Currentalliance_health_ncPolicy 8D-4

Clinically Managed Population Specific High-Intensity Residential Program (ASAM Level 3.3) for beneficiaries with SUD and TBI

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Defines Medicaid coverage, eligibility, and specific clinical criteria for a high-intensity residential rehabilitation program (ASAM Level 3.3) for beneficiaries with co-occurring substance use disorder (SUD) and traumatic brain injury (TBI) in the NC Medicaid program.

Policy Summary

Payeralliance_health_nc

PolicyClinically Managed Population Specific High-Intensity Residential Program (ASAM Level 3.3) for beneficiaries with SUD and TBI

Policy CodePolicy 8D-4

Change TypeNo material change

Effective Date

Last ReviewJan 1, 2026

Next Review Date

Key ActionProviders must bill H0047 (Billing Unit = 1, Unit = 1 Day) for this program and ensure required documentation and credentialing are maintained.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ASAM 3.3Program level

18+Medicaid age eligibility

24-hour24-hour environment

7 days

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Currentalliance_health_ncPolicy 8D-4

Clinically Managed Population Specific High-Intensity Residential Program (ASAM Level 3.3) for beneficiaries with SUD and TBI

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Policy Summary

Payeralliance_health_nc

PolicyClinically Managed Population Specific High-Intensity Residential Program (ASAM Level 3.3) for beneficiaries with SUD and TBI

Policy CodePolicy 8D-4

Change TypeNo material change

Effective Date

Last ReviewJan 1, 2026

Next Review Date

Key ActionProviders must bill H0047 (Billing Unit = 1, Unit = 1 Day) for this program and ensure required documentation and credentialing are maintained.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ASAM 3.3Program level

18+Medicaid age eligibility

24-hour24-hour environment

7 days

30 daysPerson-Centered Plan (PCP)

Jan 1, 2026Medicaid amended date

Coverage Criteria and Clinical Requirements

inv-01: Covered when ALL of the following are met

Medicaid shall cover the service when medically necessary and general coverage conditions are met, and when all specific criteria below are satisfied.

General coverage conditions: (a) individualized, specific, and consistent with symptoms/confirmed diagnosis and not in excess of needs; (b) can be safely furnished and no equally effective more conservative/less costly treatment is available statewide; (c) furnished not primarily for convenience of beneficiary/caretaker/provider.

from Section 3.1

Specific Medicaid coverage criteria: (a) current SUD diagnosis per DSM-5; (b) meets ASAM Level 3.3 admission criteria per The ASAM Criteria, Third Edition; (c) documented diagnosis of TBI as defined in Section 1.1; (d) able to actively engage in treatment services with identified support according to their Person-Centered Plan.

from Section 3.2.1

inv-02: Specific Criteria Covered by Medicaid — ALL required criteria for coverage

Medicaid shall cover Clinically Managed Population Specific High-Intensity Residential Program services when ALL of the following are met

Covered when ALL of the following are met: a. has a current substance use disorder (SUD) diagnosis as defined by DSM-5; b. meets ASAM Level 3.3 admission criteria as defined in The ASAM Criteria, Third Edition, 2013; c. has a documented diagnosis of TBI as defined in Section 1.1; and d. is able to actively engage in treatment services with identified support according to their Person-Centered Plan.

inv-03: Admission Criteria and Assessments — documented elements required in service record (ALL/ANY nested logic)

Admission documentation requirements (must include ALL of the following documented elements in service record)

Admission assessment content: initial abbreviated physician assessment including: presenting problem; needs and strengths; provisional/admitting diagnosis; ASAM level determination; physical exam including pregnancy testing as indicated and labs/toxicology within 24 hours; medical records confirming TBI or NC TBI Physician Referral Form; social/family/medical history; other necessary evaluations; RN alcohol/drug-focused nursing assessment at admission; CCA or DA completed by licensed professional within 7 days including NC TBI Waiver Risk Support Needs Assessment and NC TBI Waiver Wellness Assessment.

