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Our glossary contains relevant terms, abbreviations, and acronyms often used in our industry in general, and in North Carolina in particular.

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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: If your health plan makes a decision you do not agree with, you can ask them to review it. This is called an “appeal.” Ask for an appeal when you do not agree with your health care service being denied, reduced, stopped or limited. When you ask your health plan for an appeal, you will get a new decision within 30 days. This decision is called a “resolution.” Appeals and grievances are different.

Co-Payment (Copay): An amount you pay when you get certain health care services or a prescription.

Durable Medical Equipment (DME): Certain items (like a walker or a wheelchair) your doctor can order for you to use at home if you have an illness or an injury.

Emergency Medical Condition: A situation in which your life could be threatened, or you could be hurt permanently if you do not get care right away.

Emergency Medical Transportation: Ambulance transportation to the nearest hospital or medical facility for an emergency medical condition.

Emergency Department Care (or Emergency Room Care): Care you receive in a hospital if you are experiencing an emergency medical condition.

Emergency Services: Services you receive to treat your emergency medical condition.

Excluded Services: Services that are not covered by the BH I/DD Tailored Plan.

Grievance: A complaint about your provider, care or services. Contact your health plan and tell them you have a “grievance” about your services. Grievances and appeals are different.

Habilitation Services and Devices: Health care services that help you keep, learn or improve skills and functioning for daily living.

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

Home Health Care: Certain services you receive outside a hospital or a nursing home to help with daily activities of life, like home health aide services, skilled nursing or physical therapy services.

Hospice Services: Special services for patients and their families during the final stages of terminal illness and after death. Hospice services include certain physical, psychological, social, and spiritual services that support terminally ill individuals and their families or caregivers.

Hospitalization: Admission to a hospital for treatment that lasts more than 24 hours.

Hospital Outpatient Care: Services you receive from a hospital or other medical setting that do not require hospitalization.

Medically Necessary: Medical services, treatments or supplies that are needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Network (or Provider Network): A group of doctors, hospitals, pharmacies and other health professionals who have a contract with the BH I/DD Tailored Plan to provide health care services for members.

Out-of-Network (or Non-participating Provider): A provider that is not in your health plan’s provider network.

Network Provider (or Participating Provider): A provider that is in your health plan’s provider network.

Physician Services: Health care services you receive from a physician, nurse practitioner or physician assistant.

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

Prior Authorization (or Preauthorization): Approval you must have from your health plan before you can get or continue getting certain health care services or medicines.

Premium: The amount you pay for your health insurance every month. Most Medicaid beneficiaries do not have a premium.

Prescription Drug Coverage: Refers to how BH I/DD Tailored Plan helps pay for its members’ prescription drugs and medications.

Prescription Drugs: A drug that, by law, requires a provider to order it before a beneficiary can receive it.

Primary Care Provider (or Primary Care Physician): The doctor or clinic where you get your primary care (immunizations, well-visits, sick visits, visits to help you manage an illness like diabetes.) Your PCP should also be available after hours and on weekends to give you medical advice. They also refer you to specialists (cardiologists, behavioral health providers) if you need it. Your PCP should be your first call for care before going to the emergency department.

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

Rehabilitation Services and Devices: Health care services and equipment that help you recover from an illness, accident, injury or surgery. These services can include physical or speech therapy.

Skilled Nursing Care: Health care services that require the skill of a licensed nurse.

Specialist: A provider who is trained and practices in a specific area of medicine.

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 illness or injury.

Other Terms You May See or Hear

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

1115 Demonstration Waiver: As defined by Section 1115 of the Social Security Act, state demonstrations that give states additional flexibility to design and improve their programs by demonstrating and evaluating state-specific policy approaches to better serving Medicaid populations. Specifically, North Carolina’s amended 1115 demonstration waiver application to the federal Centers for Medicare & Medicaid Services (CMS) focuses on the specific items of the Medicaid Managed Care transformation that require CMS waiver approval (waiver #11-W00313/4; 2. Adult Care Home (ACH): A licensed facility with seven (7) or more beds that provides residential care for aged or disabled persons whose principal need is a home which provides the supervision and personal care appropriate to their age and disability and for whom medical care is only occasional or incidental.

1915(i) Services: The Section 1915(i) SPA – Home and Community-Based Services (HCBS) for eligible members that the BH I/DD Tailored Plan offers its geographic area.

Advance Directive: Has the same meaning as Advance Directive as defined in 42 C.F.R. § 489.100 and includes advance instructions for mental health treatment as defined in Part 2 of Article 3 of Chapter 122C of the General Statutes.

Advanced Medical Home (AMH): State-designated primary care practices that have attested to meeting standards necessary to provide local care management services.

Advanced Medical Home Plus (AMH+): Primary care practices certified by the Department as AMH Tier 3 practices, whose providers have experience delivering primary care services to the BH I/DD Tailored Plan eligible population, or can otherwise demonstrate strong competency to serve that population and have certified by the State (prior to BH I/DD Tailored Plan launch) or BH I/DD Tailored Plan(s) (after launch) as such.

Adverse Benefit Determination: Has the same meaning as Adverse Benefit Determination as defined in 42 C.F.R. § 438.400. Any decision to deny, reduce, suspend, or terminate waiver participation or requests for or placement on the Registry of Unmet Needs are considered Adverse Benefit Determinations consistent with the definition at 42 C.F.R. 438.400.

Alcohol and Drug Abuse Treatment Center (ADATC): State-operated treatment center that provides inpatient treatment, psychiatric stabilization and medical detoxification for adults with substance use and other co-occurring mental health diagnoses to prepare for ongoing community-based treatment and recovery.

Alternative Services: Services proposed by the BH I/DD Tailored Plan and approved by the Department to fill network adequacy and accessibility service needs that are met with the current state-funded service array.

American Society of Addiction Medicine (ASAM) Criteria: Evidence-based guidelines for placement, continued stay, and transfer/discharge for the treatment of adolescents and adults with addiction and co-occurring conditions.

Appeal: As relates to members, has the same meaning as Appeal as defined in 42 CFR 438.400(b).

Area Director: The Area Director is the administrative head of the BH I/DD Tailored Plan. The Area Director is an employee of and serves at the pleasure of the entity’s governing board and shall be appointed in accordance with N.C. Gen. Stat. § 122C-117(a)(7). It is often synonymous with Chief Executive Officer (CEO).

Authorized Representative: An individual, provider or organization designated by a member, or authorized by law or court order, to act on their behalf in assisting with the individual’s participation in the Medicaid Managed Care program. With written consent of the member, or as otherwise legally authorized, an authorized representative may, for example, request an Appeal, file a Grievance, or request a State Fair Hearing on behalf of the beneficiary with the exception that a provider cannot request continuation of BH I/DD Tailored Plan benefits Authorized Representative may be used interchangeably with member wherever a member has a right for purposes of exercising a right on behalf of that member. Sometimes referred to as Legally Responsible Person (LRP).

Automated Call Distribution System (ACD): An automated call center system that disperses incoming calls of all members and potential members to appropriate service line staff.

Automated Voice Response System (AVRS): An automated system that allows members to perform self-service activities and resolve simple inquiries without the need to interact with an agent. The AVRS interacts with the member through voice prompts and recognition or numeric prompts.

Behavioral Health (BH): Refers generally to mental health and substance use disorders.

Behavioral Health Crisis Line: A confidential, toll-free service line available twenty-four (24) hours a day, seven (7) days a week, every day of the year to members and recipients which provides emergency referral with immediate access to trained, skilled, licensed BH professionals who provide assistance for any type of BH issue the member may be experiencing, and offers assistance in linking members and recipients to supportive available community resources.

Behavioral Health Crisis Referral System (BHCRS): A secure web-based application that connects a statewide network of facilities that make referrals (Referring Facilities) with facilities that offer inpatient or facility-based treatment (Receiving Facilities) to assist facilities in timely and appropriate placement of individuals experiencing a BH crisis.

