Road Map for Contractors by quAf07



 Fiscal Year
               Operations Manual Table of Contents

Preface       Guilford Center Mission and Guiding Principles         Page 3
Chapter 1     About Us                                               Page 4
Chapter 2     Request for Proposal (RFP) Process                     Page 6
              Contracts Overview
              Sole Source Contracting
              Provider Orientation
Chapter 3     Screening, Triage and Referral and Registration        Page 9
              Initial Authorization for State Funds
Chapter 4     Enrollment                                             Page 11
Chapter 5     Utilization Management of State Funds                  Page 16
              Utilization Review
              Care Coordination
              Authorization of Services
Chapter 6     Claims Processing                                      Page 22
              National Provider Identifier Requirement
Chapter 7     Audit Procedures                                       Page 26
              Periodic Audits of State and County Funded Services
Chapter 8     Quality Management                                     Page 29
              Client Rights
              Complaint Management
              Incident Reporting
Chapter 9     Endorsement                                            Page 34
Chapter 10    Referring Between Community Providers                  Page 35
              Referrals from Guilford Center to Community Provider
Chapter 11    Person Centered Planning Information                   Page 37
Chapter 12    Best Practices                                         Page 39
              Evidence-Based Practices
Chapter 13    List of State and Federal Requirements                 Page 43
Chapter 14    Glossary of Terms                                      Page 46
Chapter 15    Resource Links                                         Page 62
              Carelink User Manual
Attachments   Attachment A – Contract Audit Tool                     Page 83
              Attachment B – Staff Competency Audit Tool             Page 85
              Attachment C – Audit Results Grid                      Page 87
              Attachment D – Payback Guide                           Page 88
              Attachment E – Co Pay Checksheet                       Page 89

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Page 3 of 89
                                           Chapter 1

                                           About Us

The Guilford Center, Local Management Entity (LME) for the administration of public mental
health, developmental disabilities and substance abuse treatment, is organized under the North
Carolina Department of Health and Human Services’ Division of Mental Health, Developmental
Disabilities and Substance Abuse Services (NCDHHS-MH/DD/SAS) and Guilford County. The
LME is responsible for governance and administration of public mental health, developmental
disabilities and substance abuse services (MH/DD/SAS) for the single county catchment area.
Administrative duties include policy development, collaboration with public and private
organizations, development of a qualified provider network, strategic planning, stewardship of
funds and other resources, and relationship with the Consumer and Family Advisory Committee
(CFAC). Additionally, the Guilford Center manages business functions, information technology
and data systems as well as local, state and federal funds. The Center is charged with
overseeing provider relations and assuring quality of services provided to MH/DD/SAS
consumers. The agency recruits community providers, implements the State endorsement
process locally, provides training and technical assistance to providers, monitors their
performance, manages incident reporting, investigates/resolves provider complaints and
concerns, and is responsible for overall system-wide quality improvement efforts. Customer
service/consumer affairs also fall within the managerial realm of the LME. In addition to handling
consumer complaints, the Guilford Center investigates client rights violations, assures
compliance with Title VI language access requirements, and provides information/education to
the public in-person and via print, broadcast and Web media. The Guilford Center authorizes
services through utilization management and review. It provides telephonic screening, triage
and referral and authorizes the use of State hospitals and other facilities. The Guilford Center’s
Call Center conducts telephonic screenings and referrals.

In addition, the Center provides the following services to consumers in Greensboro and High
     Crisis/Emergency treatment is available 24 hours a day, 7 days a week, to provide
        stabilization for individuals who are at risk of harming themselves or others, and those
        who have a medical emergency requiring treatment by a psychiatrist.
     Our hospital diversion staff, part of the Crisis/Emergency Services unit, provides a bridge
        to care for individuals recently discharged from hospitals and institutions. Its members
        also offer outreach and prevention services to individuals who may be at risk for
        hospitalization or who have a history of repeated hospitalizations.
     Psychiatric Services, with a staff of nurses, physician extenders and psychiatrists,
        provides personalized medical interventions and individualized monitoring.
     The Specialized Treatment of Perpetrators (STOP) program provides treatment ot sex
        offenders to help the offender develop skills to manage abusive behaviors and to
        prevent future offenses.
     Court liaisons provide a bridge to treatment for young people who have been involved
        with the court system.

Easy ACCESS to Care
Accessing our services is just one phone call away. Our ACCESS to Care line
(1.800.853.5163) provides a centralized way to reach our services any time, day or night. A
special TTY number for deaf and hard of hearing consumers is available at 1.866. 518.6778.

Walk-in treatment is available at Crisis/Emergency Services 24 hours a day, seven days a week

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at the Bellemeade Center in Greensboro, and during business hours at the High Point Center or
nights and weekends at High Point Regional Health System.

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                                            Chapter 2

                                 Provider Selection Criteria
                             Request for Proposal (RFP) Process
                                    Contracts Overview
                                  Sole Source Contracting
                                    Provider Orientation

Provider Selection Criteria: The Guilford Center will primarily use a Request for Proposal
Process (RFP) to solicit proposals from prospective qualified, responsible providers to fulfill
a described service need. RFPs will be let based on available funding and identified unmet
service needs within the County.

Responsible providers have been determined to:
    Provide quality of care as defined in the Guilford Center’s Principles and Indicators of
     Best Practice tools for each population served
    Provide quality of service as defined in the Guilford Center’s Principles and Indicators of
     Best Practice tools for each population served and by the agency’s credentialing criteria,
     including staff qualifications, clinical supervision and on-going staff training and staff
    Be capable of complying with the required performance schedule, taking into account all
     other existing commitments;
    Have a satisfactory performance record;
    Be otherwise qualified and eligible to receive a contract award under all applicable laws
     and regulations, and
    RFPs will be determined by the business needs of the Guilford Center based on data
     and trends from the annual community needs assessment

Request for Proposal Process (RFP): A solicitation process used to solicit proposals from
prospective qualified, responsible providers to fulfill a described service need. The RFP
document sets forth the description of the client population to be served, scope and array of
services to be provided, quality of care and quality of service standards, cost parameters, goals,
program outcomes, reporting requirements, and the evaluation criteria for selecting providers
through the RFP process (see above criteria). It also identifies contract requirements for incident
reporting, authorization of services, billing and insurance, etc.; it describes the format and time
frame for submitting an application and the appeal process in the event an applicant wishes to
appeal the committee’s decision.

Determined by the business needs of the Guilford Center, the RFP process is initiated on an as-
needed basis for new services or to fill gaps in existing service arrays. On-going state funded
services are typically re-bid every 3-5 years. The RFP is advertised in the newspaper when
appropriate, posted on the Guilford Center website, and notice is mailed to interested parties on
the RFP mailing list maintained by the Guilford Center Contracts Unit. After the RFP has been
released, one or more Question and Answer Sessions are held to answer questions about the
RFP Scope of Work and Application. Minutes of the Question and Answer Session are mailed to
all respondents to the RFP.

The RFP selection is typically limited to one or more responsible providers whose proposals are
determined to be acceptable and most responsive to the requirements of the RFP. Although

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cost is a major consideration, the Guilford Center may choose not to award a contract to the
lowest bidder, or it may choose not to award a contract at all. Costs associated with responding
to an RFP are the sole responsibility of the respondent.

Evaluation Process: Using the criteria published in the RFP Scope of Work document, a non-
partisan evaluation committee evaluates the written applications. This committee is made up of
Guilford Center staff, members of the Guilford Center Board and Consumer and Family
Advisory Committee, and individuals from the community with expertise in the subject matter of
the services under consideration.

Respondents with the highest ranking scores are invited to an interview. In most cases, the
interview includes both administrative and clinical sections. Contracts will be awarded to those
applicants who successfully complete the interview process.

Appeals Process: Written protests with respect to the RFP and the final selection must be
based upon Area Authority violation or noncompliance with specific applicable relevant law(s) or
regulation(s) and must be in writing.

Sole Source/Out of Network Providers: A method of procurement, which may be subject to
federal and state funding requirements, that involves negotiation with a single responsible
provider to meet an identified unmet service need. Sole source contracting shall not be used
unless there is clear evidence that the provider network can not fulfill the requirement.

Contracts Overview

The Contract: The contract is a written document that identifies the expectations and
responsibilities of the parties to the contract. This includes description of services to be
provided, personnel requirements, authorization of services, reporting requirements, claims
submission, cost parameters, and other applicable state and federal standards to be met, etc.
and the contract term.

       o State funded services can not be authorized until the contract packet is complete,
           correctly signed, and returned to The Guilford Center.
       o Only authorized services are eligible for reimbursement.

Requirements to be Met Prior to Executing the Contract
    Endorsement or Accreditation: A contractor must be either endorsed or accredited for
      each service to be provided under contract with The Guilford Center.
    Insurance: A contractor must meet insurance requirements before a contract can be
      routed for signature. Insurance requirements are listed in the RFP and in the provider
    CareLink and CareLink Security Officer: A contractor must designate a Carelink Security
      Officer. This person is responsible for informing the Guilford Center which contractor
      staff should have access to the Guilford Center authorization and billing system through
    Register Service and Location: Each service and each service location must be
      registered with the Guilford Center. The contract administrator will assist the contractor
      with this process.
    For endorsed periodic services, the contractor must have a Medicaid Core Number.

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       For endorsed residential services, the contractor must have a Medicaid Residential Core
       If applicable, contractors must obtain NPI number(s) for services and locations. (For
        more information, visit website:

   Registering Licensed Therapists: In order to pay licensed therapists, who are eligible to bill
    CPT codes for outpatient services provided to state funded consumers, the therapist must
    be registered with the Guilford Center.

After the Contract Is Signed by the Contractor
 It can take several weeks to route the contract for all necessary signatures. Incomplete
   contract packets, including missing signatures and seals on signature page, will delay the

 Medicaid Funded Services: Four (4) Medicaid funded services are billed by the provider
   directly to EDS. The paid claims pass through the Guilford Center and are dispersed to the
   provider under contract with the Guilford Center. The services are: targeted case
   management, outpatient H-code services, child residential level I, and child residential II-
   therapeutic foster care. All other Medicaid services must be endorsed and are billed directly.
   Medicaid services are not subject to the RFP process.
 State/IPRS Funded Services: Contractors must successfully complete a Request for
   Proposal (RFP) process in order to have a state funded contract.

New and On-Going Provider Orientation: Guilford Center Contract Administrators will provide
Contractor Orientation with new providers and with on-going providers on an as needed basis.
During the orientation the provider receives and reviews a copy of the annotated contract
between the Guilford Center and provider agency; receives a copy of the Guilford Center’s
Benefit Plan; receives and reviews a copy of the service specific contract between Guilford
Center and provider agency; receives Guilford Center’s web site address and a description of
the information on the web site; receives an electronic link to the Guilford Center’s Operations
Manual and a description of the information found in the Operations Manual. This information is
also reviewed annually with providers during a regularly scheduled Provider Forum before the
start of each new fiscal year.

Disputes with Contracting Parties: Guilford Center strives to maintain strong partnerships
with network providers. To that end, Guilford Center implements mechanisms to resolve
provider disputes with contracting parties. Guilford Center’s policies regarding disputes with
contracting parties is reviewed and updated at least annually with the involvement of
participating providers.

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                                            Chapter 3

                          Screening, Triage and Referral and Registration
                               Initial Authorization for State Funds

Screening, Triage and Referral (STR) and Registration
The Guilford Center provides prompt and easy access to care for the residents of Guilford
County through the operation of its existing toll free access to care line with TTY capability. The
access line is available 24 hours a day, 365 days a year for Guilford County residents. Our toll
free line has been in existence since 1997 and is widely publicized. Walk in capability is also
available. We embrace the “no wrong door concept” and conduct trainings for our provider
community on uniform screening and registration.

      STR is the process for obtaining information necessary to direct new consumers to
       appropriate services.
      All consumers that receive enhanced Medicaid services or any State funded services
       must receive STR.
      STRs completed by the LME for state funded services are sent via Carelink to the
       provider along with the initial authorization for assessment.
      In order for there to be no wrong door for persons seeking services, the State developed
       a procedure whereby endorsed providers can conduct STR as of October 1, 2006.
      Performing STR is mandatory. Providers may choose to conduct STR or refer to the
       LME’s STR unit. There is no payment for providers choosing to do STR.
      Providers may conduct STR for consumers requesting services that they do not offer, or
       they may assist those consumers in contacting the LME for STR.
      Providers conducting STR must meet all State requirements.
      Professionals conducting STR must meet the State requirements to be a Qualified
       Professional (Qs) or higher. A licensed clinician must be on site for consultation.
      STR requires triaging the clinical urgency (emergent, urgent or routine) of persons
       requesting services and linking them with appropriate services within the required
       timeframes (two hours for emergent, 48 hours for urgent, and fourteen calendar days for
      All State funded providers serving as clinical homes are required to use the Guilford
       Center’s web based calendar. See training section.
      Providers conducting STR must forward information to selected providers about the
       referral in a HIPPA and 42CFR compliant manner, and must promptly provide STR data
       to the LME by fax to 641-3655.
      Providers receiving State funded referrals from another provider that conducted STR
       must contact the LME for authorization prior seeing the consumer.
      The registration component of the STR form (items A-H; 51-56) must be submitted to the
       LME within 5 business days of the initial face to face session with the consumer by fax to
      Within 30 days of service initiation, the provider completes the Person Centered Plan
       (PCP) and the PCP Admission Form and submits to the LME. Note, the Introductory
       PCP may be used.

See Enhanced Services Implementation Update # 14: Uniform Screening and Registration for
additional information by clicking on

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Initial Authorization for State Funds
   Provider submits authorization requests to the LME for additional services for State
      funded consumers.
   The LME completes data entry of the LME Admission and Discharge Form and submits
      CDW record to the State.

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                                                Chapter 4


Enrollment Basics
    Enrollment is the process that moves a client from Triage to Universal funding, and
      admission status, allowing the full array of services
    Enrollment provides the LME with the information needed to claim services, and form a
      foundation for UR/UM
    Most services are not eligible for reimbursement until the client is enrolled

E-Forms Required for State Funding
    Guilford Center has developed a series of electronic forms, or e-forms, that provide the
      basic information needed to open a client’s billing record
    The e-forms can be found on our website at this address:
    Required forms are: The LME Admission and Discharge Form; Fee Setting and
      Insurance Information
    Forms are in MS Word format, and can be downloaded. Forms may also be filled out
      online, but must be saved to provider’s local computer before they can be submitted.
    Forms should be saved in a separate folder using the client’s number and/or initials in
      the filename for easy identification, along with a form identifier. It is critical for Guilford
      Center staff to be able to identify which forms are being submitting. For example, the
      fee and admission form for John Doe, 123456 might be saved as JD123456Fee.doc.
    Saved forms should be attached in Carelink to an existing authorization or authorization
      request. Attachment in Carelink ensures everyone at Guilford Center who needs the
      forms can access them.
    Faxes are acceptable, but less reliable than attachment.

