ModifiedAlliance HealthPolicy 12B

HIV Case Management (HIV CM)

This policy governs North Carolina Medicaid coverage, eligibility, and provider requirements for HIV Case Management services that help eligible beneficiaries access medical, social, and educational supports and require establishment of a medical home with CCNC/NCCCN.

Policy Summary

PayerAlliance Health

PolicyHIV Case Management (HIV CM)

Policy CodePolicy 12B

Change TypeOperational & Administrative

Effective Date

Next Review Date

Key ActionObtain a written physician or attending practitioner's order prior to initiation of HIV Case Management and for continuation beyond two consecutive months.

SourceLink

POLICY UPDATE CHANGES

Reduced number of initial quality assurance visits and capped chart reviews.

Updated policy template language due to North Carolina Health Choice Program's move to Medicaid.

16monthly unit limit per beneficiary

≤30:1beneficiary-to-staff ratio

noneprior approval

15 minbilling unit

12 hrs

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annual CEU requirement

Coverage and Medical Necessity

General Coverage/Service Description

Covered when services facilitate access to medical, social, and educational needs and beneficiary is enrolled in NC Medicaid and maintains the required medical home.

HIV CM coverage requirements: Beneficiary is enrolled in NC Medicaid; services assist access to needed medical, social, and educational supports; beneficiary establishes and maintains a medical home with the Community Care of North Carolina (CCNC) Program and Network; North Carolina Community Care Networks, Inc. (NCCCN) coordinates overall health care.

Refer to Subsection 5.6 for core service component definitions.

Eligible Categories

Beneficiary categories that may be eligible

Eligible beneficiary categories: Beneficiaries with regular Medicaid identification (MID) cards; beneficiaries covered by Medicaid for Pregnant Women (MPW) may be eligible due to pregnancy-related risks or complications.

MPW eligibility is limited to pregnancy-related conditions but may include HIV CM given potential impact on pregnancy, fetus, or infant.

General medical necessity criteria

Covered when ALL of the following are met

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

General Medicaid medical necessity rules.

HIV diagnosis documentation requirement

Covered when ANY ONE of the following documents proves HIV diagnosis

Acceptable HIV diagnosis documentation: a. Confidential positive HIV test results using: (1) antibody testing with two or more repeated positive ELISA tests; (2) positive ELISA/EIA confirmed by Western Blot; or (3) positive HIV RNA test; b. Physician's statement indicating diagnosis; c. Hospital discharge statement or other medical report verifying diagnosis; d. Copy of approval for participation in the North Carolina AIDS Drug Assistance Program (ADAP).

Documentation must contain at least one of the listed items.

Infant coverage

Special coverage exception

Infants of HIV-infected mothers: Infants (birth to 12 months) born to HIV-infected mothers are covered for HIV Case Management regardless of the infant's HIV status.

Coverage provided without regard to the infant's HIV status.

Covered services with required documentation and frequencies

Covered when the provider delivers the defined HIV case management core components and documents them as required

Core components must be performed and documented: Intake and assessment; care planning; referral, linkage and resource development; monitoring and follow-up; reassessment; and discharge/termination as defined in Subsection 5.6.

Each core component must be fully documented in the beneficiary record and the CM must sign assessment and care plan documents.

Monitoring and follow-up frequency: Monitoring and follow-up activities are to be conducted monthly (preferred), but at least quarterly, and as frequently as necessary to determine adequacy of services and need for plan adjustments.monthly (preferred) / at least quarterly

Monthly contact with CCNC Network or PCP required to report specified items; use DMA-3155 or similar tracker.

Reassessment frequency: Reassessment must be conducted at least every 12 months and as needed secondary to unanticipated events or changes in status.

Medicaid for Pregnant Women — additional coverage coordination

Pregnant beneficiaries qualifying under MPW are high-risk and require additional coordination in addition to standard monitoring

MPW additional risk factor coordination: Case manager shall assure the beneficiary receives an annual physical exam and coordinate care for risk factors including tobacco use, homelessness, substance abuse, intimate partner violence, anemia, hypertensive disorders, other chronic diseases, fetal complications, hyperemesis, and mental illness.