Behavioral Health Intellectual/Developmental Disability Tailored Plan (BH I/DD Tailored Plan): Has the same meaning as BH I/DD Tailored Plan as defined in N.C. Gen. Stat. § 108D-1(4).

Beneficiary: An individual who is enrolled in the North Carolina Medicaid program but who may or may not be enrolled in the Medicaid Managed Care program.

Beneficiary with Special Health Care Needs: Populations who have or are at increased risk of having a chronic illness and/or a physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that usually expected for individuals of similar age. This includes but is not limited to individuals with: HIV/AIDS; an SMI, I/DD or SUD diagnosis; Chronic Pain; Opioid Addiction; or receiving Innovations or TBI waiver services.

Business Associate Agreement (BAA): Under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the written agreement between a HIPAA-covered entity and HIPAA Business Associate, as defined in 45 C.F.R. 160.103.

Business Day: Business days are defined as traditional State workdays, Monday-Friday and includes traditional work hours 8:00 AM – 5:00 PM EST. North Carolina State holidays are excluded. A list of North Carolina State Holidays is located at the following link, accurate as of August 9, 2022:

Calendar Day: Includes the time from midnight to midnight each day, and all days in a month, including weekends and holidays.

Care Coordination: The act of organizing patient care activities and sharing information among all the participants involved with a member’s care to achieve safer and more effective care. Through organized care coordination, members’ needs and preferences are known ahead of time and communicated at the right time to the right people to provide safe, appropriate, and effective care addressing the member’s clinical needs and unmet health-related resource needs.

Care Management: Team-based, person-centered approach to effectively managing patients’ medical, social, and behavioral conditions. Care Management shall include, at a minimum, the following:

  • High-risk care management (e.g., high utilizers / high-cost beneficiaries)
  • Care Needs Screening
  • Identification of members in need of care management
  • Development of Care Plans (across priority populations)
  • Development of comprehensive assessments (across priority populations)
  • Transitional Care Management: Management of member needs during transitions of care and care transitions (e.g. from hospital to home)
  • Care Management for special populations (including pregnant women and children at-risk of physical, development, or socio-emotional delay)
  • Chronic care management (e.g., management of multiple chronic conditions)
  • Coordination of services (e.g., appointment/wellness reminders and social services coordination/referrals)
  • Management of unmet health-related resource needs and high-risk social environments
  • Management of high-cost procedures (e.g., transplant, specialty drugs)
  • Management of rare diseases (e.g., transplant, specialty drugs)
  • Management of medication-related clinical services which promote appropriate medication use and adherence, drug therapy monitoring for effectiveness, medication related adverse effects
  • Development and deployment of population health programs.

Care Management Agency (CMA): Provider organization with experience delivering BH, I/DD, and/or TBI services to the BH I/DD Tailored Plan eligible population that will hold primary responsibility for providing integrated, whole-person care management to BH I/DD Tailored Plan members assigned to it, under the Tailored Care Management model as certified by the State (prior to BH I/DD Tailored Plan launch) or BH I/DD Tailored Plan(s) (after launch).

Care Management Comprehensive Assessment: A person-centered assessment of a member’s health care needs, functional needs, accessibility needs, strengths and supports, goals and other characteristics that will inform the member’s ongoing Care Plan and treatment.

Care Management for At-Risk Children: Care management services provided to a subset of the Medicaid population ages 0-5 identified as being “high-risk.”

Care Management for High-Risk Pregnant Women: Care management services provided to a subset of the Medicaid population who is pregnant and identified as “high-risk” by providers, local health departments (LHDs), social service agencies, Standard Plans, BH I/DD Tailored Plans, and/or PIHPs.

Care Plan: A written individualized person-centered plan of care for members/recipients with BH needs, that is developed using a collaborative approach led by the member/recipient or their guardian when appropriate, incorporates the results of the Care Management Comprehensive Assessment, and identifies the member’s/recipient’s desired outcomes and the training, therapies, services, strategies, and formal and informal supports needed for the member/recipient to achieve those outcomes.

Care Transitions: The process of assisting a member to transition to a different care setting or through a life stage that results in or requires a modification of services (e.g. school-related transitions).

Caregivers: Family members, friends or neighbors who provide unpaid assistance to a person with a chronic illness or disabling condition.

Catchment Area: The group of counties for which a BH I/DD Tailored Plan arranges for services. For Alliance Health, that includes Cumberland, Durham, Johnston, Mecklenburg, Orange and Wake counties.

Child and Adolescent Needs and Strengths (CANS): A multi-purpose tool developed for children and adolescent BH and developmental services to support decision making, including level of care and service planning; facilitate quality improvement initiatives; and allow for the monitoring of outcomes of services.

Child/Adolescent Psychiatrist: A physician who has completed an ACGME-accredited child/adolescent psychiatry fellowship and/or has board certified or has board-diplomat status as a child/adolescent psychiatrist.

Children with Complex Needs: Medicaid eligible children ages five (5) through twenty (20) with a developmental disability (including Intellectual Disability and/or Autism Spectrum Disorder) and a mental health disorder, who are at risk of not being able to enter or remain in a community setting. The term “at risk” is defined for this purpose as acts or behaviors that present a substantial risk of harm to the child or to others.

Child and Family Team: Group consisting of a child/youth receiving services, parent/caregiver/guardian, and other community supports as determined by the child/youth and/or their parent/caregiver/guardian. The Child and Family Team is responsible for creating, implementing, and updating an individualized child and family plan on the child/youth’s needs. Child and Family team may include extended family members, community members, and individuals involved in the child/youth’s education, care, and support.

Children with Medical Complexity (CMC): Also known as “complex chronic” or “medically complex,” children who have multiple significant chronic health problems that affect multiple organ systems and result in functional limitations, high health care need or utilization, and often the need for or use of medical technology.

Choice Counseling: Has the same meaning as Choice Counseling as defined in 42. C.F.R. § 438.2.

Civil Monetary Penalty: Financial penalties authorized or required to be imposed by States under federal requirements for certain conduct that is set forth in 42 C.F.R. § 438.700.

Claim: A request for payment by a healthcare provider to an insurer for rendered services. Also refers to (1) a bill for services, (2) a line item of service, or (3) all services for one beneficiary within a bill, as referenced at 42 CFR §447.45(b). Claims may be filed for professional, institutional, dental, and pharmacy transactions in conformance with existing laws (e.g., HIPAA) and using relevant industry standards (e.g., ASC X12N, NCPDP) and typically include information on the patient, provider, diagnoses, procedures performed or services rendered, and related charges.

Claim Adjudication: The process of paying Claims submitted or denying them after comparing the claim data elements to the benefit or coverage requirements.

Claim Adjudication Date: The date the BH I/DD Tailored Plan or its Subcontractor processed a Claim for determination of payment, acceptance, denial, or rejection.

Clean Claim: A claim submitted to a BH I/DD Tailored Plan by a service provider which that can be processed without obtaining additional information from the provider of the service or from a third party. It includes a claim with errors originating in a State’s claims system (claims that will deny). It does not include a claim from a provider who is suspended, under investigation for fraud or abuse, or a claim under review for medical necessity. 42 C.F.R. § 447.45(b)(3). Determination of whether a claim is a “clean claim,” rests with the Contractor and must be determined for each claim, provided applied consistently and reasonably. 85 FR 72754, 72819.

Clinically Integrated Network (CIN) or Other Partner: Entities with which provider practices choose to partner to share responsibility for specific functions and capabilities required to operate as an AMH+ practice or CMA.

Closed Loop Referral: The capacity to know whether a Member accessed social services to which they were referred.

Closed Network: Has the same meaning as Closed Network defined in N.C. Gen. Stat. § 108D-1(6).

