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Day Supports (I/DD & TBI) — Coverage Criteria

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Defines coverage, eligibility, and clinical criteria for state-funded Day Supports for individuals age 16 and older with intellectual/developmental disabilities or traumatic brain injury, including telehealth provisions and authorization requirements.

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CurrentclearhealthalliancePolicy N/A

Day Supports (I/DD & TBI) — Coverage Criteria

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Policy Summary

Payerclearhealthalliance

PolicyDay Supports (I/DD & TBI) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization from the LME‑MCO by submitting a completed service authorization request with required documentation before starting services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

16+minimum age for coverage

State-fundedfunding source

Prior authauthorization requirement

30 hrs/wkmax weekly service

15 minbilling increment

Not Medicaid billableMedicaid billing status

Coverage and Medical Necessity Criteria

Specific Criteria Covered

State funds shall cover Day Supports (I/DD & TBI) when ALL of the following criteria are met:

Specific criteria covered by State Funds: a. 16 years of age or older and express a desire to obtain and maintain service

Specific criteria covered by State Funds: b. The individual has a condition that is identified as a developmental disability or Traumatic Brain Injury as defined in G.S. 122-C-3(12a) or G.S. 122-C3(38a)

Specific criteria covered by State Funds: c. NC Support Needs Assessment (Level 2 or higher), Supports Intensity Scale (Level C or higher), or TBI Assessment requiring a minimum to low level of supervision and support in most settingsLevel 2 (SNAP) or Level C (SIS)

General Criteria Covered

State funds shall cover the service when medically necessary and ALL of the following are met:

General medical necessity: a. Service is individualized, specific, and consistent with the symptoms or confirmed diagnosis under treatment, and not in excess of the individual's needs

General medical necessity: b. The service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide

General medical necessity: c. The service is furnished in a manner not primarily intended for the convenience of the individual, the individual's caretaker, or the provider

Admission Criteria

Admission Criteria — State funds shall cover Day Supports services when the following Admission Criteria are met:

Admission: developmental disability with testing: A psychological, neuropsychological, or psychiatric assessment that includes appropriate validated testing performed by a licensed clinician; disability manifested before age 22 unless caused by TBI

Admission: developmental disability without intellectual disability: A physician assessment substantiating a definitive diagnosis and associated functional limitations; associated psychological or neuropsychological testing is not required

Admission: service authorization: Prior authorization by the LME-MCO is required; a service authorization request must be completed by a Qualified Professional and submitted to the LME-MCO prior to services

Admission: PCP/ISP and goals: Relevant clinical information must be obtained and documented in the individual's Person-Centered Plan or Individual Service Plan; individual requires service for acquisition, retention, or improvement in socialization and daily living skills as documented by detailed deficiencies and planned goals

Continued Stay Criteria

Continued Stay Criteria — Day Supports should be maintained when the individual meets criteria for continued stay if ONE of the following applies:

Continued stay conditions: a. The desired outcome or level of functioning has not been acquired, sustained, restored, or improved over the timeframe documented in the individual's PCP or ISP

Continued stay conditions: b. Documentation supports that regression is likely if the service is withdrawn based on current clinical assessment, history, or the tenuous nature of functional gains

Continued stay conditions: c. Continuation of service is supported by documentation of the individual's progress toward goals within the individual's PCP or ISP

Continued stay authorization: Prior authorization by the LME-MCO is required; a service authorization request must be completed by a Qualified Professional and submitted to the LME-MCO prior to services

Transition and Discharge Criteria

Transition and Discharge Criteria — The individual meets criteria for discharge if any ONE of the following applies:

Discharge criteria: a. Individual's level of functioning has improved with respect to the goals outlined in the PCP or ISP (i.e., goals do not show progression)

Discharge criteria: b. Individual no longer benefits from this service

Discharge criteria: c. Individual has achieved PCP or ISP goals; discharge to a lower level of care is indicated

Discharge criteria: d. Individual is not making progress, or is regressing, and all realistic treatment options within this modality have been exhausted

Discharge criteria:

This service is not covered when the individual does not meet the eligibility requirements in Section 2.0, does not meet the clinical criteria in Section 3.0, when the service duplicates another provider's service, or when the service is experimental, investigational, or part of a clinical trial.

State funds do not cover transportation to and from school; responsibility for school transportation remains with the school system. State funds also do not cover payments made directly to members of the individual’s immediate family for Day Supports (I/DD & TBI).

