Authorize services via the annual ISP

Waiver services are authorized through the annual Individual Support Plan (ISP). Beneficiaries have a care coordinator and may select any qualified network provider; enrollment in the LME‑MCO serving the beneficiary's county is mandatory. Providers must ensure services are delivered only pursuant to the ISP authorization.

• Services authorized via annual ISP; provider must deliver services consistent with ISP.
• Beneficiary has care coordinator and freedom of choice among qualified network providers (subject to mandatory enrollment in LME‑MCO).

Follow PIHP utilization management and prior‑approval processes

LME/PIHPs perform utilization management, prior approval activities, provider network credentialing and enrollment, and provider reimbursement; DMA contracts with EQRO, MMIS, and actuarial contractors to assist with administrative and operational functions. Providers must follow PIHP utilization management and prior authorization procedures.

• LME/PIHPs conduct utilization management and prior approval activities.
• DMA contracts with EQRO, MMIS, and actuarial contractors to support enrollment and payments.

Adhere to assigned operational responsibilities

Operational responsibilities are allocated across the Medicaid agency, contracted entities, and local non‑state entities per the distribution table; functions include participant enrollment, LOC evaluation, review of service plans, prior authorization, utilization management, provider enrollment and credentialing, execution of provider agreements, and rate methodology. Providers must comply with the entity designated to perform each function in their contract/network.

• Table assigns responsibilities among Medicaid Agency, Contracted Entity, and Local Non‑State Entity for enrollment, LOC, authorizations, utilization management, provider enrollment and rates.
• Providers must follow processes specified by the responsible entity (PIHP or DMA) per contract.

Provide adverse‑action notice and appeal information

If entrance to the waiver is denied or an individual is terminated, the PIHP must send written notice stating the reason, instructions on how to request a fair hearing (including time frames), information about continuation of services during appeal (if applicable), and contact information for questions and concerns.

• PIHP sends written notice explaining the adverse action and the reason.
• Notice must include fair hearing instructions, deadline to request hearing, continuation‑of‑services information (if applicable), and contact details.

Complete PIHP entrance screening and determination

Applicants apply via the PIHP Access Center; intake/screening includes administration of the TBI Level of Care Form and the NC TBI Risk/Support Needs Assessment. The PIHP clinical director (MD, DO, or PhD) reviews identified health/safety risks and determines whether the waiver can meet the individual's needs, and provides written notice of the assessment outcome.

• Application through PIHP Access Center; complete TBI LOC Form and NC TBI Risk/Support Needs Assessment during intake.
• PIHP clinical director reviews assessments and determines ability to meet needs; written outcome notice provided.

Prioritize reserved capacity for emergencies and MFP

Reserved capacity slots are prioritized for individuals with documented emergency needs and for Money Follows the Person (MFP) participants when reserved slots are available; if reserved capacity is not available, individuals are prioritized according to non‑reserved criteria.

• Emergency slots awarded first to individuals meeting emergency criteria documented by a professional.
• MFP participants receive priority for reserved MFP slots when available; otherwise standard prioritization applies.

Conduct LOC evaluations using approved instrument

The State implements the approved LOC processes/instruments (NC TBI Level of Care Assessment) to evaluate and re‑evaluate applicants' and participants' level of care consistent with institutional LOC definitions. LOC evaluations must be completed per the approved schedule and retained as required.

• Use the NC TBI Level of Care Assessment for initial and annual LOC determinations.
• LOC evaluations must align with hospital, NF or ICF/IID level‑of‑care criteria.

PIHP initial verification and periodic re‑verification of credentials

PIHPs must verify provider and agency credentials at initial review and must re‑verify agency credentials, including a sample of employee qualifications, at a frequency determined by the PIHP but no less than every three years. Providers must ensure employee qualifications are verified at hire.

• PIHP verifies credentials upon initial review and re‑verifies agency credentials and samples of employee qualifications no less than every three years.
• Providers verify employee qualifications at hire.

Verify employee qualifications at hire; expect PIHP re‑verification

Providers must verify employee qualifications at the time of hire. The PIHP is responsible for credential verification at initial review and for agency re‑verification, including a sample of employee qualifications, at a frequency determined by the PIHP but not less than every three years.

• Provider responsibility: verify employee qualifications at hire.
• PIHP responsibility: initial credential review and re‑verification of agency credentials and employee samples at least every three years.