Medicaid Clients Receiving Enhanced Services
   You must compete the STR (see Chapter 1), the PCP and the LME Admission and
      Discharge Form (formally known as the PCP Admission form)
   The PCP Admission form is required to provide data to the state data warehouse on
   The PCP Admission Form and the Person Centered Plan need to be sent to the LME.

The Enrollment Process
    The STR process creates a client record in the Guilford Center’s system, and authorizes
      the initial assessment
    If further services are indicated by the initial assessment, client must be enrolled
    Provider prepares the e-forms to provide information needed to complete billing record
      and enroll client
    Provider requests additional services through Carelink Authorization request
    Provider attaches e-forms to this authorization request, or any existing authorization
    Care Managers enroll client in Universal as part of the utilization review for the follow on
      services being requested
    AR staff complete billing record

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Pending Authorizations
    If medical necessity is not sufficiently addressed in the authorization request, or opening
      documents are not included, or they are missing some key element, the Care Manager
      will move the authorization to “Pending” status.
    If a request is placed in pending status, the Care Manager will place a note on the
      authorization request detailing why request was pending
    Provider must respond within the time limit stated – usually 5 days – or the authorization
      will be approved with 0 units
    Provider gains access to Care Manager’s comments by clicking on the blue text word
      “Authorization” in the line that has the Pending status indicated in the Authorization
    Provider responds as indicated and then re-files the request by clicking on the red button
      “File Request”

Completion of the Enrollment Process for Medicaid Clients Billing Through LME
   Those Medicaid services still billing through the LME are authorized by Value Options,
     not Guilford Center Care Managers
   E-forms are still required. Provider should either attach to an authorization request
     entered for the sole purpose of attaching documents (preferred) or fax
   No UR/UM will take place, but e-form data will be reviewed for completeness

Final Steps for Enrollment
    Billing record is completed by AR staff, who review for completeness
    Contact is made via email or telephone when data is incomplete or inaccurate.
    Provider should respond with corrections as soon as possible. Inaccurate or incomplete
       data will cause delay in claiming to EDS or denials from EDS

Common Errors
   Admission Date is after Dx date: Dx date must be the same as the Admission date to
    the provider’s facility for our system to accept the Dx as active. If Dx date is prior to
    Admission, claim will fail
   Dx code does not match description, or Dx code is invalid. Providers should make
    certain a valid code is entered, and that the description used is appropriate
   IPRS Target Pop start date must be the same as the admission date and end date must
    be exactly one year from the start date

Documentation Requirements

The Provider must establish a clinical service record in accordance with the Division’s
Funded MH/DD/SA Services CAP-MR/DD Services and Local Management Entities. The
Manual can be found on the Division”s website at this address:
The clinical service record, also known as the medical record or service record, is the official
document that reflects all the clinical aspects of service delivery.

Though additional information may be needed for specific situations, the clinical service record
should include the following information or items when applicable:
    Individual’s name
    Record number [and Medicaid ID number for Medicaid-eligible individuals]

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    Demographic information included on a Client Face Sheet, including the individual’s full
    name, record number, date of birth, race, gender, marital status, admission date, and
    discharge date
    Emergency information which shall include the name, address, and telephone number
    of the person to be contacted in case of sudden illness or accident, and the name,
    address, and telephone number of the individual’s preferred physician
    Informed written consent for treatment
    Informed written consent for planned use of a restrictive intervention [27D .0303(b)]
    Written consent granting permission to seek emergency care from a hospital or
    Consent to release information [26B .0202 and .0203]
    Documentation of written notice given to client/legally responsible person upon
    admission that disclosure may be made of pertinent confidential information without his
    or her expressed consent in accordance with G.S. § 122C-52 through 122C-56.
    Log of releases and disclosures of confidential information
    Evidence of a written summary of client rights given to client/legally responsible person,
    according to 10A NCAC 27D .0201, and as specified in G.S. § 122C, Article 3
   Documentation that client rights were explained to the individual/legally responsible
    Screening, which shall include an assessment of the individual’s presenting
    problem/needs, whether or not the provider agency can provide services that can
    address the individual’s needs, and disposition, including recommendations and
    Documentation of strategies used to address the individual’s presenting problem, if a
    service is provided prior to the establishment of a plan
    Admission/eligibility assessments and other clinical evaluations, completed prior to the
    delivery of services, with the following minimum requirements:
   Reason for admission, presenting problem
        o Description of the needs, strengths, and preferences of the individual
        o Diagnosis according to DSM-IV-TR
        o Social, family, medical history
        o Evaluations or assessments, such as psychiatric, substance abuse, medical,
             vocational, etc., as appropriate to the needs of the individual
        o Mental status, as appropriate
        o Recommendations
   Health history, risk factors
   Documentation of mental illness, developmental disability, or substance abuse
    diagnosis, according to DSM-IV-TR or ICD-9-CM.
   Person-Centered Plan [must include Medicaid ID number for Medicaid-eligible
   Plan of Care and Cost Summary - CAP-MR/DD [must include Medicaid ID number]
   Service plan [for situations when a PCP or POC is not required]
   Written notifications, consents, approvals, and other documentation requirements per
    10A NCAC 27E .0104(g) whenever a restrictive intervention is used as a planned
   Inclusion of any planned restrictive interventions in the individual’s service plan
    according to 27E .0104(f), whenever used
   Documentation in the service record that meets the specific requirements of 27E
   when a planned restrictive intervention is used, including:

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      Documentation of rights restrictions [10A NCAC 27E .0104 (e)(15), per
      G.S. § 122C-62(e)], and
      Documentation of use of protective devices [27E .0104(g)].
      Documentation of incidents, including description of the event, action taken on behalf of
      client, and the client’s condition following the event. [Note: Incident reports are to be filed
       separately from the client record.]
      Documentation of progress in service notes/service grids
      Documentation of medication and other known allergies and adverse reactions, as well
       as the absence of known allergies.
      Medications, dosages, and a Medication Administration Record [MAR], per 27G .0209
      Medication orders and copies of lab tests
      Identification of other team members
      Documentation of coordination with the rest of the individual’s team
      Clinical or level of functioning measurement tools
      Referral documentation [sending or receiving]
      Treatment decision-making process, including thought processes and the issues
      Advance directives
      Service authorizations
      Incoming and outgoing correspondence, including copies of STR & admissions forms,
       NC-TOPPS assessments, etc.
      Discharge summaries

Service Notes:
A service note shall include, but not be limited to the following:
   1. Name of the individual receiving the service
   2. Record number of the individual
   3. Medicaid Identification Number for services reimbursed by Medicaid
   4. Full date the service was provided [month/day/year]
   5. Name of the service
   6. Purpose of the contact [tied to specific goal(s) in the service plan]
   7. Description of the intervention(s)/treatment/support provided
   8. Interventions/treatment/support described in a service note, whether for periodic,
       day/night, or twenty-four-hour services, must accurately reflect the duration of time
   9. Total amount of time spent performing the service [required for periodic services, unless
       the periodic service is billed on a per event basis, and any other service as required by
       the service definition,
   10. Effectiveness of the intervention(s)
   11. For professionals: Signature, credentials, degree, or licensure of clinician who provided
       the service. The signature must be handwritten; however, the credentials, degree, or
       licensure may be typed, printed or stamped.
   12. For paraprofessionals: Signature and position of the individual who provided the service.
       The signature must be handwritten; the position may be typed, printed or stamped.

North Carolina Treatment Outcomes and Program Performance System [NC-TOPPS]

NC-TOPPS is required to be completed by the clinical home provider with individuals who
receive mental health or substance abuse services and who have been assigned a service

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record number by the LME. NC-TOPPS is administered in a face-to- face interview as a regular
part of developing and updating an individual’s Person-Centered Plan [PCP] and providing

NC-TOPPS is the program by which the Division of MH/DD/SA Services measures outcomes
and performance. It captures key information on an individual's current episode of treatment,
aids the provider in the evaluation of active treatment services, provides data for meeting
federal performance and outcome measures, and supports LMEs in their responsibility for
monitoring treatment services.

NC-TOPPS uses a number of assessment forms for on-line data collection. The Initial Interview
is completed when an individual begins services. The Update Interview is completed at
scheduled intervals [3 months, 6 months, 12 months, and every 6 months thereafter]. The
Episode Completion [Discharge] Interview is completed when the individual moves to a new
clinical home provider, terminates services as defined in the PCP, or has a lapse in services of
more than 60 days for general consumers, or more than 365 days for the Adult Mental Health
Stable Recovery Population. For more detailed information, please see the NC-TOPPS support
materials, linked here:

Please find the web portal for NC-TOPPS data entry below:

NC-SNAP for Individuals with Developmental Disabilities

The North Carolina Support Needs Assessment Profile [NC-SNAP] is an assessment protocol
used to assess the level of intensity of services and supports needed by an individual with
developmental disabilities. The NC-SNAP is required for all individuals with developmental
disabilities, regardless of whether the services they are receiving are Medicaid or state-funded.
The NC-SNAP is not a diagnostic tool, and it is not intended to replace any formal professional
or diagnostic assessment instrument. The three domains addressed by the NC-SNAP are:
     Behavioral Supports
     Daily Living Supports
     Health Care Supports

For more information and resources related to the NC-SNAP, please go to the following link:


An Episode Completion [Discharge] Record is sent to the LME when the following occurs:

      When a client completes an episode of care [is discharged] from the program
      Or there has been no billable activity in the past 60 days, except for the Adult Mental
       Health Stable Recovery Population clients who may experience up to a 365-day break in
       service before a discharge record is required.

Providers must complete the discharge section of the LME Admission and Discharge form and
submit to the LME.

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                                            Chapter 5

                            Utilization Management of State Funds
                                        Utilization Review
                                       Care Coordination
                                    Authorization of Services

Utilization Management
Overarching principles ensure:
     The highest quality of care is provided for each person receiving services, by reviewing
        care against established evidence based and best practice measures
     All State and Federal requirements, including medical necessity, are met in regards to
     A timely response to all requests for services
     Staff who participate in the UM process are qualified within specific disability areas
     Adequate review processes, as determined by the Division, exist within the system for all
        non-Medicaid service denials, reductions, terminations or suspensions
     The person receiving services has a process for appealing any UM decision and is
        aware of this process
     Persons who do not use English as a primary language have access to written material
        and/or interpreter services in their own language.

The Medical Director, a board certified psychiatrist, provides clinical oversight to all UM
authorization activities related to State funded services. The Medical Director also monitors a
random sample of utilization management decisions and supporting documentation for
consistency with State guidelines and medical necessity criteria, as well as for inter-rater
reliability. The Medical Director consults with state and local hospital psychiatrists regarding
individual consumer care, including but not limited to, continued stay and discharge
medications. Our board certified child psychiatrist monitors utilization management decisions
for consumers under the age of 21 receiving child mental health services. UM staff consult with
the Medical Director whenever they have questions regarding medical necessity as it relates to
a specific individual’s request for State funded services. The Medical Director supervises
physician advisers responsible for issuing decisions regarding denials, reductions, terminations
or suspensions of State funded services. Any appeals regarding medical necessity must be
reviewed by the Medical Director or a designated physician adviser who makes the final
determination, in keeping with the Division’s non-Medicaid appeal process.

The UM unit has a standard turnaround time of 10 business days to review and issue an
authorization for routine State funded services. UM has the capacity to approve requests for
reauthorization within two days of expiration of the previous authorization. The provider will be
notified electronically of the authorization through Carelink. The UM unit also issues
authorizations for admissions and extensions for State Operated Facilities. This is monitored on
a daily basis by the UM supervisor. In reviewing an authorization request, the UM staff conduct
a thorough review of the PCP in keeping with the benchmarks established by the State. The
review focuses on the quality of plan development, evidence of person centeredness, use of
best practices, natural and community supports and crisis planning. The review also focuses on
the appropriateness and effectiveness of services provided to facilitate optimal service delivery.
Goals are reviewed to ensure that progress is being made toward optimal outcomes. If
outcomes are not being met, the UM staff will contact the provider and consumer to determine
possible reasons why the intervention may not be working and if other options need to be

                                        Page 16 of 89
explored. The UM staff ensure that community and natural supports are incorporated in the
plan, and that discharge planning begins at time of admission. The UM staff have the capability
to participate in consumer meetings to assist with identification of appropriate services.

The UM unit is also responsible for identifying consumers who are potentially eligible for CAP
services. Each individual referred for CAP-MR/DD services is assessed by the Guilford Center’s
CAP Coordinator using the CAP-MR/DD Waiver Services Prioritization Tool, which gives a
numeric score based on service needs. Each individual referred must meet the ICF/MR Level of
Care criteria. A list of these consumers is maintained and reviewed as funding becomes
available. Murdoch Center determines eligibility for ICF-MR level of care for each consumer.

In addition, Utilization Management regulates the provision of services in relation to the capacity
of the system and the needs of the consumer. The system is data driven and the collection of
data begins with the first contact between a consumer and the access to care system, and
continues through service activities to discharge. Data collected include, but are not limited to,
disposition of all calls, wait times, denials of care, no show rates, services requested, service
authorizations (granted, denied, and appealed), admissions, treatment outcomes, discharges,
hospitalizations, and crisis assessments. 100% of State funded consumers’ Person Centered
Plans are also reviewed. The reviews focus on high risk and high cost consumers. Data is
aggregated, analyzed, and shared with the Area Board, the Client Rights Committee, Quality
Council, CFAC, Management Team, and other stakeholders as appropriate.

The UM unit has multiple avenues for assisting providers in improving their performance. On
site training, such as making the case for medical necessity, service record documentation, the
importance of first responder responsibilities 24/7/365, and ongoing consultation, is available to
the community of providers. Best Practice Specialists are available to provide consultation and
education regarding evidenced based treatments and best practices. Information Systems also
provides ongoing technical assistance.

Utilization Review (UR)
Under the auspices of the Utilization Management unit, staff perform systematic case reviews,
with the goal of determining the extent to which necessary care was provided and unnecessary
care was avoided. Concurrent and retrospective reviews of care for targeted groups of
individuals receiving services provide information focused on the correct amount of service at
the correct time (at the best cost) for the individual. Service authorizations are based on the
consumer’s individualized Person Centered Plan. Service authorization standards as developed
by the State are followed. UM staff conduct concurrent reviews of Person Centered Plans for
our Medicaid consumers. This review of the Person Centered Plan assesses the providers’ use
and implementation of the Person Centered Planning Manual and compliance with DHHS
policies, procedures and guidelines.

