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NC Medicaid Behavioral Health and Intellectual/Developmental Disabilities Tailored Plans will launch July 1, 2024. Choice period ends on May 15, 2024. Please call to select your PCP. Find PCPs available in our health plan.

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

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Medicaid B: HRI Residential (Level 1, Level 2 Group, Level 3 and Level 4)

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About

Coverage Information Icon

Medicaid Direct (Medicaid B)

Diagnosis Group(s) Information Icon

Mental Health, Substance Use, Developmental Disability

Age Group(s) Information Icon

Adults 18+, Child, 18-20

Authorization

Submission Requirements Information Icon

Level 1 Family Type (H0046)
Initial: In Network Providers are eligible for Notification Authorization of up to 180 days.  Out of Network providers are not eligible for Notification Authorization and are required to submit the following:

  • Service Authorization Request (SAR)
  • Person Centered Plan (PCP) with Service Order
  • Comprehensive Clinical Assessment (CCA)

Concurrent:

  • Service Authorization Request (SAR)
  • Updated Person Centered Plan (PCP)

Level 2 Group Home (H2020)
Initial: In Network Providers are eligible for Notification Authorization of 120 days.  Out of Network providers are not eligible for Notification Authorization and are required to submit the following:

  • Service Authorization Request (SAR)
  • Person Centered Plan (PCP) with Service Order
  • Comprehensive Clinical Assessment (CCA)

Concurrent:

  • Service Authorization Request (SAR)
  • Updated Person Centered Plan (PCP)
  • Comprehensive Clinical Assessment (CCA) within prior 60 days for continued stay beyond 12 months

Level 3 and Level 4 Group Home (H0019 with modifiers)
Mandatory referral to Care Management

Initial: In Network Providers are eligible for Notification Authorization of 120 days for Level 3 and 60 days for Level 4.  For Level 4, members must be age 14+ to be eligible for Notificaiton Authorization. Out of Network providers are not eligible for Notification Authorization and are required to submit the following:

  • Service Authorization Request (SAR)
  • Person Centered Plan (PCP) with Service Order
  • Comprehensive Clinical Assessment (CCA) completed within 30 calendar days from the requested initial authorization start date
  • Transition/Discharge Plan (Federally Required)

Concurrent:

  • Service Authorization Request (SAR)
  • Updated Person Centered Plan (PCP)
  • Transition/Discharge Plan (Federally Required)
  • For length of stay beyond 180 days: Independent updated Psychiatric or Psychological Evaluation. If provider is a CABHA agency, this is not required to be an independent evaluation

Level 3 SAY Program (H0019 TJ HE)
Mandatory referral to Care Management

Initial: In Network Providers are eligible for Notification Authorization of 120 days.  Out of Network providers are not eligible for Notification Authorization and are required to submit the following:

  • Service Authorization Request (SAR)
  • Person Centered Plan (PCP) with Service Order
  • Comprehensive Clinical Assessment (CCA) or CCA addendum completed within 30 days prior to admission
  • Transition/Discharge Plan (Federally Required)
  • A current specific evaluation that addresses sexual harm behaviors (within last 3-6 months)
  • If psychological w/in last 30 days that addresses both MH and the sexualized behaviors, this can be accepted without CCA

Concurrent:

  • Service Authorization Request (SAR)
  • Updated Person Centered Plan (PCP)
  • Transition/Discharge Plan (Federally Required)
  • For length of stay beyond 180 days: Independent updated Psychiatric or Psychological Evaluation
  • If provider is a CABHA agency, this is not required to be an independent evaluation

 

Service Definition Authorization Parameters Information Icon

Level 1 Family Type (H0046)

  • Concurrent: up to 180 days

Level 2 Group Home (H2020)

  • Concurrent: up to 90 days

Level 3, Level 3 SAY Program and Level 4 Group Home (H0019 with modifiers)

  • Concurrent: up to 30 days

Service Codes & Descriptions

  • H0019 HQ 22- Enhanced Residential for Complex Needs
  • H0019 22 US HE - Res L3 >5 Specialized Prog
  • H0019 HK - HRI Res Level IV 4 beds or less
  • H0019 HQ - HRI Res Level III, 4 beds or less
  • H0019 TJ - HRI Res Level III, 5 beds or more
  • H0019 UR HRI Res Level IV, 5 beds or more
  • H0046 - HRI Residential level I
  • H2020 - HRI Residential Level II Group Home
  • H0019 TJ HE- HRI Res Level III 5 beds or more

Full Service Definition

<a target="_blank" href="https://medicaid.ncdhhs.gov/8d-2-residential-treatment-services/download?attachment">Download PDF</a>

Alliance Statement of Work