Community Alternatives Program for Children (CAP/C): A North Carolina Medicaid 1915(c) waiver program that provides home- and community-based services to medically fragile children who are at risk for institutionalization in a nursing home because of their medical needs (4141.R06.00; the approved waiver document is available at the following link, accurate as of August 9, 2022:

Community Alternatives Program for Disabled Adults (CAP/DA): A North Carolina Medicaid 1915(c) waiver program that allows seniors and disabled adults ages eighteen (18) and older to receive support services in their own home, as an alternative to nursing home placement (#0132.R07.00; the approved waiver document is available at the following link, accurate as of August 9, 2022:

Community Collaboratives: Local and regional convenings of county agencies, community-based organizations, non-profits, members, relatives/natural supports, and health care providers, and peers, that meet regularly to identify and address community needs through coordinated efforts and system planning.

Community Integration Plan (CIP): A planning document completed as part of the diversion process that documents that community integration planning occurred and indicates which residential option and other services were by the member and/or their relatives or guardian.

Community Mental Health Block Grant (CMHBG or MHBG): The Substance Abuse and Mental Health Services Administration (SAMHSA) disburses these funds annually to North Carolina each year to support the state’s efforts to provide comprehensive community mental health services, including prevention, early intervention, treatment and resiliency and/or recovery supports to children and youth at risk for or experiencing serious emotional disturbance (SED) and adults living with a serious mental illness (SMI).

Compatible Medicaid NCCI Methodologies: The six (6) NCCI Methodologies used in the Medicare Part B program and determined by CMS as compatible methodologies for claims filed in Medicaid: (1) a methodology with procedure-to-procedure edits for practitioner and ambulatory surgical center services; (2) a methodology with procedure-to-procedure edits for outpatient services in hospitals (including emergency department, observation, and hospital laboratory services); (3) a methodology with procedure-to-procedure edits for durable medical equipment; (4) a methodology with medically unlikely edits for practitioner and ambulatory surgical center services; (5) a methodology with medically unlikely edits for outpatient services in hospitals; and (6) a methodology with medically unlikely edits for durable medical equipment. Although the Medicare methodologies are compatible for Medicaid, the actual edits used are not identical between programs.

Credentialing: The approach to collecting and verifying provider qualifications (e.g., the provider’s training and education, licensure, liability record); and determining, for Medicaid Managed Care and State-funded Services, whether to allow the provider to be included in a BH I/DD Tailored Plan’s network, subject to certain Department requirements.

Crossover: The timeframe immediately before and after implementation of BH I/DD Tailored Plans in the applicable Region. Crossover-related requirements and timeframes are activity-specific but are all designed to ensure continuity of care for the crossover population during this time of transition.

Cross-over Population: Refers to North Carolina Medicaid beneficiaries that are enrolled in the NC Medicaid Direct program and will transition to Medicaid Managed Care at a specific date determined by the Department.

Cross Area Service Program (CASP): DMH/DD/SAS designated specialty service program that is funded by the DMH/DD/SAS through federal and/or State funds to provide targeted services to an identified population segment (e.g. pregnant women, families, etc.). A CASP is designated by the DMH/DD/SAS as a result of a critical federal grant initiative or a priority state service initiative.

Cultural and Linguistic Competency (or Culturally and Linguistically Competent): The ability to understand, appreciate and interact effectively with people of different cultures and/or beliefs to ensure the needs of the individuals are met. The ability to interact effectively with people of different cultures helps to ensure the needs of all community members are addressed. It also refers to such characteristics as age, gender, sexual orientation, disability, religion, income level, education, geographical location, or profession. Cultural and Linguistic Competency means to be respectful, responsive, and sensitive to the health beliefs, practices, cultural and linguistic needs of diverse populations and groups.

Culturally and Linguistically Appropriate Services (CLAS): Services that are respectful of and responsive to individual cultural health beliefs and practices, preferred languages, health literacy levels, and communication needs and employed by all members of an organization (regardless of size) at every point of contact.

Date of Payment: The point in time following the Claim Adjudication Date when reimbursement is generated for services, either initiated by date of Electronic Funds Transfer (EFT) or processes to generate a paper check.

Date of Receipt: Has the same meaning as Date of Receipt as defined in 42 C.F.R. § 447.45(d)(5).

Denied Claim: When a BH I/DD Tailored Plan or its Subcontractor refuses to reimburse a participating provider for all or a portion of the services submitted on the medical or pharmacy claim.

Diversion: The process of identifying individuals living in the community who are at risk of requiring care in an institutional setting or an adult care home, and providing additional, more intensive supports and services to prevent further deterioration of their condition that could result in placement in an institutional setting or an adult care home.

Dually-Eligible for Medicare and Medicaid: Describes beneficiaries eligible for both Medicare and Medicaid.

Duplicate Claim: Any claim submitted by a participating provider for the same service provided to an individual on a specified date of service that was included in a previously submitted claim.

Durable Medical Equipment (DME): Has the same meaning as Durable Medical Equipment as defined in 42 C.F.R. § 414.202.

Eastern Band of Cherokee Indian (EBCI): A federally recognized Indian Tribe located in southwestern North Carolina whose members are exempt from Medicaid Managed Care.

Eastern Band of Cherokee Indian (EBCI) Tribal Option: The tribal-designed and operated primary care case management entity option developed collaboratively by the Department and the EBCI. This includes the following counties: Cherokee, Graham, Haywood, Jackson and Swain Counties. Eligible members in the following counties may opt in: Buncombe, Clay, Henderson, Macon, Madison, and Transylvania.

Emergency Closure: A closure of licensed residential care facilities that occurs without the Facility providing the required 30-day notice to residents and the state (or sixty (60) Calendar Days’ notice as required for I/DD residential facilities pursuant to N.C.G.S. § 122C-63(b)) as described in posted lawful guidance.

Emergency Medical Condition: Has the same meaning as Emergency Medical Condition as defined in 42 C.F.R. § 438.114(a).

Emergency Services: Has the same meaning as Emergency Services as defined in 42 C.F.R. § 438.114(a).

Encounter: A record of a rendered service provided by a healthcare provider irrespective of whether payment is required. Encounter data typically includes information otherwise present on a claim.

Enrollment: The process through which a beneficiary selects or is auto-enrolled to a Standard Plan, BH I/DD Tailored Plan, Medicaid Direct PIHP, Statewide Specialized Foster Care Plan and/or Tribal Option to receive North Carolina Medicaid benefits through the Medicaid Managed Care program.

Enrollment Broker (EB): Has the same meaning as Enrollment Broker as defined in 42 C.F.R. § 438.810(a). 83. Essential Providers: Federally qualified health centers, rural health centers, free clinics, local health departments, State Veteran’s Homes, and any other providers as designated by the Department in accordance with N.C. Gen. Stat. § 108D-22(b).

Episode of Care: A treatment or intervention covered under the Tailored Plan benefit, initiated prior to NC Medicaid Managed Care Tailored Plan Launch and evidenced by a current treatment plan, which is related to a member’s condition or circumstance and is provided to the member by the non-participating provider within the first sixty (60) Calendar Days after Tailored Plan launch.

Excluded Person: A person or corporate entity who appears on one or more of the Exclusion Lists.

Exclusion List: Lists the BH I/DD Tailored Plan must check to determine the exclusion status of all providers and ensure that the BH I/DD Tailored Plan does not pay federal funds to excluded persons or entities, including:

  • State Exclusion List
  • U.S. Department of Health and Human Services, Office of Inspector General’s (HHS-OIG) List of Excluded Individuals/Entities (LEIE)
  • The System of Award Management (SAM)
  • The Social Security Administration Death Master File (SSADMF)
  • To the extent applicable, National Plan and Provider Enumeration System (NPPES)
  • Office of Foreign Assets Control (OFAC)

Exempt Population: Beneficiaries in Exempt Populations may voluntarily enroll in Medicaid Managed Care on an opt-in basis, if they meet other eligibility requirements for being enrolled in Medicaid Managed Care. Members of Exempt Populations are allowed to opt into Medicaid Managed Care or into NC Medicaid Direct at any time, upon request to the Enrollment Broker.

Facility: Has the same meaning as Facility in N.C. Gen. Stat. §122C—3(14).

