Services Not Covered When Medical Necessity/Eligibility Not Met

Services that fail to meet the medical necessity criteria in Section 3.0, duplicate another provider's service, are experimental/in a clinical trial, or the individual does not meet NC Tracks Benefit Plan eligibility are not covered.

Prior Approval Required on or Before First Day

Prior approval is required on or before the first day of service for all state-funded services except those explicitly listed in Attachment D; providers must submit a prior approval request with supporting documentation to the LME-MCO.

• Submit prior approval request and all supporting documentation demonstrating the individual meets specific criteria in Subsection 3.2 to the LME-MCO.

Prior Approval Exceptions (MCM, SAIOP, SACOT)

Mobile Crisis Management, SAIOP, and SACOT are listed exceptions to the prior approval requirement in Attachment D; these services have separate authorization rules.

• Confirm exception status for the specific service in Attachment D before billing without prior approval.

LME-MCO Responsible for Authorization and Utilization Management

Utilization management and authorization of state-funded services must be performed by the LME-MCO; refer to Attachment D for service-specific authorization requirements.

• LME-MCO validates medical necessity and issues authorizations per Attachment D.

Facility-Based Crisis — Initial Auth, UR Timing, and 24‑Hour Billing

Professional Treatment Services in Facility-Based Crisis Program: initial authorization was updated to 8 days and utilization review to 7 days; allowable billing units were increased to reflect 24 hours in a 24-hour period.

• Units are billed in 1-hour increments up to 24 hours per day.
• Initial authorization shall not exceed 8 days (192 units); utilization review after 7 days (168 units).

Auth Units and Utilization Review Timing (Facility-Based Crisis)

Facility-Based Crisis Program continuation/UR periods were revised: utilization review must occur after the first 7 days (168 units) and initial authorization shall not exceed 8 days (192 units); units billed in 1-hour increments up to 24 hours/day.

• Document all utilization review activity in the service plan.

Day‑Limit Billing Constraints for H0012/H0013/H2036

Certain HCPCS codes for residential and detox services have day limits per 12-month period: H0012 and H0013 are limited to not more than 45 days; H2036 is limited to not more than 30 days.

• Do not bill H0012 or H0013 beyond 45 days in a 12-month period.
• Do not bill H2036 beyond 30 days in a 12-month period.

Mobile Crisis Management — No PA but LME‑MCO Utilization Oversight

There is no prior authorization required for Mobile Crisis Management; however, utilization management is performed by the LME-MCO and providers should contact the LME-MCO for enrollment/coordination and any authorization expectations for related services.

• Concurrent review may occur after the first 32 units to determine ongoing medical necessity.

IIH Initial Authorization — PA Required (Up to 60 Days)

IIH requires prior authorization by the LME-MCO; the LME-MCO may cover up to 60 days for the initial authorization and up to 60 days for reauthorization based on the PCP and supporting documentation.

• Submit signed PCP, required authorization request form, supporting documentation, and completed LME-MCO Consumer Admission and Discharge Form for initial authorization.

IIH Prior Authorization and Reauthorization Limits

Prior authorization by the LME-MCO is required for IIH; initial and reauthorization periods may be up to 60 days each and must be supported by the PCP and documentation demonstrating medical necessity.

• Submit reauthorization requests before the current authorization expires.

MST Authorization and Duration Limits

MST requires LME-MCO authorization; initial authorization may not exceed 30 days and reauthorization may not exceed 120 days, and utilization management is performed by the LME-MCO.

• No more than 480 units in a 3-month period unless specific authorization to exceed is approved.

PSR Requires LME‑MCO Authorization (Include PCP Details)

Psychosocial Rehabilitation (PSR) requires authorization by the LME-MCO; amount, duration, and frequency must be included in the PCP and authorized on or before the day services are provided.

• Initial authorization should not exceed 90 days; reauthorization should not exceed 180 days.

Day Treatment — PA Required Prior to or On First Date (Up to 60 Days)

Day Treatment requires prior authorization by the LME-MCO prior to or on the first date of service; initial authorization may be covered up to 60 days by state funds when supported by the PCP and required forms.

• Submit the signed PCP and required authorization request form to the LME‑MCO for initial authorization.

Partial Hospitalization — PA and 7‑Day Auth Limits

Partial Hospitalization requires prior authorization by the LME-MCO; initial and reauthorization periods shall not exceed seven calendar days and all utilization review activity must be documented.

• Initial authorization ≤7 days; reauthorization ≤7 days; utilization review documented in the Provider's Service Plan.