These coordination activities are additive to standard monitoring requirements.

Initial provider certification criteria

Provider shall meet ALL of the following to qualify for reimbursement:

Provider Certification Criteria: a) Documented successful record of three (3) years providing or managing HIV CM programs; b) Ensure HIV CM services are provided by qualified case managers per policy; c) Ensure supervision by qualified supervisors per policy; d) Enroll each physical site with NC Medicaid; e) Meet applicable state and federal laws for Medicaid participation; f) Maintain certification as a qualified provider; g) Demonstrate compliance with initial and ongoing certification processes; h) Demonstrate compliance with monitoring and evaluation of case management records through a quality improvement plan; i) Allow NC Medicaid or DHHS contractor to review beneficiary, operational and financial records; j) Notify NC Medicaid/DHHS contractor of proposed changes within 30 days and actual changes within five business days; k) Achieve national accreditation within one year of enrollment with a designated accrediting agency.

See Subsection 6.2.1 for full details.

Initial certification application contents

Initial certification requires submission of a complete application including administrative, case management, and human resource documentation as specified:

Administrative Requirements: Provide list of counties served; hours of operation; emergency after-hours plan; community resource list; articles of incorporation (unless local government); physical business site verified by site visit (site must not be a private residence or vehicle); organizational chart; list of owners with ≥5% ownership; access to NCCCN web applications; business plan and financial statements; computer capability meeting NC Medicaid IT/HIPAA/electronic billing/EFT requirements; comply with precertification onsite visit and licensure/certification requirements; have written policies including confidentiality, grievance, beneficiary rights, non-discrimination, code of ethics, conflict of interest, electronic records, medical records retention/security, freedom of choice, transfer/discharge, and abuse/neglect/exploitation identification.

Applications incomplete after 90 days will be returned.

Case Management Requirements: Describe core components (Subsection 5.6) and staff positions including FTEs; provide a quality improvement plan measuring beneficiary outcomes and monitoring/evaluation of records, tracking complaints/resolutions, conducting studies, assuring claims/service record accuracy, and assuring staff meet qualifications.

See Subsection 6.2.3 Case Management Requirements.

Recertification

To be recertified (valid for two years), the provider must:

Recertification Criteria: Submit a complete and signed Recertification Application within 60 calendar days of receipt; submit copies of items changed since initial certification; submit copies of all HIV CM and supervisor credentials; submit annual summaries of quality improvement activities including outcome metrics; submit to a recertification on-site visit including beneficiary record review; note that applications incomplete after 90 days will be returned. NC Medicaid may provide provisional recertification for six months if site visits show noncompliance to allow monitoring.valid for 2 years

See Subsection 6.2.4 for details.

Decertification

A provider may be decertified if any one of the following is substantiated:

Decertification grounds: Failure to provide core service components; fraudulent billing practices; owner(s) convicted of a felony; failure to develop/submit/implement written plan of correction within 30 days; falsification of records; violation of beneficiary confidentiality; employment of unqualified staff; staff failure to complete mandatory basic training within 90 days; failure to obtain required CEUs; failure to provide supervision; failure to submit required documentation within policy timeframes; failure to provide documentation sufficient to support billing; failure to implement/enforce a quality improvement program; failure to notify NC Medicaid/DHHS contractor of required changes within required timeframes; failure to comply with applicable federal/state laws and policies; failure to enroll beneficiaries within four months of certification; failure to achieve/maintain certification requirements.

This list is not all inclusive; provider may be dis-enrolled and may request reconsideration per regulation.