First Episode Psychosis (FEP) Programs: Evidence-based treatment programs that address the needs of individuals ages 15-30 with early onset of serious mental illness, including psychotic disorders, utilizing the Coordinated Specialty Care (CSC) model.

Fee-for-Service: A payment model in which providers are paid for each service provided. NC Medicaid’s Fee-for-Service program is also known as NC Medicaid Direct.

Foster Care: Has the same meaning as Foster Care as defined in N.C. Gen. Stat. § 131D-10.2(9).

Grantee: The State government entity (i.e., DHHS, DMH/DD/SAS) to which a federal grant is awarded and which is responsible and accountable for the use of the funds provided and for the performance of the grant-supported project or activity.

Grievance: As it relates to a member, has the same meaning as Grievance as defined in 42 C.F.R. § 438.400(b). 93. Hardship Payment: An advanced payment from the BH I/DD Tailored Plan to a provider, the provision and amount of which are in the BH I/DD Tailored Plan’s sole discretion, to address a situation in which the provider is experiencing a significant drop in BH I/DD Tailored Plan claims payments due to issues beyond the control of the provider, and which advance the BH I/DD Tailored Plan shall recoup by offset or repayment.

Health Home: A designated provider (including a provider that operates in coordination with a team of health care professionals) or a health team selected by an eligible individual with chronic conditions to provide health home services pursuant to Section 1945 of the Social Security Act. In North Carolina’s Medicaid Managed Care program, the BH I/DD Tailored Plans will serve as the Health Homes, with approval of the federal Centers for Medicare & Medicaid Services (CMS).

Health Insurance: A contract that requires a health insurer to pay some or all of a defined beneficiary’s health care costs, sometimes in exchange for a premium.

Historically Marginalized Populations: Individuals, groups, and communities that have historically and systematically been denied access to services, resources and power relationships across economic, political, and cultural dimensions as a result of systemic, durable, and persistent racism, discrimination and other forms of oppression. Longstanding and well documented structural marginalization has resulted in poor health outcomes, economic disadvantage, and increased vulnerability to harm and adverse social, political and economic outcomes. Historically Marginalized Populations are often identified based on their race, ethnicity, social economic status, geography, religion, language, sexual identity and disability status.

Human Services Organization (HSO): An organization that offers non-medical services to address unmet health-related resource needs within one or more communities. HSOs are also known as community-based organizations or social service agencies.

Implementation Plan: Comprehensive schedule of events, tasks, deliverables, and milestones developed and executed by the BH I/DD Tailored Plan to ensure successful implementation and launch of BH I/DD Tailored Plan services.

In Lieu of Services (ILOS): Services or settings that are not covered under the North Carolina Medicaid State Plan but are a medically appropriate, cost-effective alternative to a State Plan covered service.

In-Reach: The process of identifying individuals residing in an institutional setting or an adult care home whose service needs could potentially be met in a home or community-based setting, engaging them about their desire to transition to a home or community-based setting and referring them for transition, if appropriate.

Independent Assessment: Required assessment of needs used to establish a service plan for 1915(i) services. The CANS, ANSA, SNAP or SIS, depending on population shall serve as the tool used for the required independent assessment. 42 CFR § 441.720.

Independent Evaluation: Required evaluation used to determine eligibility for 1915(i) services. The Department shall provide a standardized tool to be used for the required independent evaluation. 42 CFR § 441.715(d).

Indian Health Care Provider (IHCP): Means an IHCP as defined by 42 C.F.R. § 438.14(a). In North Carolina, an IHCP is a provider of service which includes all services that Cherokee Indian Hospital Authority or the Eastern Band of Cherokee Indians offer under Medicaid.

Individual Support Plan (ISP): A written individualized person-centered plan of care for members with I/DD and TBI needs, including Innovations waiver and TBI waiver enrollees, that is developed using a collaborative approach led by the member/recipient or their guardian when appropriate, incorporates the results of the care management comprehensive assessment, and identifies the member’s/recipient’s desired outcomes and the training, therapies, services, strategies, and formal and informal supports needed for the member to achieve those outcomes. For individuals enrolled in the Innovations or TBI waiver, the ISP also documents the waiver services that a member is authorized to obtain.

Innovations Waiver: The Section 1915(c) Home and Community-Based Services (HCBS) waiver for individuals with I/DD who meet Intermediate Care Facility for Individuals with Intellectual Disability (ICF-IDD) level of care criteria that the BH I/DD Tailored Plan operates in its geographic area.

Interpersonal Violence (IPV)-Related Healthy Opportunity Pilot Services (IPV-Related Services): Any services authorized to be furnished under the Healthy Opportunities Pilot to Members experiencing or at risk of experiencing interpersonal violence or other threats to personal safety, not only including services described in the Interpersonal Violence/Toxic Stress domain and the Cross-Domain categories of the Healthy Opportunities Pilot fee schedule, but also include any services in the Housing, Food, or Transportation domains set forth in the Healthy Opportunities fee schedule that are recommended to a Member to help address interpersonal violence. The Healthy Opportunities Pilot fee schedule is located at as amended from time to time.

Institution for Mental Disease (IMD): Has the same meaning as IMD as defined in 42 C.F.R. § 435.1010.

Interactive Purchasing System (IPS): The State of North Carolina’s electronic system for advertising solicitations and publishing award notifications, where vendors can view and search for procurement opportunities, which can be found at the following link, accurate as of August 9, 2022:

Interest: For the purposes of claim payment or encounter submission, an amount from a BH I/DD Tailored Plan that is due to a participating provider for failing to timely or correctly pay a clean claim.

Into the Mouth of Babes (IMB): A clinical program that trains medical providers to deliver preventive oral health services to young children enrolled in North Carolina Medicaid. Services are provided from the time of tooth eruption until age 3½ (42 months), including oral evaluation and risk assessment, parent/caregiver counseling, fluoride varnish application, and referral to a dental home.

IPV-Related Service Data: Any authorizations, Services, data, information, reports, invoices, or other sources of information relating to or referencing IPV-Related Services authorized to be furnished to a Member or actually furnished to a member.

IPV-Trained Individual: All members of the PHP’s workforce (including PHP’s employees and contractors, whether or not they are Care Managers) with access to IPV-Related Service Data who have completed all Pilot-related IPV-trainings provided or approved in advance by the Department.

IPV-Related Data Training: All relevant trainings, each as provided or approved in advance by the Department, prior to PHP’s workforce initiating a member contact or an initial Pilot assessment.

Lead Pilot Entity: Has the same meaning of Healthy Opportunities Network Leads. 110. Limited English Proficient (LEP): Has the same meaning as LEP as defined in 42 C.F.R. § 438.10(a).

Limited Medicaid Managed Care: Medicaid Managed Care for delivery of Medicaid-covered BH, I/DD, and TBI benefits only; other Medicaid-covered benefits are delivered through NC Medicaid Direct.

Local Management Entity/Managed Care Organization (LME/MCO): Has the same meaning as LME/MCO as defined in N.C. Gen. Stat. § 122C-3(20c).

Long-Term Service and Supports (LTSS): LTSS includes:

  • Care provided in the home, in community-based settings, or in facilities
  • Care for older adults and people with disabilities who need support because of age, physical, cognitive, developmental, or chronic health conditions; or other functional limitations that restrict their abilities to care for themselves
  • A wide range of services to help people live more independently by assisting with personal health care needs and activities of daily living such as:
    • Eating
    • Taking baths
    • Managing medications
    • Grooming
    • Walking
    • Getting up and down from a seated position
    • Using the toilet
    • Cooking
    • Driving
    • Getting dressed
    • Managing money
  • Care management provided to individuals who, because of age, physical, cognitive, developmental or chronic health conditions or other functional limitations, are at risk of requiring formal LTSS services to remain in their communities.

Maintenance of Effort (MOE): Federal requirement that grant recipients maintain non-federal funding for activities described in their application at a level which is not less than expenditures for such activities during the fiscal year prior to receiving the grant or cooperative agreement to be eligible for full participation in federal grant funding. Public Health Service Act, Section 797(b).