Facility‑Based Crisis / PH — UR After 168 Units; Initial Auth ≤192 Units

For Facility-Based Crisis and Partial Hospital, utilization review by the LME-MCO must be conducted after the first 7 days (168 units); initial authorization shall not exceed 8 days (192 units) and units billed in 1-hour increments up to 24 hours/day.

• Service may not exceed 45 days in a 12‑month period.

SAIOP Initial 30‑Day Pass‑Through — PA Required After

SAIOP initial 30 calendar days do not require prior authorization; services after this initial 30-day pass-through require LME-MCO authorization and the pass-through is available only once per treatment episode and once per state fiscal year.

• Reauthorization shall not exceed 60 calendar days; one additional up to 2 weeks may be approved in exceptional circumstances.

SACOT Initial 60‑Day Pass‑Through — PA Required After

SACOT initial 60 calendar days do not require prior authorization; services beyond that require LME-MCO authorization and reauthorization periods shall not exceed 60 calendar days.

• The 60‑day pass‑through is available only once per treatment episode and once per state fiscal year.

SANMCRT/SAMMCRT — LME‑MCO Authorization Required (10‑Day Limits)

SANMCRT/SAMMCRT require LME-MCO authorization; initial authorization and each reauthorization are limited to 10 days and all utilization review activity must be documented in the Provider's Service Plan.

• Service must be included in the individual's PCP; utilization management performed by the LME‑MCO.

Billing Precedence — Mobile Crisis is 'Second Level' Service

Mobile Crisis Management is a 'second level' service; if another appropriate service (e.g., outpatient clinician or Community Support Team) stabilized the crisis, that service's billing code should be used instead of Crisis Management.

• Bill the stabilizing service's code when that service resolved the crisis rather than Mobile Crisis Management.

Condition: Outpatient Attempts Must Be Considered/Documented

Certain services (e.g., IIH, Day Treatment) require that outpatient treatment services were considered or previously attempted and found inappropriate or ineffective prior to authorization for the more intensive service.

• Document prior outpatient attempts or rationale in the comprehensive clinical assessment and PCP.

LME‑MCO Evaluates Level‑of‑Care and May Require Step‑Down/Up

The LME-MCO will evaluate authorization requests to determine if medical necessity supports a more or less intensive level of care and may require stepping to a different level based on that evaluation.

• Providers must submit the PCP and supporting documentation so the LME‑MCO can assess appropriate level of care.

Day Treatment Requires Evidence of Failed Educational Interventions

Before Day Treatment authorization, providers must document that less restrictive rehabilitative services in the educational setting have been attempted and were unsuccessful (e.g., FBA, FBP, IEP, or 504 Plan documentation).

• Include school documentation (FBA, FBP, IEP, 504 Plan) in the PCP/authorization request.

Utilization Review and Level Adjustment — Provider Must Submit PCP/Docs

The LME-MCO conducts utilization review and will evaluate requests to determine if medical necessity supports more or less intensive services; providers must submit the PCP and authorization request with supporting documentation for continued services.

• Document utilization review activity in the service/Provider's Service Plan as required.

SAIOP 30‑Day Pass‑Through Available Only Once per Episode/Fiscal Year

The SAIOP initial 30-day pass-through may be applied only once per treatment episode and only once per state fiscal year; providers must obtain LME‑MCO authorization for services after that pass-through.

• Track pass-through usage to ensure it is not applied more than once per episode or fiscal year.

SACOT 60‑Day Pass‑Through — Single Use Per Episode/Fiscal Year

The SACOT initial 60-day pass-through is available only once per treatment episode and once per state fiscal year; utilization review must be performed by the LME‑MCO and documented in the service record.

• Providers must request LME‑MCO authorization after the 60‑day pass‑through expires.

Prior Approval Submission — Include PCP and Supporting Docs

Providers must submit the prior approval request and all supporting documentation demonstrating the individual meets the specific criteria in Subsection 3.2 for the requested service to the LME‑MCO.

• Include signed PCP, authorization request form, assessment, and any school or collateral documentation required by the service definition.

Service Note Content and Signature Requirements

Service notes must include date of service; name of service; contact type (in-person, telehealth, phone, collateral); place of service when required; purpose tied to PCP goals; description of the intervention; duration/time spent; assessment of effectiveness/progress; and signature with credentials or job title. Each page must identify the individual's name and service/record numbers.

• The staff who provides the service must sign the entry and include credentials or job title.
• QP countersignature is not required for notes written by non-QP staff unless specified.