Observational information from first 7 days must be included and assessments updated as new strengths/barriers observed.

inv-04: Continued Stay and Discharge Criteria — criteria and decision points for continued stay and discharge

Continued stay and discharge determinations

Continued stay criteria: The beneficiary meets the criteria for continued stay if ANY ONE of: 1) The beneficiary has achieved initial PCP goals and requires this service to meet additional goals; 2) The beneficiary is making progress but hasn't achieved goals yet, so continuing at the present level of care is indicated; 3) The beneficiary is not making progress, is regressing, or new problems have been identified and the beneficiary has the capacity to resolve the problems; 4) The beneficiary is actively working towards goals and the PCP is modified to identify more effective interventions.

Each of the six ASAM dimensions must be reviewed and documented for determinations.

Discharge criteria: The beneficiary meets the criteria for discharge if ANY ONE of: 1) The beneficiary has achieved positive life outcomes that support stable and ongoing recovery; 2) The beneficiary's admitting signs and symptoms have failed to respond to treatment and have intensified indicating transfer to a more intensive level of residential care; 3) The beneficiary is not making progress or is regressing and all realistic treatment options have been exhausted indicating a need for more intensive services; 4) The beneficiary or their legally responsible person requests discharge from the program.

Each of the six ASAM dimensions must be reviewed and documented for determinations.

inv-05: Initial Coverage Criteria — facility, provider, staffing, program, and training requirements (ALL must be met)

Covered when ALL of the following facility, provider, staffing, program, and training requirements are met:

Provider eligibility: Provider organization must meet NC Medicaid provider qualification policies; comply with 10A NCAC 27G or equivalent tribal code; be credentialed and contracted by the DHHS designated contractor; achieve national accreditation within one calendar year of enrollment; and be a legally constituted entity capable of meeting Medicaid enrollment and certification requirements.

See policy Section 6.1

Licensing and facility: Service must be provided in a facility licensed under 10A NCAC 27G Section .5600 Supervised Living (or approved rule waiver) and meet physical/environmental accommodations for beneficiaries with TBI.

See policy Section 6.1 and 6.3.a

Staffing: Minimum of two staff on-site whenever a beneficiary is present; program-specific staffing expectations including screening/admission coverage; designated Medical Director and Program Director with policies for admission and intake; staff to provide 24-hour emergency consultation and crisis behavioral interventions as needed.

The policy definition of Traumatic Brain Injury (TBI) explicitly excludes brain injuries that are congenital or degenerative. Providers must therefore document a TBI that meets the policy criteria (open or closed head injury, resulting functional impairments, etc.) and ensure the injury is not congenital or degenerative for this service to be considered covered.

Medicaid does not cover certain nonclinical or non-treatment activities. Specifically, transportation for the beneficiary or family members, habilitation activities, and recreational activities unless they are tied to a specific planned social skill intervention are excluded. Other exclusions include childcare, academic instruction, interventions not on the Person-Centered Plan (PCP), and payment for room and board.

There are no additional Medicaid-specific criteria not covered for this service. The policy states None apply under Medicaid Additional Criteria Not Covered.

Providers must comply with all applicable agreements, federal, state, and local laws and regulations in effect when the service is rendered, including HIPAA and record retention requirements, and all NC Medicaid clinical coverage policies, manuals, implementation updates, and relevant bulletins. Programs must also comply with confidentiality rules such as 42 CFR Part 2. Note that federally recognized tribal and IHS providers may be exempt from one or more items where allowed by federal law and regulations.

North Carolina Medicaid will not reimburse for conversion therapy. This prohibition applies to services billed under this policy and is stated as a clear reimbursement exclusion.

If a beneficiary does not meet the program eligibility requirements in Section 2.0 or the coverage criteria in Section 3.0, the service is not covered. Coverage requires that all applicable eligibility and clinical criteria be satisfied; otherwise reimbursement is precluded.

Billing Codes, Units, and Assessment Timeframes

Covered HCPCS CodesHCPCSCovered

H0047

Clinically Managed Population Specific High-Intensity Residential Program; Billing Unit = 1, Unit = 1 Day

Assessment and documentation timeframes

Physical exam timeframePhysician or physician extender must perform a physical examination (including pregnancy testing as indicated) within 24 hours of admission

CCA/DA completionComprehensive Clinical Assessment (CCA) or Diagnostic Assessment (DA) must be completed by a licensed professional within 7 calendar days of admission

Verbal service order countersignatureIf a verbal service order is used, the appropriate professional must countersign and date the service order within 72 hours

MOA/MOU provider proximity requirement (MAT)

MOA/MOU proximity for MATIf MAT is provided via MOA or MOU with another provider, that provider must be no further than 60 minutes from the facility

MAT access requirement

Provider Requirements, Prior Authorization, and Operational Policies

Prior Authorization

Prior approval required when applicable (EPSDT note)

If the service requires prior approval, prior approval remains required even for beneficiaries under 21. Refer to NCTracks and EPSDT guidance for details on submitting prior approval requests and EPSDT exceptions.

