Alliance Health ACT Program Coverage Update | OpenPayer
ModifiedAlliance HealthPolicy 8A-1
Assertive Community Treatment (ACT) Program
Defines Medicaid coverage, eligibility, service definitions, staffing, documentation, and program requirements for Assertive Community Treatment (ACT) teams serving NC Medicaid beneficiaries (standard age 18+), with EPSDT considerations for beneficiaries under 21.
Policy Summary
PayerAlliance Health
PolicyAssertive Community Treatment (ACT) Program
Policy CodePolicy 8A-1
Change TypeMaterial revision (authorization language removed to comply with MHPAEA/CFR)
Effective DateAmended Date: January 1, 2025
Next Review DateN/A
Key ActionEnsure a written service order signed by an authorized professional is in place prior to or on the first day of services and maintain required documentation tied to the Person-Centered Plan.
Language referencing prior approval and terms like authorizations, initial authorizations, reauthorizations, and utilization management were removed to comply with federal regulations
Notes clarifying tribal and IHS provider exemptions from certain state requirements under Federal law were added
Staff licensure terminology was updated then later revised to reflect state changes (e.g., LPC to LCMHC; CSAC to CADC)
18+Minimum age (standard)
Under 21EPSDT override
NCApplicable state
1.5
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Team contacts/week (avg)
H0040Per diem code
50/51-74/75-120Team size caps
Coverage criteria and program requirements
Coverage for ACT services
Covered when ALL of the following are met:
Eligibility and age: Beneficiary is enrolled in NC Medicaid and is 18 years of age or older for standard ACT coverage.age >= 18
See EPSDT exceptions for beneficiaries under 21 (EPSDT may override limits)
Clinical appropriateness: Beneficiary has severe and persistent mental illness and does not benefit from multiple, disconnected providers — requiring a single team to provide services due to risk of hospitalization, homelessness, substance use, victimization, or incarceration.
Services focus on community integration and recovery-based care
Service model: ACT team provides multidisciplinary, community-based, person-centered services with low beneficiary-to-staff ratio, frequent community contacts, and assertive engagement techniques; the team acts as the first-line (and generally sole) provider for the beneficiary's needs.
Team adjusts intensity based on changing beneficiary needs
Initial admission criteria
Covered when ALL of the following are met:
Eligibility and diagnosis: Beneficiary is 18 years or older with schizophrenia, other psychotic disorders (e.g., schizoaffective), bipolar disorder, or other psychiatric illness causing long-term disability; beneficiaries with a primary diagnosis of substance use disorder, intellectual/developmental disability, borderline personality disorder, traumatic brain injury, or autism spectrum disorder are not intended for ACT unless a co-occurring qualifying psychiatric disorder exists.
From policy clinical criteria
Functional impairment (one or more required): 1) Significant difficulty performing routine tasks required for basic adult community functioning; 2) Significant difficulty maintaining consistent employment or head-of-household responsibilities; 3) Significant difficulty maintaining a safe living situation (e.g., repeated evictions).
From admission criteria
Indicators of continuous high-service needs (one or more required): 1) High use of acute psychiatric hospital (2+ admissions in past 12 months) or psychiatric emergency services; 2) Intractable severe psychiatric symptoms; 3) Coexisting mental health and substance use disorders >6 months; 4) High risk or recent criminal justice involvement; 5) Significant difficulty meeting basic survival needs or homelessness risk; 6) Residing in inpatient/supervised residence but clinically able to live more independently if intensive services provided; 7) Difficulty using traditional office-based outpatient services.
Continued stay criteria
Continued stay covered when the desired outcome or level of functioning has not been restored, improved, or sustained AND one of the following:
Continued stay conditions: a) Beneficiary has achieved current PCP goals and additional goals are indicated; b) Beneficiary is making satisfactory progress and documentation supports that continuation will be effective; c) Beneficiary is making some progress but PCP interventions need modification to achieve greater gains; d) Beneficiary fails to make progress or regresses — diagnosis must be reassessed and treatment revised; e) Beneficiary is functioning effectively but discharge would likely cause regression based on documented history or failed titration of services.
Continued stay requires ongoing medical necessity and documented rationale
Transition / Discharge criteria
Discharge or transition when ANY of the following apply:
Transition/discharge criteria: a) Beneficiary and team determine ACT is no longer needed and a less intensive level of care will adequately address current goals; b) Beneficiary moves out of catchment area and an appropriate referral/transition is facilitated; c) Beneficiary (or legally responsible person) chooses to withdraw and documented reengagement attempts are unsuccessful; d) No significant improvement after reassessment and multiple treatment adjustments over at least three months and either alternative treatments likely to result in greater improvement, behavior has worsened making sustainable change unlikely, or more intensive care is indicated.