Managed Care Organization (MCO): Has the same meaning as MCO as defined in 42 C.F.R. § 438.2. Both Standard Plans and BH I/DD Tailored Plans are operated by MCOs.

Mandatory Populations: Medicaid beneficiaries who are required to enroll in Medicaid Managed Care with no option to enroll in Medicaid Direct.

Medicaid Direct: Refers to the Medicaid Fee-For-Service program serving Beneficiaries who are not enrolled in a Prepaid Health Plan (PHP) or the EBCI Tribal Option.

Medicaid Direct Prepaid Inpatient Health Plan: Refers to the benefit plan operated by a PIHP under contract with the Department, as recognized as contract number 30-2022-007-DHB.

Medicaid Enterprise System (MES): The aggregation of technologies and applications required to operate a State Medicaid Agency (SMA).

Medicaid Managed Care (MMC): North Carolina’s program under which contracted Managed Care Organizations arrange for integrated medical, physical, pharmacy, behavioral and other services to be delivered to Medicaid enrollees. Medicaid Managed Care will include three types of plans: (1) Standard Plans, (2) BH I/DD Tailored Plans, and (3) Statewide Foster Care Plan. The use of Medicaid Managed Care is also inclusive of EBCI Tribal Option, operating as a primary care case management entity (PCCMe).

Medicaid Managed Care Quality Rating System: A system utilizing a rating scale designed to increase transparency and accountability for the quality of services provided by North Carolina’s health plans within Medicaid Managed Care.

Medical Claim: A request for a payment that a healthcare provider submits to an insurer for rendered medical services.

Medical Encounter: a record of a rendered service provided by a healthcare provider for medical services.

Medical Home Fees: Non-visit based payments to AMH practices made in addition to fee for service payments, providing stable funding for primary care access and quality improvement at the practice level.

Medically Necessary: Medical necessity is determined by generally accepted North Carolina community practice standards as verified by independent Medicaid consultants. As required by 10A NCAC 25A.0201, a medically necessary service may not be experimental in nature.

Member and Recipient Service Line: A service line available to both members and recipients for the purposes of providing convenient access to information about benefits or claims, referral assistance and access to treatment or services.

Members: Medicaid specifically enrolled in and receiving benefits through the BH I/DD Tailored Plan.

National Correct Coding Initiative (NCCI): The CMS-developed coding policies based on coding conventions defined in the American Medical Association’s Current Procedural Terminology Manual and national and local policies and edits to promote correct coding and control improper coding that may lead to inappropriate payment of claims under Medicaid.

National Provider Identifier (NPI): Standard unique health identifier for health care providers adopted by the Secretary of US Department of Health and Human Services in accordance with HIPAA.

National Quality Forum: A not-for-profit, nonpartisan, membership-based organization that works to catalyze improvements in healthcare.

Natural Supports: Relationships with people that include coworkers, classmates, activity individuals, neighbors, family and others. These relationships are typically developed in the community through associations in schools, the workplace and participation in clubs, organizations and community activities

NCCARE360: An electronic platform providing: (a) a robust statewide resource repository of community-based organizations and social service agencies and the services they provide, and (b) a referral platform for payers, care managers, clinicians, community health workers, social service agencies, and others to refer and connect members directly to community resources and track the connections and outcomes through “Closed Loop Referral” capacity. The platform is being deployed as part of a public-private partnership with the Foundation for Health Leadership and Innovation.

NCCI Edits: Edits applied to services performed by the same provider for the same beneficiary on the same date of service. They consist of two types of edits: (1) NCCI edits, or procedure-to-procedure edits that define pairs of HCPCS/CPT codes that should not be reported together for a variety of reasons; and (2) medically unlikely edits, or units-of service edits that define for each HCPCS/CPT code the number of units of service beyond which the reported number of units of service is unlikely to be correct.

NCCI Methodologies: NCCI methodologies have four components: (1) a set of edits; (2) definitions of types of claims subject to the edits; (3) a set of claims adjudication rules for applying the edits; and (4) a set of rules for addressing provider/supplier appeals of denied payments for services based on the edits.

NCTracks: The Department’s multi-payer Medicaid Management Information System (MMIS). NCTracks adjudicates claims for multiple NC DHHS divisions, including DHB, DMH/DD/SAS, Division of Public Health, and Office of Rural Health. NCTracks also serves as a central repository for Medicaid and State-funded Services provider, member and recipient data.

Network: A group of providers, including, without limitation, doctors, hospitals, pharmacies, and others contracted by the BH I/DD Tailored Plan to provide health care services to its Medicaid Managed Care members or State-funded Services recipients.

Non-Participating Provider: Non-participating or “non-par” providers are physicians or other health care providers that have not entered into a contractual agreement with the BH I/DD Tailored Plan and are not part of the BH I/DD Tailored Plan’s Network, unlike participating providers. They may also be called out-of-network providers. Non-participating providers do not include any licensed practitioner or other healthcare provider employed by and delivering services to members through the participating provider.

Non-public Medicaid NCCI Edit Files: The quarterly Medicaid NCCI Edit files that are not accessible by the general public and are only made available to state Medicaid agencies by CMS and posted by CMS on the secure Regional Information Sharing Systems (RISSNET) portal.

Non-Unit Cost Reimbursement (Non-UCR) Expenditure: Unique service or innovative project expenditures that cannot be reported through UCR/claims methodology. Non-UCR Expenditures are for State-funded Services only.

North Carolina Controlled Substances Reporting System (CSRS): The Department’s database for collecting information on dispensed controlled substance prescriptions. The system is used as a clinical tool to improve patient care and safety while avoiding potential drug interactions and identifying individuals that may be in need of referral to substance use disorder services.

North Carolina Families Accessing Services through Technology (NC FAST): The Department’s integrated case management system that provides eligibility and enrollment for Medicaid, Food and Nutrition Services, WorkFirst, Child Care, Special Assistance, Crisis Intervention Program, Low-Income Energy Assistance Program, and Refugee Assistance, and provides services for Child Welfare and Aging and Adult Services.

North Carolina Healthcare Enterprise Accounts Receivable Tracking System (HEARTS): The primary Admission, Discharge and Transfer (ADT) and billing system used by the State’s Alcohol and Drug Abuse Treatment Centers (ADATC) and other facilities owned and/or operated by s the NC Division of State-Operated Healthcare Facilities (DSOHF).

North Carolina Identity Service (NCID): The State’s centralized Identity and access management platform provided by the Department of Information Technology. NCID is a web-based application that provides a secure environment for state agency, local government, business and individual users to log in and gain access to real-time resources, such as customer-based applications and information retrieval, which can be found at the following link, accurate as of August 9, 2022:

North Carolina Immunization Registry (NCIR): The Department’s secure, web-based clinical tool which is the official source for North Carolina immunization information.

North Carolina Support Needs Assessment Profile (NC-SNAP): A needs assessment tool that measures an individual’s level of intensity of need for intellectual and developmental disabilities supports and services.

Nurse Line: A service line available twenty-four (24) hours a day, seven (7) days a week, every day of the year to members which provides medical information and advice on where to access care.

Objective Quality Standard: Means the objective standards that the Department applies during the Provider Enrollment process.

Ombudsman Program: A Department program to provide education, advocacy, and issue resolution for Medicaid Beneficiaries whether they are in the Medicaid Managed Care program or NC Medicaid Direct. This program is separate and distinct from the Long-Term Care Ombudsman Program.

Ongoing Course of Treatment: As defined in 42 C.F.R. § 438.62(b), when a member, in the absence of continued services, would suffer significant detriment to their health or be at risk of hospitalization or institutionalization.

Ongoing Special Condition: Has the same meaning as ongoing special condition defined in N.C. Gen. Stat. § 58-67-88(a)(1).

