CurrentAlliance HealthPolicy 8-L

Mental Health/Substance Abuse Targeted Case Management (MH/SA TCM)

Defines Medicaid coverage, expectations, and provider requirements for targeted case management services for beneficiaries with serious emotional disturbance, mental illness, or substance-related disorders in North Carolina.

Policy Summary

PayerAlliance Health

PolicyMental Health/Substance Abuse Targeted Case Management (MH/SA TCM)

Policy CodePolicy 8-L

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionVerify Medicaid eligibility at each service and document at least 15 minutes of weekly case management activity plus at least one face-to-face contact per month; maintain a signed service order valid for one year.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NCApplicable state

15 minMin weekly activity

YesEPSDT applies

Weekly case rateBilling unit

1:50Max caseload ratio

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Coverage Criteria and Limits

Covered Services (General) (inv-01)

Covered when ALL of the following are met:

Eligibility and diagnosis: Beneficiary is enrolled in NC Medicaid and has a serious emotional disturbance, mental illness, or a substance-related disorder (includes pregnant beneficiaries with these conditions).

Age of adulthood varies by funding source; Medicaid adult services begin at age 21 unless EPSDT applies.

Service purpose: Services assist the beneficiary to gain access to necessary medical, behavioral, social, and other services and are individualized, person-centered, strengths-based, and outcome-focused, including assessment, person-centered planning, referral/linkage, and monitoring/follow-up.

Functions: assessment, person-centered planning, referral/linkage, monitoring and follow-up.

Provider actions: Case manager coordinates and communicates with the beneficiary's primary care physician and other providers as applicable and verifies Medicaid eligibility each time a service is rendered.

Provider qualifications and documentation requirements are detailed elsewhere in the policy.

EPSDT Coverage Exceptions (inv-02)

EPSDT provisions (beneficiaries under 21):

EPSDT medical necessity: Services, products, or procedures for beneficiaries under 21 must be medically necessary to correct or ameliorate a defect, illness, or condition identified through screening to be covered under EPSDT.

EPSDT may allow exceeding policy limits if provider documentation supports medical necessity.

Limitations under EPSDT: EPSDT does not require coverage of services that are unsafe, ineffective, experimental or investigational, or not medical in nature.

If a service normally requires prior approval, EPSDT does not eliminate that requirement.

Covered — Initial Eligibility and Coverage (inv-03)

Medicaid covers MH/SA TCM when BOTH general and specific criteria are met

General coverage requirements: Covered services must be individualized and specific to the beneficiary's diagnosis/symptoms, safely furnished with no equally effective, more conservative or less costly statewide alternative, and not primarily for convenience.

From Section 3.1.

Specific MH/SA TCM criteria: There is a current diagnosis reflecting the need for treatment and the services are medically necessary to meet preventive, diagnostic, therapeutic, or rehabilitative needs.

From Section 3.2.1.

Eligibility conditions (one or more required): Beneficiary meets at least one qualifying condition: (a) MH/SA diagnosis per DSM-5 (excluding sole intellectual/developmental disability unless pregnant); (b) requires coordination between two or more agencies; (c) unable to manage symptoms due to at least three unmet basic needs; (d) in a residential setting needing transition coordination; or (e) has experienced two or more crisis episodes requiring emergency/Mobile Crisis/hospitalization/detoxification within the past three months.

Covered — Continued Service (inv-04)

Continued service covered when ALL the following are met

Continued service criteria: Periodic reassessment documents measurable progress toward PCP goals requiring case management and continuation is effective; eligibility per Section 3.2.2 continues to be met except as noted; AND the beneficiary requires coordination between one or more agencies; AND the beneficiary is unable to manage symptoms or maintain abstinence due to at least one basic need identified in the initial assessment, OR at least three unmet basic needs identified during service.

From Section 2.3.3.

Discharge Criteria (inv-05)

Discharge occurs when ANY of the following apply

Discharge criteria: (a) Goals outlined in the Person-Centered Plan requiring case management functions have been met; (b) the beneficiary no longer meets continued service criteria; or (c) the beneficiary or legally responsible guardian no longer wishes to receive case management services.

From Section 2.3.4.