Policy allows billing during certain transitions for up to 30 days per PCP
Transition billing allowance: ACT may be billed for up to 30 days in accordance with the PCP when transitioning to or from specified services (e.g., Community Support Team, Partial Hospitalization, SAIOP, SACOT, inpatient hospitalization); psychosocial rehabilitation may be provided for a 30-day transition period.30 days
From transition/billing guidance
Coverage criteria for ACT services
Covered when ALL of the following are met
Service order and assessment: A valid written service order signed and dated by an MD, DO, Licensed Psychologist, NP, or PA must be in place prior to or on the day services are first provided; service orders are valid for one year and medical necessity must be revised and services re-ordered at least annually. Backdating is not allowed.service order required; valid 1 year
Service order required prior to billing
Person-Centered Plan (PCP): A written CCA and PCP must be in place before billing; the PCP must be completed within 15 calendar days of the service start date and rewritten at least annually; when services occur prior to full PCP implementation, strategies addressing presenting problems must be documented and PCP updated as information becomes available.PCP within 15 days; annual rewrite
PCP content must include diagnostic information from CCA
Documentation:
Staffing and Role Coverage Criteria
Staffing and team composition covered when the following staffing levels and role qualifications are met for ACT teams:
Staff-to-beneficiary ratios by team size: Maintain low beneficiary-to-staff ratios per Table 1: Small teams (up to 50) = 1 staff per 8 or fewer beneficiaries; Mid-size (51–74) = 1 per 9 or fewer; Large (75–120) = 1 per 9 or fewer. Annual average caseloads must not exceed 50, 74, and 120 respectively.team ratios: 1:8 or 1:9 depending on size
Annual average caseload limits apply
Team Leader: One full-time Team Leader dedicated to ACT; must be a licensed mental health professional (or associate-level conditional on full licensure within 30 months) with at least three years clinical experience with SPMI (minimum two years post-graduate).1.0 FTE Team Leader
Team leader provides clinical leadership and supervision
Psychiatric care provider time and composition:
Training and Supervision Criteria
Training and supervision requirements to maintain high-fidelity ACT practice:
Initial trainings: Each ACT team member must complete DHHS-approved training in high-fidelity ACT, Crisis Response, brief Motivational Interviewing, and Person-Centered Thinking within 120 calendar days of hire. QP staff responsible for PCP development must complete PCP Instructional Elements; substance abuse specialist must train in IDDT; vocational specialist must train in IPS; tenancy support lead must complete DHHS Tenancy Support training. Initial training may be waived with documentation of completion within the prior 12 months.within 120 days
Waiver allowed with prior documentation
Ongoing annual training: Each ACT team member (excluding program assistant) shall receive three additional hours of training per year in their area of expertise and cross-train team members.3 hours/year
Training may be local, online, or conference-based
Clinical supervision frequency and format:
Service frequency and intensity
Service frequency and intensity expectations
Team service frequency and intensity: The team must see beneficiaries on average 1.5 times per week and provide at least 60 minutes of face-to-face time per beneficiary per week; additional face-to-face and phone contacts with beneficiaries, supports, and other providers are expected.1.5 times/week; >=60 minutes/week
Median rate for fidelity monitoring is calculated using a 4-week mean and selecting the median beneficiary
Program fidelity monitoring
Fidelity monitoring requirement
Fidelity assessment: Programs must be evaluated using the Tool for Measurement of ACT (TMACT) or a DHHS-approved successor to assess implementation of the ACT model and support quality improvement; DHHS will track adherence and determine annual ACT performance outcomes through fidelity assessments.use TMACT or successor
Fidelity results used for quality improvement and performance measurement
Training and supervision
Staff training and supervision requirements
Supervision frequency and documentation: Team leader must maintain documentation of supervision and training activities; the majority of team members shall receive scheduled clinical supervision bi-weekly (individual or group) and no staff shall go without a supervision session in a given month.bi-weekly; at least one/month
Supervision includes group case discussion, field mentoring, review/feedback on tools and notes, didactic teaching, and formal in-office supervision
Required training topics: Staff must receive training in topics including benefits counseling; CBT for psychosis; Critical Time Intervention; CLAS; IPS-supported employment; family psychoeducation; functional assessments and psychiatric rehabilitation; Integrated Dual Disorders Treatment; LEP/blind/deaf accommodations; medication algorithms; NAMI psychoeducation; psychiatric advance directives; recovery-oriented systems of care; SOAR; permanent supportive housing models; trauma-informed care; wellness/integrated healthcare; WRAP/IMR; supervising NC Certified Peer Support Specialists; and DHHS Tenancy Supports.N/A
Full list provided in policy
Team assignment and beneficiary contacts
Team approach expectations
Team assignment and contacts: Each beneficiary is assigned to work more closely with a select group of team members; the majority of beneficiaries shall see at least 3 team members per month; high numbers of different contacts (e.g., 6 or more) are discouraged unless clinically indicated to preserve therapeutic relationships and continuity of care.>=3 team members/month typical
Assignment balances therapeutic continuity with coverage for staff absence
Clinical outcomes reporting
Expected outcomes reporting
Outcomes data submission: Teams must regularly submit outcome data via the ACT Monitoring Application including beneficiary satisfaction, adherence to plan, vocational/educational gains, length of stay in community residence, use of natural supports, reduced inpatient utilization, improved physical health, use of wellness/self-management tools, and community living supports.regular submission
Submitted data guide team performance initiatives
ACT Coverage Criteria
Covered when program and billing requirements are met
ACT per diem billing requirements: Per diem (H0040) may be billed only on days when the ACT team performed a qualifying face-to-face service with the beneficiary or family member; a qualifying contact is 15 minutes (defined as at least 8 minutes). Collateral contacts may account for up to 25% of team time; only one per diem may be billed per beneficiary per day.15 minutes (>=8); one per diem/day
Practitioners may not bill separately for services included in the per diem
Place of service and community-based mix: The majority of services must be provided in the community (natural settings); teams should achieve a median of 75% community-based face-to-face contacts across beneficiaries for fidelity monitoring. ACT services cannot be provided in an Institute for Mental Diseases (IMD) for adults or in public institutions.75% median community-based contacts
Natural settings defined in policy
Availability and crisis response:
Coverage excludes beneficiaries who are not enrolled in the NC Medicaid Program and services when a beneficiary’s eligibility category imposes restrictions that make them ineligible for ACT. Providers must verify Medicaid eligibility each time a service is rendered, and services may be denied if eligibility is not confirmed or if the beneficiary’s eligibility category restricts the service.