Prior Authorization

No prior approval required for this program

Medicaid shall not require prior approval for Clinically Managed Population Specific High-Intensity Residential Program services.

Note

Admission availability and operational policies

The facility must operate 24 hours a day, seven days a week and be available for admission at least five days per week. Providers must have written policies and procedures for admission expectations, intake processes, and staffing/back-up consultation coverage.

Program Background and Scope

This service represents an ASAM Level 3.3 Clinically Managed Population Specific High-Intensity Residential Program: a 24-hour structured recovery environment that combines high-intensity clinical services for beneficiaries with co-occurring substance use disorder and traumatic brain injury whose cognitive or functional impairments make lower-intensity care ineffective. The program addresses impaired awareness/ambivalence about substance use, provides relapse prevention and cognitive-appropriate therapies, and supports community reintegration through a person-centered plan completed within 30 days and assessments completed within seven calendar days of admission.

Key Definitions

Traumatic Brain Injury (TBI) definition and exclusion

TBI definitionTraumatic Brain Injury (TBI) is an injury to the brain caused by an external physical force resulting in total or partial functional disability or psychosocial impairment and meets criteria including open/closed head injury, may occur with or without loss of consciousness, and results in impairments in cognition, language, memory, attention, judgment, motor and other functions

Event characteristicsTBI may result from a single event or a series of events (including multiple concussions)

Exclusion noteTBI definition does not include brain injuries that are congenital or degenerative

Medication Assisted Treatment (MAT)

MAT definitionMedication Assisted Treatment (MAT) is the use of FDA‑approved medications combined with counseling and behavioral therapies to treat substance use disorders, tailored to each beneficiary's needs

Policy Summary

Payeralliance_health_nc

PolicyClinically Managed Population Specific High-Intensity Residential Program (ASAM Level 3.3) for beneficiaries with SUD and TBI

Policy CodePolicy 8D-4

Change TypeNo material change

Effective Date

Last ReviewJan 1, 2026

Next Review Date

Key ActionProviders must bill H0047 (Billing Unit = 1, Unit = 1 Day) for this program and ensure required documentation and credentialing are maintained.

SourceLink

On This Page

See policy Sections 6.3.b, 6.3.d and Staffing Requirements

Program components: Program must include initial abbreviated assessment with TBI assessment at admission; monitoring of intoxication and withdrawal; CCA/DA within 7 days; Person-Centered Plan within 30 days; daily clinical services and scheduled addiction/co-occurring treatment; cognitive, behavioral, and other therapies paced for TBI; access to MAT (on-site or via MOA/MOU within 60 minutes); access to Level I/II trauma hospital within 45 minutes; referrals for cognitive rehabilitation; medication monitoring; peer support; family involvement; discharge planning beginning at admission.

See policy Sections 6.3.e (components) and 6.3 (program requirements)

Training: Staff must complete required trainings prior to service delivery and within specified timeframes (including naloxone use, SUD and TBI care, medication administration, behavioral/cognitive interventions, ASAM criteria, motivational interviewing, trauma-informed care); some trainings require approval by NC DHHS recognized accreditation entities; waivers allowed if documentation shows appropriate training within prior 48 months.

See policy Section 6.4 Staff Training Requirements

Operational availability: Facility must operate 24 hours a day, seven days a week; physician available for consultation 24 hours a day; program medical staff and crisis-trained staff available for 24-hour emergency consultation; service must be available for admission five days per week.