Medical Necessity / Coverage Criteria (inv-06)

Covered when ALL of the following are met

Eligibility and ordering: Services provided to Medicaid beneficiaries by qualified providers require a signed service order completed by an authorized clinician (physician, licensed psychologist, physician assistant, or nurse practitioner) based on a comprehensive clinical assessment prior to or on the first date of service; service orders are valid for one year and medical necessity and orders must be reviewed at least annually.

See provider qualifications for acceptable provider types and Date of Plan validity guidance.

Provider and organizational qualifications: Provider must meet Medicaid participation qualifications, have a current signed DHHS Provider Administrative Participation Agreement, bill only within scope of practice, and be a certified CABHA or meet NC Medicaid and DMH/DD/SAS provider standards and 10A NCAC 27G.

From Sections 6.0 and 6.1.

Service delivery and documentation: There must be weekly documentation of at least 15 minutes of case management activity within any of the four functions (assessment, beneficiary-centered planning, linking, or monitoring) and at least one face-to-face contact per month; each contact must have a full service note including required elements and a discharge plan must be included when applicable.

Coverage contingent on compliance (inv-07)

Provider compliance and eligibility for coverage require adherence to the following administrative and documentation requirements

Administrative and Documentation Requirements: Provider must comply with all applicable agreements, federal, state and local laws and regulations (including HIPAA and record retention), NC Medicaid clinical coverage policies, guidelines, provider manuals, implementation updates and bulletins at the time the service is rendered; must document services to demonstrate medical necessity and billing accuracy; must use current ICD-10 reporting guidance and follow NCTracks billing guidance and national coding guidelines.

Compliance supports eligibility for reimbursement and services are subject to audits and potential recoupment for deficiencies.

EPSDT protections apply to Medicaid beneficiaries under age 21. Under EPSDT (42 U.S.C. § 1396d(r)), the state must cover services that are medically necessary to correct or ameliorate a condition identified through screening, and may allow exceeding policy limits when provider documentation supports medical necessity. However, EPSDT does not require coverage of services that are unsafe, ineffective, experimental or investigational, or not medical in nature.

The policy explicitly lists specific services that are not covered under MH/SA TCM. Examples include transportation time and transportation services, any treatment interventions such as habilitation or rehabilitation activities, and social or recreational activities (or their supervision). Also excluded are clinical and administrative staff supervision (including team meetings), writing assessment reports, person-centered plans, or service notes, and service record reviews.

Providers should note these exclusions apply even when case management activities occur in community settings; excluded items may not be billed as MH/SA TCM.

MH/SA Targeted Case Management cannot be provided during the same episode of care as certain other intensive programs, including In-Home Services, Community Support Team, Assertive Community Treatment Team, Multisystemic Therapy, Child and Adolescent Day Treatment, Substance Abuse Intensive Outpatient Program, Substance Abuse Comprehensive Outpatient Treatment, and Substance Abuse Non-Medical Community Residential Treatment. Additionally, beneficiaries receiving MH/SA TCM may not receive other Medicaid-reimbursable case management services during the same period (for example, CAP, At-Risk Case Management, or TCM for Intellectual Disabilities).

Federal rules restrict Federal Financial Participation for services delivered to inmates of public institutions and certain patients in Institutions for Mental Diseases (IMDs). As a result, services provided to inmates or IMD patients may be excluded from FFP and are subject to the statutory exceptions and limitations identified in federal regulations.

Federal Medicaid and SCHIP rules prohibit Federal Financial Participation payment for services delivered to inmates of public institutions and for certain patients in Institutions for Mental Diseases except as specifically allowed by statute or regulation. Where these prohibitions apply, reimbursement for services in those settings is paid with state-only funding rather than federal matching funds.

MH/SA TCM is not covered when the beneficiary fails to meet eligibility requirements in Section 2.0 or the coverage criteria in Section 3.0. Coverage is also denied when the service would duplicate another provider's procedure, product, or service, or when the procedure, product, or service is experimental or investigational.