The policy specifies activities that are not covered or billable as part of the ACT per diem. These include: recreational activities unless directly tied to a documented PCP therapeutic goal; academic instruction or substitute educational services; habilitative services to teach basic self-help/social/adaptive skills; childcare or parental substitute services; respite care; transportation (including services delivered in a moving vehicle); services for beneficiaries under age 18; services not rendered or not identified on the beneficiary's plan; services to family members addressing issues not directly related to the beneficiary; art/movement/drama therapies; clinical or administrative supervision of staff; and services for individuals whose primary diagnosis is substance use disorder, intellectual/developmental disability, autism spectrum disorder, personality disorder, or traumatic brain injury.
Specific limitations within this policy are noted as: None Apply.
The policy states that the psychiatric care provider role must be delivered as an integrated, in-person member of the ACT team. Responsibilities required of psychiatric care providers cannot be adequately met via telemedicine or telepsychiatry and therefore are not covered when delivered remotely for this community-based service.
For Medicaid beneficiaries under 21 years of age, the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit may override normal policy limitations when documentation demonstrates the service is medically necessary to correct or ameliorate a health condition. Refer to Subsection 2.2.1 for EPSDT specifics; providers must document medical necessity consistent with EPSDT requirements and follow applicable prior approval rules when they apply.
A core ACT feature is delivering services in beneficiaries' natural environments. For Medicaid beneficiaries, ACT services may not be provided in an Institute for Mental Diseases (IMD) for adults or in public institutions (for example, jail, detention center, or prison). Teams may bill case management when provided within 30 days prior to discharge from an inpatient hospital while Medicaid eligibility is retained.
Services that are unsafe, ineffective, experimental or investigational, or not generally recognized as accepted medical practice are not required under Medicaid coverage and are therefore not covered. Additionally, services that duplicate another provider’s covered service, or that do not meet Sections 2.0 (eligibility) or 3.0 (criteria) are also not covered.
Services will be denied when the beneficiary does not meet policy eligibility or clinical criteria, or when the billed service duplicates another provider’s service. Providers must verify eligibility at each service encounter; failure to confirm eligibility or billing duplicative services may result in claim denials.
North Carolina Medicaid will not reimburse for conversion therapy under this policy.
Billing codes, units, and team ratios
Attachments reference code sections (ICD-10-CM, CPT/PCS, Modifiers, Billing Units, Place of Service)mixed
No codes listed
Covered HCPCS CodesHCPCSCovered
H0040
Assertive community treatment per diem
Unlisted ProceduresCPT
Unlisted CPT
Unlisted Procedure or Service — follow CPT instructions and submit special report
inv-26: Team size / beneficiary ratios
Small team maximumUp to 50 beneficiaries; staff-to-beneficiary ratio: 1 staff per 8 or fewer beneficiaries (annual average caseload not to exceed 50)
Mid-size team maximum51–74 beneficiaries; staff-to-beneficiary ratio: 1 staff per 9 or fewer beneficiaries (annual average caseload not to exceed 74)
Large team maximum75–120 beneficiaries; staff-to-beneficiary ratio: 1 staff per 9 or fewer beneficiaries (annual average caseload not to exceed 120)
Psychiatry FTE/prorationPsychiatric care provider FTE prorated to number served (example: at least 16 hours/week for 50 beneficiaries; minimum 32 hours/week per 100 beneficiaries), with no more than two psychiatric providers sharing the role
inv-27: Median service frequency calculation
Provider responsibilities, authorizations, and documentation
Note
Auth language revised (historical note)
Historical administrative changes: language referencing prior approval, authorizations, initial authorizations, reauthorizations, and utilization management was revised and removed to align with federal MHPAEA and 42 CFR §438.900. This is a historical note: prior wording was changed effective 01/01/2025 to remove utilization-management phrasing from the policy text.