Day Supports may only be provided by one authorized Day Supports provider at a time and may not be furnished in a residential setting. The service may not be provided concurrently with any other State‑funded or Medicaid‑funded service that works directly with the individual, and must not duplicate other Medicaid or State‑funded services the individual receives. Individuals who are HCBS Waiver members or receiving specified I/DD/TBI meaningful day services or Medicaid In Lieu of Services with a meaningful day component are excluded. Service intensity limits include a maximum of 3 hours/day on school days for individuals ages 16–22 who have not graduated, and a maximum of 30 hours/week.

Conversion therapy is explicitly not reimbursable by DMH/DD/SUS and therefore is a non‑covered service under this policy.

Services are considered not medically necessary when the individual fails to meet the eligibility requirements in Section 2.0 or the criteria in Section 3.0. The policy also excludes services that are experimental, investigational, or part of a clinical trial.

Additional non‑coverage conditions include services that duplicate another provider’s services, services that are experimental/investigational or part of a clinical trial, and services that violate the setting or concurrency rules (for example, services provided in a residential setting or provided at the same time as another State‑ or Medicaid‑funded direct service). Conversion therapy is specifically excluded from reimbursement under this program.

Initial Authorization

Covered when ALL of the following are met

Covered Service Conditions: Service is state-funded Day Supports for individuals with I/DD or TBI; individual meets eligibility in Section 2.0 and specific criteria in Section 3.0; medical necessity is established per North Carolina community practice standards; required documents (psychological evaluation, service order for medical necessity, PCP or ISP, and LME-MCO authorization request form) are submitted; authorization is granted by the LME-MCO.

Initial authorization requirements documented in policy.

Reauthorization

Reauthorization conditions

Reauthorization requests must be submitted to the LME-MCO 14 days prior to the end date of the individual's active authorization; documentation must demonstrate ongoing medical necessity and progress toward PCP/ISP goals; duration and frequency must be based on medical necessity and progress. Consideration should be given to other, more intensive services before increasing Day Supports duration or frequency.

Place of Service and Telehealth

Coverage and billing stance and place-of-service rules include:

Service location and documentation: Service may be provided in the home or community settings that meet CMS HCBS characteristics or in specified licensed/certified facilities; telehealth claims should use the provider's usual place-of-service code(s) and require the GT modifier for interactive audio-visual communication; Day Supports may be provided in alternative facility-based settings due to COVID-19 only if health and safety can be maintained, the ISP/PCP is updated, and documentation confirms COVID-19 diagnosis.

Includes examples of acceptable alternative locations and telehealth billing requirements.

Medicaid Billing Status

Medicaid billing status: This service is not Medicaid billable.

Policy explicitly states service is not Medicaid billable.

Billing Units and Utilization Monitoring

Billing units and monitoring: Units are billed in 15-minute increments; LME-MCOs and provider agencies shall monitor utilization by conducting record reviews and internal audits of units of service billed.1 unit = 15 minutes

Monitoring requirement may affect payment if non-compliant.

Codes, Modifiers, and Billing Units

Example HCPCS Code(s)HCPCS

YM590

Group (HCPCS code listed in policy)

Unlisted procedure/service guidancemixed

unlisted CPT/HCPCS

When no specific CPT/HCPCS exists, use appropriate unlisted procedure or service code and follow CPT/HCPCS special report instructions

ModifiersModifier

GT	Modifier indicating service provided via interactive audio-visual communication

inv-21: Billing increment — 1 unit = 15 minutes

Billing increment1 unit = 15 minutes

Unit reportingProviders report appropriate code(s) which determine billing units

Utilization monitoringLME-MCOs and providers shall monitor units via record reviews and internal audits

Authorization, Documentation, and Operational Requirements

Prior Authorization

Prior authorization required (Qualified Professional must submit request)

Prior authorization from the LME-MCO is required; a service authorization request must be completed by a Qualified Professional and submitted to the LME-MCO prior to services.

Prior Authorization

Submit prior approval request with supporting records

Submit a prior approval request to the LME-MCO and include all supporting health records demonstrating the individual meets the specific criteria in Section 3.2; initial authorization must include psychological evaluation, service order for medical necessity, PCP/ISP, and the LME-MCO authorization request form.