Care Coordination
The Guilford Center is responsible for providing care coordination for consumers who are high
risk, high cost and/or do not have a clinical home provider and are in need of enhanced benefit
services. A high risk consumer means a person who has been assessed as needing emergent
crisis services three or more times in the previous 12 months. A high cost consumer means a
person whose treatment plan is expected to incur costs in the top twenty percent (20%) of
expenditures for all consumers in a disability group. This includes consumers who are utilizing
the greatest amount of local, state funded and Medicaid services.

                                        Page 17 of 89
Consumers will be identified through the review of authorizations, paid claims, contact
information from Guilford County Detention Center, daily log of consumers admitted to Central
Regional Hospital and daily log of consumers sponsored to the local hospitals. Consumers who
have difficulty accessing a clinical home and/or are identified as high risk can also be identified
by the Screening, Triage and Referral staff and referred for care coordination.

Care Coordination includes:
    Guardianship activities
    Coordinating services with State and local hospitals, the Regional Crisis/Emergency
      Services and local jails across our mental health system, with an emphasis on including
      the primary care physicians
    Identifying gaps in types and capacity of services and sharing this information with our
      Provider Relations and Contracts Administration Managers
    Monitoring of admissions to, and bed day utilization, of State and local hospitals
    Participating in child and family team meetings
    Participating in the person centered planning process for high risk/high cost consumers,
      with the focus being to improve the person’s mental health status and to change the
      pattern of resource utilization
    Choice of provider offered throughout the various stages of treatment (noted as one of
      the top five priorities identified by respondents during the community input process)
    Working with providers to strengthen outpatient services in an effort to reduce the need
      for more restrictive services such as Levels III and IV Residential Services, particularly
      since these high level services are likely to be reduced in the future.
    Facilitating appropriate connections to primary health care services through community
      care, the Health Department or other physical healthcare providers.

LME State Hospital Liaison
   The State Hospital Liaison provides coordination of care both onsite at state hospital
      facilities as well as locally within the LME.
   The Liaison participates in treatment team meetings for many consumers and assists
      state hospital social workers with discharge planning. The Liaison serves as a conduit
      for information for UM staff requesting additional information about the status of
      hospitalized consumers.
   The Liaison schedules the consumer’s initial discharge appointment within 5 days of
   The Liaison will track all discharges from the State Hospital.
   The Liaison will follow up with the assigned provider to confirm compliance with the five
      day aftercare appointment. The Liaison will also determine which billable service code
      the provider used to provide the service and will maintain a log of this information.
   The Liaison will assure that the provider follows up on consumers who no show for
      appointments so that they are appropriately rescheduled for services.
   The Liaison will attend Olmstead meetings and assist with discharge planning and
      ensuring appropriate, adequate community services upon discharge. The Liaison will
      provide necessary Olmstead information to the Division of MH/DD/SAS.
   The Liaison will inform providers of consumers on outpatient commitment and will follow-
      up with the provider to ensure that the consumer has kept their appointment.

Authorization of Services
    All state funded services must be authorized prior to the provider providing services.
    Authorization for state funded services are completed via Carelink.

                                        Page 18 of 89
       Authorizations are reviewed based on the State approved service definitions, medical
        necessity criteria, level of care criteria, previous treatment history and most cost-
        effective service to meet the consumer’s need. If the consumer is requesting substance
        abuse treatment, then ASAM criteria is reviewed. Treatment goals, interventions, and
        plans to fade services to natural supports are reviewed during each reauthorization
        request for clinical appropriateness.
       Authorization for state funded services after the STR, should be sent via Carelink with
        the LME Admission Discharge form and fee/insurance form (also called provider e
        forms). If an enhanced service has been authorized by STR then send the Person
        Centered Plan with the above e forms.
       It is the responsibility of the service provider to monitor the utilization of services
        authorized by the Guilford Center to ensure that units of service billed do not exceed
       units of service authorized.
       Service requests for state funded services must include the consumer having a current
        target population that is appropriate to the diagnosis, level of functioning and consumer’s
        circumstances (such as homelessness).
       The care management staff have 14 calendar or 10 business days to process routine
        authorization requests. If additional information or documents are needed, the
        authorization is plac3ed in pending status and the care manager will communicate with
        the provider via Carelink. If the provider does not respond to the request for additional
        information or documents within 5 days, the care manager will issue an administrative
        denial approve 000 units for the service requested.
       Authorizations that are approved are dated to begin on the date the authorization is
        received or the day after the previous authorization expired. There will be no backdating
        of authorizations.
       Crisis Services do not require authorization.

Hospital and Detox Services
    Crisis Emergency Services approves the initial hospital stay for consumers who are
      sponsored to Moses Cone Hospital and High Point Regional Hospital. Crisis Emergency
      Services- Greensboro can be reached by calling 336-641-4993. Crisis Emergency
      Services- High Point can be reached by calling 336-845-7946.
    The Care Management Unit approves all inpatient requests for consumers utilizing the 3-
      way contract at Moses Cone.
    The Care Management Unit approves initial hospital stay for Central Regional Hospital.
    All hospital extension requests are approved within 24 hours. State and Local hospitals
      fax authorization requests to the Care Management Unit.
    Providers who need reauthorization for detox services on the weekend (after 5:00 p.m.
      on Friday through Sunday at 5:00 p.m.) can contact the Care Manager on Monday and
      the Care Manager will approve the request for additional services provided over the
    All requests for detox services are approved within 24 hours. The provider will submit the
      authorization request via Carelink. If the consumer presents to the provider after hours,
      the provider will submit the authorization request and the authorization will be dated for
      the date received.

Supported Employment and Supported Employment Long Term Follow Up
    Authorizations for new consumers are completed in Carelink after the provider registers
     the consumer with the call center. If the consumer is open in our system, authorization
     can be requested through Carelink. If the consumer is not viewable to the provider in

                                        Page 19 of 89
       Carelink, the provider can email the provider help desk and request that consumer be
       made viewable to their agency.

Respite Services
    Reauthorizations for all services except Respite require that a person centered plan or
      service plan be submitted an as attachment with the authorization request. The
      signature page of the person centered plan can be faxed to the LME care manager.

Consumer Notification
   Consumers/guardians are notified of their appeal rights for all denials, terminations or
     reductions in state funded services.

Registration of services for H-code Providers
    Basic benefit H-code providers who serve Medicaid consumers need to fax the LME
       Admission Discharge form to the Guilford Center (336-389-6540). The provider will direct
       bill Medicaid.

Targeted Case Management Authorizations for Medicaid Consumers
    Targeted Case Management providers who serve Medicaid consumers will obtain
      authorization from Value Options. Providers need to fax the LME Admission Discharge
      form to the Guilford Center (336-389-6540). The provider will direct bill Medicaid.

Child Mental Health Medicaid Residential Providers
    Residential providers of Medicaid consumers who wish to bill for room and board need
       to submit the required documentation based on Communication Bulletin
       16-06.pdf ).

Medicaid Consumers receiving Enhanced Service
   Enhanced Service Providers of Medicaid consumers should send the Guilford Center
      their consumers Person Center Plan and LME Admission Discharge Form within 30
      days of initiating service.

Services for MR/MI consumers (former Thomas S)
    The following services will need to be authorized by the LME for MR/MI (former Thomas
      S) consumers: residential services, personal assistance, day activity, supported

CAP-MR/DD Services
   As directed by DMH/DD/SAS, a list shall be maintained of individuals that are potentially
     eligible for CAP-MR/DD Services. The CAP-MR/DD list is a prioritized needs list, with
     individuals with the greatest needs being ranked higher in the list.
   In order to be placed on the CAP-MR/DD list, each individual referred for CAP-MR/DD
     Services shall be assessed by the LME CAP Coordinator using the CAP-MR/DD Waiver
     Services Prioritization Tool which gives a numeric score based on the service needs of
     an individual.
   Additionally, as required by DMHDDSAS, each individual referred must meet the
     ICF/MR Level of Care Criteria as defined by the Division of Medical Assistance and the
     Division of Mental Health. Individuals are ‘screened’ by the LME CAP Coordinator;
     however, final eligibility determination for ICF-MR level of care is made by the staff at
     Murdoch Center.

                                      Page 20 of 89
   The LME CAP Coordinator is also responsible for signing the initial and annual MR2 for
    CAP consumers.

                                   Page 21 of 89
                                            Chapter 6

                                      Claims Processing
                           National Provider Identifier Requirement

Claims Processing
The Guilford Center has an Accounts Receivable (AR) Unit which processes claims for the
provider network. An electronic authorization and claims processing system, Carelink, is utilized
to conduct transactions with the provider community. The provider community has free access
to the electronic system and has ongoing access to training on use of the system through the
AR staff. Providers also have at their disposal an electronic Provider Help Desk which is staffed
by various LME staff members and provides fast answers to technical questions involving
authorizations, claims, denials and other topics.

The AR Unit staff processes provider claims submissions for reimbursement through the IPRS
system. The AR staff enters client fees set by providers and based on the Guilford Center’s
sliding fee scale policy. The AR staff creates client billing records from the data that is
electronically entered by providers. The AR unit releases batches of events from the providers
and the Information Technology (IT) group transmits them to the state of North Carolina’s
adjudication system. After the state determines which claims it will pay, the information is sent
back to The Guilford Center on an 835 report. The IT department manipulates the data into an
Explanation of Benefits (EOB) report and puts it on our shared drive so the Account Technicians
can access it.

Another major role of the A/R Unit is to research all denied claims and re-bill if possible. Payers
(State funds, Insurance companies, Government Employees Insurance Funds, Medicare) deny
payment for services that do not meet the criteria established for payment. The A/R unit
researches all denied claims. Once the cause is determined, the A/R unit will request that the
Provider make the appropriate changes if possible so that the claim can be re-billed and
hopefully paid. Missing or incorrect billing criteria are the most common denial reasons.

The Accounts Payable Account Technicians use the information on the EOB to create payment
packages. The information is sorted by contract provider and then by individual contract. The
Account Tech determines if there is a contract associated with the charges and if that contract
has enough money encumbered. If those conditions are met the Account Tech puts together a
payment package. The payment package is approved by an appropriate individual in the
Business office and then sent to the Finance department to cut the checks.

The Guilford Center is obligated to make a payment within 48 days of a clean claim submission.
The IPRS checkwrite schedule is available at:

Prompt Pay guidelines are strictly adhered to in the process of making payments. The provider
contracts stipulate requirements for timely claims submissions, and delineate the consequences
of failure to meet those requirements as noted below in an email sent to the providers.

       Subject:       Provider Notice Regarding Opening Packets

       Date:          July 16, 2008

       To:            Guilford County Community Providers

                                        Page 22 of 89
       From:          Provider Help Desk

       Your have recently been notified that the Guilford Center expects providers to comply
       with the 60-day timely billing requirement already contained in your IPRS UCR contracts
       (the Medicaid billing timeframe of one year does not change). This memorandum
       provides a couple of implementation details that accompany the transition to this billing

       First, the effective date of the new policy is July 1, 2008. This means that events with
       dates of service in June 2008 and earlier must be billed to the Guilford Center by August
       31, 2008, in order for the provider to be paid; July 2008 services must be billed by
       September 30, 2008; and so on.

       You will notice that the Guilford Center is interpreting the 60-day time frame as being two
       calendar months from the end of the month during which the service is provided.

       Second, submitting a complete, accurate service event in CareLink within two months
       does not necessarily mean that the claim will be considered as meeting the timely filing
       rules; the provider must also submit complete and accurate timely client information to
       the Guilford Center through the e-forms process.

       Ordinarily, it is no problem for the Guilford Center to receive and enter the e-forms data
       before the billing for service events arrives. However, some providers still allow
       substantial time to pass between the time we inform them of incomplete, inadequate, or
       missing data in an e-forms packet and the time they submit the correction. Beginning in
       August, we will need these providers to make up those insufficiencies more promptly, or
       there will not be time to submit and enter the claim data within the 60-day time frame.
       The Guilford Center is not establishing a deadline for submitting the original or corrected
       e-forms data; however, it must be done quickly enough that the associated service event
       can be billed to the State at the end of the 60-day time frame.

       We are certain that provider compliance with this policy will result in more accurate
       billing to the Guilford Center, and will result in quicker payments to providers.

       Thank you for your attention to this change. If you have questions, please submit them
       to the Provider Help Desk.

Billing Procedures
     All billing through Guilford Center will be via Carelink submission
     Funding source and/or service determine billing method
     Use Procedural Outline to determine method

Procedural Outline for Clients with Medicaid

Medicaid Client receiving endorsed service:
   Provider bills EDS directly
   Provider has endorsed Medicaid provider MOA with LME
   Only LME involvement is STR, PCP and PCP Admission form to register client
          o VO authorization

                                       Page 23 of 89
      Ex: CS, CST, Psychosocial Rehab, OP Opioid

Medicaid Client receiving Medicaid funded non-endorsed service
   Provider has contract with LME
   Provider bills through LME
   LME requires complete billing record (see chapter 2)
   VO authorizes with LMEs’ Medicaid number
   Existence of authorization does not guarantee payment.
   LME registers authorization in Carelink allowing electronic billing by provider when VO
      auth received. (see attached procedure)
   Ex: DD Targeted CM, H code OP

Medicaid client receiving non-Medicaid funded service
   Provider has contract with LME
   Provider bills through LME
   LME requires complete billing record (eforms)
   LME authorizes all state funded services except Room & Board, Thera. Leave
   Ex: Supported employment, Day Activity, Room & Board
           o VO residential authorization is used to register Thera Leave
           o Existence of authorization does not guarantee payment.

Procedural Outline for State funded clients (non-Medicaid)

   Non-Medicaid client receiving state funded enhanced service
    Provider has contract with LME
    Provider bills through LME
    LME requires complete billing record (eforms)
    LME authorizes service
    Existence of authorization does not guarantee payment
    Provider bills using core number and ESVS drop downs in Carelink
    Must provide core number to LME
    Ex: CS, Psychosocial Rehab, OP Opioid, Diag Assessment

Non-Medicaid client receiving state funded non-enhanced service:
    Provider has contract with LME
    Provider bills through LME
    LME requires complete billing record (eforms)
    LME authorizes service
    Existence of authorization does not guarantee payment
    Billed without the ESVS drop downs
    Ex: Development Therapy, Supported Employment, Day Act

Non-Medicaid client receiving basic services
    Provider has contract with LME
    Provider bills through LME
    LME requires complete billing record (eforms)
    LME authorizes service (from day one)
    Existence of authorization does not guarantee payment
    Provider bills without the ESVS drop downs

                                     Page 24 of 89
National Provider Identifier Requirement
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated that the
Secretary of Health and Human Services adopt a standard unique health identifier for health
care providers. On January 23, 2004, the Secretary published a Final Rule that adopted the
National Provider Identifier (NPI) as this identifier. This number will eventually replace Medicaid
and Medicare enrollment numbers.
All HIPAA covered healthcare providers, whether they are individuals or organizations, must
obtain an NPI for use to identify themselves in HIPAA standard transactions. Once enumerated,
a provider's NPI will not change. The NPI remains with the provider regardless of job or location
changes. Once you have received your NPI, please inform the Contracts Unit of your number.