Prior Authorization
Eligibility verification and restrictions
Verify Medicaid eligibility each time a service is rendered. Services may be denied or not reimbursed if the beneficiary is not eligible for the service based on enrollment or eligibility category. Retroactive eligibility may allow reimbursement for services provided during the retroactive period, but providers must follow reimbursement and third-party billing rules.
Confirm current enrollment and eligibility category before billing.
If beneficiary is retroactively eligible, file for reimbursement per NCTracks guidance; exclude third-party payments and cost-sharing.
Services may be restricted or ineligible based on the beneficiary's eligibility category.
Program background and scope
Assertive Community Treatment (ACT) is a multidisciplinary, community-based team model that serves individuals with serious and persistent mental illness who have not benefited from multiple, disconnected providers. ACT functions as a single point of responsibility for treatment and rehabilitation by delivering intensive, person-centered services in natural community settings, employing low beneficiary-to-staff ratios, frequent face-to-face contacts, assertive engagement, and a recovery-oriented approach to support community integration and role recovery.
Key definitions
inv-62: Assertive Community Treatment (ACT) team
DefinitionAn ACT team is a community-based multidisciplinary group of medical, behavioral health, and rehabilitation professionals that serves as the single point of responsibility and provides person-centered services for beneficiaries with severe and persistent mental illness
Single point of responsibilityACT is the first-line (and generally sole) provider for the beneficiary's needed services, requiring higher frequency/intensity of community-based contacts and low beneficiary-to-staff ratios
Core functionsAssertive engagement, monitoring mental status, delivering recovery-based supports across domains to enhance community integration and role recovery
inv-63: Preventive
DefinitionPreventive: to anticipate the development of a disease or condition and preclude its occurrence
Level-of-care definitions and admission/placement guidance
Service components: ACT team provides multidisciplinary medical, behavioral health, and rehabilitation services; uses assertive engagement, monitors mental status, and delivers recovery-based interventions as the single point of responsibility for beneficiaries with SPMI.
Team delivers services across domains to support community integration
Community-based Intensive (ACT)
Community-based Intensive (ACT)
Admission and care focus: Intensive community-based ACT serves adults with SPMI meeting admission criteria (diagnosis, functional impairment, and indicators of high-service needs); CCA and PCP required prior to billing.
No equally effective alternatives within LME-MCO array must exist
Services provided by ACT teams
ACT team services
ACT team services — team-delivered services (one top-level node)
threshold":"","note":"Team provides flexible levels of care adjusted to individual needs","children":[]}
ACT concurrent services
ACT concurrent services — rules for concurrent service delivery
Concurrent services allowed when medically necessary: Opioid treatment; detoxification; facility-based crisis; IPS supportive employment (non-Medicaid reimbursable only); specialized acute inpatient/outpatient therapy when licensed professionals lack training; substance abuse residential treatment; adult mental health residential programs; and psychosocial rehabilitation for a 30-day transition period may be provided concurrently with ACT when medically necessary.
Service delivery to others only when directed exclusively toward the beneficiary's benefit
Psychotherapy / Integrated Dual Disorders Treatment / Medication Support
Caseloads, contact frequency, and per-diem rules
inv-89: Billing for ACT during transitions to/from certain services (first/last 30 days)
Allowed billing window during transitionsACT team services may be billed for up to 30 days in accordance with the Person-Centered Plan when transitioning to or from specified services (first/last 30 days)
Applicable transitionsTransitions to/from Community Support Team, Partial Hospitalization, SAIOP, SACOT, Inpatient Hospitalization and other listed programs as coordinated in the PCP
Case management during transitionCST and PSR case management components may continue for first and last 30 days of transition and must be performed by the QP or ACT QP
inv-90: ACT team caseload
Caseload maximums by team size (annual average)Small: up to 50; Mid-size: up to 74; Large: up to 120
Policy changes and effective dates
01/01/2025material_revisionLatest
Policy language revised to comply with the Mental Health Parity and Addiction Equity Act and 42 CFR §438.900 by removing references to prior approval, authorizations (initial and reauthorizations), and utilization management; related technical edits made to Person-Centered Planning language and staff definition subsections.
01/01/2025non-material_addition
Notes added clarifying that federally recognized tribal and Indian Health Service (IHS) providers may be exempt from certain state requirements (staffing, claims, billing units) under federal law.
01/01/2025
Policy Summary
PayerAlliance Health
PolicyAssertive Community Treatment (ACT) Program
Policy CodePolicy 8A-1
Change TypeMaterial revision (authorization language removed to comply with MHPAEA/CFR)
Effective DateAmended Date: January 1, 2025
Next Review DateN/A
Key ActionEnsure a written service order signed by an authorized professional is in place prior to or on the first day of services and maintain required documentation tied to the Person-Centered Plan.