Codes, Billing Units, and Visit Minimums

Example service codeHCPCSCovered

H0032

Mental health service plan development by nonphysician

Billing units definitionmixed

No codes listed

inv-16: Weekly documentation — >= 15 minutes of case management activity per week

Requirement>= 15 minutes of case management activity documented per week

ScopeMust be within any of the four case management functions: assessment, beneficiary-centered planning, linking, or monitoring

Face-to-face allowanceWeekly minutes may be non-face-to-face; however, at least one face-to-face contact per month is required

Provider Requirements, Documentation, and Authorization

Prior Authorization

Prior Approval — EPSDT Exception

EPSDT beneficiaries under 21 remain subject to prior approval when the service requires it; EPSDT does not eliminate prior approval requirements for services that require prior approval.

See NCTracks Provider Claims and Billing Assistance Guide and EPSDT provider page for additional EPSDT/prior approval guidance: https://www.nctracks.nc.gov/content/public/providers/providermanuals.html; https://medicaid.ncdhhs.gov/

Prior Authorization

Prior Authorization Guidance

MH/SA Targeted Case Management (TCM) does not require prior authorization in general; however, EPSDT beneficiaries under 21 must follow prior approval processes when the requested service itself requires prior approval.

Medicaid shall not require prior approval for MH/SA TCM (non-EPSDT exception).
If a particular service or procedure associated with the case management plan requires prior approval, follow NCTracks and EPSDT procedures.

Background and Scope

Targeted case management for mental health and substance abuse assists eligible Medicaid beneficiaries to access necessary medical, behavioral, social, and other services. It is a person-centered, strengths-based service focused on individualized assessment, person-centered planning, referral/linkage, and monitoring/follow-up. Services are tailored to beneficiary needs, periodically reassessed, and coordinated with primary care and specialty providers to support engagement and improved outcomes.

Key Definitions

Level of Care / Service Setting Criteria

Treatment Modalities and Service Components

Case management / care coordination (inv-55)

Modality — Care coordination and linkage: Case management/care coordination activities include coordinating service delivery to reduce fragmentation, facilitating access and connection to services/supports identified in the PCP, making referrals and scheduling appointments, assisting transitions across levels of care, facilitating communication among providers and supports, and assisting beneficiaries to establish and maintain a medical home or prenatal care for pregnant beneficiaries.

Referral and linkage functions are central to case management modality.

Case Management (inv-56)

Modality — Case Management service delivery rules: Case management is provided by certified CABHA agencies; a beneficiary may receive case management from only one CABHA during an episode of care; services are directed exclusively to benefit the beneficiary; may be provided up to 60 consecutive days for transitions from medical institutions; services are not reimbursed for adults in IMDs or inmates of public institutions in specified circumstances.

From Section 5.2.2 and service limitations in 5.3.1.

Visit Frequency, Units, and Billing Periods

Policy Summary

PayerAlliance Health

PolicyMental Health/Substance Abuse Targeted Case Management (MH/SA TCM)

Policy CodePolicy 8-L

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

SourceLink

On This Page

>=15 minutes/week; >=1 face-to-face/month

Service is billed on a weekly case rate basis.

Documentation Required

Signed Service Order Required

A signed service order is required prior to or on the day the service is initially provided. The order must be completed and signed by an authorized clinician (physician, licensed psychologist, physician assistant, or nurse practitioner) and be based on a comprehensive clinical assessment. Service orders are valid for one year from the Date of Plan on the PCP and must be reviewed at least annually.

Service order must include signature, credentials, and date of order.
Order must be based on a comprehensive clinical assessment of the beneficiary's needs.
Service orders valid for one year from Date of Plan; review medical necessity annually.

Note

Prior Approval/Authorization Removed

Language referencing prior approvals, authorizations, reauthorizations, and utilization management has been removed for MH/SA TCM per policy revision; prior approval is not required for MH/SA TCM except where EPSDT or another service rule explicitly requires it.

Removed references to utilization management, initial authorizations, and reauthorizations for MH/SA TCM.
Prior approval/authorization language removed from general MH/SA TCM authorization requirements.

Denial Risk

Eligibility Verification

Providers must verify each beneficiary's Medicaid eligibility at every service encounter. Failure to verify eligibility may result in claim denial.