Please see for important details on this

Additional information regarding the NPI:
    NPI assignment is a function of the National Plan and Provider Enumeration System
    Establishes a nationally accepted unique 10 digit numeric identifier for each provider
    Once a provider is given a number, it is his/hers for life
    Will replace legacy provider numbers when sending in claims and eligibility transactions
    Application and transition period began May 23, 2005
    Website for NPPES contains web based
       and paper application
    Anticipated application processing time is 20 business days for paper, 5 business days
       for Web
    All health care providers are eligible to apply for an NPI

Who MUST get an NPI?
   The following providers are required to request an NPI number:
     • Physicians
     • Dentists
     • Chiropractors
     • Psychologists
     • Acute Care Facilities
     • Long-Term Care Facilities
     • Pharmacies
     • DME Suppliers
     • Hospice Agencies
     • Non-Physician Practitioners who bill for their services using covered transactions e.g.
       Nurse Practitioners, Clinical Nurse Specialists, and Physician Assistants
   A covered health care provider is a health care provider who transmits any health
     information in electronic form in connection with a covered transaction
   A covered health care provider is required to get and use an NPI
   Both the individual provider and the organization must get an NPI

Who CAN get an NPI
– Providers Eligible, But Not Required to Get an NPI
   • Most registered nurses
   • Some clinical technicians
   • Providers of health care who don’t bill using covered transactions

                                        Page 25 of 89
                                            Chapter 7

                                      Audit Procedures
                     Periodic audits of state and county funded services

Audits of state and county funded service providers will be carried out periodically, but no less
than once per year. Audits will consist of a review of client charts maintained in support of paid
state or county funded services, review of personnel records of staff who performed and/or
signed the service note for those services selected for audit, and review of agency’s IPRS co-
pay policy and procedures.

The audit process will be as follows:

   1. Events to be audited will be selected at random from all events paid to provider over a 6
      – 8 week period.

   2. At least five paid events will be selected for each service code billed and paid during the
      above referenced 6 -8 week period. If five events not available, all events available will
      be selected.
   3. Contracts Administrator will schedule audit date with provider. List of charts will be given
      to the provider on the day of the scheduled audit.
   4. Audits may take place either on site at The Guilford Center, or at the provider’s place of
      business, according to the auditor’s choice.

   5. Prior to audit, the audit team may review records of previous audits, plans of correction
      or other monitoring reports.

   6. Providers are required to have available to the auditors all requested client records;
      personnel records of those personnel who performed the service and/or signed the
      service note for those services selected for audit; and documentation of IPRS co-pay
      policies and procedures, records of collections or attempts to collect co-pays, records of
      expenditure of collected co-pays, and the sliding fee scale used. Documents not
      available to auditors may be presented to audit team leader by 5 PM on the third
      business day following audit, and if presented within said timeframe will be treated as
      having been available at the audit.

   7. The audit tools to be utilized are included in the as attachments A – E in the following

   8. Copies of out of compliance documents may be made during the audit. The audit team
      may utilize portable copiers for this purpose.

   9. Audit team may consist of contracts administrator(s), reimbursement specialist and
      Medical Records personnel.

   10. An exit interview will take place at the conclusion of the audit to discuss preliminary
       results with provider. Missing documents will be identified, and rules for submission of
       missing documents (see 6, above) will be emphasized. Copies of audit tools will be
       provided upon request.

                                        Page 26 of 89
11. Written audit results, including payback request, will be forwarded to the provider within
    10 business days from the deadline of timely submission of data, as per 6, above. The
    written report of audit findings will include:
        a. Identification of each service event included in audit
        b. Identification of each event out of compliance, and the reason(s) event was non-
        c. Amount of payback for each non-compliant event.
        d. Identification of each staff member reviewed, and results of said review.
        e. Amount of payback for non-compliant staff reviewed.
        f. Identification of issues requiring plan of correction.
        g. Identification of others receiving report.

12. Requested plans of correction will be due to the audit team leader by 5PM on the 10th
    business day after receipt of written audit results. Plans of correction may be accepted,
    partially accepted, or not accepted. If plan of correction is partially accepted or not
    accepted, it will be returned to provider with written explanation of why plan is being
    returned. Provider will have until 5PM on 10th business day after receiving returned plan
    of correction to modify and resubmit plan of correction.

13. A follow up audit of issues cited in the audit report and addressed in the plan of
    correction will be scheduled within 120 days of acceptance of the plan of correction.

14. Follow-up audits have the same potential consequences as any other audit.

15. Paybacks will be due within 30 days from receipt of the invoice, or 30 days from written
   notification of findings of the audit appeals committee, if results are appealed.

16. Audit results, and any notification of findings of audit appeals committee, will be sent to
    The Guilford Center’s Quality Improvement unit, the appropriate Best Practices
    manager, the Provider Relations manager and the Compliance Verification Team
    manager, and may result in additional monitoring, reduction of contract amount, or
    termination of contract.

17. Provider may appeal audit results to Guilford Center’s audit appeals committee by:
       a. sending appeal in writing within 10 business days of receipt of written audit
           findings to:
                  The Guilford Center
                  Audit Appeals Committee
                  Second Floor
                  201 North Eugene Street
                  Greensboro NC 27401

18. Appeals may be filed only on the grounds that:
       a. Guilford Center audit team did not follow procedures;
       b. Guilford Center audit team did not apply the requirements of the Records
          Management and Documentation Manual, or other referenced state or federal
          manual or rule.

19. No new materials or documents may be submitted with an appeal. All materials and
    documents must be submitted in accordance with No. 6 above.

                                     Page 27 of 89
20. Audit Appeals committee will be empowered to uphold or overturn audit findings, in
    whole or in part, or order a new audit be completed.

21. Any appeal beyond the Audit Appeals committee will be referred to Guilford Center’s
    established conflict resolution process.

                                   Page 28 of 89
                                            Chapter 8

                                      Quality Management
                                          Client Rights
                                     Complaint Management
                                       Incident Reporting

The Guilford Center QM System promotes the provision of high quality, evidenced-based
treatment for Guilford County consumers of public mental health, developmental disabilities and
substance abuse services.
This QM System supports partnerships between consumers, families, providers and
Guilford Center staff. We propose a shared effort to establish, maintain and continually
improve the quality of treatment available to Guilford County residents.
Consumers and their families are the most important part of our QM system.
Without them, there is no reason for a treatment service to exist. Consumer treatment progress
and satisfaction are the two primary goals of the QM system.
The QM System includes:
 Quality Assurance - compliance with externally imposed requirements
 Quality Improvement – a dynamic process of internally generated improvement efforts
  based on ongoing self-evaluation and input from consumers, families and stakeholders

Three primary QM System components:
 Quality Planning to meet compliance standards.
 Quality Control Procedures to self-monitor and ensure that compliance standards are
  continually met.
 Quality Improvement Processes to use information from consumers, families, staff and other
  stakeholders in an effort to continuously improve treatment services.
Our Quality Improvement Process is based on the following principles and desired
 Monitoring helps providers ensure that Statutes, Rules and Service Definitions are met
 Information from Complaints, Incidents and Onsite Monitoring Visits is valued as essential
  input into self-monitoring and continually improving the system.
 Consumers experience progress in attaining treatment goals and satisfaction with services.
 Employees feel a sense of accomplishment
 Reputation of quality services spreads so that consumers, families, and stakeholders support
  the provider organization
 Everyone feels successful

                                      Page 29 of 89
Our process aims to:
 Support a “quality improvement attitude” in the organization from the beginning and eliminate
  the need for Corrective Action Plans.
 Apply a Preventive Approach and continue to self-monitor and look for ways to continually
  improve treatment services.
 Measure success by continuously asking, “How would I want to be treated if I were receiving
  this treatment service?”
Based on information from Complaints, Incidents or Local Monitoring Reviews, we will work with
providers to:

Study the situation
Determine the Root Cause
Develop a plan to correct the cause and prevent a reoccurrence
Implement the plan
Evaluate the results of the implementation and plan accordingly in order to continue the
improvement process


It is the policy of the State to assure basic human rights to each client of a facility. These
rights include the right to dignity, privacy, humane care, and freedom from mental and physical
abuse, neglect, and exploitation. Each facility shall assure to each client the right to live as
normally as possible while receiving care and treatment. (G.S. 122C, Article 3)

(a) A written summary of client rights as specified in G.S. 122C, Article 3 shall be made
available to each client and legally responsible person.

The governing body shall develop and implement policy to assure that all staff are kept informed
of the rights of clients as specified in 122C, Article 3, all applicable rules, and policies of the
governing body. Documentation of receipt of information shall be signed by each staff member
and maintained by the facility.

EACH PROVIDER is responsible for developing procedures and functions ensuring
protections of Clients Rights in compliance with the following North Carolina Mental Health,
Developmental Disabilities and Substance Abuse Laws (Statutes) and the North Carolina
Administrative Code (Rules):
 10A NCAC 27C, 27D, 27E, and 27F governing the protection of client rights in
  community mental health, developmental disabilities and substance abuse services
   10A NCAC 26B governing confidentiality

                                          Page 30 of 89
   10A NCAC 27G core rules for MH/DD/SA services
   General Statute 122C, Article 3 Clients' Rights and Advance Instruction.

To help Guilford County providers develop and maintain high quality treatment services, the
Guilford Center is charged with monitoring providers of publicly funded mental health,
developmental disabilities and substance abuse treatment services in Guilford County through
onsite monitoring reviews, and providers’ responses to Complaints and to Incidents and
oversight of Client Rights protections. This mandate is based on regulations established in N.C.
Statute 122C-111 and Title 10A North Carolina Administrative Code 27G .0600-.0610.

For more information on Client Rights and Client Rights Committees, you may contact the
Guilford Center Client Rights Coordinator at 336-641-6644.



Process for Complaints About Providers

The right to make a complaint is so important that informing consumers and guardians of that
right and the requirement to develop written procedures is included in the North Carolina
Administrative Code.

Providers are expected to inform consumers and guardians of whom to contact and what to do if
they have a complaint, believe that someone is trying to take away their rights or are not
satisfied with services.

Complaints are often made to the Guilford Center where complainants are offered the option of
accessing the provider's complaint process; however, they may choose to submit it to the
Guilford Center first.
We view these complaints as valuable information for the quality management of our
service system, and we work with providers to use the information to enhance their

After a complaint has been reported to Guilford Center staff, information is gathered to
determine the next action. At least one of the following steps will be taken:
 Informal review process
 Investigation
 Input and recommendations from members of the Guilford Center’s Provider Quality
  Improvement Committee (PQIC), a multidisciplinary committee comprised of representatives
  from Provider Relations, Best Practices, Contracts, Access and Care Management, Nursing,
  Business Office, Compliance Verification, Quality Improvement, and DSS.

Serious concerns that could immediately impact the health and safety of the clients are reported
to the Department of Social Services (Child or Adult Protective Services) and to the Division of
Health Regulation Services (DHSR) if the facility is licensed.

                                         Page 31 of 89
Findings from the complaint review/investigation will be reported to the complainant, the
provider and the consumer’s home Local Management Entity (if it is not The Guilford Center).

The overall goal for the resolution of complaints about providers is for consumers,
guardians, staff and providers to be able to trust and communicate comfortably with
each other.

Additional information regarding complaints:
 Sometimes complainants request to remain anonymous. We respect this request and do not
  reveal their identities.
 Sometimes complainants express fear of retribution from a provider if they make a complaint.
  The North Carolina Administrative Code specifically requires the protection of a complainant
  or any staff member from harassment or retaliation.
 Consumers and guardians must be informed of their right to contact the DMH/DD/SAS, the
  DHSR and the Disability Rights North Carolina (DRNC): the North Carolina Protection and
  Advocacy System designated under law to provide advocacy on behalf of all North
  Carolinians with disabilities.
 Options that must be considered in resolving a complaint include making a report to a
  regulatory body such as DMH, DHSR, DSS or other state or local government agency or
  licensing board responsible for the regulation & oversight of the provider.

The purpose of Incident and Death Reporting is to ensure that serious adverse events involving
persons receiving publicly-funded mental health, developmental disabilities, and/or substance
abuse services are addressed quickly and analyzed for ways to prevent future occurrences and
improve the service system.
The DHHS Incident and Death Reporting System is a quality improvement practice used to
assure a consistent statewide process for protecting the health and safety of consumers and to
provide standardized data from across the state. It is so important that reporting is required in
the North Carolina Administrative Code. The State provides specific guidelines and requires that
Incident Reports be submitted through IRIS, an internet-based reporting system.
Failure to report incidents as required by 10A NCAC 27G .0600 may result in DHHS taking
administrative action against the provider’s license or authorization to provide services.

WHAT is a reportable incident?
Any event that is not consistent with the routine operation of a facility or service or the routine
care of a consumer and has the potential to affect the consumer’s health or safety may be
considered “an incident.” However, not all incidents need to be reported.
WHO is responsible for reporting?
 Providers of publicly funded Mental Health, Developmental Disabilities and Substance Abuse
  Services licensed under N.C. General Statutes 122C, except hospitals.
 Providers of publicly funded non-licensed periodic or community-based mental health,
  developmental disabilities and substance abuse services.
WHEN is an incident reported?
Level I Incidents must be reported quarterly to the Guilford Center's Quality Improvement Unit.