Outpatient Commitment: Occurs pursuant to N.C.G.S. § 122C, Article 5, Part 7, when a judge orders a person to receive treatment in the community for their BH condition. Before ordering Outpatient Commitment, the outpatient provider must agree to accept the patient into treatment and serve as the responsible party for the management and supervision of the Outpatient Commitment order.

Participating Provider: Participating provider or ”par” providers are physicians or other health care providers that have a contractual agreement with the BH I/DD Tailored Plan and are included in the BH I/DD Tailored Plan’s Network. Participating providers may also be called “in-network providers”.

Performance Incentive Payments: Payments additional to fee for service, Tailored Care Management payments, and any medical home fees that are contingent upon AMH Practices, AMH+ Practices, or CMAs’ reporting of and/or performance against Performance Metrics.

Permanent Supportive Housing (PSH): A program that has the same meaning as “permanent supportive housing” in 24 C.F.R. § 578.3 and offers safe and stable housing environments with voluntary and flexible supports and services to help people manage serious, chronic issues such as mental and substance use disorders. PSH is based on the following principles: 1) Choice in housing; 2) No prerequisite for housing placement; 3) Functional separation of housing and services; 4) Decent, safe, and affordable housing; 5) Housing is integrated into the community; 6) Rights of tenancy; 7) Housing access and privacy; and 8) Flexible, voluntary recovery-focused services. .

Pharmacy Claim: A request for payment that a healthcare provider submits to an insurer for rendered pharmaceuticals or pharmacy services, including outpatient pharmacy (point-of-sale claims) as well as physician-administered (professional claims) drug claims

Pharmacy Encounter: A record of a rendered service provided by a healthcare provider for pharmaceuticals or pharmacy services, including outpatient pharmacy as well as physician-administered drugs.

Pharmacy Service Line: A service line to assist pharmacies and prescribers participating in the Medicaid program with point of sale claims questions and pharmacy prior authorizations and clinical coverage criteria, resolve claims payment and adjudication issues, and address general provider questions.

PHP Contract Data Utility (PCDU): A secure file transfer platform to allow for posting of Department guidance to the BH I/DD Tailored Plans and submission of key contract deliverable and reports by the BH I/DD Tailored Plans for review and approval by the Department.

Pilot Eligibility and Service Assessment (PESA): A Department-standardized tool in NCCARE360 that facilitates the documentation of a member’s eligibility for the Healthy Opportunities Pilot and Pilot services, and the authorization of Pilot services.

Pilot Implementation Period: A period of time during which BH I/DD Tailored Plans, Network Leads, HSOs, and Designated Pilot Care Management Entities build the capacity and infrastructure to participate in the Healthy Opportunities Pilot and prepare for Pilot service delivery.

Pilot Service Delivery Period: A period of time during which Healthy Opportunities Pilot services are delivered to Pilot enrollees. The Pilot Service Delivery Period is divided into sub-periods to align with State Fiscal Years.

Post-stabilization Care Services: Has the same meaning as post-stabilization care services as defined in 42 C.F.R. § 438.114(a).

Protected Health Information (PHI): Has the same meaning as PHI as defined by 45 C.F.R. § 160.103.

Potential Member: A beneficiary enrolled in Medicaid and eligible for enrollment in a BH I/DD Tailored Plan, but not enrolled in that BH I/DD Tailored Plan.

Pregnancy Management Program: A care program that encourages adoption of best prenatal, pregnancy, and perinatal care for Medicaid Managed Care members.

Prepaid Health Plan (PHP): Has the same meaning as Prepaid Health Plan, as defined in N.C. Gen. Stat. § 108D-1(30). A PHP is an MCO. A PHP may operate a Standard Plan or a BH/IDD Tailored Plan.

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 all the member’s health care needs and to initiate and monitor referrals for specialized services, when required.

Program of All-Inclusive Care for the Elderly (PACE): A federal program that provides a capitated benefit for individuals age fifty-five (55) and older who meet nursing facility level of care. PACE features a comprehensive service delivery system and integrated Medicare and Medicaid financing.

Provider: Provider means any individual or entity that is engaged in the delivery of services, or ordering or referring for those services, and is legally authorized to do so by the State in which it delivers the services. (42 C.F.R. § 438.2).

Provider (for the purposes of credentialing): Individual practitioners and facilities, hospitals, health systems, entities, organizations, atypical organizations/providers, and institutions, unless otherwise noted.

Provider-based Care Management: Care management where the care manager is affiliated with an AMH+ practice or CMA and performs care management at the site of care, in the home, or in the community through in-person and other methods of interaction between members and providers.

Provider Contracting: The process by which the BH I/DD Tailored Plan negotiates and secures a contractual agreement with credentialed providers that will be included in in the BH I/DD Tailored Plan’s Network, or with out-of-network providers.

Provider Enrollment: The process by which a provider is enrolled in the North Carolina’s Medicaid or State-funded Services programs with credentialing as a component of enrollment. A provider who has enrolled in North Carolina’s Medicaid programs shall be referred to as a “Medicaid Enrolled provider” or an “Enrolled Medicaid provider.” A provider who has enrolled in North Carolina’s State-funded Services program shall be referred to as a “State-funded Services Enrolled provider” or an “Enrolled State-funded Services provider.”

Provider Grievance: Any oral or written complaint or dispute by a provider over any aspects of the operations, activities, or behavior of the BH I/DD Tailored Plan except for any dispute over for which the provider or related member has appeal rights.

Provider Support Service Line: A service line available to Medicaid and State-funded Services providers with enrollment, service authorization, contracting, or reimbursement questions or issues, and resolve provider questions, comments, inquiries and complaints.

Qualified Health Plan (QHP): Means a health plan that has in effect a certification that it meets the standards described in subpart C of part 156 of Title 45 of the Code of Federal Regulations issued or recognized by each Exchange through which such plan is offered in accordance with the process described in subpart K of part 155 of Title 45 of the Code of Federal Regulations. 45 C.F.R. § 155.20.

Qualified Interpreter: Has the same meaning as described in 45 C.F.R. § 92.4.

Readily Accessible: Has the same meaning as defined in 42 C.F.R. § 438.10(a).

Readiness Review: Has the same meaning as described in 42 C.F.R. § 438.66(d).

Reasonable Accommodation: A reasonable accommodation is a change, exception, or adjustment to a rule, policy, practice, or service that may be necessary for a person with disabilities to have an equal opportunity to use and enjoy a dwelling, including public and common use spaces, or to fulfill their program obligations.

Receiving Entity: The entity (e.g., BH I/DD Tailored Plan, Standard Plan, NC Medicaid Direct) that is enrolling the transitioning member and receiving the member’s information.

Recipient: an individual who is actively receiving a State-funded Service or State-funded function (e.g., care management or diversion).

Redeterminations: The annual review of Beneficiaries’ income, assets and other information by the Department and county DSS offices to confirm eligibility for North Carolina Medicaid.

Region: The group of counties for which a BH I/DD Tailored Plan arranges for services. Also referred to as Catchment Areas.

Remote Patient Monitoring: Remote patient monitoring is the use of digital devices to measure and transmit personal health information from a patient in one location to a provider in a different location. Remote patient monitoring enables providers to collect and analyze information such as vital signs (e.g., blood pressure, heart rate, weight, blood oxygen levels) in order to make treatment recommendations.

Reprocess: For the purposes of Claims and Encounters, the activities completed by a BH I/DD Tailored Plan to reconsider the outcome of a previously adjudicated claim.

Security Assertion Markup Language (SAML): The State’s preferred standard for the implementation of identity and access management. 190. Service Organization Control: reports on various organizational controls related to security, availability, processing integrity, confidentiality or privacy.

Settlement Agreement: Means the court-enforceable Settlement Agreement between the United States and the State of North Carolina files with the Court on August 23, 2012 and modified in October 2017 and which created the Transition to Community Living (TCL) program.

Shadow Claim: Refers to the claims record against non-Medicaid funds.