Documentation, timing, and record retention criteria

Covered when documentation and time-frame requirements are met as specified below

Required beneficiary record elements: Intake with proof of HIV status incorporated into the medical record within 15 calendar days; assessments; written attestation of proper and secure record storage; care plans with documented timelines; progress notes; medication sheet; contact sheets; discharge notification/summary as applicable; beneficiary consent forms (release of information, consent for case management, rights); and physician or attending practitioner's written order obtained prior to initiation (PCP written order required to continue beyond two consecutive months and must indicate diagnosis and medical necessity).proof of HIV status within 15 days

Progress notes minimum content specified separately.

Progress note requirements: Progress notes must document activities tied to care plan goals; place and date of service; nature, extent and duration of time (1 unit = 15 minutes) including start/end times and number of minutes/units; CM legal signature with title; statements reflecting individualized care; quarterly care plan updates including communication with PCP; documentation of all direct and indirect contacts with beneficiary and support network/providers; documentation if beneficiary declined services; and documentation of achievement of care plan goals.incorporate within 24 hours of contact

Quality assurance, corrections, and expansion

Quality assurance and expansion criteria

Quality Assurance Site Visits: Newly certified providers receive two QA site visits within the first year; site visits include technical assistance, medical record/billing review, review of staff qualifications and training, chart review of 10% of active and closed caseload or 10 beneficiary records (whichever is fewer), investigation of complaints, and verification of quality improvement activities.10 records or 10%

Failure to correct deficiencies can result in decertification or referral to Program Integrity.

Corrective action: If unmet program requirements are identified, provider must submit a written plan of correction within 30 calendar days; additional QA visits scheduled as needed to verify compliance.30 days

Provider responsible for implementing corrections.

Expansion request requirements:

Coverage criteria for HIV Case Management

Covered when ALL of the following are met

Service delivery and place: Service is a one-to-one HIV Case Management interaction delivered in an office, the beneficiary's primary private residence, or an adult care home.

HIV CM shall not be billed when beneficiary is institutionalized except on the dates of admission and discharge.

Billing unit and monthly limits: Provider reports units where 1 unit equals 15 minutes of service; total billed units must not exceed 16 units per calendar month per beneficiary.<=16 units/month

Billing more than 16 units per calendar month per beneficiary may be denied.

Single-beneficiary rule: Provider shall not bill units that represent billing for more than one beneficiary during any specified period of the day.

HIV CM is based on one-to-one interaction between CM and beneficiary.

The following aid categories are ineligible for HIV Case Management: beneficiaries covered only by the Medicaid for Family Planning Waiver and Medicaid beneficiaries receiving Medicare benefits (Medicare-qualified beneficiaries). Providers must verify eligibility before delivering or billing HIV CM services.

HIV Case Management services are not covered while a beneficiary is institutionalized in the listed facilities, including a general hospital, psychiatric hospital, nursing facility or inpatient detoxification, an intermediate care facility for individuals with intellectual and developmental disabilities (ICF-IDD), any form of incarceration, or a halfway house that provides case management. Services may be provided and billed only on the date of a beneficiary's admission and on the date of discharge; otherwise billing is excluded when the beneficiary is institutionalized.

Provision of treatment adherence education and counseling is considered a direct service and is not coveredlinking the beneficiary to a provider who can deliver adherence education or counseling rather than delivering it directly as an HIV CM activity.

Beneficiaries receiving HIV Case Management shall not also receive other Medicaid-reimbursed case management services that would duplicate targeted programs (for example, Community Alternatives Programs, at‑risk case management, or targeted case management for intellectual/developmental disability). Providers must avoid duplication of Medicaid case management services.

When requesting to expand services, the expansion site must be a physical business site and must not be located in a private residence or a vehicle. If the expansion area is more than 60 miles from the existing office a new physical site is required and must be enrolled with Medicaid.

HIV Case Management shall not be billed while a beneficiary is institutionalized, except that services performed on the date of admission and the date of discharge may be billed. Billing for institutional discharge planning is specifically excluded.

HIV Case Management cannot be billed on the same day as any Community Alternatives Program (CAP) service (including Choice Option), behavioral health/intellectual developmental disability case management, or at‑risk case management for adults or children. Providers must ensure no same‑day billing conflicts with these programs.