                                         Page 32 of 89
Level II incidents must be submitted to the Guilford Center’s Quality Improvement Unit within
72 hours of learning of the incident.
Level III incidents must be verbally reported immediately to the Guilford Center’s Quality
Improvement Unit. A completed form must be submitted to the Guilford Center’s Quality
Improvement Unit and to the State within 72 hours of learning of the incident.
HOW is an incident reported?
 See the Incident and Death Response System: Guidelines for Provider Response and
  Reporting Using Form QM02
 Level I Incidents must be reported on the Provider Quarterly Incidents Report Form
 Level II and Level III Incidents must be reported using IRIS:
        -If IRIS is unavailable or not working properly, reports may be submitted using the
  Incident and Death Report form QM02:

Incident Reports should be submitted by mail or fax to The Guilford Center’s QI Unit
Daniel McManus, Quality Improvement Specialist
Fax: 336.641.8026
The Guilford Center
232 North Edgeworth Street
Greensboro, N.C. 27401
How to get assistance with incident reporting
The Guilford Center provides training and technical assistance to help providers understand
incident reporting requirements. If you have questions, contact:
Daniel McManus, Quality Improvement Specialist
Phone: 336.641.4174

                                       Page 33 of 89
                                              Chapter 9

                                     Endorsement of Providers

Endorsement Process
In accordance with the standards set forth with Communication Bulletin #44, the Guilford Center
has developed policies and procedures to endorse providers verifying each endorsed provider’s

To assure Guilford County citizens receive Medicaid services and supports from MH/DD/SA
service providers who comply with State and Federal laws and regulations (exceptions: ICF/MR,
hospitals, independent practice settings or groups) and to assure provision of Medicaid services
in a manner consistent with the State Medicaid Plan and the State MH/DD/SAS Reform Plan,
the Guilford Center implements State policies and procedures for the endorsement process of
qualifying providers to provide specific Medicaid-covered MH/DD/SA services.

The Guilford Center staff use standardized checklists and forms provided by the Division of
MH/DD/SAS to conduct application and onsite reviews. We maintain State deadline and
documentation requirements throughout the endorsement process, including return receipts and
written notifications.

All providers intending to either provide enhanced benefits or interface with individuals in the
target population and their “clinical home” (enhanced provider organization) should become
familiar with the service definitions that went into effect March 20, 2006, available on the
Division’s website at
06rev.pdf. The service definitions describe many requirements and implementation parameters
that may influence a provider’s interest in the service.

Provider organizations need to be endorsed by Guilford Center to provide each specific
enhanced benefit service. The policy and procedure guiding this process can be viewed at .

                                       Page 34 of 89
                                         Chapter 10

                        Referring Between Community Providers
                  Referrals from Guilford Center to Community Provider

For Consumers with Medicaid
   Referrals should be made by the provider who best knows the consumer, usually the
      clinical home
   Referring providers should provide PCP or appropriate service plan to new provider.
      Plan should include goals for new service.
   Adding service/provider triggers PCP review, with new signatures/goals as indicated and
   Referring Provider should complete/assist with authorization request to Value Options
      for Medicaid services for which consumer is being referred More information on VO
      authorization procedures can be found here:
   Provider receiving referral should confirm authorization prior to providing services
   If no authorization exists, new provider must request from Value Options immediately
   A Consent to Release of Information is required to share protected information
   Providers receiving Medicaid consumer referrals for state funded services, (see below
      for authorization information) or Medicaid services billing through the Guilford Center,
      may need to complete the opening packet forms to establish a billing record. Forms are
      located here: and include the
      Admission, Care Management Enrollment, and Fee Set forms
   Providers uncertain if consumer is open to Guilford Center may call 1-800-853-5163 to
      register consumer or check on status of consumer record. Guilford Center must have a
      Consent to Release of Information on hand prior to release of protected health
   Consumers admitted to state and local hospitals may be referred back to Guilford Center
      for re-entry, or referred directly to a community provider
   Inquires to can also confirm if a consumer is
      open to Guilford Center. No protected information can be released without a Consent to
      Release of Information on hand.

For consumers with State funding or Medicaid consumer receiving state funded service
   Referrals should be made by the provider who best knows the consumer, usually the
      clinical home
   Referring providers should provide PCP or appropriate service plan to new provider.
      Plan should include goals of new service.
   Adding service/provider triggers PCP review, with new signatures/goals as indicated and
   For services being authorized by Guilford Center (state funded), referring provider
      would request authorization using authorization e-form and listing agency for which the
      request is being made in the appropriate area of the e-form. Form can be found here:
   Provider receiving referral should confirm authorization prior to providing services
   If no authorization exists, new provider must request authorization from the Guilford
      Center, either via Carelink or the above form, immediately
   A Consent to Release of Information is required to share protected information

                                      Page 35 of 89
      Providers receiving state funded consumer referrals, or Medicaid services billing through
       the Guilford Center, may need to complete the opening packet forms to establish a
       billing record. Forms are located here: and include the LME
       Admission Discharge form, and the Fee Set form.
      Providers uncertain if consumer is open to Guilford Center may call 1-800-853-5163 to
       register consumer or check on status of consumer record. Guilford Center must have a
       Consent to Release of Information on hand prior to release of protected health
      Consumers admitted to state and local hospitals may be referred back to Guilford Center
       for re-entry, or referred directly to a community provider
      Inquires to can also confirm if a consumer is
       open to Guilford Center. No protected information can be released without a Consent to
       Release of Information on hand.

Referrals from Guilford Center to Community Provider
    Consumers open to the system should be referred to the community provider who best
       knows the client (usually the clinical home) for assessment, treatment and referral as
    Consumers new to the system, or those with no known clinical home, will be offered a
       choice of available community providers
    Community providers with IPRS contracts are required to use our calendar system to
       facilitate consumer entry into system

                                      Page 36 of 89
                                            Chapter 11

                            Person Centered Planning Information

Person-Centered planning is considered to be the heart of mental health reform efforts. The
State Plan 2003 defines person-centered planning as “the life planning process that applies
across all citizens who are supported and served.” It is intended to be a departure from a
traditional emphasis on regulatory standards that govern the process of treatment plan
development, instead placing the individual receiving services in an informed and in command
role for life planning. The State Plan 2003 emphasizes that person-centered planning is not a
program but a “life planning method (process) of determining ends (real life outcomes) for
individuals and developing means to those ends (strategies).”

While there are several different approved methods for approaching person-centered planning
(see document below), all methods emphasize a process that is dynamic and strengths-based;
that is driven and owned by the individual receiving services; that involves crisis planning; that is
“real life” outcome oriented; and that “contains strategies that reflect the most natural, durable
and sustainable methods of achieving real life outcomes”. Continuous quality improvement is a
core feature of all person-centered planning. Progress towards stated goals is continuously
monitored and improvements to the plan continuously sought and implemented in order to
achieve the desired outcomes.

Person-centered planning is intended to develop and emphasize personal resources, natural
supports and natural community resources over formal supports. The person-centered plan is
the map that guides the individual towards developing independence.

Person Centered Planning
 Person centered planning is the process of determining real life outcomes with consumers
   and developing strategies to achieve those outcomes. The process supports strengths and
   recovery and applies to everyone supported and served in the system.
 Person centered planning provides for individuals with a disability to assume an informed
   and in command role for life planning and treatment, service and support options.
 Person centered planning uses a blend of paid and unpaid natural and public specialty
   resources uniquely tailored to the consumer/family needs and desires.
 The PCP is the umbrella under which all planning for treatment, services and support
 The PCP is coordinated by the consumer’s clinical home.
 Person centered planning begins with the reason for the request for assistance.
 The plan focuses on needs and desired life outcomes, not a request for a specific service.
 The plan is designed to capture all goals and objectives and delineates each team
   member’s responsibilities.
 The development of a crisis plan is critical to the PCP.
 The crisis plan includes early warning signals and triggers of an impending crisis and the
   necessary interventions to ensure the health and safety of the consumer and others.
 The PCP is a fluid document and should be revised as often as necessary to reflect the
   needs of the consumer.
 A PCP is required for consumers receiving services funded with State dollars and Medicaid
   consumers receiving enhanced services.
 The PCP is the basis for treatment and funding.
 The LME is required to perform concurrent reviews of 10% of Medicaid PCPs and a review
   of 25% of State funded PCPs.

                                         Page 37 of 89
   The reviews focus on the quality of plan development, evidence of person centeredness,
    use of best practices, natural and community supports and crisis planning. The reviews also
    focus on the appropriateness and effectiveness of services provided to facilitate optimal
    service delivery. Goals are reviewed to ensure that progress is being made toward optimal
    outcomes. If outcomes are not being met, the UM staff will contact the provider and
    consumer to determine possible reasons why the intervention may not be working and if
    other options need to be explored. The UM staff ensure and that discharge planning begins
    at time of admission.
   The LME will retain the PCP and all other LME administrative records electronically for each
    individual receiving services, using the individual’s name and assigned record number. The
    LME administrative record for consumers receiving services shall be retained until notified
    by the Department that such record may be destroyed.

Please review the Enhanced Services Implementation Update #8 as well as the Division’s
Person-Centered Plan form and instructions at Use of this standardized format is
required beginning June 1, 2006. We have also posted the PCP form and instructions on the
Guilford Center’s website under the Provider tab under “Enhanced Services Transition
Information” link.

Further information on Person-Centered Planning may be viewed at the following links:

                                       Page 38 of 89
                                           Chapter 12

                                        Best Practices
                                   Evidence-Based Practices

Best Practices
Best practices are those that have consistently resulted in positive outcomes based on scientific
studies. In the mental health field, these are specific services or interventions that have been
proven to produce benefits to consumers and their quality of life. Other terms related to best
practices are defined in the N.C. Science to Service Project's Definitions of Frequently Used
Terms ( 20k PDF ).

At the Guilford Center, we are committed to implementing components of emerging best
practices. We also are committed to providing pertinent information about these practices to our
service providers and to helping you find resources, training opportunities and further
information as it develops.

To aid in provider understanding and implementation of best practices, Best Practice Principles
and Indicators have been developed for Mental Health, Developmental Disabilities and
Substance Abuse services. These Principles and Indicators can be found at:

Mental Health:

Developmental Disabilities:

Substance Abuse:

System of Care
System of Care is a philosophy and foundation which defines how to provide services to
children and families with the best possible outcomes. It creates the standard for best practice in
children's mental health. It is based on some of the following beliefs for providing services:
     Family and child centered
     Based on family strengths
     Plans and services are family driven
     Services are provided in the least restrictive settings
     Respect for and culturally appropriate
     Provided in child's home and local community settings
     Clinically appropriate and adhere to best practice standards
     Work collaboratively with multiple human service agencies involved with the family
     Children, their families and community supports (both formal and informal) are equal and
        integral partners and a team that respects, listens and works together to accomplish
     Builds on family and community supports for resources to accomplish goals
     Builds on natural support systems for the children and families

                                        Page 39 of 89
      Focus on safety and success for child and family at home, school and community

Core values and guiding principles for System of care were developed in 1986 (Stroul &
Friedman) to support the federal Child and Adolescent Service System Program (CASSP). They

System of Care Core Values
  The System of Care should be child-centered and family-focused, with the needs of the
    child and family dictating the types and mix of service provided.
  The System of Care should be community based, with the locus of services as well as
    management and decision-making responsibility resting at the community level.
  The System of Care should be culturally competent, with agencies, programs, and services
    that are representative to the cultural, racial, and ethnic differences of the populations they

System of Care Guiding Principles
   1. Children with emotional disturbances should have access to a comprehensive array of
      services that address the child's physical, emotional, social, and educational needs.
   2. Children with emotional disturbances should receive individualized services in
      accordance with the unique needs and potential of each child and guided by an
      individualized service plan.
   3. Children with emotional disturbances should receive services within the least restrictive,
      most normative environment that is clinically appropriate.
   4. The families and surrogate families of children with emotional disturbances should be full
      participants in all aspects of the planning and delivery of services. Children with
      emotional disturbances should receive services that are integrate, with linkages between
      child-serving agencies and programs, and mechanisms for planning, developing and
      coordinating services.
   5. Children with emotional disturbances should be provided with case management or
      similar mechanisms to ensure that multiple services are delivered in a coordinated and
      therapeutic manner and that they can move through the system of services in
      accordance with their changing needs.
   6. Early identification and intervention for children with emotional disturbances should be
      promoted by the System of Care in order to enhance the likelihood of positive outcomes.
   7. Children with emotional disturbances should be ensured smooth transitions to the adult
      service system as they reach maturity.
   8. The rights of children with emotional disturbances should be protected, and effective
      advocacy efforts for children and youth with emotional disturbances should be promoted.
   9. Children with emotional disturbances should receive service without regard to race,
      religion, national origin, sex, physical disability, or other characteristics, and services
      should be sensitive, and responsive to cultural differences and special needs.

Evidence-Based Practice
Evidenced-based practices (EBPs) are practices that have been:
    Shown to be efficacious and to produce meaningful outcomes in controlled research
    Replicated by other researchers
    Documented to describe the model and how the service is provided
    Replicated in real-life treatment settings

                                        Page 40 of 89
Community Support Service (or Community Support Team or ACTT) becomes the “umbrella”
service in which most EBPs will be delivered in the enhanced services model. North Carolina
has identified six EBPs for severe mental illness:

1. Wellness (Illness) Management and Recovery: A broad set of strategies designed to help
individuals with serious mental illness collaborate with professionals, reduce their susceptibility
to the illness, and cope effectively with their symptoms. Recovery occurs when people with
mental illness discover, or rediscover, their strengths and abilities for pursuing personal goals
and develop a sense of wellness.

2. Family Psycho-Education: The provision of information, clinical guidance and support to
families of seriously mentally ill consumers. Psycho-Education can be provided in single-family
and multi-family groups. The format is structured and pragmatic to assist people with developing
skills for handling problems posed by mental illness. Over time, practitioners, family members
and consumers form a partnership as they work toward recovery.

3. Assertive Community Treatment Team (ACTT): A comprehensive community-based model
for delivering treatment, support and rehabilitation services to adults with severe mental illness.
A team of professionals assumes direct responsibility for providing the specific array of services
needed by a mental health consumer, for as long as they are needed.

4. Supported Employment: A well-defined approach to helping people with disabilities
participate as much as possible in the competitive labor market, working in jobs they prefer with
the level of professional help they need. Supported Employment programs for persons with
mental illness typically provide individual placements in competitive employment—that is,
community jobs paying at least minimum wage that any person can apply for—in accord with
client choices and capabilities.

5. Integrated Dual Disorders Treatment: Promotes ongoing recovery from co-occurring
severe substance abuse and severe mental illness by providing service agencies with specific
strategies for organizing and delivering services. Co-occurrence is common—about 50 percent
of individuals with severe mental disorders are affected by substance abuse. Dual diagnosis is
associated with a variety of negative outcomes, including higher rates of relapse,
hospitalization, violence, incarceration, homelessness and serious infections such as HIV and

6. Medication Management Approaches in Psychiatry (MedMAP): MedMAP is designed to
involve consumers, family members/supporters, practitioners, program leaders, and the public
mental health authority in a united effort to practice medication prescribing in the interest of
recovery of the consumer. MedMAP provides guidelines and algorithms that were developed
using research and evidence to help the agencies, practitioners, and consumers achieve the
best possible recovery outcomes. Currently established as an EBP only for schizophrenia, it is
likely that in the near future this approach will be expanded to include the pharmacological
treatments for other mental illnesses.