See policy Section 6.3.a and 6.3.d

Providers shall ensure access to FDA‑approved medications for Medication Assisted Treatment (MAT) for beneficiaries who meet medical necessity

On‑site MAT optionMAT may be administered directly by the facility as an alternative to an MOA/MOU

Trauma center proximity requirement

Trauma center proximityProviders shall ensure access to a Level I or Level II trauma hospital no further than 45 minutes from the facility

Trauma center criteria referenceTrauma hospitals must meet requirements of 10A NCAC 13P .0901 Level I or Level II Trauma Center Criteria

Transfer protocolsProgram policies and protocols must specify when physician care or transfer to an acute care hospital is necessary

Billing Unit

Billing codeH0047 — Clinically Managed Population Specific High‑Intensity Residential Program

Billing unitBilling Unit = 1; Unit = 1 Day

Coding guidanceReport the most specific CPT/HCPCS or unlisted code that accurately describes the service per current coding manuals

Facility operates 24/7; admission availability at least five days/week
Program must have physician-supported policies for admission, intake, and staffing/back-up

Billing Rule

Billing unit and separable E/M billing

Bill the Clinically Managed Population Specific High-Intensity Residential Program using HCPCS code H0047 with a billing unit of 1 = 1 day. Evaluation and management CPT codes for medical assessments may be billed separately when appropriate.

H0047 — Billing Unit = 1, Unit = 1 Day
E/M CPTs (e.g., medical exam, lab work) may be billed separately

Note

Provider actions (placeholder)

(No specific action text provided in source.)

Step Therapy

Single-provider restriction during episode of care

A beneficiary shall receive Clinically Managed Population Specific High-Intensity Residential Program services from only one provider organization during any active episode of care; services must not be provided and billed on the same day (except admission or discharge day) with the listed other services.

Only one provider organization per active episode of care
Do not bill program on same day as other specified residential/outpatient services except admission/discharge

Note

Ensure access to MAT and delivery options

Providers shall ensure access to FDA‑approved medications for Medication Assisted Treatment (MAT) for beneficiaries who meet medical necessity; MAT may be administered on-site or via a Memorandum of Agreement/Memorandum of Understanding (MOA/MOU) with another provider located no further than 60 minutes from the facility.

Access to FDA‑approved MAT medications required when medically necessary
MOA/MOU MAT partners must be within 60 minutes if MAT is provided off-site

Denial Risk

Conversion therapy is not reimbursable

North Carolina Medicaid shall not reimburse for conversion therapy. Providers must not bill Medicaid for conversion therapy services.

Documentation Required

EPSDT documentation to exceed limits (under 21)

For beneficiaries under 21, providers must document medical necessity per EPSDT criteria to exceed policy limits; note that prior approval remains required when the service requires it and EPSDT guidance resources are available in NCTracks and on the EPSDT provider page.

Document how the requested service corrects or ameliorates a condition per EPSDT
Follow NCTracks guidance for EPSDT/prior approval submissions

Documentation Required

Initial abbreviated physician assessment — required record elements

An initial abbreviated physician assessment must be included in the service record at admission and must document: presenting problem; needs and strengths; provisional/admitting diagnosis; ASAM level determination; physical exam (including pregnancy testing as indicated) with labs/toxicology within 24 hours; medical records confirming TBI or NC TBI Physician Referral Form; social/family/medical history; plus a Registered Nurse alcohol/drug-focused nursing assessment at admission.

Physical exam and indicated labs/toxicology within 24 hours of admission
RN alcohol/drug-focused nursing assessment at admission
Use NC TBI Physician Referral Form if medical records do not confirm TBI

Documentation Required

Maintain staff licensure, certification, and training records

Providers must retain documentation demonstrating staff licensure, certifications, and training records; training documentation must be maintained and certain trainings require approval by NC DHHS recognized accreditation entities.

Maintain licensure and certification records for clinicians and nursing staff
Retain training records; some trainings require accreditation entity approval

Billing Rule

Claims and billing documentation compliance

Claims must comply with the NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, and NC Medicaid clinical coverage policies; programs must retain training and service documentation as required. Federally recognized tribal and IHS providers may have exemptions as allowed by law.

Follow NCTracks and Medicaid bulletins for claims submission
Retain documentation as required for audits and billing support

Billing Rule

Coding specificity and documentation requirements

Report ICD-10-CM and PCS codes to the highest level of specificity using the current edition at the time of service. Use the most specific CPT/HCPCS code that accurately describes the procedure or an appropriate unlisted code when necessary.

Use current ICD-10 edition and highest specificity supporting medical necessity
Use most specific CPT/HCPCS; use unlisted codes if no specific code exists

Note

Verify Medicaid eligibility at each encounter

Providers shall verify each Medicaid beneficiary's eligibility at each service encounter. A beneficiary may have service restrictions due to their eligibility category that make them ineligible for this service.