Services are not medically necessary and therefore not covered when the beneficiary does not meet the eligibility requirements in Section 2.0, does not meet the coverage criteria in Section 3.0, or when the procedure/service duplicates another provider's service. Services that are experimental, investigational, or part of a clinical trial are also not covered.

Failure to adhere to policy requirements may lead to corrective actions including submission of a written plan of correction; persistent or significant noncompliance can result in decertification or provisional recertification and referral to the NC Medicaid Program Integrity Program. Decertification may be imposed for substantiated conditions such as failure to provide core service components or to correct identified deficiencies.

Provider Responsibilities, Documentation, and Billing

Prior Authorization

Prior Approval Requirement

Prior Approval: Prior approval is not required for HIV Case Management (HIV CM) services. However, when a beneficiary is under 21 years of age and the requested service ordinarily requires prior approval, EPSDT does not waive the prior approval requirement; providers must follow EPSDT guidance and submit prior approval requests when applicable. Providers must verify eligibility at each service encounter and follow NCTracks/EPSDT guidance for prior approval processes.

No prior approval required specifically for HIV CM services.
If a service normally requires prior approval, EPSDT does not eliminate that requirement for beneficiaries under 21 — follow NCTracks and EPSDT guidance.

Note

Prior approval not required

No prior approval is required for HIV Case Management services delivered under this policy. Providers must still verify beneficiary eligibility at each encounter and must not assume coverage if the beneficiary's aid category or enrollment status renders them ineligible for HIV CM.

Verify Medicaid eligibility at each service.

Billing Codes, Units, and Limits

Attachment A: Claims-Related Information (sections listed)mixed

No codes listed

ICD-10-CM CodesICD-10

ICD-10-CM

ICD-10-CM Codes reflecting highest level of medical necessity for HIV Case Management

Claim types / Billingmixed

CMS-1500/837P

Professional claim type; Institutional claims billed per National Uniform Billing Guidelines

ICD-10-CM CodesICD-10

ICD-10-CM

Codes reflecting highest level of medical necessity for HIV Case Management

Covered CPT/HCPCS CodesmixedCovered

G9012

CPT/HCPCS code for HIV Case Management

Unlisted Procedure or ServiceCPT|HCPCS

Unlisted CPT/HCPCS

Use appropriate unlisted procedure or service code and submit special report per current CPT/HCPCS instructions

Unlisted Procedure or ServiceCPT|HCPCS

Unlisted CPT/HCPCS

Refer to and comply with current CPT/HCPCS instructions for Unlisted Procedure or Service and submit Special Report as required

inv-30: Monthly service unit limit — 16 units per calendar month

Monthly service unit limit16 units per calendar month

Unit billing cap noteBilling more than 16 units per calendar month per beneficiary may be denied

EPSDT exceptionEPSDT may allow exceeding limits for beneficiaries under 21 if medically necessary per EPSDT guidance

inv-31: Beneficiary to staff ratio — may not exceed 30 to 1

Beneficiary-to-staff ratioMay not exceed 30 to 1

Program Background and Scope

HIV Case Management (HIV CM) assists eligible North Carolina Medicaid beneficiaries in accessing needed medical, social, and educational services and supports. Services are intended to establish and maintain a medical home with the Community Care of North Carolina (CCNC) Program, with NCCCN coordinating overall health care. HIV CM core components include intake and assessment, care planning, referral and linkage, monitoring and follow‑up, reassessment, and discharge/termination, all of which must be fully documented in the beneficiary record.