The Substance Abuse and Mental Health Services Administrations’ (SAMHSA) Center for
Mental Health Services has “toolkits” for EBPs on their website:

                                         Page 41 of 89
Five evidence-based practice toolkits can be downloaded:
a. Illness Management and Recovery
b. Assertive Community Treatment
c. Family Psychoeducation
d. Supported Employment
e. Co-occurring Disorders: Integrated Dual Diagnosis Treatment
f. Assertive Community Treatment

For more information about Evidence-Based, Best Practice or System of Care:

Mental Health Best Practice Consultation:
Wes Early, Mental Health Best Practice Specialist
Telephone: 336-641-4333

Developmental Disabilities Best Practice Consultation:
Tammi Grubb-Newton, Developmental Disabilities, Best Practice Specialist
Telephone: 336-641-6072

Substance Abuse Best Practice Consultation:
Joe Fortin, Substance Abuse Best Practice Specialist
Telephone: 336-641-4947

System of Care Consultation:
Lisa Salo, System of Care Coordinator
Telephone: 336-641-4962

                                        Page 42 of 89
                                                 Chapter 13

                                        State and Federal Requirements

    The chart below serves as sufficient and necessary direction to Providers for accessing
    pertinent rules, regulations, standards, and other information referenced in Article I, Section 1.2
    of the Agreement and Article I, Section 1.1 of the State Contract. These documents change
    based on legislative action, change in federal and state policy, and state procedures.

    There is a mutual responsibility for Providers and LME to each routinely check these items for
    updates on requirements. If a Provider is uncertain how a State or Federal change will be
    implemented, or if a LME has concerns about how a change will be implemented, then the LME
    shall make a good faith effort to get further information or resolution regarding implementation
    and share this with the Provider. However, the Provider shall not exclusively rely upon only the
    LME for information.

                                                          SUGGESTED                  WEB SITE, IF
                                                           CONTACTS                  AVAILABLE
APSM 30-1 (Rules for MH/DD/SA- Core rules for            DMH MH/DD/SAS       Contact Web Master for the NC
services and also includes State-covered services        Mail Service        Division of MH/DD/SA Services
definitions)                                             Center, 3015        and NC Division of Medical
APSM 45-1 (Confidentiality)                              Raleigh, NC 27699   Assistance
APSM 45-2 (Service Record Manual)                        (919) 715-1294
APSM 45-2a (Service Records Resource Manual)                                 dsas/statspublications/manualsf
APSM 95-2 (Client Rights)                                                    orms/index.htm#manuals
APSM 10-3 (Records Retention and Disposition
APSM 75-1 (Area Programs Budget Procedures Manual)
45 CFR Part 2 & 164 (HIPAA Standards for Privacy and
Security of Health Information)
CAP-MR/DD Manual – (CAP Providers and Core               DMH MH/DD/SAS
Competencies Training Requirements for MR/MI service     Mail Service        /cap-mrdd/index.htm
providers)                                               Center, 3015
                                                         Raleigh, NC 27699
                                                         (919) 715-1294
Medicaid-Related Documents                               DMH MH/DD/SAS
Medicaid-covered services definitions                    Mail Service        /government.htm
Medicaid Services Guidelines                             Center, 3015
Medicaid Communiqués                                     Raleigh, NC 27699
                                                         (919) 715-1294
Health Care Personnel Registry                           (919) 733-8500      http://facility-
                                                         (919) 715-0562      m and
SB 163- Monitoring of Providers                                    
Endorsement Policy and Procedures                        DMH MH/DD/SAS
                                                         Mail Service        dsas/stateplanimplementation/pr
                                                         Center, 3015        oviderendorse/index.htm
                                                         Raleigh, NC 27699
                                                         (919) 715-1294

                                               Page 43 of 89
                                                           SUGGESTED                WEB SITE, IF
                                                            CONTACTS                AVAILABLE
General Statutes
122-C Mental Health, Substance Abuse,                                       All of the NC general statutes
Developmental Disabilities Act of 1985                                      can be located on-line at the
Applicable sections include but are not limited to:                         following site. Just type in the
 122C-3 Definitions                                                        statute number you wish to
 122C-4 Use of phrase “client or his legally                               review in the search box that is
    responsible person”                                                     in this site.
 122C-51 Declaration of Policy on clients rights
 122C-52 Right to confidentiality                                
 122C-53-56 Exceptions…
 122C-57 Right to treatment and consent to treatment
 122C-58 Civil Rights and civil remedies
 122C-59 Use of corporal punishment
 122C-60 Use of physical restraints or seclusion
 122C-61 Treatment rights in 24-hour facilities
 122C-62 Additional rights in 24-hour facilities
 122C-63 Assurance for continuity of care for
    individuals with mental retardation
 122C-64 Human Rights Committees
 122C-65 Offenses relating to clients
 122C-66 Protection from abuse and exploitation;
 122C-67 Other rules regarding abuse, exploitation,
    neglect, etc.
 122C-(116,141,142,146) Local Government Entity
 122C-151.3 and 151.4 Resolving Disputes with
    Contractors, etc
 90-21.4 Treatment of Minors
 7A 517, 452-553 Abuse and Neglect of Minors
 108A 99-111 Abuse and Neglect of Disabled Adults
 122C-151.3 and 151.4 Resolving Disputes with
    Contractors, etc.
DHHS Disaster Preparedness, Response and Recovery                 
Plan                                                                        /disasterpreparedness/
SB 926- Monitoring of Providers                           SB163 link

                                                          NCAC 10A
                                                          27G.0600          /statspublications/manualsforms/
Performance Agreement between DMH and Area                        
programs                                                                    performanceagreement

Contract between the Area Authority and the NC division           
of MH/DD/SAS – Results and information regarding                            /performanceagreement/
Performance Measures                                                        m
Drug Free Workplace Act of 1988 as revised                Library-Federal
                                                          Laws              e.htm
Section 503 and 504 of the Rehabilitation Act of 1973     Library-Federal
                                                          Laws              e/compliance-majorlaw.htm#eeo

                                               Page 44 of 89
                                                             SUGGESTED                WEB SITE, IF
                                                              CONTACTS                AVAILABLE
Civil Rights Act of 1964                                    Library-Federal
Non-Profit Agencies-Conflict of Interest 1993 Session       Library-Federal
Laws: Chapter 321, Section 16                               Laws    
Public Law 99-319, May 1986                                 Library-Federal
Protection and Advocacy for Mentally Ill Persons            Laws              099laws.html
                                                                              Search for 99-320
   Title I Protection and Advocacy Systems                         
   Title II Reinstatement of Rights for Mental Health                        de/42/ch114.html
Public Law 100-509 Protection & Advocacy for Mentally       Library-Federal
Ill                                                         Laws              100laws.html
                                                                              Search for 100-509
Individual Amendments Act of 1988, October 1988                     
Public Law 101– 496 Developmental Disabilities              Library-Federal
Assistance and Bill of Rights Act of 1990                   Laws              101laws.html
                                                                              Search for 101-496
42 CFR Part 2 Confidentiality Regulations for consumers     Library-Federal   Federal Regulations search:
with SA Diagnosis                                           Laws    
45 CFR Part 160 & 164 HIPAA Standards for                                     dex.html
Privacy of Health Information
Office of the Inspector General (Exclusions - “Lower-tier   Library-Federal
Transactions and disbarment”)                               Laws
Pro-children Act                                            Library-Federal
Section 1041-1044 of the Educate America Act of 1994                          ALS2000/TheAct/intro.html
prohibiting smoking in areas used by children.
Americans with Disabilities Act                             Library-Federal
National Provider Information Number                                
North Carolina Council of Community MH/DD/SAS                       

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                                             Chapter 14

                                         Glossary of Terms

Definitions included in this section are primarily for clarification of terms used in the body of this
Agreement, its attachments, and manual. However many of these definitions are also used in
existing state and LME documents and are included here to be helpful but are not to be
considered comprehensive. Where similar definitions apply to multiple terms, the terms are
grouped. Broad categories are defined with specific elements detailed as a part of the entire

ACCESS (Not to be confused with the Access Program) – An array of treatments, services and
supports is available; consumers know how and where to obtain them; and there are no system
barriers or obstacles to getting what they need, when they are needed.

ACCREDITATION – Certification by an external entity that an organization has met a set of

ACT - Assertive Community Treatment

ADULT - means a person 18 years of age or older, unless the term is given a different definition
by statute, rule, or policies. Medicaid considers a person an adult at age 21.

ADMINISTRATIVE SERVICES - means the services other than the direct provision of
MH/DD/SA services (including case management) to eligible or enrolled persons, necessary to
manage the MH/DD/SA system, including but not limited to: provider relations and contracting,
provider billing accounting, information technology services, processing and investigating
grievances and appeals, legal services (including any legal representative of the Contractor at
Administrative hearings concerning the Contractors decisions and actions), planning, program
development, program evaluation, personnel management, staff development and training,
provider auditing and monitoring, utilization review and quality management.

ADVOCACY – Activities in support of, or on behalf of, people with mental illness, developmental
disabilities or addiction disorders including protection of rights, legal and other service
assistance, and system or policy changes.

AMERICAN SOCIETY OF ADDICTION MEDICINE (ASAM) - An international organization of
physicians dedicated to improving the treatment of people with substance use disorders by
educating physicians and medical students, promoting research and prevention, and informing
the medical community and the public about issues related to substance use. In 1991, ASAM
published a set of patient placement criteria that have been widely used and analyzed in the
alcohol, tobacco and other drug fields.

AOC - Administrative Office of the Courts

APPEAL - means a formal request for review of a decision made by the Area Program related
to eligibility for covered services or the appropriateness of treatment services provided.

APPEALS PANEL - The State MH/DD/SA appeals panel established under NC. G.S.371.

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ASSESSMENT – A comprehensive examination and evaluation of a person’s needs for
psychiatric, developmental disability or substance abuse treatment, services and/or supports
according to applicable requirements.

AUTHORIZATION - The process by which Utilization Management agrees to a medically
necessary specific service or plan of care based upon best practice. The granted request of a
provider is assigned a number for tracking and linked to the subsequent claim that will be made
for reimbursement. PRE AUTHORIZATION/PRIOR AUTHORIZATION is the process of
approving use of certain resources in advance rather than after the service has been requested.
Approval for admission to hospitals in an emergent situation is one example. RE-
AUTHORIZATION is the process of submitting a request for services for a consumer who has
already received authorized services. The request shall specify the scope, amount and duration
of service requested and shall indicate the consumer’s progress toward outcomes, the use of
natural and community supports, and how the requested services will support the outcome the
individual is seeking. RETROSPECTIVE AUTHORIZATION is authorization to provide services
after the services have been delivered.

BASIC SERVICES – Mental health, developmental disability or substance abuse services that
are available to North Carolina residents who need them whether or not they meet criteria for
target or priority populations.

BENEFIT PACKAGE OR PLAN – An array of treatments, services and/or supports intended to
meet the needs of target or priority populations. BENEFIT LIMITATIONS are any provision,
other than an exclusion, which restricts coverage, regardless of medical necessity. Covered
Benefits are medically necessary services that are specifically provided for under the provisions
of Evidence of Coverage. A covered benefit shall always be medically necessary, but not every
medically necessary service is a covered benefit. For example, some elements of custodial or
maintenance care, which are excluded from coverage, may be medically necessary, but are not

BEST PRACTICE(S) – Interventions, treatments, services or actions that have been shown by
substantial research or professional consensus to generate the best outcomes or results. The
terms, EVIDENCE-BASED, or RESEARCH-BASED may also be used.

BLOCK GRANT – Funds received from the federal government (or others), in a lump sum, for
services specified in an application plan that meet the intent of the block grant purpose. Also

CARE COORDINATION – The methods utilized to notify other providers of significant events in
the course of care and to enable multiple providers to give integrated care to an individual.
Professionals with a broad knowledge of the resources, services and programs supported by
the public MH/DD/SA system and the community at-large advocate for access and link
individuals to entitlements and services. It is an administrative Service Management Function
performed by the Area Program for individuals not enrolled or not meeting target population

CARF – Commission on Accreditation of Rehabilitation Facilities

CATCHMENT AREA - The geographic part of the State served by a specific Contractor. The
GEOGRAPHIC AREA can be a specific county or defined grouping of counties that are

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available for contract award. The Contractor is responsible to provide covered services to
eligible residents of their area.

responsible for overseeing the Medicaid and Medicare programs. Formerly, it was known as the
Health Care Financing Administration, (HCFA).

CERTIFICATION – A Statement of approval granted by a certifying agency confirming that the
program/service/agency has met the standards set by the certifying agency. The Area Program
or the NC Council may be the certifying agency for subcontracted providers.


CHILD - means a person who is under the age of 21, unless the term is given a different
definition by statute, rule or policies. IPRS defines a child as a person under the age of 18.

CLAIMS MANAGEMENT – The process of receiving, reviewing, adjudicating, investigating,
paying, and otherwise processing service claims submitted by network and facility providers.
CLAIM – An itemized Statement of services, performed by a provider network member or
facility, which is submitted for payment. CLEAN CLAIM - means a claim that successfully
passes all adjudication edits. CLIENT - An individual who is admitted to or receiving public
services. “Client” includes the client’s personal representative or designee and the terms
CONSUMER, RECIPIENT and PATIENT are often used interchangeably.

CLIENT DATA WAREHOUSE (CDW) - The DHHS’s source of information to monitor program,
clinical and demographic information on the clients served. The data are also used to respond
to Departmental, Legislative and Federal reporting requirements.

CLINICAL PRACTICE GUIDELINES – Utilization and quality management mechanisms
designed to aid providers in making decisions about the most appropriate course of treatment
for a specific clinical case. The guidelines or TREATMENT PROTOCOLS are summaries of
best practice research and consensus. They include professional standards for providing care
based on diagnostically related groups.

COA - Council on Accreditation

reflect the presence of two or more disorders at the same time (e.g. substance abuse and
mental illness; developmental disability and mental illness; substance abuse and physical health
conditions, etc.) and require specialized approaches.

COMPLAINT – A report of dissatisfaction with some aspect of the public MH/DD/SA system.
The term DISPUTE is used to indicate a specific complaint about a service or a provider that
requires attention and joint resolution.

CONFLICT OF INTEREST – A situation where self interest could negatively impact the best
interests of the person being served or the system.

CONSENSUS - Majority opinion regarding a group decision. It is not the same as total

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CONSUMER - An individual who is admitted to or receiving public services. “Consumer”
includes the consumer’s personal representative or designee and the terms CLIENT,
RECIPIENT and PATIENT are often used interchangeably.