Prior Authorization

Submit reauthorization 14 days before authorization end

Reauthorization requests must be submitted to the LME-MCO 14 days prior to the end date of the individual's active authorization and are based on documented medical necessity and progress toward PCP/ISP goals.

Background and Scope

Day Supports is a group service for individuals aged 16+ with intellectual/developmental disabilities (I/DD) or traumatic brain injury (TBI). It is designed to help individuals acquire, retain, or improve socialization and daily living skills and to promote community inclusion, independent living skills, and meaningful day activities. The service can include prevocational, community involvement, coordination of education/healthcare/finances, training for assistants, transportation skills training, and acquisition of new interpersonal and self‑care skills. Expected outcomes align with the individual’s Person‑Centered Plan (PCP) or Individual Service Plan (ISP) and include increased life skills, self‑sufficiency, self‑determination, and community membership.

Key Definitions

inv-38: Telehealth definition — Two-way real-time interactive audio and video

Telehealth definitionThe use of two-way real-time interactive audio and video to provide and support health care services when participants are in different physical locations.

PurposeTo provide and support health care services when participants are separated by location

Modality requirementRequires real-time interactive audio and video (synchronous communication)

inv-39: Facility-Based — Definition of facility-based services

Facility-Based definitionIndividuals often receive services in a licensed Day Supports provider facility or an Adult Day Health provider certified by NC Division of Aging and Adult Services; individuals are required to check in at the Day Supports facility as defined within the ISP or PCP.

Service setting note

Level of Care / Service Setting Criteria

Service Types and Modalities

Prevocational supports

Prevocational supports: May include career and employment exploration, business tours, informational interviews and job shadows; prevocational supports are unpaid and require employment-related goals in the individual's PCP or ISP

Competitive integrated employment is the optimal outcome.

Day Supports services

Service components: Community involvement, coordination of education/healthcare/finances, day-to-day planning, training/support for assistants, transportation skills training, new skill acquisition, and paraprofessional-delivered interventions under qualified supervision; interventions must be tied to PCP/ISP goals and documented

Day Supports (I/DD & TBI)

Service Frequency and Unit Limits

inv-49: Visit limits — No explicit visit limits specified in this portion of the document

Visit limits unspecifiedNo explicit visit limits are specified in this portion of the document.

Service documentationService may be provided as long as PCP/ISP activities can be fully addressed.

Person-centered time allocationPerson-centered practices determine appropriate on-site versus community time.

inv-50: Day Supports — Maximum per school day for ages 16-22 not graduated: 3 hours/day

Maximum per school day (ages 16-22, not graduated)3 hours per day

ApplicabilityLimit applies on school days for individuals 16-22 years of age who have not graduated.

Policy Summary

Payerclearhealthalliance

PolicyDay Supports (I/DD & TBI) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization from the LME‑MCO by submitting a completed service authorization request with required documentation before starting services.

SourceLink

On This Page

e. Individual has expressed they desire discharge from the service

Prior Authorization

Prior authorization required (service code YM590)

Prior authorization by the LME-MCO is required; a service authorization request must be completed by a Qualified Professional and submitted prior to services (HCPCS YM590 referenced for the service).

Step Therapy

Step therapy not specified

Step therapy is not specified in this document for Day Supports.

Step Therapy

Consider higher-intensity services before increasing Day Supports

If medical necessity requires increased duration or frequency of Day Supports, clinicians must consider other services or interventions with a more intense clinical component before authorizing increased Day Supports.

Documentation Required

Document supports in PCP/ISP based on SNAP, SIS, or TBI assessments

Supports must be documented in the individual's Person-Centered Plan (PCP) or Individual Service Plan (ISP) and be based on assessments such as the SNAP, SIS, or TBI assessment; documentation must include detailed deficiencies and planned goals.

Documentation Required

Maintain full service notes for each contact with required elements

Providers must maintain service records documenting the nature and course of progress; a full service note for each contact is required, signed by the person who provided the service, and must include specified elements (individual name, record ID, date, service name, contact type/place, purpose tied to PCP/ISP goals, intervention description, start/end times and total duration, assessment of effectiveness/progress, and date/signature with credentials).

Billing Rule

Report diagnosis and procedure codes to highest specificity; follow unlisted code guidance

Report ICD-10-CM and procedural/CPT/HCPCS/UB-04 codes to the most specific level that supports medical necessity; if no specific code exists use appropriate unlisted procedure code and follow CPT/HCPCS special report instructions.