Definitions and Expected Outcomes

inv-67: Definitions — document states 'None Apply' for definitions specific to this section

Definitions specific to this sectionNone Apply

Referencing noteUse policy body for operational definitions and terms when needed

LocationSee Subsection 1.1 in policy document

inv-68: Documented diagnosis of HIV disease or HIV seropositivity — acceptable documentation examples

Acceptable HIV diagnosis documentationConfidential positive HIV test results (Ab testing with 2+ positive ELISA; positive ELISA/EIA confirmed by Western Blot; or positive HIV RNA)

Alternate documentationPhysician's statement indicating diagnosis; hospital discharge statement or other medical report that verifies diagnosis

Policy Changes and Revision History

Policy Summary

PayerAlliance Health

PolicyHIV Case Management (HIV CM)

Policy CodePolicy 12B

Change TypeOperational & Administrative

Effective Date

Next Review Date

Key ActionObtain a written physician or attending practitioner's order prior to initiation of HIV Case Management and for continuation beyond two consecutive months.

SourceLink

On This Page

Reassessment follows Assessment and Care Planning requirements.

Discharge process requirements: Written notification to beneficiary at least seven business days prior to discharge (unless beneficiary requests immediate discharge); prepare written discharge summary placed in record within seven days and sent to the beneficiary's PCP; discharge summary must include identifying information, referral/linkage resources, summary of services, reason/effective date, and CM signature and credentials.7 business days notice / 7 days summary placement

Multiple allowed reasons for termination outlined in policy.

Human Resource Requirements: Provide HR policies for credential validation, continuing education, criminal background checks; plans for covering caseload if staffing insufficient; delegation of management authority; volunteer utilization and supervision; submit supervision and training plan, CM orientation and annual in-service plan, networking plan with CCNC or PCP, and plan for tracking CM skills/competencies; owners/operators must not have disqualifying felony convictions; employ qualified/trained CMs and supervisors or contract for those services.

See Subsection 6.2.3 Human Resource Requirements.

Progress notes must be incorporated into the record within 24 hours of contact.

Timing requirements: Initial assessment completed within five business days of referral; care plan completed within five business days of assessment; contact sheet completed with care plan and updated at least every three months; beneficiary contacted within 30 calendar days of care plan completion and at least quarterly thereafter; care plan reviewed at least every three months; annual reassessment at least every 12 months; annual beneficiary satisfaction survey; written notice of termination/change sent seven business days prior to change; document any deviations in progress notes.initial assessment/care plan within 5 business days; contact within 30 days; review at least every 3 months; annual reassessment

Providers must document deviations in progress notes.

Electronic records and retention: Keep electronic clinical and billing documentation for a minimum of six years; promptly retrieve and provide electronic copies of signed documents upon request; present records with necessary equipment to read them; retain hard copies if unable to maintain historical documentation electronically; ensure electronic signatures comply with state regulations.6 years

Records must be available for audits and claims review.

Expansion requests must be submitted to NC Medicaid or DHHS contractor; new physical site required if area is more than 60 miles from existing office (expansion site must not be a private residence or vehicle); designate at least one CM for new site meeting qualifications; enroll new site with Medicaid to receive separate provider number; provide resource list for proposed area; provider must have no significant citations/corrective actions in past 18 months and be compliant with laws and policies.

60 miles; 18 months citation-free

Expansion applications incomplete after 90 days will be returned.

Medicaid for Family Planning Waiver and Medicare Qualified Beneficiaries are not eligible for HIV CM.

Prior Authorization

Physician order required

Physician or attending practitioner's written order must be obtained prior to initiation of HIV CM services. If HIV CM continues beyond two consecutive months, the beneficiary's Primary Care Physician (PCP) must provide a written order attesting to medical necessity. For managed care/CCNC enrolled beneficiaries, the PCP/medical home must be involved in ongoing authorization and coordination; annual physician attestation is required if services continue and unmet needs persist.

Written order required prior to initiation of HIV CM.
PCP written order required to continue services beyond two consecutive months and annually if ongoing unmet needs.
Documentation must indicate diagnosis and medical necessity.

Denial Risk

Service restrictions based on beneficiary eligibility

Service restrictions and eligibility: Beneficiaries may be ineligible for HIV CM based on their Medicaid aid category or institutional status. Providers must confirm eligibility and aid category; services are not covered while beneficiaries are institutionalized in specified facilities (except the day of admission and discharge). Duplicate Medicaid-reimbursed case management is not permitted.