Alternatives: No available alternative interventions within the LME-MCO service array would be equally or more effective based on North Carolina community practice standards.
From admission requirements
Assessment and planning: A comprehensive clinical assessment (CCA) demonstrating medical necessity and a Person-Centered Plan (PCP) containing relevant diagnostic information must be completed prior to provision of services.
CCA and PCP required before billing
Each contact requires a full signed service note including beneficiary name, Medicaid ID, date, service name, contact type, place, purpose tied to PCP goals, description of intervention and duration, assessment of effectiveness and progress toward PCP goals, and provider signature/credentials. Discharge documentation must include reasons, biopsychosocial status, final evaluation summary, follow-up plan, and required signatures; a completed LME-MCO Consumer Admission and Discharge Form must be submitted.
per-contact note
Documentation obligations support medical necessity and billing compliance
Psychiatric care provider FTE is prorated by number served with minimum hours escalating with team size (example: at least 16 hours/week for 50 beneficiaries; minimums increase by team size; at least half of psychiatric time must be fulfilled by a psychiatrist; no more than two psychiatric providers may share the role).
Psychiatric roles not covered via telemedicine for this community-based service
Nursing FTE prorated by team size (Small: 1.0 FTE RN/APRN; Mid: 2.0 FTE; Large: 3.0 FTE) with at least one RN/APRN having >=1 year experience with adults with SMI; no more than two individuals may share 1.0 FTE.prorated nursing FTE
Nursing supports medication monitoring and community services
Substance Abuse Specialist: 1.0 FTE substance abuse specialist with QP status and appropriate certification/licensure (e.g., CCS, LCAS, LCAS-A, CADC); no more than two individuals may share this role.1.0 FTE
Vocational Specialist: One full-time vocational specialist (AP or QP) preferred with at least one year experience providing employment services; must deliver IPS model supported employment and act as the primary provider of employment services for ACT beneficiaries.1.0 FTE
Vocational specialist should not refer primary employment services outside the ACT team
Peer Specialist: At least 1.0 FTE NC Certified Peer Support Specialist per team (no more than two individuals may share this role) providing recovery-oriented coaching and community-based supports.1.0 FTE
Peer specialist must have lived experience
Program Assistant: One full-time office-based program assistant dedicated to the ACT team responsible for non-clinical operations, records, data entry, and supporting daily team functions.1.0 FTE
Program assistant supports documentation and Beneficiary Log
Additional staff: Additional clinical staff (licensed mental health professionals, QP/AP) as needed to reflect program size and population served; QP staff facilitate person-centered planning and maintain required competencies.
Staffing should reflect targeted population needs
Ongoing clinical supervision is provided by ACT clinical leadership with the team leader as primary supervisor; the majority of staff shall receive scheduled bi-weekly supervision (individual or group) and no staff shall go without a supervision session in a given month.
bi-weekly; at least one/month
Supervision may include group meetings, field mentoring, tool review, didactic teaching, and in-office individual supervision
Teams must be available 24/7/365 for crisis response, provide first-responder crisis services, ensure psychiatric coverage 24/7, and on-call staff must have access to beneficiaries' crisis plans; licensed staff must be available for on-site assessment and de-escalation when needed.
24/7 availability
Planned services must be available seven days per week and teams maintain an office with extended hours
Calculation periodUse a 4-week period: total the number of face-to-face contacts for each beneficiary over 4 weeks and divide by 4 to get that beneficiary's weekly mean
Rank-orderingCompute weekly means for all beneficiaries, rank-order them low to high, and select the middle (median) beneficiary to represent the team median rate
PurposeMedian beneficiary weekly mean is used for ACT program fidelity monitoring to represent typical service frequency
inv-28: Minimum face-to-face duration to generate per diem
Per-diem qualifying durationPer diem (H0040) may be billed only when a qualifying face-to-face contact of 15 minutes occurs
15-minute definitionA 15-minute contact is defined in policy as lasting at least 8 minutes
Collateral time limitCollateral contacts may account for up to 25% of the team's time; indirect activities are included in per diem rate calculations and not billed separately
Denial Risk
Telemedicine limitation for psychiatric care provider
The psychiatric care provider role requires in-person integration and direct services on the ACT team. Telemedicine or telepsychiatry cannot substitute for the required psychiatric care provider activities for this community-based service and are not covered for fulfilling that role.
Billing Rule
Audit and refund procedures
Audits and compliance reviews are conducted to ensure documentation and billing accuracy. Deficiencies may be forwarded to NC MEDICAID Program Integrity and can result in refunds or withholding from future payments.
Audit findings will include a report of finding, time period covered, sampling method, and copies of supporting documentation.
Supporting documentation must show beneficiary name, Medicaid ID, date(s) of service, procedure code, units billed in error, and reason for error.
Refunds or requests for withholding payments must be sent to: Office of Controller NC Medicaid Accounts Receivable, 2022 Mail Service Center, Raleigh, NC 27699-2022.