Documentation Required

Maintain paraprofessional competencies and comply with legal/policy requirements

Paraprofessionals must maintain documented competencies through training and supervision consistent with professional standards; providers must comply with HIPAA, 42 CFR Part 2, record retention, and applicable state service definitions and manuals.

Denial Risk

Denial risk: eligibility, criteria, duplication, or experimental/clinical trial

Services will not be covered when the individual does not meet eligibility (Section 2.0) or the criteria in Section 3.0, when the service duplicates another provider's service, or when the service is experimental/investigational or part of a clinical trial.

Denial Risk

Denial risk: non-coverage if eligibility/criteria unmet or duplicate service

Services are not covered when eligibility or criteria are not met, or when the service duplicates another provider's service; such circumstances will result in non-coverage.

Billing Rule

Bill in 15-minute units and monitor utilization (audits may trigger actions)

Bill units in 15-minute increments (1 unit = 15 minutes); failure to bill in correct 15-minute increments or to monitor units via record reviews and audits may trigger utilization management actions or payment denials.

1 unit = 15 minutes
LME-MCOs and provider agencies will monitor utilization via record reviews and internal audits of units billed

Billing Rule

Append GT telehealth modifier and avoid billing non-reimbursable services

Append modifier GT to HCPCS codes for services provided via interactive audio-visual telehealth; failure to append GT or billing services that are not Medicaid billable per policy may lead to denial or non-reimbursement.

GT modifier required for interactive audio-visual telehealth claims
Policy notes these services are subject to same restrictions as face-to-face and that conversion therapy is not reimbursed

Historically a facility-based service though person-centered practices determine on-site vs community time

Adult day care roleFor aging individuals, Day Supports can provide a structured day program with nursing supervision in an Adult Day Care Program

inv-40: Day Supports (I/DD & TBI) — Definition of the service

Service definitionSupportive therapeutic service addressing interventions in the PCP/ISP to promote community involvement, independent living skills, coordination of education/healthcare/finances, training for assistants, transportation skills, and new skill acquisition related to interpersonal and self-care functioning.

Program focusIndividualized interventions tied to PCP/ISP goals to acquire, retain, or improve socialization and daily living skills

Includes prevocational activitiesMay include prevocational supports, community involvement, and training for public transportation access

inv-41: Expected outcomes for Day Supports — Outcomes such as increased life skills, self-sufficiency, community membership

Increase life & independent living skillsTo increase the individual's life skills and independent living skills.

Maximize self-sufficiencyMaximize the individual's self-sufficiency.

Enhance self-determination and community membershipIncrease self-determination and ensure opportunity for full membership in the community as defined in the PCP/ISP goals.

inv-42: Paraprofessional competencies — List of required competencies including communication, crisis prevention/intervention, cultural competency, etc.

CommunicationBuilds trust and productive relationships through respectful and clear verbal and written communication.

Person-centered practicesUses person-centered practices to assist individuals in making choices and planning goals tied to PCP/ISP.

Crisis prevention and interventionIdentifies risk and behaviors that can lead to crisis and uses strategies to prevent or intervene in collaboration with others.

Cultural competencyRespects cultural differences and provides services consistent with an individual's preferences.

Professionalism, evaluation, health & trainingIncludes professionalism/ethics, evaluation/observation, health and wellness, community inclusion/networking, and ongoing education/training.

Services should be individualized to meet PCP/ISP goals focused on life skills, independent living, self-sufficiency, self-determination, and community inclusion

Expected outcomes guide treatment modalities.

Provider exclusivityOnly one Day Supports provider can provide this service to an individual at a time (related limitation).

inv-51: Day Supports — Maximum weekly service: 30 hours/week

Maximum weekly service30 hours per week

Duplication restrictionService must not duplicate other Medicaid or State-Funded services the individual is receiving.

Not for HCBS waiver membersIndividuals receiving HCBS Waiver or certain Medicaid meaningful day services are excluded from receiving this service.

inv-52: Units in 15-minute increments — Billing unit increment

Billing unit incrementUnits are billed in 15-minute increments.

Utilization monitoringLME-MCOs and provider agencies shall monitor utilization by conducting record reviews and internal audits of units billed.

Unit determinationAppropriate code(s) reported by provider determine the billing units.