Significant Change: Means any change in the services offered by BH I/DD Tailored Plans, the benefits, the geographic service area, and the composition of or payments to the BH I/DD Tailored Plan’s network, and the enrollment of a new population in the BH I/DD Tailored Plan.

Single-Stream Funding: State-funding that is authorized by the General Assembly and disbursed to the LME/MCOs and subsequently the BH I/DD Tailored Plans to pay for State-funded BH, I/DD, and TBI services.

Special Categorical State-Funds: State-funds dedicated to members of a category defined by statute, grants, or legislation.

Standard Plan or Standard Benefit Plan: Has the same meaning as Standard Plan as defined in N.C. Gen. Stat. § 108D-1(36).

State: The State of North Carolina, the Department as an agency or in its capacity as the Using Agency.

State Developmental Center: State-operated certified Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID) that provides residential, medical, habilitation, and other supports to individuals with intellectual and developmental disabilities who have complex behavioral challenges and/or medical conditions and for whom appropriate community-based services are not available.

State Fair Hearing: The hearing conducted at the Office of Administrative Hearings (OAH) under N.C. Gen. Stat. § 108D-15 to resolve a dispute between a member and a BH I/DD Tailored Plan about an Adverse Benefit Determination.

State-Fund Balance: Comprised of any state funds allocated by DMH/DD/SAS that were not expended in prior fiscal years.

State-funded Services: Refers to state and non-Medicaid federally funded services for mental health, I/DD, TBI and substance abuse.

Subgrantee: The BH I/DD Tailored Plan or other legal entity to which a sub-grant is awarded or sub award is made and which is accountable to the grantee for the use of the funds provided. The terms sub grant/subgrantee and sub award/sub recipient are used interchangeably in practice.

Substance Abuse Prevention and Treatment Block Grant (SAPTBG): SAMHSA grant disbursed annually to North Carolina to provide for planning, implementing and evaluating activities that prevent and treat substance abuse and promote public health.

Supports Intensity Scale (SIS)®: An assessment tool designed to measure the level of practical supports required by individuals with I/DD.

Tailored Care Management: The care management model for BH I/DD Tailored Plan members.

Tailored Care Management Payments: Per member per month, acuity-tiered payments made to AMH+ practices, Care Management Agencies (CMAs), and BH I/DD Tailored Plans for the provision of Tailored Care Management. Tailored Care Management Payments will be subject to rates set by DHHS, which shall not be placed at risk.

Telehealth: Telehealth is the use of two-way real-time interactive audio and video to provide and support health care services when participants are in different physical locations.

Transitions of Care: The process of assisting a member to transition between BH I/DD Tailored Plans; from Standard Plans to BH I/DD Tailored Plans; between delivery systems; including transitions that result in the disenrollment from managed care. Transitions of care also includes the process of assisting a member to transition between providers upon a provider’s termination from the BH I/DD Tailored Plan network.

Transferring Entity: The entity (e.g., BH I/DD Tailored Plan, Standard Plan, Medicaid Direct) that is disenrolling the transitioning member and transferring the member’s information. 213. Transition Entity: Department-designated entity responsible for coordinating transition of care activities and supporting members through the transition between service delivery systems. Transition entities include BH I/DD Tailored Plans, other Tailored Plans, CCNC, Tribal Option and other designated entities. 214. Transition Notice Date: The date a transitioning member’s anticipated enrollment change is reflected on the Tailored Plan’s eligibility file.

Traumatic Brain Injury Waiver (TBI Waiver): The Section 1915(c) Home and Community-Based Services (HCBS) waiver for eligible individuals with traumatic brain injury (TBI) that the BH I/DD Tailored Plan operates in its geographic area. The TBI Waiver may not operate in all geographic areas of the state. Contract requirements for the TBI Waiver apply for the BH I/DD Tailored Plan to the extent that the TBI Waiver is operational in its geographic area.

Unit Cost Reimbursement (UCR): An expenditure paid in support of services that are not supported with an approved shadow claim and are not disallowed per federal guidelines. Unit Cost Reimbursement is for State-funded Services only.

Unmet Health-Related Resource Needs: Non-medical needs of individuals that foundationally influence health, including but not limited to needs related to housing, food, transportation and addressing interpersonal violence/toxic stress.

Value-Added Services: Services in addition to those covered under the Medicaid Managed Care benefit plan that are delivered at the BH I/DD Tailored Plan’s discretion and are not included in capitation rate calculations. Value-added services are designed to improve quality and health outcomes, and/or reduce costs by reducing the need for more expensive care.

Value-Based Payment (VBP): Payment arrangements between BH I/DD Tailored Plans and providers that fall within Levels 2 and 4 of the multi-payer Health Care Payment (HCP) Learning and Action Network (LAN) Alternative Payment Model (APM) framework.

Vendor: A company, firm, entity or individual, other than the Contractor, with whom the Department has contracted for goods or services.

Video Remote Interpreting: Has the same meaning as described in 28 C.F.R. § 35.104.

Virtual Patient Communication: The use of technologies other than video to enable remote evaluation and consultation support between a provider and a patient or a provider and another provider. Virtual patient communication services include: telephone conversations (audio only); virtual portal communications (e.g., secure messaging); and store and forward (e.g., transfer of data from beneficiary using a camera or similar device that records (stores) an image that is sent by telecommunication to another site for consultation).

Warm Handoff: Time-sensitive, member-specific planning for Care-Managed members or other members identified by either the transferring or receiving entity to ensure continuity of service and care management functions. “Warm Handoffs” require collaborative transition planning between both transferring and receiving entities and, when possible, occur prior to the transition.

Warm Transfer: Occurs when a call from a beneficiary, member, or provider is transferred directly from the original call center to the appropriate party during business hours without requiring the caller to make an additional call and without the BH I/DD Tailored Plan abandoning the call until the other party answers.

Work First: North Carolina’s Temporary Assistance for Needy Families (TANF) program that provides parents with short-term training and other services to help them become employed and move toward self-sufficiency.

X12 Transactions: Any EDI transaction included in the standard. This includes but is not limited to the 834 Benefit Enrollment and Maintenance, the 837 Health Care Claim, and the 277 Health Care Information Status Notification. The entire transaction set can be found at

Abbreviations and Acronyms

AAP: American Academy of Pediatrics

ACD: Automated Call Distribution System

ACA: Patient Protection and Affordable Care Act

ACE: Adverse Childhood Experience

ACGME: Accreditation Council for Graduate Medical Education

ACH: Adult Care Home

ADATC: Alcohol and Drug Abuse Treatment Center

ADL: Activities of Daily Living

ADT: Admission, Discharge, Transfer

AMH: Advanced Medical Home

AMH+: Advanced Medical Home Plus

ANSA: Adult Needs and Strengths Assessment

API: Administrative Provider Identification

APM: Alternative Payment Method

ASAM: American Society for Addiction Medicine

ASC: Accredited Standards Committee

AVRS: Automated Voice Response System

AWOL: Absence Without Leave

BAA: Business Associate Agreement

BAHA: Bone Conduction Hearing Aids

BCCCP: Breast and Cervical Cancer Control Program

BH: Behavioral Health

BIP: Behavioral Intervention Plan

CAH: Critical Access Hospital

CAHPS: Consumer Assessment of Healthcare Providers and Systems Plan Survey

CANS: Children and Adolescents Needs and Strengths

CAP: Corrective Action Plan

CAP/C: Community Alternatives Program for Children

CAP/DA: Community Alternatives Program for Disabled Adults

CASP: Cross Area Service Program

CBO: Community-Based Organization

CCNC: Community Care of North Carolina

CCO: Chief Compliance Officer

CDC: Centers for Disease Control

CDSA: Children’s Developmental Services Agency

CEO: Chief Executive Officer

CFAC: Consumer and Family Advisory Committee

CFO: Chief Financial Officer

CFT: Child and Family Team

CHIP: Children’s Health Insurance Program

CIN: Clinically Integrated Network

CIO: Chief Information Officer

CIP: Community Integration Plan

CM: Care Management

CMA: Care Management Agency

CMC: Children with Medical Complexity

CMO: Chief Medical Officer

CMP: Civil Monetary Penalty

CMS: Centers for Medicare & Medicaid Services

COD: Cost of Dispensing

CP: Commercial Plan

CPT: Current Procedural Terminology

CVO: Credentialing Verification Organization

DAAS: Division of Aging and Adult Services

DHB: Division of Health Benefits

DHHS: Department of Health and Human Services

DHSR: Division of Health Service Regulation

DID: Direct Inward Dialing

DIT: Department of Information Technology

DME: Durable Medical Equipment

DMH/DD/SAS: Division of Mental Health, Developmental Disabilities and Substance Abuse Services

