse: A condition in which the person describes signs and symptoms consequent to substance use resulting in a level of impairment which can likely be diagnosed as a substance use disorder according to the current version of the Diagnostic and Statistical Manual.

Service Limit: The maximum amount of a specific service that can be received under the NC Innovations waiver.

Service Location: Any location at which a consumer may obtain any covered service from a network provider.

Service Records Manual: The DMH/DD/SAS document that provides the requirements for maintenance of client information, documentation of service provision, and confidentiality requirements.

Slots: The annual allocation of the number of individuals that may be served in NC Innovations. The Center for Medicare & Medicaid Services (CMS) allows North Carolina to serve a given number of individuals on NC Innovations each waiver (calendar) year. This number is the number of ‘slots’ available for that year.

SNAP: Measurement used for the level of care for I/DD. This scale will be replaced by the Supports Intensity Scale (SIS).

Special Needs Population: Population cohorts are defined by diagnostic, demographic, and behavioral characteristics that are identified in a Managed Care Waiver. The managed care organization responsible for waiver operations must identify and ensure that these individuals receive appropriate assessment and services.

Spend Down: Medicaid term used to indicate the dollar amount of charges a Medicaid consumer must incur before Medicaid coverage begins during a specified period of time.

State Plan: The term that refers to the State Medicaid Plan for Medicaid for the State of North Carolina that is approved by the Center for Medicare & Medicaid Services (CMS).

Supplemental Security Income (Social Security): Social Security program that pays benefits to disabled adults and children who have limited income and resources.

Support Plan: A component of the Person-Centered Plan that addresses the treatment needs, natural resources, and community resources needed for the consumer to achieve personal goals and to live in the least restrictive setting possible.

Support Services: Services that enable an individual to live in their community. These include services that can provide direct assistance to the individual, and/or services that provide assistance to the individual’s caregivers and/or support staff.

Supports Intensity Scale: A nationally recognized assessment that measures the level of supports required by people with disabilities to lead normal, independent, quality lives in their home community.

The Joint Commission: The national accrediting organization that evaluates and certifies hospitals and other healthcare organizations as meeting certain administrative and operational standards.

Third-Party Billing: Services billed to an insurance company, Medicare, or another agency.

Treatment Planning Case Management: A managed care function that ensures that consumers meeting special needs population criteria receive needed assessments and assistance in accessing services. Alliance care coordinators carry out this function working with providers if the consumer is already engaged with providers or assists in connecting and engaging the consumer with providers that will provide the necessary services to meet his/her needs. Activities may include:

  • Referral for assessment of the eligible individual to determine service needs.
  • Development of a specific care plan.
  • Referral and related activities to help the individual obtain needed services.
  • Monitoring and follow-up.
  • Unmanaged benefit.
  • Services that do not require authorization from Utilization Management.

URAC: The national accrediting body under which Alliance Health is accredited.

Urgent Need Mental Health: A condition in which a person is not actively suicidal or homicidal, denies having a plan, means, or intent for suicide or homicide but expresses feelings of hopelessness, helplessness, or rage, has the potential to become actively suicidal or homicidal without immediate intervention, a condition which could rapidly deteriorate without immediate intervention, and/or without diversion and intervention will progress to the need for emergent services and care.

Urgent Need Substance Abuse: A condition in which the person is not imminently at risk of harm to self or others or unable to adequately care for self, but by virtue of their substance use is in need of prompt assistance to avoid further deterioration in the person’s condition which could require emergency assistance.

Utilization Management Authorization: The process of evaluating the medical necessity, appropriateness, and efficiency of behavioral healthcare services against established guidelines and criteria and to ensure that the client receives necessary, appropriate, high-quality care in a cost-effective manner.

Utilization Management Department: The Alliance department is responsible for approving individual support plans and authorizing medically necessary services. Care managers work in the UM Department.

Utilization Review: A formal review of the appropriateness and medical necessity of behavioral health services to determine if the service is appropriate, if the goals are being achieved, or if changes need to be made in the person-centered plan or services and supports provided.

Utilization Review Manager: LME/MCO qualified professional who reviews a consumer’s clinical data to determine the clinical necessity of care and authorizes services associated with the plan of care.

Waiver Year: The 12-month period that the Center for Medicare & Medicaid Services (CMS) uses to authorize, monitor, and control waiver programs and expenditures. The waiver year begins on the effective date of the waiver approval and includes the 12 months following that date. For NC Innovations this is August 1 to July 31.

Waste and Abuse: Incidents or practices that are inconsistent with sound fiscal, business, or medical practices that could result in unnecessary costs to Alliance, the state or federal government, or another organization. Waste could also result in reimbursement for services that are not medically necessary or services that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary costs to the Medicaid program.

This page was last reviewed for accuracy on 07/06/2021