Prior authorization / SAR timeline

Prior authorization is not required for the first 9 months of service; however, a Notification Service Authorization Request (SAR) must be submitted within one week of service initiation for the first 9 months. Reauthorizations are up to 60 days.

• Submit Notification SAR within one week of service start for initial 9-month period.
• Reauthorization requests may be approved for periods up to 60 days.

Prior approval still required for under‑21 beneficiaries

If the service requires prior approval, providers must obtain prior approval when applicable even for beneficiaries under 21; EPSDT does not remove the prior approval requirement.

• Being under age 21 does not eliminate prior approval obligations for services that require it.

Distinct service — excluded and non‑duplicative care

Transitional Youth Services excludes multiple other modalities and does not duplicate certain rehabilitative or vocational services; providers must not bill this service when the member is receiving excluded services.

• Excluded services include Multisystemic Therapy; Intensive In‑Home; Intercept; Day Treatment; Assertive Community Treatment; Community Support Team; Psychosocial Rehabilitation; and Supported Employment.
• Does not duplicate NC Division of Vocational Rehabilitation supported employment; refer members to VR when supported employment is needed.

Safety screening and referral for high‑risk members

Members whose current behaviors pose serious safety risks or who lack adequate protective factors may be inappropriate for admission and should be referred to a higher level of care.

• Consider referral to a higher level of care for members with extensive violent charges, extreme aggression, deep gang involvement, or other high‑risk behaviors.

Required clinical documentation before first service and for reauthorization

A Comprehensive Clinical Assessment (CCA) or equivalent addendum demonstrating medical necessity, a Life Skills Assessment, a Treatment Plan/Person‑Centered Plan (PCP), and a signed service order by an authorized licensed professional are required prior to or on the first date of service; continued authorization after 9 months requires updated CCA, Life Skills Assessment, Treatment Plan/PCP, and a signed service order.

• CCA or equivalent that reflects current level of functioning and required elements.
• Life Skills Assessment administered prior to service delivery.
• Person‑Centered Plan (PCP)/Treatment Plan completed prior to or on first date of service.
• Signed service order in place prior to or on first service date; valid for one year and may not be backdated.
• For continued authorization after 9 months, submit updated CCA, Life Skills Assessment, Treatment Plan/PCP, and signed service order.

Service note and RMDM documentation requirements

Services must be documented per the DMH/DD/SAS Records Management and Documentation Manual (RMDM) 45‑2; a full service note is required and must include Items 1 through 12 under Contents of a Service Note (RMDM Chapter 7). The PCP must include amount, duration, and frequency of service and an enhanced crisis plan.

• Complete a full service note meeting Items 1–12 in RMDM Chapter 7 prior to seeking reimbursement.
• Ensure the PCP is fully complete before or on the first date of service and contains service amount, duration, frequency, and enhanced crisis plan.

EPSDT documentation expectations for under‑21 beneficiaries

For beneficiaries under 21, provider documentation must demonstrate that the requested services meet EPSDT criteria — showing medical necessity to correct, ameliorate, maintain, or prevent worsening of a health problem; prior approval requirements still apply.

• Document how the service meets EPSDT criteria (correct/ameliorate/maintain/prevent worsening).
• Reference NCTracks EPSDT guidance and Provider Claims and Billing Assistance Guide as needed.

Document program goals and measurable outcomes

Documentation should support program goals and expected outcomes that justify medical necessity, including housing stability, engagement in education or employment, and absence of new legal involvement.

• Evidence of housing stability, maintenance of productive activity, current engagement in education, current work status, and freedom from new legal involvement.
• Use periodic post‑discharge measures to document outcomes where applicable.

Safety exclusions and admission considerations

Members with behaviors that pose serious safety risks to themselves or the community may be excluded from admission or require referral to a higher level of care; assess protective factors and safety prior to admission.

• Assess for violent history, aggression, gang entrenchment, or serious chronic mental health issues that may indicate inappropriateness for this service.
• Refer to higher level of care when safety concerns are identified.

Denial risk if required prior approval is not obtained

Failure to obtain required prior approval when the service requires prior approval may result in claim denial; EPSDT status (under 21) does not eliminate this prior approval requirement.

• Verify whether the requested service requires prior approval and obtain approval before providing/billing when required.
• Noncompliance with prior approval processes risks denial of coverage or payment.

NCTracks enrollment and Partners Provider Network contracting required

Providers must be enrolled in NCTracks and be credentialed, enrolled, and contracted as a network provider with the Partners Provider Network in good standing; failure to meet these requirements risks denial or nonpayment.

• Confirm NC Medicaid participation and NCTracks enrollment before delivering services.
• Maintain credentialing and an active contract with the Partners Provider Network.