DMVA: Department of Military and Veterans Affairs

DOI: Department of Insurance

DOS: Date of Service

DSOHF: Division of State Operated Healthcare Facilities

DSS: Division of Social Services

DUR: Drug Utilization Review

EB: Enrollment Broker

EBCI: Eastern Band of Cherokee Indians

ECSII: Early Childhood Services Intensity Instrument

EDI: Electronic Data Interchange

EFT: Electronic Funds Transfer

EHR: Electronic Health Record

EPS: Episodic Payment System

EPSDT: Early and Periodic Screening, Diagnostic and Treatment

EQRO: External Quality Review Organization

ESRD: End Stage Renal Disease

EUP: End User Procedures

EVV: Electronic Visit Verification

FAR: Federal Acquisition Regulation

FDA: Food and Drug Administration

FEP: First Episode Psychosis

FFS: Fee-for-Service

FFY: Federal Fiscal Year

FQHC: Federally Qualified Health Center

HCPCS: Healthcare Common Procedure Coding System

HEARTS: Healthcare Enterprise Accounts Receivable Tracking System

HHS: U.S. Department of Health and Human Services

HIE: Health Information Exchange

HIPAA: Health Insurance Portability and Accountability Act

HIPP: Health Insurance Premium Payment

HIT: Health Information Technology

HITECH: Health Information Technology for Economic and Clinical Health Act

HIV: Human Immunodeficiency Virus

HRSA: Health Resources and Services Administration

HSO: Human Service Organizations

I/DD: Intellectual/Developmental Disability

ICF: Intermediate Care Facility

ICF-IID: Intermediate Care Facility for Individuals with Intellectual Disabilities

IDG: Interdisciplinary Group

IDM: Identity Management

IDM Tool: Informed Decision Making Tool

IEM: Inborn Errors of Metabolism

IEP: Individualized Education Program

IFSP: Individual Family Service Plan

IHCP: Indian Health Care Provider

IHP: Individual Health Plan

ILOS: In Lieu of Services

IMB: Into the Mouth of Babes

IMCE: Indian Managed Care Entities

IMD: Institution for Mental Disease

IPA: Independent Practice Association

IPS: Interactive Purchasing System

IPV: Interpersonal violence

IRF: Inpatient Rehabilitation Facility

IRS: Internal Revenue Service

ISP: Individual Support Plan

ITD: Information Technology Division (DHHS)

LAN: Learning and Action Network

LCMHC: Licensed Clinical Mental Health Counselor

LCSW: Licensed Clinical Social Worker

LEA: Local Education Agencies

LEIE: List of Excluded Individuals/Entities

LEP: Limited English Proficient

LGBTQ: Lesbian, Gay, Bisexual, Transgender, Questioning

LHD: Local Health Department

LP: Licensed Practitioners

LME/MCO: Local Management Entities/Managed Care Organization

LMFT: Licensed Marriage and Family Therapist

LPA: Licensed Psychological Associate

LPE: Lead Pilot Entity

LPN: Licensed Practical Nurse

LTSS: Long-Term Service and Supports

MAC: Maximum Allowable Cost

MAO: Medicare Advantage Organization

MCAC: Medical Care Advisory Committee

MCO: Managed Care Organization

MES: Medicaid Enterprise System

MHPAEA: Mental Health Parity and Addiction Equity Act

MID: North Carolina Attorney General’s Medicaid Investigations Division

MIMS: Medicaid Integrated Modular Solution

MIS: Management Information Systems

MLR: Medical Loss Ratio

MME: Morphine Milligram Equivalent

MMIS: Medicaid Management Information Systems

MOA: Memorandum of Agreement

NADAC: National Average Drug Acquisition Cost

NC: North Carolina

NC FAST: North Carolina Families Accessing Services through Technology

NCAC: North Carolina Administrative Code

NCCI: National Correct Coding Initiative

NCDPH: North Carolina Division of Public Health

NCGA: North Carolina General Assembly

NCHC: North Carolina Health Choice

NCID: North Carolina Identity Management Service

NCIR: North Carolina Immunization Registry

NCPDP: National Council for Prescription Drug Programs

NCQA: National Committee for Quality Assurance

NDC: National Drug Code

NEMT: Non- Emergency Medical Transportation

NIEM: National Information Exchange Model

NPI: National Provider Identifier

NPPES: National Plan and Provider Enumeration System

NQF: National Quality Forum

OAH: Office of Administrative Hearings

OCR: Office of Civil Rights

OFAC: Office of Foreign Assets Control

OMB: Office of Management and Budget

PA: Prior Authorization

PACE: Program of All-Inclusive Care for the Elderly

PBM: Pharmacy Benefit Managers

PCDU: PHP Contract Data Utility

PCP: Primary Care Provider

PCS: Personal Care Services

PDL: Preferred Drug List

PDM: Provider Data Management

PDN: Private Duty Nursing

PDSA: Plan-Do-Study-Act

PESA: Pilot Eligibility and Service Assessment

PHA: Public Housing Authorities 176. PHHS: Public Health and Human Services

PHE: Public Health Emergency

PHI: Protected Health Information

PHP: Prepaid Health Plan

PI: Program Integrity

PIHP: Prepaid Inpatient Health Plans

PIP: Performance Improvement Program

PLE: Provider-Led Entity

PMPM: Per Member Per Month

PRC: Purchased/Referred Care

PRTF: Psychiatric Residential Treatment Facility

PSH: Permanent Supportive Housing

PSO: North Carolina Department of Health and Human Services Privacy and Security Office

PTA: Privacy Threshold Analysis

QAPI: Quality Assurance and Performance Improvement

QHP: Qualified Health Plan

REOMB: Recipient Explanation of Medical Benefit

RFA: Request for Application

RHC: Rural Health Clinic

RN: Registered Nurse

ROI: Return on Investment

SAM: System of Award Management

SAMHSA: Substance Abuse and Mental Health Services Administration

SAML: Security Assertion Markup Language

SBI: North Carolina State Bureau of Investigation

SBIRT: Screening, Brief Intervention, and Referral to Treatment

SED: Serious Emotional Disturbance

SFTP: Secure File Transfer Protocol

SID: System Integration Design

SIP: System Integration Plan

SIS: Supports Intensity Scale®

SIU: Special Investigations Unit

SLA: Service Level Agreements

SLPA: Speech/Language Pathology Assistant

SMA: State Medicaid Agency

SMAC: State Maximum Allowable Cost

SMI: Serious Mental Illness

SNF: Skilled Nursing Facility

SOC: Service Organization Control

SP: Standard Plan

SPH: State Psychiatric Hospital

SSA: Social Security Act

SSADMF: Social Security Administration Death Master File

SUD: Substance Use Disorder

SUPPORT: Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act

TBI: Traumatic Brain Injury

TCL: Transition to Community Living

TDD: Telecommunications Device for the Deaf

TP: Tailored Plan

TPA: Third Party Administrator

TPL: Third Party Liability

TTY: Text Telephone

UM: Utilization Management

VBP: Value-based Payments

VEO: Visual Evoked Potential

VFC: Vaccines for Children

VRI: Video Remote Interpreting

WCA: Web Content Accessibility Guidelines

WHCRA: Women’s Health and Cancer Rights Act of 1998

WIC: Women, Infants and Children

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