Denial Risk
Billing per diem (H0040) on days without a qualifying face-to-face contact
ACT per diem (H0040) may be billed only on days when a qualifying face-to-face contact occurs. Billing H0040 on days without a qualifying contact may lead to claim denial and audit recovery.
A qualifying face-to-face contact must be at least 8 minutes (counts as a 15-minute contact) to support a per diem.
Only one per diem (H0040) may be billed per beneficiary per day.
Do not bill H0040 for services included in the per diem elsewhere; licensed direct care staff must provide services within their scope.
Documentation Required
Medical necessity and EPSDT documentation
Medical necessity must be documented for all services; for beneficiaries under 21 EPSDT allows exceeding policy limits when documentation demonstrates medical necessity to correct or ameliorate a condition. A comprehensive clinical assessment (CCA) demonstrating medical necessity is required prior to service provision and relevant diagnostic information must be included in the Person-Centered Plan (PCP).
For beneficiaries under 21, document how the requested service meets EPSDT criteria (correct/ameliorate, prevent worsening, or prevent development of additional health problems).
CCA must reflect current level of functioning and include required elements per community practice standards.
Diagnostic information from the CCA must be included in the PCP.
Documentation Required
Required documentation and service order
Service orders and person-centered documentation requirements: a valid service order and written CCA/PCP are required before billing. Service orders must be written and signed by an authorized practitioner, cannot be backdated, and are valid for one year. The PCP must be completed within 15 calendar days of the service start date.
Service orders are valid for one year; medical necessity and orders must be updated at least annually.
If services are provided prior to PCP completion, document interim strategies and update PCP when additional information is available.
A signed service note is required for each contact and must include beneficiary identifiers, date of service, type/place of contact, purpose tied to PCP goals, intervention description, duration, assessment of effectiveness, and signature with credentials/job title.
Documentation Required
Documentation and recordkeeping responsibilities
Documentation and recordkeeping responsibilities: the staff member who provides the service must accurately document and sign entries. The team leader must maintain supervision and training records and a Beneficiary Log as part of daily team operations.
Service notes must be signed by the staff person who provided the service; QP countersignature not required for non-QP staff.
Team leader documents supervision and cross-training activities annually and ensures staff receive required trainings.
Maintain a Beneficiary Log that documents encounters, attempts, symptoms, functioning, medications, interventions, responses, and housing status; used during daily team meetings.
Billing Rule
Providers must report ICD-10-CM and procedure/professional codes to highest specificity
Coding and claims reporting requirements: report ICD-10-CM and procedural codes to the highest specificity and use current CPT/HCPCS/UB-04 specifications. Claims must comply with National Uniform Billing Guidelines or CMS-1500 and National Coding Guidelines.
Report the most specific ICD-10-CM diagnosis codes that support medical necessity.
Use current CPT/HCPCS codes and UB-04 revenue codes where applicable; refer to the applicable edition for code descriptions.
Failure to report the most specific billing code or billing unit inconsistently may result in claim denial or adjustment.
Note
Single ACT team assignment
A beneficiary may be served by only one ACT team at a time. The beneficiary must make an informed choice to be served by the ACT team prior to receiving services.
Document the beneficiary's informed choice in the PCP.
Ensure team assignment is exclusive and update records when admissions or discharges occur.
Scope
Covers activities intended to prevent worsening or onset of conditions that would increase need for higher-intensity services
ReferenceSee Section 1.1.1 for formal definition
inv-64: Diagnostic
DefinitionDiagnostic: to examine specific symptoms and facts to understand or explain a condition
ApplicationUsed to inform medical necessity, diagnoses included in the CCA and PCP
ReferenceSee Section 1.1.2 for formal definition
inv-65: Therapeutic
DefinitionTherapeutic: to treat and cure disease or disorders; may also preserve health
ApplicationIncludes psychotherapy, medication support, and interventions aimed at symptom reduction and functional improvement
ReferenceSee Section 1.1.3 for formal definition
inv-66: Rehabilitative
DefinitionRehabilitative: to restore that which one has lost to a normal or optimum state of health
ApplicationIncludes community-based rehabilitation supports to regain roles and daily functioning
ReferenceSee Section 1.1.4 for formal definition
inv-67: SPMI / qualifying diagnosis
SPMI definitionA DSM-5 (or successor) diagnosis consistent with serious and persistent mental illness that causes long-term psychiatric disability and requires treatment to meet preventive, diagnostic, therapeutic, and rehabilitative needs
Typical diagnosesIncludes schizophrenia, schizoaffective disorder, bipolar disorder; other diagnoses considered based on long-term disability
ExclusionsNot intended for primary diagnosis of substance use disorder, intellectual/developmental disability, borderline personality disorder, TBI, or autism spectrum disorder absent co-occurring psychiatric disorder
inv-68: CCA — Comprehensive Clinical Assessment
DefinitionComprehensive Clinical Assessment (CCA): an assessment that demonstrates medical necessity and must be completed prior to provision of ACT services