CONSUMER and FAMILY ADVISORY COMMITTEE (CFAC) – A Board appointed group of
persons receiving services, families of persons receiving services, who participate in meaningful
decision making relative to the local program. The group shall meet at least monthly in a public
forum to review data, practices, policies and plans of the Area Program and make
recommendations to the Board from the consumer/family perspective.

CONTRACT- A legal agreement between a payer and a subscribing group or individual which
specifies rates, performance covenants, the relationship among the parties, schedule of benefits
and other pertinent conditions. The contract usually is time limited. A contract is defined as a
document that governs the behavior of a willing buyer and a willing provider. The Contract in
this case is the Performance Agreement between the Department of MH/DD/SAS and the LME.

CONTRACTOR - an organization or entity agreeing by signature to provide the goods and
services in conformance with the stated contract requirements, NC statute and rules and federal
law and regulations.

CONTRACT YEAR - a period from July 1 of a calendar year through and including June 30 of
the following year.

COPAYMENT - The portion of the cost of services which the enrolled person pays directly to
the Contractor or the subcontracted providers at the time-covered services are rendered.

CORE SERVICES – BASIC SERVICES such as screening, assessment, crisis or emergency
services available to persons who needs them whether or not they are a member of a target or
priority population. The term also includes universal services such as education, consultation
and prevention activities intended to increase knowledge about mental illness, addiction
disorders, or developmental disabilities, reduce stigma associated with them and/or prevent
avoidable disorders.

CORPORATE COMPLIANCE – The systematic local governance plan for detection of fraud
and abuse as defined in the Balanced Budget Act.

CREDENTIALING – The process of approving providers for membership in a network to
provide services to consumers. This term can also refer to a peer competency-based credential
such as a license for professionals.

CRISIS – Response to internal or external stressors and stressful life events that may seriously
interfere with compromise a person’s ability to manage. A crisis may be emotional, physical, or
situational in nature. The crisis is the perception of and response to the situation, not the
situation itself. CRISIS RESPONSE is the immediate action to assess for acute MH/DD/SA
service needs, to assist with acute symptom reduction, and to ensure that the person in crisis
safely transitions to appropriate services. These services are available 24 hours per day, 365
days per year. These services may be referred to as EMERGENCY services as well. NC
requires a CRISIS PLAN for consumers to promote recovery and to lessen the trauma of
emergency events.

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CULTURAL COMPETENCE/PROFICIENCY – A process that promotes development of skills,
beliefs, attitudes, habits, behaviors and policies which enable individuals and groups to interact
appropriately, showing that we accept and value others even when we may disagree with them.

CUSTOMER – Customers may be ULTIMATE CUSTOMERS who are the intended and actual
recipients of the services provided by the public system, INTERNAL CUSTOMERS are those
individuals internal to the system who rely on each other to provide the service to the ultimate
customer; and EXTERNAL CUSTOMERS are those groups and individuals outside the system
that have a take in the outcomes and products produced by the system.

DEFAULT – The breach of conditions agreed to in this Contract and/or failure to perform based
upon defined terms and conditions the scope of work specified in the Contract.

DE-INSTITUTIONALIZATION – Release of people from institutions to care, treatment and
supports in local communities. De-institutionalization became national policy with the
Community Mental Health Centers Act of 1963. The 1997 Supreme Court decision in
OLMSTEAD V. LC has given new momentum to development of community based services for
individuals who have remained in State hospitals and mental retardation centers because
community services were not available. This movement is often referenced as movement to
least restrictive care or to lower levels of care where safety and community integration are
balanced and supported through the community system of services.

oversees State government human services programs and activities.

DEVELOPMENTAL DISABILITY - A severe, chronic disability of a person which: a) is
attributable to a mental or physical impairment or combination of mental and physical
impairments; b) is manifested before the person attains age 22, unless the disability is caused
by a traumatic head injury and is manifested after age 22; c) is likely to continue indefinitely and,
d) results in substantial functional limitations in three or more of the following areas of major life
activity: self-care, receptive and expressive language, capacity for independent living, learning,
mobility, self-direction and economic self sufficiency; and e) reflects the person’s need for a
combination and sequence of special interdisciplinary, or generic care, treatment, or other
services which are of a lifelong or extended duration and are individually planned and
coordinated; or f. when applied to children from birth through four years of age, may be
evidenced as a developmental delay.

DHHS - Department of Health and Human Services.

DIAGNOSTIC AND STATISTICAL MANUAL-4th edition (DSM IV) – A book, published by the
American Psychiatric Association, that identifies and describes MH/DD/SA disorders, and lists
specific codes for each.

DISASTER – A disaster is any natural or human-caused event, which threatens or causes
injuries, fatalities, widespread destruction, distress, and economic loss. Disasters result in
situations that call for a coordinated, multi-agency response. A disaster calls for a response and
resources that usually exceed local capabilities.

DIVERSION – Choosing lower cost and/or less restrictive services and/or supports. For
example, choosing a community program instead of sending a person to a State hospital. The
term is also used when preventing arrest or imprisonment by providing services that restore

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functioning and avoid detention. In North Carolina diversion programs are in place in response
to SB859 that prohibits admission of persons with mental retardation to public psychiatric

ABUSE SERVICES (DMH/DD/SAS) - A division of the State of North Carolina, Department of
Health and Human Services responsible for administering and overseeing public mental health,
developmental disabilities and substance abuse programs and services.

DJJDP - Department Of Juvenile Justice and Delinquency Prevention

DOMAINS - Major areas of concern to the NC public MH/DD/SA system and its mission, goals,
and strategies and for which indicators and measures are developed to examine outcomes of
service in the lives of people served.

DPI - Department of Public Instruction

DSS - Department of Social Services

Early and Periodic Screening, Diagnosis and Treatment is a Medicaid program for Title XIX
individuals under the age of 21. This mandatory preventive child health program for Title XIX
children requires that any medically necessary health care service identified in a screening be
provided to an EPSDT recipient. The MH/DD/SA component of the EPSDT diagnostic and
treatment services for Title XIX members under age 21 years are covered by this contract.

EDUCATION – Activities designed to increase awareness or knowledge about any and all
aspects of mental health, mental illness, developmental disability or substance abuse to
individuals and/or groups. Education and training are also activities or programs delivered to
staff to ensure that service providers are competent to provide services identified as best

ELIGIBILITY – Determination of the service and/or benefit package an individual may be
entitled to or determination of a class membership that allows entry to certain services and
supports. The determination that individuals meet prescribed criteria for a particular program,
set of services or benefits.

EARLY INTERVENTION - The provision of psychological help to victims/survivors within the
first month after a critical incident, traumatic event, emergency, or disaster aimed at reducing
the severity or duration or event-related distress. For mental health service providers, this may
involve psychological first aid, needs assessment, consultation, fostering resilience and natural
supports, and triage, as well as psychological and medical treatment.

EMERGENCY - Means a situation in which an individual is experiencing a serious mental illness
or a developmental disability, or a child is experiencing a serious emotional disturbance, and
one of the following applies: The individual can reasonably be expected within the near future
to physically injure himself, herself, or another individual, either intentionally or unintentionally.
The individual is unable to provide himself or herself food, clothing, or shelter, or to attend to
basic physical activities such as eating, toileting, bathing, grooming, dressing or ambulating, and
this inability may lead in the near future to harm to the individual or to another individual. The
individual’s judgment is so impaired that he or she is unable to understand the need for

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treatment and, in the opinion of the mental health professional, his or her continued behavior as
a result of the mental illness, developmental disability, or emotional disturbance can reasonably
be expected in the near future to result in physical harm to the individual or to another individual.

ENROLLED – Individuals are admitted for service and have been provided at least one service
and assigned a unique identifying number.

FAIR HEARING RIGHTS – Advance and Adequate Notice - The Contractor notice in
accordance with DHHS policy and procedure using prescribed forms when denying, reducing,
suspending or terminating covered services that require prior authorization. The Contractor
shall comply with all notice, appeal and continuation of benefits requirements specified by State
and federal law and regulations.

FEE FOR SERVICE – A method of payment for health care. A payer pays the Contractor or a
service provider for each reimbursable treatment, upon submission of a valid claim, and
according to agreed upon business rules. The FEE SCHEDULE is a list of reimbursable
services and the rate paid for each service provided.

FEMA - Federal Emergency Management Agency

FORENSIC – This term is a synonym for LEGAL.

FORMULARY – A reference guide to pharmaceutical products; items can be included in the
formulary or not.

FUNCTIONAL OUTCOMES - The extent to which individuals receiving services and supports
reach their goals. These outcomes generate from DOMAINS as defined earlier related to
desirable life developments that all people wish to achieve, such as safe and affordable
housing, employment or a means of support, meaningful relationships, participation in the life of
the community, etc.

GACPD - Governor’s Advocacy Council for Persons with Disabilities

GENERAL FUND – State funds used by the General Assembly for public programs and

GEOGRAPHIC ACCESSIBILITY – A measure of access to services, generally determined by
drive/travel time or number and type of providers in a service area.

GRIEVANCE – A formal complaint by a service recipient that shall be resolved in a specified

HEALTH CHOICE – The health insurance program for children in North Carolina that provides
comprehensive health insurance coverage to uninsured low-income children. Financing comes
from a mix of federal, State, and other non-appropriated funds.

104-191, 1996 to improve the Medicare program under title XVIII of the Social Security Act, the
Medicaid program under title XIX of the Social Security Act, and the efficiency and effectiveness
of the health care system, by encouraging the development of a health information system
through the establishment of standards and requirements for the electronic transmission of

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certain health information. The Act provides for improved portability of health benefits and
enables better defense against abuse and fraud, reduces administrative costs by standardizing
format of specific healthcare information to facilitate electronic claims, directly addresses
confidentiality and security of patient information - electronic and paper-based, and mandates
“best effort” compliance.

HIPAA - Health Insurance Portability and Accountability Act (See Above)

HUD - Housing and Urban Development

HUMAN RIGHTS COMMITTEE – The body established by statute for hearing grievances and
appeals related to violation of rights guaranteed by law and this contract.

INCURRED BUT NOT REPORTED (IBNR) - means liability for services rendered for which
claims have not been received. Refers to claims that reflect services already delivered, but, for
whatever reason, have not yet been reimbursed. Failure to account for these potential claims
could lead to inaccurate financial estimates.

system for reporting services and making payments of claims processing. The IPRS system will
be built on the existing Medicaid Management Information System (MMIS) currently processing
Medicaid claims for the Division of Medical Assistance, (DMA). The goal of the IPRS project is
to replace the existing UCR systems with one integrated system for processing and reporting all
MH/DD/SAS and Medicaid claims.

IPRS - Integrated Payment Reporting System (See Above)

–Agency that reviews the care provided by hospitals and determines whether accreditation is

LBP - Local Business Plan

LEAST RESTRICTIVE CARE – The service that can be provided in the most normative setting
while ensuring the safety and well being of the individual.

LENGTH OF STAY (LOS) – The amount of time that a person remains in a service program,
including hospitals, expressed in days.

LEVEL OF CARE (LOC) - A structured system for evaluating acuity and INTENSITY OF NEED
against the amount, duration and scope of service required by a consumer. For substance
abuse programs, as used in the ASAM criteria for substance abuse, this term refers to four
broad areas of treatment placement, ranging from inpatient to outpatient.

LICENSURE – A State or federal regulatory system for service providers to protect the public
health and welfare. Licensure of healthcare professionals and hospitals are examples.

LME - Local Management Entity

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LOCAL BUSINESS PLAN – In the reformed MH/DD/SA system, a comprehensive plan
required of local management entities for mental health, developmental disabilities and
substance abuse services in a certain geographical area.

LOCAL MANAGEMENT ENTITY (LME) - The local administrative agency that plans, develops,
implements and monitors services within a specified geographic area according to the terms of
this Contract including the development of a full range of services and/or supports for both
insured and uninsured individuals.

LOCAL QUALITY MANAGEMENT COMMITTEE – A cross system group of stakeholders
including the LME, providers, consumers, and family members that reviews data and trends to
make recommendations for continuous improvement in the system of care and supports.

MANAGEMENT REPORTS – Collections of data that are benchmarked to enable the agency to
compare performance against standards and to seek continuous improvement. The reports
should be comprehensive incorporating timeliness, utilization and penetration rates, customer
satisfaction, functional outcomes and compliance with various standards and in terms inherent
in this Contract.

MEDICAID – A jointly funded federal and State program that provides medical expense
coverage to low-income individuals, certain elderly people and people with disabilities. The
Federal government requires that the State and local government match the federal government
funds. In North Carolina, this is approximately 60% federal/40% State/local match. People
qualifying for Medicaid are “entitled” to supports and services based upon a State Medicaid Plan
that is approved by the Federal Government. That Plan describes the services and benefits the
individual is entitled to receive and the conditions of service provision.

MEDICAL DIRECTOR – A Board Certified Psychiatrist responsible for establishing and
overseeing medical policy throughout the system, under the terms of this contract.

MEDICAL NECESSITY - Criteria established to ensure that treatment is essential and
appropriate for the condition or disorder for which the treatment is provided. The criteria
reference the scope, amount and duration of service appropriate for levels of acuity and
rehabilitative care.

MEDICARE – A federal government hospital and medical expense insurance plan primarily for
elderly people and people with long term disabilities.

MEMBER HANDBOOK – A document developed and disseminated by the Contractor
according to the parameters established in this Contract to inform potential eligibles, eligibles,
and enrolled persons of their rights, responsibilities and treatment coverages.

– A written document, signed by two or more parties, containing policies and/or procedures for
managing issues that impact more than one agency or program.

MH - Mental Health

MMIS - Medicaid Management Information System.

MST - Multi-Systemic Therapy

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created to improve patient care quality and health plan performance in partnership with system
management plans, purchasers, consumers, and the public sector.

NATIONAL PRACTITIONER DATA BANK (NPDB) – A database maintained by the federal
government that contains information on physicians and other medical practitioners against
whom medical malpractice claims have been settled or other disciplinary actions that have been

NATURAL AND COMMUNITY SUPPORTS - Places, things and, particularly, people who are
part of our interdependent community lives and whose relationships are reciprocal in nature.