Verify Medicaid eligibility each time a service is rendered; beneficiary eligibility category may restrict coverage.

Denial Risk

Denial Triggers

Claims may be denied if the beneficiary does not meet Section 2.0 eligibility, Section 3.0 coverage criteria, if the service duplicates another provider's service, or if the procedure/product/service is experimental or investigational.

Denial triggers include: not meeting eligibility (Section 2.0), not meeting coverage criteria (Section 3.0), duplication of services, or experimental/investigational status.

Billing Rule

Billing Activity and Contact Requirements

To bill for weekly case management, documentation must show at least 15 minutes of weekly case management activity across assessment, person-centered planning, linking, or monitoring. A minimum monthly face-to-face contact with the beneficiary is required. Billing without documentation of these activities or without the monthly face-to-face contact may be denied.

At least 15 minutes of documented weekly case management activity is required to bill the weekly case rate (1 unit per calendar week).
Minimum monthly face-to-face contact is required; weekly activities may be non-face-to-face.
Insufficient documented activity or missing monthly face-to-face contact are grounds for denial.

Denial Risk

Audit Findings and Potential Recoupment

Deficiencies identified during audits (including billing errors, incorrect beneficiary identifiers, procedure code or unit errors, or inadequate documentation) will be reported to NC Medicaid Program Integrity and may result in recoupment, refund requests, or withholdings from future payments.

Audit findings forwarded to NC Medicaid's Program Integrity Section with supporting documentation.
Refunds or withholdings should be sent to Office of Controller NC Medicaid Accounts Receivable.

Note

Funding Ineligibility — Inmates and IMD Patients

Claims for services delivered to inmates of public institutions or certain IMD patients may be ineligible for Federal Financial Participation; such services may be paid with state-only funds where federal participation is prohibited.

Federal Medicaid laws prohibit FFP payment for services to inmates of public institutions unless the beneficiary is a patient in a medical institution.
FFP prohibitions for IMD patients may apply; 100% state funding may be required in those settings.

Documentation Required

Required Documentation and Orders

Providers must complete and maintain required documentation: a comprehensive clinical assessment documenting medical necessity prior to service, the LME Consumer Admission and Discharge Form as required, and a full service note for each contact or date of service. Service notes must include beneficiary identifiers, service details, date and place of service, type and purpose of contact, description of activities, time spent, outcomes/next steps, and signature with credentials. A documented discharge plan must be included in the service record.

Comprehensive clinical assessment documenting medical necessity is required prior to service.
Submit Local Management Entity (LME) Consumer Admission and Discharge Form.
Full service note content requirements: beneficiary name, Medicaid ID, service record number, service provided, date, place, contact type and purpose, activity description, time spent, results/outcomes, signature and credentials.
Case manager providing the service must sign and include credentials.

Documentation Required

Compliance and Recordkeeping

Providers must comply with all applicable agreements, federal, state and local laws (including HIPAA), record retention requirements, NC Medicaid clinical coverage policies, guidelines, provider manuals, implementation updates, and bulletins. Providers must also follow NCTracks billing guidance and applicable coding rules.

Comply with HIPAA and record retention requirements.
Follow NCTracks Provider Claims and Billing Assistance Guide and NC Medicaid clinical coverage policies for coding and reimbursement.
Report ICD-10-CM and PCS coding to highest level of specificity supporting medical necessity.

Targeted Case Management (TCM) (inv-57)

Modality — Targeted Case Management (TCM): Targeted Case Management encompasses the four case management functions (assessment, beneficiary-centered planning, linking, and monitoring); activities may be non-face-to-face but require at least monthly face-to-face contact and are billed on a weekly case-rate basis.

Billed on weekly case rate; weekly activity must reflect at least 15 minutes per week.

Case Management / Person-Centered Planning (inv-58)

Modality — Person-centered planning and provider competencies: Providers delivering case management must demonstrate competencies in data collection from multiple sources, modifying care plans with stakeholder input, communicating about quality of care, monitoring beneficiary engagement, cultural competence, ethical decision-making, confidentiality, clear verbal and written communication, identifying referral needs, and pursuing ongoing training and supervision.

These are competency expectations rather than service-specific clinical criteria.