Documentation and Record Retention — Compliance Required

Providers must retain records and comply with DMH/DD/SAS documentation policies and be prepared for LME‑MCO and DMH/DD/SAS monitoring and audits; follow the Records Management and Documentation Manual.

• Ensure documentation is accurate, timely, objective, specific, consistent, comprehensive, and clear per Attachment C guidance.

Diagnosis Coding — Use ICD‑10‑CM to Highest Specificity

Providers must bill ICD-10-CM diagnosis codes to the highest level of specificity that supports medical necessity and use the current ICD-10 edition in effect at the time of service; diagnosis coding is required on all claims to NC Tracks.

• NC Tracks does not accept DSM diagnostic codes on claims; map DSM/DC diagnoses to ICD‑10-CM.

State‑Funded Service Documentation Must Align to PCP and NC Tracks Rules

State‑funded services must comply with DMH/DD/SAS NC Tracks Benefit Plan reimbursement guidelines and documentation must relate to goals in the individual's PCP; documentation must meet Attachment C standards.

• Ensure claims comply with NC Tracks reimbursement rules and obtain appropriate referrals when required.

Minimum Documentation — Daily Full Service Note Required

A daily full service note is the minimum documentation standard and must include the individual's name; service record number; date of service; purpose of contact; description of interventions; time spent; effectiveness; and signature of the staff providing the service. Treatment logs or preprinted check sheets are not sufficient.

• For individuals new to the public system, develop a crisis plan before discharge (Mobile Crisis).

Initial Authorization — Submit PCP, Auth Form, and Admission/Discharge Form

To request initial prior authorization, submit the signed PCP, the required authorization request form, any additional documentation required by the LME‑MCO, and a completed LME‑MCO Consumer Admission and Discharge Form.

• Ensure all required forms and signatures accompany the authorization request to avoid denial.

Service Note and Diagnostic Documentation for Referrals

A full service note is required to document activities leading to referral to alternative services; relevant diagnostic information must be obtained and included in the PCP.

• Use the full service note to justify referrals and document clinical rationale.

IIH Full Service Note Requirements

IIH requires a full service note for each contact or intervention for each date of service that is written and signed by the service provider and includes individual identifiers, service provided, date/place, contact type, purpose, interventions, time spent, effectiveness vs PCP goals, and signature/credentials.

• A documented discharge plan and completed LME‑MCO Consumer Admission and Discharge Form must be submitted at discharge.

MST Daily Full Service Note Requirement

MST requires a daily full service note including individual's name, service record number, date, purpose, description of intervention, time spent, effectiveness, and staff signature.

• Maintain daily notes to meet MST minimum documentation standards.

Submit LME‑MCO Consumer Admission and Discharge Form at Discharge

Providers must submit a completed LME‑MCO Consumer Admission and Discharge Form to the LME‑MCO at discharge.

• Include the completed form with discharge documentation to the LME‑MCO.

MST Documentation Minimum — Daily Full Service Note

MST minimum documentation standard is a daily full service note that includes the individual's name, service record number, date of service, purpose, description of the provider's intervention, time spent, effectiveness of interventions, and staff signature.

PSR Documentation Minimum — Weekly Service Note

PSR minimum documentation standard is a full weekly service note.

• Ensure weekly notes document purpose, interventions, and effectiveness.

Per‑Encounter Full Service Note Required for Each Date of Service

A full service note is required for each date of service, written and signed by at least one provider; it must include patient identifiers, service details, staff involved, contact type and purpose, interventions, time spent, effectiveness versus PCP goals, and staff signature/credentials.

Assessment and Service Order Requirement Prior to Service

A comprehensive clinical assessment demonstrating medical necessity must be completed prior to service; a service order is recommended for state‑funded services and providers must coordinate with the LME‑MCO regarding service order requirements.

• Include assessment findings and rationale for selected service in the PCP to support authorization.

Minimum Required Service Note Elements

Full service notes must include the individual's name, service record number, service provided, date/place of service, other staff involved, contact type and purpose, description and time of interventions, effectiveness versus PCP goals, and staff signature/credentials.

Discharge Plan and Admission/Discharge Form Required

A documented discharge plan must be developed with the individual/family/Child and Family Team and included in the service record; a completed LME‑MCO Consumer Admission and Discharge Form must be submitted at discharge.

Partial Hospital/FBC Minimum Service Documentation Requirements

Partial Hospitalization minimum documentation is a weekly service note including purpose of contact, interventions, and effectiveness; Facility‑based Crisis requires a daily service note per shift.

• Document utilization review and service maintenance decisions in the service plan.

