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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 health plan participants or for providers.

Alliance Health
Provider Support: 855-759-9700
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Home / Services / Medicaid B: Outpatient Behavioral Health Assessment (CESH, TFCBT, SOSE, Diagnostic)

Medicaid B: Outpatient Behavioral Health Assessment (CESH, TFCBT, SOSE, Diagnostic)

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About

Coverage Information Icon

Medicaid Direct (Medicaid B)

Diagnosis Group(s) Information Icon

Developmental Disability, Mental Health, Substance Use

Age Group(s) Information Icon

18, 18-20, Adults 18+, All, Child

Reference Documents

Authorization

Submission Requirements Information Icon

Clinical Assessment (90791, 90792)

  • Child and Adult
  • Clinical Coverage Policy 8C
  • No prior approval up to maximum of 2 per fiscal year
  • Service Authorization Request (SAR) required beyond maximum of 2 per fiscal year

Diagnostic Assessment (T1023)

  • Child and Adult
  • Clinical Coverage Policy 8A-5
  • No Prior Approval up to maximum of 1 per fiscal year
  • Service Authorization Request (SAR) required beyond maximum of 1 per fiscal year

Comprehensive Evaluation of Sexual Harm-CESH (90899)

  • Child Only (up to age 21)
  • Service Authorization Request (SAR)

Trauma Focused Assessment (90791 22 Z1)

  • Child Only (up to age 21)
  • Clinical Coverage Policy 8C
  • Unmanaged benefit limited to scope in provider network contract
  • Maximum of 1 Assessment per fiscal year

Trauma Informed Comprehensive Clinical Assessment – TICCA (90791 22 Z2)

  • Child Only (up to age 21)
  • Clinical Coverage Policy 8C
  • Service Authorization Request (SAR)
  • Assessment identifying justification

Service Definition Authorization Parameters Information Icon

Clinical Assessment (90791, 90792)

  • Maximum of 2 per fiscal year

Diagnostic Assessment (T1023)
Comprehensive Evaluation of Sexual Harm-CESH (90899)
Trauma Focused Assessment (90791 22 Z1)
Trauma Informed Comprehensive Clinical Assessment – TICCA (90791 22 Z2)

  • Maximum of 1 per fiscal year

Request Prior Approval from Alliance Health

Service Codes & Descriptions

  • 90791 22 SE Z1 - SOSE Encounter
  • 90791 - Psychiatric Diagnostic Evaluation (No Medical Services)
  • 90791 U3 SE - SOSE Assessments
  • 90791 22 IN - LOC Assessment
  • 90791 CA -Facility Based assessment
  • 90791 - SP GT Psychiatric Diagnostic Evaluation
  • 90899- Comprehensive Evaluation for Sexual Harm (CESH)
  • T1023 - Diagnostic Assessment
  • T1023GT-Diagnostic Assessment
  • 90791 ES - Access
  • 90791 GT- Psychiatric Diagnostic Evaluation (No Medical Services)
  • 90792 - Psychiatric Diagnostic Evaluation With Medical Services
  • 90792GT - Psychiatric Diagnostic Evaluation With Medical Services
  • 90791 22 Z1 - Trauma Focused Assessment
  • 90791 22 Z1 GT - Trauma Focused Assessment
  • 90791 22 Z2- Psychiatric Diagnostic Evaluation; Specialty Child Service

Full Service Definition

<a target="_blank" href="https://medicaid.ncdhhs.gov/8c-outpatient-behavioral-health-services-provided-direct-enrolled-providers/download?attachment">Download PDF</a>
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<a target="_blank" href="https://medicaid.ncdhhs.gov/8a-5-diagnostic-assessment-0/download?attachment">Download PDF</a>
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Alliance Statement of Work

Alliance Provider Support is available to answer provider questions about authorization, billing, claims, enrollment, ACS, or other issues.

Call 855-759-9700 Monday-Saturday from 7:00am-6:00pm.