Acceptable alternativesA substantially equivalent recent assessment may be used if it reflects current functioning and contains all required elements per community practice standards and federal/state requirements
Documentation roleRelevant diagnostic information from the CCA must be included in the Person-Centered Plan (PCP)
inv-69: Person-Centered Planning (PCP)
DefinitionPerson-Centered Planning (PCP): a process to determine real-life outcomes with the beneficiary, develop strategies to achieve them, and document individualized goals and interventions directed by the beneficiary and supports
Timing requirementA written CCA and PCP must be in place before any service can be billed; the PCP must be completed within 15 calendar days of the service start date
ContentPCP must reflect CCA diagnostic information and include strategies, supports, and people important to the beneficiary as appropriate
inv-70: Vocational Specialist / IPS
DefinitionVocational Specialist / IPS: a full-time vocational specialist (AP or QP) who provides evidence-based supported employment using the Dartmouth IPS model and is the primary provider of employment services for ACT beneficiaries
Role expectationsProvide direct IPS services consistent with eight practice principles and avoid referring beneficiaries to employment services outside the ACT team
Preferred qualificationsPreference for at least 1 year experience providing employment services or advanced education with field training
inv-71: Peer Specialist
DefinitionPeer Specialist: an NC Certified Peer Support Specialist with lived experience who is fully integrated into the ACT team and provides recovery-oriented coaching and supports
Staffing requirementEach ACT team must have at least 1.0 FTE peer specialist; no more than two individuals may share this role
Core functionsProvides coaching, wellness management, assists with psychiatric advance directives, models recovery values, and may facilitate PCP if QP
inv-72: Fidelity monitoring (TMACT)
DefinitionFidelity monitoring (TMACT): evaluation of ACT teams using the Tool for Measurement of ACT (TMACT) or DHHS-approved successor to assess implementation of defining model elements
RequirementPrograms must be evaluated using TMACT (or approved successor); DHHS will track adherence and determine annual performance outcomes
PurposeUsed for quality improvement feedback and guided consultation to maintain high-fidelity ACT practice
DefinitionNatural environment / community-based services: settings where services are taken to the beneficiary (primary private residence, places of recreation/socialization, place of work or school, or the street)
Majority requirementACT teams shall provide the majority of services in the community; on average 75% of face-to-face contacts should be in community settings for fidelity monitoring
RestrictionsServices must be delivered respectfully (e.g., not appearing at work without permission) and may not be provided in IMDs or public institutions
inv-74: ACT per diem (H0040)
Per diem definitionACT per diem (HCPCS H0040) covers team-based services and may be billed only on days when the ACT team performed a qualifying face-to-face service with the beneficiary or family member
Billing conditionsOnly one per diem may be billed per beneficiary per day; services included in the per diem may not be billed separately outside the per diem
Collateral and indirect timeCollateral contacts count toward up to 25% of team time; other contacts, meetings, and travel are indirect costs included in the per diem rate
inv-75: Ambiguous action words
Ambiguous words to avoidto know; to understand; to really understand; to appreciate; to fully appreciate; to grasp the significance of; to enjoy; to believe; to have faith in; to internalize
ReasonThese words are open to many interpretations and hinder measurable, objective goal writing
Use guidanceRefer to PCP goal-writing guidance (Attachment B) for alternatives
inv-76: Preferred action words
Preferred measurable action wordsto write; to recite; to identify; to sort; to solve; to construct; to build; to compare; to contrast; to smile
Use in goalsThese action words are more specific and measurable and should be used when writing PCP goals
ExamplesPolicy provides sample goal templates demonstrating use of preferred words with conditions and criteria
Service intensity: Provides high frequency and intensity of community contacts with low beneficiary-to-staff ratios and multidisciplinary interventions to maintain community functioning and reduce institutional utilization.
Team acts as primary provider
ACT / Community-based intensive team
ACT / Community-based intensive team
Direct service domains: ACT teams directly provide biopsychosocial and rehabilitation services across domains including assertive engagement, assessment and service planning, empirically supported interventions and psychotherapy, family and social supports, health care coordination, housing supports and tenancy services, integrated dual disorders treatment, medication support, money management, psychiatric rehabilitation, vocational services, and wellness/self-management interventions.
Services listed in Table 2 must be delivered directly by the ACT team
Community-based Assertive Community Treatment (ACT)
Community-based Assertive Community Treatment (ACT)
Team leadership and psychiatric integration: Team leader provides clinical leadership and oversight; psychiatric care provider is integrated on the team (psychiatrist/PNP/PA) with defined FTE expectations and direct community services; psychiatric responsibilities cannot be fulfilled adequately via telemedicine for this community-based service.
Team leader and psychiatric provider roles defined in staffing section
Entry process: A comprehensive clinical assessment (CCA) demonstrating medical necessity must be completed prior to provision of services; relevant diagnostic information must be included in the PCP.
