Child Focused Assertive Community Treatment (Child ACT)
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Defines the Child ACT team-based community service for youth with Serious Emotional Disturbance (SED), including eligibility, service components, documentation, utilization management, exclusions, and discharge/continued-stay criteria for Partners Health Management Medicaid members.
No material clinical or coverage changes in this revision.
Coverage Criteria and Level-of-Care
inv-01: Initial Eligibility
Covered when ALL of the following are met:
Children with primary MH diagnoses are target; co-occurring mild/moderate I/DD or autism assessed case-by-case; members with primary SUD, severe/profound I/DD, TBI, or ASD are not the intended population but may be considered case-by-case
inv-02: Continued Stay Criteria
Medicaid covers continued stay when ALL of the following are met:
Child ACT must be maintained when regression is likely if withdrawn, based on documented history of regression or epidemiologic expectation of persistent symptoms
inv-03: Discharge
Discharge when ANY of the following is met:
Child ACT services may be billed up to 30 days to support transitions to/from other intensive services per the PCP
inv-04: Service Eligibility and Delivery
Covered when ALL of the following are met:
Service intensity and staffing must be matched to member needs; virtual delivery allowed in extenuating circumstances
inv-05: Staffing and Caseload
Covered when ALL of the following staffing requirements are met:
Additional staff added based on caseload and clinical needs; associate-level licensed staff must achieve full licensure within specified timeframes
inv-06: Training and Supervision
Covered when ALL of the following training and supervision requirements are met:
Frequency may be greater for less-experienced staff
Training in at least one evidence-based model is required for several roles
Child ACT is a bundled, comprehensive team service. To avoid duplication of services, concurrent provision of the programs listed below is excluded during the same authorization period except as explicitly allowed for transition/step-down: Tailored Care Management, Intensive In-Home Services, Family Centered Treatment, Multi-Systemic Therapy, Intercept, In Home Therapy, Day Treatment, TASK, High Fidelity Wraparound (HFW), and Level II, III, and IV group homes and PRTF. Level II Family is allowed to be provided concurrently. Inpatient, facility-based crisis, and emergency department services remain available when medically necessary.
Child ACT is intended for youth with a primary mental health diagnosis; co-occurring mild to moderate intellectual/developmental disability or autism, or co-occurring substance use, are evaluated on a case-by-case basis. The program emphasizes individualized assessment of functional impairment and service needs before enrolling members with co-occurring conditions to ensure the team can meet treatment goals within the Child ACT model.
Members whose primary diagnosis is a substance use disorder, intellectual developmental disability, traumatic brain injury, or autism spectrum disorder are not the intended population for Child ACT and will only be considered on a case-by-case basis. Child ACT is not to be provided concurrently with services deemed duplicative of this bundled model.
Additional coverage requirements include demonstration of medical necessity through a comprehensive clinical assessment and documentation that the youth meets both: (A) a current DSM-5 (or successor) mental health diagnosis consistent with treatment needs; and (B) significant functional impairment as shown by either marked difficulty performing routine community functioning tasks (safety, self-regulation, social interaction) or significant difficulty maintaining consistent educational/vocational performance. Teams must document written admission criteria reflecting these elements, maintain required team composition and staffing, and ensure services are delivered primarily in natural environments per program expectations.
Level of Care Definitions and Criteria
inv-27: Community-based intensive team service (Child ACT)
Co-occurring mild/moderate I/DD or autism considered case-by-case
inv-28: Intensive Community-Based (Child ACT)
Co-occurring SUD or mild/moderate I/DD considered case-by-case; teams adjust intensity with changing needs
Services and Interventions Provided
inv-29: Psychotherapeutic and skill-based interventions — modalities included
Not an exhaustive list
inv-30: Medication/nursing and care coordination — modalities included
Team assesses whole family needs and provides medication evaluation within two weeks of admission when indicated
inv-31: Community-based behavioral health services — modalities included
Medication evaluation and management is provided by the psychiatric care provider as clinically indicated
Billing Codes, Units, and Visit Expectations
| H0040 U5 HA EN | Encounters — Child ACT reported as weekly unit of service |
Service Unitization and Visit Limits
Provider Responsibilities, Billing, and Operational Risks
Billing code and prior approval
Report Child ACT encounters using HCPCS code H0040 U5 HA EN as a weekly unit of service. Prior approval requirements apply per NCTracks and EPSDT guidance; prior approval is still required for beneficiaries under 21 when applicable.
