Enhanced Crisis Response (ECR) Rapid Response Team (RRT) — In Lieu of Service (ILOS)
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Defines eligibility, service elements, utilization management, documentation, staffing, and operational requirements for ECR RRT services as an in-lieu-of service for NC Medicaid Healthy BlueCare Together members ages 5-64 experiencing acute behavioral health crises.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
inv-01: Eligibility and Clinical Indications
Covered when ALL of the following are met:
inv-02: Authorization and Duration Criteria
Service provision and authorization rules
inv-03: Service Delivery and Goals
Operational and clinical service expectations
inv-04: Coverage criteria for ECR RRT ILOS
Covered when ALL of the following staffing, availability, and documentation conditions are met:
Training in crisis intervention required
Backup personnel permitted with written coverage plan submitted to HBCT
Adjust caseload based on intensity of needs
Care plan must describe collaboration with Care Management
For beneficiaries under 21 years of age, EPSDT (42 U.S.C. § 1396d(r)) requires coverage of medically necessary services to correct or ameliorate conditions identified through screening. However, EPSDT does not obligate coverage for services that are unsafe, ineffective, experimental, investigational, or not medical in nature. Providers should apply EPSDT standards when determining coverage for members under 21 but recognize these exceptions to required coverage.
ECR services must not be requested for members who are already receiving other enhanced services as defined in Clinical Coverage Policy 8A unless prior approval is obtained under EPSDT. Providers should secure the required prior approval before billing or initiating overlapping enhanced services to avoid duplication and denial risk.
Weekly billable claims should not be submitted for any week in which the provider delivered less than 2 hours of ECR RRT services. Submitting claims for weeks that do not meet the minimum service-hour requirement risks denial and is inconsistent with the service exclusions and billing rules.
Codes, Units, and Minimum Service Rules
| H2011 U5 U1 | Enhanced Crisis Response Rapid Response Team |
Authorization, Documentation, and Billing Responsibilities
No PA for first 8 weeks; SAR required within 7 days
No prior authorization is required for the initial eight-week pass-through (one billable unit per week). A Service Authorization Request (SAR) must be submitted within 7 days of starting service; if the member is already receiving an enhanced service at referral, a SAR must be submitted to permit overlap and for utilization management review.
- Initial authorization = one billable unit/week for first 8 weeks.
- SAR required within 7 days of service start.
- If linked to another service, submit SAR to allow overlap per linkage rules.
Obtain prior approval for overlap with other enhanced services
Do not begin ECR services for members already receiving enhanced services under Clinical Coverage Policy 8A without obtaining prior approval; such overlaps require EPSDT exception approval and a SAR to allow simultaneous services.
- ECR services should not be requested for members already receiving enhanced services unless prior approval is obtained under EPSDT.
- Utilization Management will review to prevent duplication.
One billable unit/week initially; reauthorization allows additional units
Bill one pass-through billable unit per week for the first eight weeks (initial authorization). After the initial eight units, request reauthorization for additional units — up to four additional units may be requested with each reauthorization.
- Initial billing cadence: 1 billable unit/week for first 8 weeks.
- After 8 weeks, reauthorization required; each reauthorization may request up to 4 additional units.
Do not bill weeks with <2 hours; bill only after >=2 hours/week
Submit weekly billable claims only for weeks when you deliver at least 2 hours of ECR services; do not submit a billable claim for any week with less than two hours of service.
- Minimum threshold for a billable weekly claim: >= 2 hours of service.
- Weeks with <2 hours must not be billed; such claims would be considered not authorized for payment.
Maintain SAR, Crisis Plan, and Person‑Centered Plan; SAR timing rules
Document and maintain a SAR, a Crisis Plan, and a Person‑Centered Plan (PCP). When linking to another service, submit a SAR to allow overlap (per linkage guidance).
- SAR is required within 7 days of starting service.
- Include an up-to-date Crisis Plan and Person‑Centered Plan in the member record.
- When linked to other services (e.g., In Home Therapy, FCT, MST), submit SAR to permit allowed overlap.
Include contact counts, frequency, and time modifiers on encounter claims
Submit encounter claims that document total number of contacts and frequency and include modifiers reflecting time spent with the member; encounter claims must account for all time spent.
- Encounter claims must detail total contacts and frequency.
- Include time-based modifiers to account for all member contact time.
- Encounter data will be tracked and reported quarterly against H2011 U5 U1.
Record all member time in encounters and document care‑plan coordination
Record all time spent with the member in encounter claims using appropriate modifiers; ensure the member's care plan documents collaboration with Care Management to avoid duplication of services.
- All member time must be recorded via encounter claims with modifiers showing contacts and frequency.
- Care plan must explicitly describe collaboration with Care Management to prevent service duplication.
Authorization required for services beyond initial 8 weeks
Obtain authorization to continue services beyond the initial eight weeks; reauthorization is required after 8 weeks if the crisis remains unresolved, and services typically do not exceed 12 weeks.
- Reauthorization required after the initial 8 weeks.
- Service typically does not exceed 12 weeks; continued stay requires clinical review and authorization for additional units.
Submit weekly claims after meeting hours and file encounter claims with modifiers
Submit weekly claims only after meeting the >=2 hours/week minimum and include encounter claims with time-based modifiers that account for all time spent; failure to submit required weekly claims and encounters with modifiers may risk denial.
- Weekly billable claims must follow weeks with >=2 hours of service.
- Submit encounter claims with modifiers detailing time and contacts.
- Failure to submit required claims/encounters with modifiers may result in denial.
Weeks with <2 hours risk denial — do not bill those weeks
Do not submit billable claims for weeks with less than two hours of service; submitting such claims risks denial as they are considered not authorized for payment — remediate by withholding claims for those weeks or documenting additional time to meet the threshold.
- Claims for weeks with <2 hours are not authorized for payment and risk denial.
- If insufficient hours were provided, do not bill that week or document additional qualifying service time before billing.
Key Terms and Abbreviations
Level-of-Care and Service Setting Criteria
inv-23: Community/Home-based Crisis (ECR RRT)
Level-of-care criteria for community/home-based crisis services
inv-24: Rapid Response / Crisis Outreach
Criteria for rapid response and outreach operations
Service Components and Modalities
inv-25: Linkage to therapeutic and residential services
Criteria for linkage to higher levels of care
inv-26: Crisis response outreach / Rapid Response Team
Treatment modality and team composition for crisis outreach
Billing Units and Visit Limits
Background and Rationale
The Enhanced Crisis Response Rapid Response Team (ECR RRT) is a 24/7 community- and home-based crisis intervention service designed to provide immediate telephonic assessment and in-person crisis management for members in acute behavioral health crises. Services focus on rapid evaluation, triage, stabilization, harm reduction, crisis planning, linkage to supports and community services, and next-day follow-up to reduce unnecessary ED boarding or inpatient admission and to stabilize members in the least restrictive setting.
As an ILOS (In Lieu Of Service), ECR RRT includes a case management component and requires encounter-level documentation. Providers must record all time with the member via encounter claims (using modifiers to reflect contacts and frequency) and comply with weekly reporting and quarterly encounter tracking against H2011 U5 U1 to support program measurement and avoid duplication with other care management activities.
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