Beneficiaries in Medicaid for Family Planning Waiver or Medicare Qualified Beneficiaries are not eligible for HIV CM.
HIV CM is not covered while institutionalized in general/psychiatric hospitals, nursing facilities, ICF-IDD, incarceration, or halfway houses that provide case management (except admission/discharge days).
Beneficiaries shall not receive duplicative Medicaid-reimbursed case management (e.g., CAP programs, at-risk case management, targeted case management).

Denial Risk

Coverage-based denial triggers

Coverage-based denial triggers: Services will be denied when eligibility or coverage criteria are not met, when the beneficiary does not meet diagnostic criteria, when services duplicate another provider's Medicaid-reimbursed case management, when billed units exceed policy limits, or when services are experimental or investigational.

Denied if beneficiary does not meet Section 2.0 eligibility or Section 3.0 diagnostic criteria.
Denied if duplicate Medicaid-reimbursed case management is billed.
Denied if billed units exceed 16 units per calendar month per beneficiary.
Denied if service is experimental, investigational, or part of a clinical trial.

Billing Rule

Eligibility verification and prior approval

Eligibility verification and prior approval actions: Providers must verify each beneficiary's Medicaid eligibility at the time of service. Even though HIV CM itself does not require prior approval, providers must follow EPSDT and NCTracks rules when other services require prior approval, and must document eligibility and any prior authorization actions taken.

Verify Medicaid eligibility at each service encounter.
Follow NCTracks Provider Claims and Billing Assistance Guide and state EPSDT guidance for prior approval processes when applicable.

Documentation Required

Monitoring documentation

Monitoring documentation: Case managers must have monthly contact with the CCNC Network or the beneficiary's primary care physician and document communications using DMA-3155 or a similar tracker. Monthly updates must address changes in nutrition, hospitalizations (inpatient vs ER), medication adherence, new symptoms, and relevant social determinants.

Use DMA-3155 or similar tracker to document monthly communication with PCP/CCNC.
Monthly reporting items: nutritional status, number/type of hospitalizations, medication compliance, new symptoms, social determinants.

Documentation Required

Required beneficiary documentation and progress note minimum content

Required beneficiary documentation: Maintain an intake (including proof of HIV status within 15 calendar days), assessments, care plans, progress notes, medication sheets, contact sheets, discharge summaries/notifications, beneficiary consent forms, and physician/attending practitioner's written orders. Progress notes must document activities linked to care plan goals, place/date of service, start/end times, duration (15-minute units), signatures, quarterly care plan updates, and all contacts.

Proof of HIV status must be incorporated into the medical record within 15 calendar days of intake.
Progress notes must be documented within 24 hours of contact and include date/place, start/end time, duration in minutes and units, CM signature, and documentation of contacts and goal progress.
Care plan completed with initial assessment and reassessments; signed by CM and beneficiary/representative.

Documentation Required

Required record elements and orders

Required record elements and physician orders: The beneficiary record must include intake, assessments, written attestation of record storage, care plans with timelines, progress notes, medication and contact sheets, discharge documents, consent forms, and the physician or attending practitioner's written order prior to initiation. PCP written order is required for continuation beyond two consecutive months and orders must indicate diagnosis and medical necessity.

Physician/attending practitioner's written order required prior to initiation.
PCP written order required to attest to medical necessity for continuation beyond two months.
Records must include attestation that records are properly stored and available.

Documentation Required

Electronic recordkeeping requirements

Electronic recordkeeping requirements: Electronic clinical records and electronic billing documentation must be retained for a minimum of six years. Providers must promptly retrieve and supply electronic copies of signed documents upon request and present necessary equipment to read electronic records during audits. Electronic signatures must comply with state regulations.

Keep electronic clinical and billing records for at least six years.
Provide electronic copies of signed documents upon request for audits or reviews.
Ensure electronic signatures comply with GS § 66-58.5 and provider policy.