Verify Medicaid eligibility at every service rendering
Confirm any eligibility-related service restrictions before providing/billing

Denial Risk

Coverage denial conditions — eligibility, criteria, duplication, trial

Services are not covered if the beneficiary does not meet Section 2.0 eligibility, does not meet the criteria in Section 3.0, duplicates another provider's service, or is experimental/investigational/part of a clinical trial.

Prior Authorization

Credentialing and accreditation required or risk noncoverage

Provider organizations must be credentialed and contracted by the DHHS designated contractor and must achieve national accreditation within one calendar year of enrollment; failure to meet these requirements may preclude billing eligibility.

Credentialing and contract with DHHS designated contractor required
Obtain national accreditation within one calendar year of enrollment

Documentation Required

Maintain minimum on-site staffing (≥2) and staffing ratio policies

Programs must maintain a minimum of two staff on-site at all times when a beneficiary is present; develop and adhere to staffing ratio policies considering census and acuity to ensure health, safety, and availability of clinical supports.

Minimum two staff on-site whenever a beneficiary is present
Staffing ratio policies must account for number of residents and acuity

Billing Rule

Claims must comply with NCTracks and clinical coverage policies

Claims that do not comply with NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, and NC Medicaid clinical coverage policies may be denied; follow Attachment A for claims-related requirements and retain supporting documentation.

Noncompliant claims risk denial
Follow Attachment A and NCTracks guidance for correct billing

MAT provides a 'whole patient' approach integrating medications with psychosocial interventions

Medication approvalMedications used in MAT are approved by the Food and Drug Administration (FDA)

ASAM Criteria, Third Edition — six dimensions overview

ASAM frameworkThe ASAM Criteria, Third Edition is a comprehensive framework for assessment and service planning using six dimensions

Dimension 1Acute Intoxication and Withdrawal Potential

Dimension 2Biomedical Conditions and Complications

Dimension 3Emotional, Behavioral, or Cognitive Conditions and Complications

Dimension 4Readiness to Change

Dimension 5Relapse, Continued Use, or Continued Problem Potential

Dimension 6Recovery and Living Environment

TBI diagnosis — documentation requirements and NC TBI Physician Referral

TBI diagnosis documentationMedical records confirming a TBI diagnosis as defined in Section 1.1 must be included in the service record at admission

NC TBI Physician Referral alternativeIf medical records confirming TBI are unavailable, providers may use the NC TBI Physician Referral Form to confirm diagnosis

Inclusion in assessmentsTBI confirmation must be part of the initial abbreviated physician assessment and incorporated into the CCA/DA and PCP

ASAM Level 3.3 definition reference

ASAM Level referenceAdmission to this program requires meeting ASAM Level 3.3 admission criteria as defined in The ASAM Criteria, Third Edition (2013)

ASAM purposeASAM criteria establish the required admission level of care and guide service planning for co‑occurring conditions

Source editionThe ASAM Criteria, Third Edition (2013) is cited as the standard for Level 3.3 admission

Person‑Centered Plan (PCP) definition and timeframe

PCP timeframePerson‑Centered Plan (PCP) must be completed within 30 calendar days of admission

PCP contentPCP must identify problems across ASAM dimensions two through six, treatment goals, measurable objectives, and activities to meet those objectives

PCP rolePCP guides individualized treatment and documents supports needed for active engagement in services

CCA or DA definition and completion timeframe

CCA/DA definitionComprehensive Clinical Assessment (CCA) or Diagnostic Assessment (DA) is a licensed‑professional assessment to determine ASAM level of care and discharge planning

Completion timeframeCCA or DA must be completed within seven (7) calendar days of admission and include observational information from the first seven days

Assessment updatingThe CCA/DA must be updated as new strengths and barriers are observed in the residential setting and relevant diagnostic information documented in the PCP

Place of Service — licensed residential facility

Place of serviceServices are provided in a licensed residential facility as identified in Section 6.0

Licensing standardFacility licensing follows requirements under 10A NCAC (see Section 6.0 program and facility licensing requirements)

Environment requirementsPhysical and environmental layout must meet the unique needs of beneficiaries with TBI (lighting, noise, privacy, medication storage/transportation protocols)