CCA and PCP required prior to billing
Community-based intensive team (ACT)
Community-based intensive team (ACT)
Participation and fidelity: Continued participation requires adherence to ACT model fidelity, meeting service frequency/intensity expectations (mean 1.5 contacts/week and >=60 minutes/week), and participation in outcome monitoring as required by DHHS.see fidelity and frequency requirements
Inferred from monitoring and service frequency sections
Natural environment focus: Services are delivered primarily in beneficiaries' natural environments (home, work, recreation, street) with respect for privacy and permission; teams provide majority community-based contacts (median 75%) and cannot provide ACT services in IMDs or public institutions.75% median community-based contacts
Availability and crisis response: ACT teams must provide 24/7/365 availability and first-responder crisis response with psychiatric coverage and on-call access to beneficiaries' crisis plans; licensed staff provide on-site assessment when needed.24/7
Teams maintain office hours and flex staffing for evenings/weekends
Psychotherapy / Integrated Dual Disorders Treatment / Medication Support — modalities described
Psychotherapy and evidence-based interventions: Provide cognitive-behavioral interventions and psychotherapy by trained/licensed therapists; basic CBT may be delivered by non-licensed staff with appropriate training and supervision. Medication support includes shared decision-making, prescribing/administration/monitoring by appropriate medical staff and assistance accessing and managing medications.licensed therapist for psychotherapy; supervised training for non-licensed staff
Integrated dual disorders treatment and medication management are team responsibilities
Vocational services and substance use treatment
Vocational services and substance use treatment
IPS supported employment: Vocational specialists must deliver Dartmouth IPS model supported employment directly, adhere to IPS practice principles, and act as the primary provider of employment services for ACT beneficiaries; referrals outside ACT for primary employment services are discouraged.
Preference for at least 1 year experience in employment services
Integrated Dual Disorders Treatment (IDDT): Substance abuse specialist(s) shall receive training in integrated dual disorders treatment and provide substance use assessment, stage-based interventions, outreach, motivational interviewing, relapse prevention, and consultation to the team.
Specialist must hold QP status and appropriate certification/licensure
Rehabilitation and recovery supports: Interventions include supported employment (IPS), illness management/recovery (IMR), wellness/self-management (WRAP), tenancy supports and other community-based rehabilitation and housing supports as identified in the PCP.as identified in PCP
These modalities are part of required staff training and service offerings
Crisis response and on-site assessment
Crisis response and on-site assessment — crisis response availability and on-site assessment
Crisis response: Team members shall provide first-responder crisis response 24/7/365, receive crisis calls directly, have on-call access to beneficiaries' crisis plans, handle many crises by phone, and arrange licensed staff for on-site assessment, de-escalation, and follow-up as needed; psychiatric coverage must be available 24/7 with backup arranged for unscheduled hours.24/7 coverage
Teams must maintain office hours and flex staffing for evenings/weekends
Expectation
Movement onto/off the team may temporarily breach maxima, but teams must maintain annual averages within these limits
Recommendation for titrationNew teams recommended to titrate intakes (e.g., 4–6/month) to gradually build capacity to serve no more than stated maxima
inv-91: Psychiatric follow-up contacts
Follow-up frequency expectationPsychiatric care frequency varies by beneficiary; the majority are seen within 4–6 weeks of the last appointment
Community contactsMany psychiatric contacts will occur in the community; less frequent visits only in unusual circumstances (e.g., beneficiary difficult to find)
RolesPsychiatrist provides clinical supervision/oversight for NP/PA psychiatric services and participates in daily team meetings and treatment planning
inv-92: face-to-face beneficiary contacts
Median rate purposeThe median weekly mean of face-to-face beneficiary contacts (calculated from a 4-week period) is used for fidelity monitoring
Calculation methodTotal each beneficiary's face-to-face contacts over 4 weeks, divide by 4 for weekly mean, rank-order means and select the middle beneficiary as the median
Relation to fidelityUsed to assess service frequency expectations (team average 1.5 times/week; >=60 minutes/week) for ACT fidelity monitoring
inv-93: ACT per diem (H0040)
Single per diem ruleOnly one ACT per diem (H0040) may be billed per beneficiary per day
Qualifying contact requiredPer diem may only be billed when a qualifying face-to-face contact (15 minutes defined as >=8 minutes) occurs that meets documentation requirements
Bundled servicesServices included in the per diem cannot be billed separately outside the per diem for beneficiaries enrolled in ACT
non-material_revision
Staff definitions updated to reflect amendments to 10A NCAC 27G (effective 01/01/2024) removing references to certain licensure/certification names (e.g., removal of LPC/CSAC references where applicable).
04/15/2023administrative_revision
Updated policy template language due to North Carolina Health Choice Program's move to Medicaid; policy posted 4/15/2023 with effective date 4/1/2023.
10/01/2020administrative_revision
Multiple revisions in 2020 updating licensure/certification references (e.g., adding CADC and LCMHC language) and other section edits reflected in the history.
12/15/2019administrative_revision
Attachment and billing guidance updated to align with National Uniform Billing Guidelines and National Coding Guidelines; table of contents and template language changes recorded.