Perform enrollment verification every ≤3 years

PIHP and provider must verify qualifications prior to initial enrollment and at least every three years thereafter. Providers and PIHPs should document verification evidence as required by enrollment procedures.

• Verification required prior to initial enrollment and at minimum every three years.
• Documentation of verification must be maintained per PIHP/DMA requirements.

Follow PIHP credentialing and DHSR licensure verification processes

PIHPs must credential providers initially and re‑verify credentials at least every three years; supervised living facilities are licensed by DHSR and the facility verifies employee qualifications on hire with PIHP re‑verification no less than every three years.

• PIHP credentialing at initial enrollment and re‑verification at least every three years.
• DHSR inspects and licenses supervised living facilities; facilities verify employee qualifications upon hiring.

Maintain verification responsibilities and frequency

Provider agencies must verify employee qualifications at hire. The PIHP performs initial credential review and re‑verifies agency credentials and a sample of employee qualifications at a PIHP‑determined frequency, not less than every three years.

• Provider verification at hire is mandatory.
• PIHP re‑verification of agency credentials and employee samples no less than every three years.

Expect PIHP re‑verification of agency credentials every ≤3 years

The PIHP must verify and re‑verify agency credentials, including a sample of employee qualifications, at a frequency determined by the PIHP but no less than every three years; providers verify employee qualifications at hire.

• PIHP‑determined re‑verification frequency (minimum every three years) for agency credentials and employee samples.
• Provider role: verify employees at hiring.

Obtain MCO prior authorization for waiver OT exceeding State Plan limits

Occupational Therapy waiver services are provided when State Plan OT limits are exhausted; waiver OT is limited to a maximum of 3,120 units per year (1 unit = 15 minutes) and requires prior authorization from the MCO because waiver funding is payer of last resort.

• OT provided only when State Plan limits are exhausted and waiver is last‑resort payer.
• Maximum 3,120 units/year (1 unit = 15 minutes).
• MCO prior authorization required for waiver‑funded OT services.

Obtain MCO prior authorization for waiver‑funded OT/PT/ST

When HCBS/TBI waiver funding is used as the funding source of last resort for OT, PT, or ST services that exceed State Plan limits, providers must obtain prior authorization from the MCO; the maximum combined limit is 3,120 units per year (1 unit = 15 minutes).

• Prior authorization from MCO required when waiver funds are last‑resort for OT/PT/ST.
• Maximum combined rehabilitation therapies limit: 3,120 units/year (1 unit = 15 minutes).

Get MCO prior authorization for waiver speech‑language therapy

Speech‑language therapy provided by the waiver beyond State Plan limits is funded as last resort and requires prior authorization from the MCO; the services are limited to a maximum of 3,120 units per year (1 unit = 15 minutes) either alone or combined with other TBI waiver rehabilitation therapies.

• Waiver funds are payer of last resort for speech‑language therapy beyond State Plan limits.
• MCO prior authorization required for waiver‑funded speech‑language therapy.
• Maximum 3,120 units/year combined across PT/OT/ST (1 unit = 15 minutes).

Comply with $20,000 Assistive Technology cap and documentation rules

Assistive Technology expenditures are limited to $20,000 over the life of the waiver period; providers must follow PIHP verification procedures and obtain required written professional recommendations and documentation of medical necessity as specified in the Assistive Technology service requirements.

• Lifetime/waiver‑period cap: $20,000 for Assistive Technology.
• Professional recommendation and Certificate of Medical Necessity/prescription required; PIHP verifies provider qualifications prior to first use.

Adhere to CR annual unit limit and provider qualifications

Cognitive Rehabilitation (CR) is limited to 192 units annually (15‑minute units). Providers must ensure CR does not duplicate Specialized Consultation or Natural Supports Education and that CR is delivered by appropriately licensed clinicians per provider qualifications.

• CR limit: 192 15‑minute units per year.
• CR providers must meet licensure/education/experience requirements and avoid duplication of similar services.

Perform required verification and credentialing actions

PIHPs verify provider qualifications at initial review and annually thereafter for individuals where specified; providers verify employee qualifications at hire; PIHPs re‑verify agency credentials no less than every three years.

• PIHP: initial verification and annual verification thereafter (for individuals where specified).
• Provider: verify employee qualifications at hire.
• PIHP: re‑verify agency credentials no less than every three years.