- Unit of service = 1 week; anticipated 24 units per person (6 months).
- Follow NCTracks prior authorization processes and EPSDT guidance for members under 21.
Unitization for authorization requests
The policy references a service bundle of 24 units (noted as 24 units (5-6 months) or 24 units (6 months)); interpret this unitization for prior authorization and initial authorization requests according to payer billing rules (i.e., whether to request weekly units or a 24‑unit bundle).
- Service unit reference: 24 units (5-6 months) / anticipated 24 units (6 months).
- Confirm with Partners Health Management whether initial authorization should be submitted as weekly units (H0040 U5 HA EN) or as a bundled 24‑unit authorization.
Concurrent service restriction—Tailored Care Management
Tailored Care Management may not be provided during the same authorization period as Child ACT to avoid duplication; Child ACT is a bundled comprehensive service and providers must not deliver Tailored Care Management concurrently except as allowed during defined transition periods.
- Child ACT provider must fulfill all care management duties; a separate care coordinator may be assigned only to prevent gaps in care, not to duplicate services.
- Concurrent provision of other listed intensive community services is excluded except during step‑down/transition periods.
Person‑Centered Plan and service documentation
Ensure each member has a fully completed Person‑Centered Plan (PCP) prior to or on the first date of service that includes the enhanced crisis plan and the amount, duration, and frequency of service. Maintain a full-service note for each contact that meets the NCDHHS Record Management and Documentation Manual and contains identity, date/place/time/duration, service provided, purpose tied to PCP goals, interventions, assessment of effectiveness, and signature/credentials.
- PCP must meet NC PCP Instruction Manual requirements and include enhanced crisis plan.
- Full-service note required for each contact with specified elements and signature.
- A comprehensive clinical assessment demonstrating medical necessity must be completed prior to provision of service.
NC TRACKS enrollment, PEF, credentialing, and contracting
Be enrolled in NC TRACKS and listed on the PEF file received by the Health Plan; maintain Partners Health Management network enrollment, credentialing, and an active contract to deliver Child ACT. Ensure licensed staff complete MCO credentialing (including CAQH and other identifiers) and that unlicensed staff have primary source verification as required.
- Provider organization must be enrolled in NC TRACKS and on the PEF file.
- Complete MCO credentialing, CAQH, and any needed identifiers (NCID, NPI) for licensed staff.
- Perform primary source verification for unlicensed staff and ensure staff meet role qualifications.
Signed service order required prior to first service
Obtain and document a signed service order from an authorized prescriber (MD, DO, Doctoral Licensed Psychologist, PA, or NP) that is dated and in place prior to or on the first day of service; service orders may not be backdated and are valid for one year from the original date.
- Service order must be signed and dated by an authorized prescriber and indicate the date service was ordered.
- Service order required prior to or on the day service is initially provided; orders cannot be backdated and are valid for one year.
Operational compliance triggers that risk denial or termination
Failure to maintain required NC TRACKS enrollment/PEF listing, required credentialing and contracting, minimum team staffing (at least 5.0 FTE with required roles), or 24/7 availability for crisis response and psychiatric consultation may place services out of compliance and risk denial or termination of authorization.
- Teams must maintain at least five FTE staff (Team Lead, Nurse, Licensed Clinician, Behavioral Specialist, plus additional staff) and psychiatric coverage.
- Teams must be available 24/7 for crisis de‑escalation (phone within 15 minutes; face‑to‑face within 2 hours) with psychiatric provider available minimally by phone 24/7.
- Noncompliance with enrollment, credentialing, staffing, or crisis availability may trigger operational noncompliance and authorization risk.
Key Definitions
Background and Purpose
Background: Child ACT is a multidisciplinary, community-delivered intensive service for youth ages roughly 10–18 with Serious Emotional Disturbance who are at high risk for residential placement or have histories of multiple hospitalizations or placements. The model makes the team the single point of responsibility for a youth’s behavioral health needs, provides high-frequency community-based contacts, involves the family/caregiver, and delivers services across life domains to maintain community functioning and avoid higher levels of care.
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