SAIOP Daily Full Service Note and Discharge Plan Required

SAIOP minimum documentation is a daily full service note for each day of SAIOP that includes individual's name, service record number, date, purpose, description of interventions and time spent, effectiveness, and signature/credentials; include a documented discharge plan in the record.

SACOT Daily Service Note and Discharge Plan Requirement

SACOT requires a daily full service note for each day of service including client name, service record number, date, purpose, description of interventions with time and effectiveness, and provider signature/credentials; a documented discharge plan must be included.

Residential Programs — Minimum Daily Documentation

Residential programs' minimum documentation is a full daily note including individual's name, service record number, date of service, purpose, description of interventions, time spent, effectiveness, and staff signature/credentials; programs serving children must also document services to children and parent‑child interaction goals/progress.

Coverage Denial Triggers — Eligibility, Medical Necessity, Duplicates, Experimental

Coverage denials can be triggered when the individual does not meet NC Tracks eligibility, does not meet the medical necessity criteria in Section 3.0, the service duplicates another provider's service, or the service is experimental/in a clinical trial.

Risk of Denial for Failure to Obtain LME‑MCO Authorization

Failure to obtain authorization from the LME‑MCO may result in services not being validated as medically necessary and jeopardize reimbursement.

• Obtain required authorizations from the LME‑MCO before or on the first date of service as specified by the service definition.

Compliance and Monitoring Risks — Laws, HIPAA, 42 CFR Part 2, Audits

Noncompliance with federal, state, or local laws (including HIPAA, 42 CFR Part 2), DMH/DD/SAS policies, or failure to comply with LME‑MCO monitoring/audits may trigger denial, corrective action, or sanctions.

• Maintain required records and be prepared for annual DMH/DD/SAS monitoring and LME‑MCO compliance reviews.

Noncompliance with NC Tracks Benefit Plan Guidelines Jeopardizes Reimbursement

Failure to comply with DMH/DD/SAS NC Tracks Benefit Plan reimbursement guidelines, including obtaining appropriate referrals for NC Tracks‑eligible individuals, may jeopardize reimbursement.

Conversion Therapy Excluded from Reimbursement

Conversion therapy is excluded and will not be reimbursed by DMH/DD/SAS.

Concurrent Review Trigger After First 32 Units

Concurrent review may occur after the first 32 units rendered (e.g., Mobile Crisis Management) to determine ongoing medical necessity.

• Be prepared for concurrent review triggers once utilization reaches the defined threshold.

Notification and Appeal Rights Required on Adverse Actions

Any denial, reduction, suspension, or termination of service requires notification to the individual or legally responsible person about appeal rights pursuant to G.S. 143B‑147(a)(9) and Rules 10A NCAC 27I .0601‑.0609.

Appeal Notification Required for Adverse Actions

When an adverse action occurs (denial, reduction, suspension, termination), the individual or legally responsible person must be notified of appeal rights per cited statute and NCAC rules.

Appeal Notification Obligations on Adverse Actions

Providers must notify individuals of appeal rights when services are denied, reduced, suspended, or terminated and follow the statutory and NCAC procedures for notices and appeals.

Notices Must Describe Appeal Rights

Adverse action notifications must include appeal rights information and comply with G.S. 143B‑147(a)(9) and Rules 10A NCAC 27I .0601‑.0609.

Medical Necessity Determination and Prior Authorization

Medical necessity is determined by the LME‑MCO and prior authorization is required where specified; services not meeting medical necessity will not be authorized.

Denial Notification and Appeal Procedures

If a service is denied, providers and the individual must be notified and advised of appeal rights; follow LME‑MCO and statutory appeal procedures.

Appeal Notification Required on Adverse Actions

Appeal notification is required for any adverse action (denial, reduction, suspension, termination) and must reference statutory appeal rights.

Notices Must Follow Statutory/NCAC Appeal Requirements

General notices must include appeal rights and follow the statutory and NCAC requirements when services are denied, reduced, suspended, or terminated.

Authorization and Exclusions for SACOT and Pass‑Through Services

SACOT and other services with pass-through provisions: services provided after the initial pass-through require LME‑MCO authorization and certain services may not be billed during the same authorization (see exclusions).

• SACOT may not be billed during the same authorization as SAIOP, most detoxification services (with listed exceptions), or Non‑Medical/Medically Monitored Community Residential Treatment.

SACOT — Authorization Required After 60‑Day Pass‑Through; Billing Exclusions

Services after the initial 60‑day pass‑through (SACOT) require LME‑MCO authorization; SACOT may not be billed during the same authorization as SAIOP, most detoxification services, or residential community treatment.