Authorize services only by ISP

Waiver services are authorized only through the Individual Support Plan (ISP) developed via person-centered planning; the ISP lists waiver services, projected frequency, provider type, complementary supports, and is subject to Medicaid agency approval. Beneficiaries may select any willing, qualified provider and have a care coordinator as specified in the ISP process.

• All waiver services furnished pursuant to the ISP; FFP is not claimed for services furnished prior to development of the ISP.
• ISP must document waiver services, frequency, provider type, and other supports; Medicaid agency approval required.

Develop and obtain approval for participant-centered service plan

A participant-centered service plan must be developed per 42 CFR §441.301(b)(1)(i) and approved by the Medicaid agency; Federal Financial Participation (FFP) cannot be claimed for waiver services provided before the service plan is developed or for services not listed in the plan.

• Service plan must describe waiver services furnished, projected frequency, provider type, and complementary services/supports.
• FFP not claimed for services prior to development of approved service plan.

Prior authorization responsibilities documented (matrix incomplete)

The application includes a responsibility matrix for prior authorization of waiver services, but the checkboxes for which entity holds prior authorization responsibility are not completed in this excerpt—PIHPs/MCOs remain responsible for utilization management and prior authorization as reflected elsewhere.

• Appendix A lists prior authorization as an operational function but specific assignments are blank.
• HCBS/TBI waiver funding requires prior authorization from the MCO for waiver-funded therapies and services of last resort.

Implement corrective action and immediate notification to State

PIHPs must implement corrective action plans for problems identified; the Division of Health Benefits (DHB) requires the corrective action plan and the PIHP must notify the State immediately if a beneficiary's health or safety is jeopardized.

• PIHPs address and correct problems case-by-case per contract; DHB monitors corrective action plans with the IMT.
• Immediate State notification required when health/safety of a beneficiary is jeopardized.

Prior approval required for cost-limit exceedance > $135,000

Requests for services or supports that would exceed the individual waiver cost limit of $135,000 must be prior approved through the beneficiary's Individual Support Plan or Plan Update and approved by the beneficiary's LME/MCO; approvals must be related to beneficiary needs and not for provider or caregiver convenience.

• Beneficiaries receiving Supported Living Level III with 24-hour support may request exceedance via ISP/plan update.
• Assistive Technology, Home and Vehicle Modifications may be used to exceed the limit for beneficiaries not using Supported Living Level III.

Apply via PIHP; complete intake screening and provide written notice

Individuals apply for the waiver through the PIHP; intake screening includes a comprehensive clinical review and administration of the NC TBI Risk/Support Needs Assessment, and the PIHP provides written notification of the outcome.

• Screening determines preliminary potential eligibility and whether the waiver can meet the individual's needs.
• If health/safety risks are identified, PIHP reviews assessments to determine service appropriateness.

Use reserved slots and priority access for emergencies and MFP

Reserved capacity slots are maintained for emergencies and for Money Follows the Person (MFP) when available; individuals meeting reserved criteria receive priority access to these slots.

• When reserved capacity is not available, individuals are prioritized based on non-reserved criteria (first-come, first-served).

Place unfunded eligible individuals on TBI Waiver Registry of Unmet Needs

When waiver funding is unavailable, potentially eligible individuals are placed on the TBI Waiver Registry of Unmet Needs; placement on the registry preserves their status for future enrollment when funding permits.

• Registry used for individuals determined potentially eligible but not immediately funded.

Conduct initial and annual LOC evaluations; re-evaluate within 30 days of change

Level-of-care (LOC) evaluations must be conducted initially and re-evaluated at least annually tied to the beneficiary's birth month; if a change in condition is identified, a re-evaluation must occur within 30 days.

• Annual re-evaluations completed by a Qualified Professional or care coordinator within the PIHP or community.
• PIHP must maintain a computerized tracking system of LOC evaluations, review data monthly, and retain LOC records for five years for beneficiaries over age 18.

Bill Day Supports in 1-hour units; require ≥15 minutes before billing

Day Supports (Day Habilitation) is billed in one-hour increments; an individual must receive a minimum of 15 minutes of Day Supports before an hour unit may be billed. The amount is subject to the 'Limit on Sets of Services' and EPSDT benefits must be exhausted prior to waiver use for individuals under 21.

• Billed in 1-hour unit increments; 15 minutes of service required before billing an hour unit.
• Service amount subject to Appendix C-4 limits and EPSDT exhaustion requirement for minors.

Meet agency licensing/certification and staff competency requirements

Agency providers (e.g., Adult Day Care Programs) must meet specified licensing, certification and competency standards: staff must be at least 18 years old, have CPR/First Aid training, a high school diploma/GED, pass criminal background checks, not be listed in the NC Health Care Abuse Registry, and paraprofessionals must be supervised per 10A NCAC 27G.0204.