Billing Rule

Coding and documentation requirements

Coding and documentation requirements: Report ICD-10-CM and PCS codes to the highest level of specificity that supports medical necessity and use current code editions. Use the most specific CPT/HCPCS/UB-04 codes available; when no specific code exists, use appropriate unlisted procedure codes and submit required special reports. HIV CM billable code: G9012.

Report ICD-10-CM and PCS to highest specificity.
Use current CPT/HCPCS/UB-04 editions; if no specific code exists, use unlisted procedure codes and follow reporting instructions.
Bill HIV CM with CPT/HCPCS code G9012.

Denial Risk

No duplicate Medicaid case management

No duplicate Medicaid case management: Beneficiaries receiving HIV Case Management shall not concurrently receive other Medicaid-reimbursed case management services (for example, Community Alternatives Programs, at-risk case management, or targeted case management). Providers must avoid and will be denied for duplicative billing.

Do not bill HIV CM on same day as CAP services or other reimbursed case management.
Payments for targeted case management shall not duplicate payments under other program authorities.

Operational implication

Providers must staff to maintain ratio when delivering HIV CM services

Billing impactProvider must not bill units that represent services to more than one beneficiary during the same period

inv-32: Progress note timing — progress notes to be completed within 24 hours of contact

Progress note timingProgress notes must be documented and incorporated into the record within 24 hours of contact

Required timing elementsProgress note must be timed and dated with start/end times of the activity

Signature requirementProgress notes must include the CM's legal signature with title or licensure indicated

inv-33: Billing unit — 1 unit = 15 minutes

Billing unit definition1 unit = 15 minutes

Progress note linkageProgress notes must document duration including number of minutes and units and start/end times

Reporting instructionReport appropriate code(s) that determine billing units per CMS/CPT/HCPCS guidance

inv-73: Unit — One billing unit equals 15 minutes of service (duplicate unit definition)

Unit definition (duplicate)One billing unit equals 15 minutes of service

Place of service noteUnits apply to one-to-one interactions delivered in office, beneficiary's primary private residence, or adult care home

Monthly cap reminderUnit counting is subject to the 16-unit per calendar month limit per beneficiary

Program approvalCopy of approval for participation in the North Carolina ADAP also acceptable

inv-69: Assessment — definition entry for Assessment

Assessment purposeScreen and evaluate prospective beneficiary status to determine need for initial case management services (intake and assessment)

Content requirementsCollect, analyze, synthesize and prioritize information to identify needs, resources, and strengths; document physical appearance and behavior; CM signature required

Domains to addressMedical coordination, treatment adherence linkage, physical needs, mental health/substance use/developmental needs, housing, financial, social/recreation

inv-70: Care Planning — care plan timing and signature requirements

Care plan timingCare plan must be completed with the initial assessment, at annual reassessment, and as needed (within five business days of assessment completion)

Signature requirementCare plan must be signed and dated by the CM and the beneficiary or legally responsible representative; CM signature must include first and last name with title or licensure

Coordination requirementFor managed care beneficiaries, use NCCCN web-based applications and coordinate with CCNC Care Manager when open with CCNC network

inv-71: Progress note unit — one unit equals 15 minutes; documentation of start/end times required

Progress note unitOne unit equals 15 minutes; progress notes must document start and end time, number of minutes and units

Minimum contentProgress notes must include place/date of service, nature/extent/duration, CM legal signature with title, individualized care statements, and documentation of contacts and care plan activities

Incorporation timeframeProgress notes must be incorporated into the beneficiary record within 24 hours of contact

inv-72: Expected outcomes — expected outcomes of HIV Case Management

Expected outcomes — access and continuityEarly access to and maintenance of comprehensive health care and social services; enhanced continuity of care

Clinical impactPrevention of disease transmission and delay of HIV progression; increased knowledge of HIV disease

Quality of life and empowermentPersonal empowerment, reinforcement of positive health behaviors, greater participation in health/social service systems, improved quality of life