LME/MCO prior authorization — Qualified Professional submission required

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, including for continued stay reviews.

• Service authorization request must indicate the recipient would benefit from Community Living and Support and be completed by a Qualified Professional.
• All requests for Community Living and Supports require prior approval by the LME/MCO; requests for up to 8 hours daily may be authorized for up to six months.

State-funded prior approval — include required attachments

State-funded Community Living and Support requires prior approval. Providers must submit the prior approval request and all health and other records that support the individual meets the specific criteria in Subsection 3.2 (including psychological evaluation, service order, and PCP/ISP for initial authorization).

• Submit prior approval request to the LME/MCO.
• Include supporting health records and documentation (psychological evaluation, service order for medical necessity, PCP or ISP, and the required LME/MCO authorization request form for initial requests).

Reauthorization — submit 14 days before end date

Submit reauthorization requests to the LME/MCO at least 14 days prior to the end date of the individual's active authorization; reauthorization is based on medical necessity documented in the PCP or ISP and supporting documentation.

• Reauthorization timing: submit 14 days before authorization end date.
• Reauthorization decisions consider medical necessity, progress toward PCP/ISP goals, and supporting documentation.

Service authorization must be completed by a Qualified Professional

A service authorization request must be completed by a Qualified Professional and submitted to the LME/MCO prior to services; prior authorization is required for initial and continued stay reviews.

• Qualified Professional must complete the authorization request.
• Prior authorization applies to initial requests and continued stay/service authorization requests.

Consider conservative/less costly alternatives first

Services must be individualized, medically necessary, not in excess of the individual's needs, and provided only when no equally effective, more conservative, or less costly statewide treatment is available.

• Ensure service is specific and consistent with symptoms/diagnosis and not primarily for convenience.
• Consider and document that no equally effective more conservative/less costly treatment is available before authorizing service.

Authorize services based on medical necessity and PCP/ISP habilitative goals

Authorizations are granted only when medical necessity is documented and services are expected to achieve specific habilitative goals in the individual's PCP or ISP; medical necessity is determined by NC community practice standards and services must be authorized in the most cost‑effective similarly efficacious manner.

• Medical necessity must be demonstrated in the PCP or ISP and supported by documentation.
• Authorization favors the most cost‑effective option that is similarly efficacious to the requested service.

Billing unit context — 15-minute increments and code mapping

Bill and document units in 15‑minute increments; ensure billing aligns with the service note and authorized units.

• HCPCS codes YM851 (individual) and YM852 (group) correspond to 1 unit = 15 minutes.
• LME/MCOs and provider agencies will monitor utilization and conduct record reviews/internal audits of units billed.

Document clinical rationale in the PCP/ISP

Relevant clinical information must be obtained and documented in the individual's Person‑Centered Plan (PCP) or Individual Service Plan (ISP); requests must include detailed deficiencies and planned goals reflecting strategies to correct deficiencies.

• Document assessments (SNAP, SIS, or TBI assessment) and clinical findings in the PCP/ISP.
• Include evidence used to demonstrate developmental disability per policy (psychological/neuropsychological/psychiatric testing or physician assessment as applicable).

Maintain a full service note for each contact/date

For each contact/date of service, maintain a full service note written and signed by the person who provided the service that includes: individual's name; service record ID; date; name of service; type of contact (face‑to‑face or telehealth with applicable telehealth policy); place of service; purpose related to PCP/ISP goals; description of intervention; duration with start/end times; assessment of effectiveness/progress; and date, signature and credentials/job title of staff.

• Telehealth services must follow State‑Funded Telehealth and Virtual Communications Services policy when indicated.
• More than one intervention/activity may be reported in a service note if applicable.

Obtain a signed service order before first service (no backdating)

A signed service order by an authorized professional (qualified professional, physician, licensed psychologist, physician assistant, or nurse practitioner) must be in place prior to or on the first day the service is provided; backdating is not allowed and service orders are valid for one calendar year.

• Service order must be signed and dated and indicate the date the service was ordered.
• Service orders cannot be backdated and are valid for one calendar year; medical necessity must be reviewed at least annually.

Use the most specific diagnosis coding that supports medical necessity

Report ICD‑10‑CM and Procedure Coding System (PCS) to the highest level of specificity that supports medical necessity and use the current ICD‑10 edition in effect at the time of service.

• Use the current ICD‑10 edition and any subsequent editions in effect at the time of service.
• Codes should support the medical necessity documented in the PCP/ISP.

Use most specific procedure code; follow unlisted code reporting rules

Report the most specific billing code (CPT, HCPCS, UB‑04 revenue) that accurately and completely describes the procedure; if no specific CPT/HCPCS code exists, report using the appropriate unlisted procedure or service code and follow special report instructions.

• Refer to current CPT, HCPCS, and UB‑04 manuals for code descriptions.
• When using unlisted procedure codes, comply with instructions to submit a Special Report.

Update ISP/PCP and provide COVID documentation for alternative locations

When services are provided in alternative locations due to COVID‑19, update the individual's ISP and PCP to indicate the need for alternative location delivery and provide documentation confirming a COVID‑19 diagnosis; ensure health and safety of the recipient can be maintained.

• All three conditions must be met to provide services in alternative locations: maintain health/safety; update ISP/PCP documenting need; provide documentation confirming COVID‑19 diagnosis.
• Services may be provided in hotel, shelter, church, alternative facility, or home of a direct care worker for COVID‑19 reasons only if criteria are met.

General denial triggers — eligibility, criteria, duplication, experimental services

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

• Confirm eligibility per Section 2.0 and that specific criteria in Section 3.0 are met before submitting requests.
• Avoid duplicative services—only one Community Living and Support provider may provide the service at a time; duplication is a denial trigger.

Coverage denial conditions — eligibility, duplication, investigational status

State funds shall not cover services when eligibility or specific criteria are not met, when the service duplicates another provider's service, or when the service is experimental, investigational, or part of a clinical trial; these conditions are grounds for denial or non‑coverage.

• Verify that requested services do not duplicate other state‑funded services or conflict with exclusions (e.g., concurrent residential services or certain Medicaid State Plan services).
• Document alternatives considered and rationale if other services were not appropriate.

COVID‑19 alternative location eligibility — document all three criteria

Services provided in an alternative location for COVID‑19 reasons are allowable only if ALL the following are met: the recipient's health and safety can be maintained; the individual's ISP and PCP have been updated indicating the need for alternative location delivery due to a COVID‑19 related issue; and documentation confirming a COVID‑19 diagnosis is provided—failure to meet these conditions may result in denial.

• Alternative locations include hotel, shelter, church, or home of a direct care worker for COVID‑19 reasons, but all three criteria must be documented.
• Services may not be provided in the home of provider staff except for COVID‑19 related issues.