• If providing transportation, staff must have a valid driver's license, safe driving record, and appropriate automobile liability insurance.
• Providers must be approved in the PIHP provider network.

Provider verifies hires; PIHP performs agency credential verification and sampling

Providers must verify employee qualifications at the time of hire; the PIHP verifies agency credentials on initial review and re-verifies agency credentials and a sample of employee qualifications at a frequency determined by the PIHP, no less than every three years.

• Provider responsibility: verify employee qualifications at hire.
• PIHP responsibility: initial credentialing and re-verification of agencies and sampled employee qualifications at least every three years.

Verify credentials prior to enrollment and re-verify ≥ every 3 years

Verification of provider and employee credentials is required prior to initial enrollment and must be repeated at least every three years thereafter.

• PIHP re-verification frequency: no less than every three years for agency credentials and sampled employee qualifications.
• Provider-level verification occurs at time of hiring.

Apply 'Limits on sets of services' and EPSDT exhaustion for Residential Supports

Residential Supports amounts are subject to the 'Limits on sets of services' in Appendix C-4; for individuals under age 21, EPSDT benefits must be exhausted before waiver services are used.

• Service limits and EPSDT exhaustion requirements apply to Residential Supports as specified in Appendix C.

PIHP credentials and monitors facilities; re-credential ≥ every 3 years

The PIHP credentials facilities at initial enrollment and re-credentials them at least every three years; the PIHP monitors facilities per the DHHS Monitoring Process.

• PIHP monitoring of facilities is conducted according to DHHS monitoring requirements.

Division of verification responsibilities between providers and PIHP

Providers verify employee qualifications when hired; the PIHP verifies credentials on initial review and re-verifies agency credentials and samples of employee qualifications at least every three years.

• Provider responsibility: verify at hire.
• PIHP responsibility: initial and periodic re-verification of agencies and employee samples no less than every three years.

PIHP and provider credential verification frequency and duties

PIHPs must verify and re-verify agency credentials on initial review and at a minimum every three years; providers must verify employee qualifications at hiring.

• PIHP verification cadence: initial credentialing and re-verification no less than every three years.
• Provider-level verification: at time of hire for each employee.

Require MCO prior authorization; waiver is payer of last resort

HCBS/TBI waiver services are funded as payer of last resort and require prior authorization from the MCO before waiver-funded services are provided.

• Waiver-funded rehabilitation therapies are provided only when State Plan limits are exhausted and require MCO prior authorization.
• Providers must document medical necessity and attempts to use other formal resources where applicable.

Obtain MCO prior authorization for waiver-funded therapies

Prior authorization from the MCO is required for waiver-funded therapies (occupational therapy, physical therapy, speech-language therapy) which are provided when State Plan limits are exhausted.

• Maximum combined annual units for each rehabilitation therapy is 3,120 units/year (1 unit = 15 minutes).
• EPSDT benefits must be exhausted for beneficiaries under 21 prior to waiver therapy use.

Exhaust EPSDT benefits before waiver services for beneficiaries <21

For individuals under 21 years old, all State Plan and EPSDT benefits must be exhausted prior to use of waiver services.

• EPSDT exhaustion requirement applies across multiple waiver services including Day Supports and rehabilitation therapies.

PIHP must verify Assistive Technology providers prior to first use

PIHPs must verify Assistive Technology provider qualifications prior to first use; Assistive Technology vendors must hold applicable state/local business licenses and meet state/local requirements for devices provided.

• Alert Response Centers must be staffed 24/7/365 by trained individuals and meet applicable state/local requirements.
• PIHP is responsible for verification of provider qualifications prior to first use.

PIHP initial and periodic credential verification for CR agencies

For Cognitive Rehabilitation provider agencies, the PIHP verifies agency credentials on initial review and re-verifies agency credentials, including a sample of employee qualifications, at a frequency determined by the PIHP but no less than every three years.

• PIHP must include sampling of employee qualifications during re-verification.

Provider agencies verify employee qualifications at hiring

Employer/provider agencies must verify employee qualifications at the time an employee is hired (for Cognitive Rehabilitation and other services).

• Provider verification at hire is an ongoing requirement tracked by PIHP during sampling and re-verification.

Allow verbal authorization for Crisis Supports with prompt ISP and budget updates

Crisis Supports may be verbally authorized for immediate intervention; following verbal authorization, the ISP and individual budget must be updated within five working days and the Comprehensive Crisis Plan updated within 14 days as warranted.

• Crisis Supports available 24/7 to intervene and stabilize individuals in acute crises.
• Post-authorization ISP and budget modifications within five working days; crisis plan updated within 14 days.