NEEDS ASSESSMENT - A process by which an individual or system (e.g., an organization or
community) examines existing resources to determine what new resources are needed or how
to reallocate resources to achieve a desired goal.

instrument used to determine the care or supports needed by a person with developmental

OUTREACH - Programs and activities to identify and encourage enrollment of individuals in
need of MH/DD/SA services and/or to encourage people who have left service prematurely to

PATIENT PLACEMENT CRITERIA (PPC) - Standards of, or guidelines for, alcohol, tobacco
and other drug (ATOD) abuse treatment that describe specific conditions under which patients
should be admitted to a particular level of care (admission criteria), under which they should
continue to remain in that level of care (continued stay criteria), and under which they should be
discharged or transferred to another level (discharge / transfer criteria). PPC generally describe
the settings, staff, and services appropriate to each level of care and establish guidelines based
on ATOD diagnosis and other specific areas of patient assessment.

PCP - Person Centered Plan

PCPM – Per Citizen Per Month. The basis on which the Contractor is paid for administrative
functions under the terms of some contracts.

PEER REVIEW – The analysis of clinical care by a group of that clinician’s professional
colleagues. The provider’s care is generally compared to applicable standards of care, and the
group’s analysis is used as a learning tool for the members of the group.

PENETRATION – The extent to which the system serves those individuals expected to have a
specific medical condition, in this case persons with developmental disabilities, persons with
mental illnesses and persons with substance abuse disorders.

PERFORMANCE INDICATORS - Measurable evidence of the results of activities related to
particular areas of concern as indicated in this Contract. The measures are quantitative
indicators of the quality of care provided that consumers, payers, regulators and others could
use to compare the care or provider to other care or providers.

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PERFORMANCE STANDARDS - Benchmarks an agency or provider is expected to meet. The
standards define regulatory expectations and in meeting them the agency or provider may meet
a required level for “certification” or “accreditation”.

PERSON-CENTERED PLANNING - A process focused on learning about an individual’s whole
life, not just issues related to the person’s disability. The process involves assembling a group of
individuals selected by the consumer who are committed to supporting the person in pursuit of
desired outcomes. Planning includes discovering strengths and barriers, establishing time limits,
and identifying and gaining access to supports from a variety of community resources prior to
utilizing the community MH/DD/SA system to assist the person in pursuit of the life he/she
wants. Person-centered planning results in a written plan that is agreed to by the consumer and
that defines both the natural and community supports and the services being requested from the
public system to achieve the consumer’s desired outcomes. The plan is used as the basis for
requesting an authorization for services.

PHYSICAL DEPENDENCE - A condition in which the brain cells have adapted as a result of
repeated exposure to a drug and consequently require the drug in order to function. If the drug
is suddenly made unavailable, the cells become hyperactive. The hyperactive cells produce the
signs and symptoms of drug withdrawal.

PLAN OF CORRECTION – A written response to findings of an audit or review that specify
corrective action, time frames and persons responsible for achieving the desired outcomes.

PP - Primary Provider

PREVALENCE – The estimated degree of incidence of a condition in a given population.

PREVENTION – Activities aimed at teaching and empowering individuals and systems to meet
the challenges of life events and transitions by creating and reinforcing healthy behaviors and
lifestyles and by reducing risks contributing mental illness, developmental disabilities and
substance abuse. Universal Prevention programs reach the general population; Selective
Prevention programs target groups at risk for mental illness, developmental disabilities and
substance abuse; Indicated Prevention programs are designed for people who are already
experiencing mental illness or addiction disorders.

PSR - Psychosocial Rehabilitation

RESPONSIBLE CLINICIAN - An assigned professional deemed competent and credentialed by
the Contractor to serve as a fixed point of accountability for the consumer’s PCP, monitoring
and outreach.

PRIMARY CARE - (a) Basic or general health care usually rendered by general practitioners,
family practitioners, internists, obstetricians and pediatricians—often referred to as primary care
practitioners. (b) Professional and related services administered by an internist, family
practitioner, obstetrician-gynecologist or pediatrician in an ambulatory setting, with referral to
secondary care specialists, as necessary.

PRIMARY SOURCE VERIFICATION – A process through which an organization validates
credentialing information from the organization that originally issued the credential to the

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PRINCIPAL DIAGNOSIS - The medical condition that is ultimately determined to have caused
the consumer to seek care. The principal diagnosis is used to assign every consumer to a
diagnosis-related group. This diagnosis may differ from the admitting diagnosis.

PRIORITY POPULATIONS – Groups of people within target populations who are considered
most in need of the services available within the system.

PROMPT SERVICES - Services provided when needed. For target or priority populations,
routine appointments within 14 days, initial hospital discharge visits within 3 days, urgent visits
within 2 days, emergent visits immediately and no later than 24 hours qualify as prompt.

PROVIDER – In this Contract, a person or an agency that provides MH/DD/SA services,
treatment, and supports under a subcontract to the LME.

OPERATIONS MANUAL – A document attached to a subcontract for the purpose of explaining
how to work with the local system, the requirements for service delivery, authorization, claims
submission, etc.

PROVIDER PROFILING – The process of compiling data on individual provider patterns of
practice and comparing those data with expected patterns based on national or local statistical
norms. The data may include medication prescribed, hospital length of stay, size of caseload,
and other services. Some data may be compiled for use by consumers in choosing preferred
providers based on performance indicators.

SERVICES SYSTEM – The network of managing entities, service providers, government
agencies, institutions, advocacy organizations, and commissions and boards responsible for the
provision of publicly funded services to consumers.

QA - Quality Assurance

QI - Quality Improvement

QIC - Quality Improvement Committee

QM - Quality Management

QPN - Qualified Provider Network

QUALIFIED PROVIDER NETWORK – The group of subcontractors subcontracted by a
Contractor to provide supports and services to persons for whom the Contractor authorizes

QUALITY MANAGEMENT (QM) - The framework for assessing and improving services and
supports, operations, and financial performance. Processes include: QUALITY ASSURANCE,
and QUALITY IMPROVEMENT. QUALITY IMPROVEMENT (QI) is a process to assure that
services, administrative processes, and staff are constantly improving and learning new and
better ways to provide services and conduct business. QUALITY ASSURANCE (QA) involves
periodic monitoring of compliance with standards.

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RECOVERING STAFF - Counselors with and without educational degrees working in the
substance abuse treatment fields who are in recovery.

RECOVERY – A personal process of overcoming the negative impact of a disability despite its
continued presence. Like the victim of a serious accident who undergoes extensive physical
therapy to minimize the impact of damaging injuries, people with active addictions as well as
serious, disabling mental illnesses can also make substantial recovery through symptom
management, psychosocial rehabilitation, other services and supports, and encouragement to
take increasing responsibility for self.

REFERRAL - Establishing a link between a person and another service or support by providing
authorized documentation of the person’s needs and recommendations for treatment, services,
and supports. It includes follow–up in a timely manner consistent with best practice guidelines.

REGISTER – The process of gathering initial data and entering an individual into the service

REVENUES – Money earned through reimbursements paid for covered services or other local
sources, grants, etc.

SA - Substance Abuse

SAPT - Substance Abuse Prevention and Treatment

STATE - means the State of North Carolina.

STATE PLAN - Annual (each fiscal year) updated comprehensive MH/DD/SAS systems reform
plan derived from the systems reform statute and titled “Blueprint for Change”.

STATE PLAN (MEDICAID) - The written agreements between the State of NC and CMS which
describe how the NC DMH/DD/SAS programs meet all CMS requirements for participation in
the Medicaid program and the Children’s Health Insurance Program.

SCREENING/TRIAGE – An abbreviated assessment or series of questions intended to
determine whether the person needs referral to a provider for services based on eligibility
criteria and acuity level. A screening may be done face-to-face or by telephone. Screening is a
core or basic service available to anyone who needs it whether or not they meet criteria for
target or priority populations.

SEAMLESS - Treatment system without gaps or breaks in service, such that persons being
served transition smoothly and with ease from one treatment component to another.

SELF-DETERMINATION – The right to and process of making decisions about one’s own life.

include any type of incident that is clinically undesirable and avoidable. Sentinel events signal
episodes of reduced quality of care. Many organizations monitor medication errors, review of
deaths, accidents, evacuation drill responses, rights violations, medical emergencies, use of
restraint or seclusion, behavior management etc. The purpose of sentinel event monitoring is to
discover root causes and implement a continuous improvement process to prevent further

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SERIOUSLY EMOTIONALLY DISTURBED (SED) – A designation for people less than 18
years of age who, because of their diagnosis, the length of their disability and their level of
functioning, are at the greatest risk for needing services.

SERIOUSLY MENTALLY ILL (SMI) – Refers to adults with a mental illness or disorder that is
described in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, that impairs
or impedes functioning in one or more major areas of living and is unlikely to improve without
treatment, services and/or supports. People with serious mental illness are a target or priority
population for the public mental health system for adults.

SEVERELY AND PERSISTENTLY MENTALLY ILL (SPMI) – Refers to people with a mental
illness or disorder so severe and chronic that it prevents or erodes development of functional
capacities in primary aspects of daily life such as personal hygiene and self care, decision-
making, interpersonal relationships, social transactions, learning and recreational activities.

SERVICE MANAGEMENT – An administrative function that includes Utilization Management
and Care Coordination under this Contract. The service is carried out by experienced
professionals with broad knowledge of the services and programs supported by the public
system, managing a set of services by advocating for access and linking the person to the
services. At the system level, this means activities such as implementing and monitoring a set of
standards for access to services, supports, treatment; making sure that people receive the
appropriate level and intensity of services; management of State facilities’ bed days, making
sure that networks create consumer choice in service providers.

SPECIALIST REVIEW – A consultation or second opinion rendered by a member of the UM
staff when an authorization request falls outside the defined criteria for service selection,
amount or duration.

STANDARD OF CARE – A diagnostic and/or treatment consensus that a clinician should follow
when providing care based upon the discipline’s peer group organization, such as the APA or

STATE MENTAL HEALTH AUTHORITY – The single State agency designated by each State’s
governor to be responsible for the administration of publicly funded mental health programs in
the State. In North Carolina that agency is the Department of Health and Human Services.

SERVICES PLAN – Plan for Mental Health, Developmental Disabilities and Substance Abuse
Services in North Carolina. This Statewide plan forms the basis and framework for MH/DD/SA
services provided across the State.

STATE OR LOCAL CONSUMER ADVOCATE - The individual carrying out the duties of the
State or Local Consumer Advocacy Program Office

SUBSTANCE ABUSE – The DSM IV defines substance abuse as occurring if the person 1)
uses drugs in a dangerous, self defeating, self destructive way and 2) has difficulty controlling
his use even though it is sporadic, and 3) has impaired social and/or occupational functioning all
within a one year period.
GOVERNMENT (SAMHSA) - SAMHSA is an agency of the U.S. Department of Health and

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Human Service. It is the federal umbrella agency of the Center for Substance Abuse Treatment,
Center for Substance Abuse Prevention and the Center for Mental Health Services.

federal program to provide funds to States to enable them to provide substance abuse services.

SUBSTANCE DEPENDENCE - DSM IV defines substance dependence as the presence of
tolerance, withdrawal, and/or continuous, compulsive use of a substance over a 1 year period.

SUBCONTRACT - means any contract between the Contractor and a third party for the
performance of all or a specified part of this Contract. The SUBCONTRACTOR means any third
party engaged by the Contractor, in a manner conforming to the se contract requirements for
the provision of all or a specified part of covered services under this Contract.

SYNAR AMENDMENT – Section 1926 of the Public Health Service, is administered through the
Substance Abuse Prevention and Treatment (SAPT) Block Grant and requires States to
conduct specific activities to reduce youth access to tobacco products. The Secretary of the US
Department of Health and Human Services is required by statute to withhold SAPT Block Grant
funds (40% penalty) from States that fail to comply with the SYNAR Amendment.

TARGET POPULATIONS – Groups of people with disabilities with attributes considered most in
need of the services available within the system; populations as identified in federal block grant
language. NON-TARGET POPULATION are those individuals with less severe disorders that
can be adequately and most cost effectively treated by the private sector, primary physicians or
by using generic community resources.

TRANSITION – The time in which an individual is moving from one life/development stage to
another. Examples are the change from childhood to adolescence, adolescence to adulthood
and adulthood to older adult.

UM - Utilization Management

UNIFORM PORTAL ACCESS - The standardized process and procedures used to ensure
consumer access to, and exit from, public services in accordance with the State Plan.

URAC - National Accreditation Body, includes modules with focus on Health Call Center, Health
Utilization Management and Health Network

UTILIZATION MANAGEMENT (UM) - is a process to regulate the provision of services in
relation to the capacity of the system and needs of consumers. This process should guard
against under-utilization as well as over-utilization of services to assure that the frequency and
type of services fit the needs of consumers. The administration of services or supplies should
meet the following tests: they are appropriate and necessary for the symptoms, diagnosis, or
treatment of the medical condition; they are provided for the diagnosis or direct care and
treatment of the medical condition; they meet the standards of good practice in the service area;
they are not primarily for the convenience of the consumer or a provider; and they are the most
appropriate level which can safely be provided. This function is carried out by professionals
qualified in disciplines related to the care being authorized and requires their use of tools such
as service definitions, level of care criteria, etc.

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UTILIZATION - is the use of services. Utilization is commonly examined in terms of patterns or
rates of use of a single service or type of service. Use is expressed in rates per unit of
population at risk for a given period such as the number of admissions to the hospital per 1,000
persons per year, or the number of services provided per 1,000 persons by a system of care

UTILIZATION REVIEW (UR) - is an analysis of services, through systematic case review, with
the goal of reviewing the extent to which necessary care was provided and unnecessary care
was avoided. The examination of documents and records assures that services that were
authorized were in fact provided in the right amount, duration and scope, within the time frames
allotted; and that consumers benefited from the service. The review also examines whether the
actual request for authorization was valid in its assessment of the consumer and the intensity of
need. There are a variety of types of reviews that may occur concurrently with the care being
provided, retrospectively, or in some cases prospectively if there are questions about the
authorization requested.

WRAP - Wellness Recovery Action Planning. WRAP is an approach to symptom self-
management that emphasizes the five essential components of recovery from mental illness:
hope, education, empowerment, personal responsibility and peer support. In WRAP classes,
each individual learns how to develop a wellness plan as well as recognize and develop a crisis
plan for times when they are not well. WRAP classes are taught by individuals that have
experienced psychiatric symptoms themselves and then received training in WRAP Facilitation.

                                       Page 61 of 89
                                           Chapter 15

                                 Resource Links and Training
                                    Carelink User’s Guide

Resources at the Guilford Center: is the email address for Guilford Center’s e-mail help desk
system for updates, news, forms and general information about Guilford Center is the direct link for provider forms on
Guilford Center’s website will link you to Guilford Center’s resource page,
which includes links to advocacy groups, additional governmental resources, professional
associations and educational websites

Resources at the Division of MH/DD/SAS is the Division of MHDDSAS home page is the direct link to the Announcements
and Communication Bulletins page of the Division’s website is the direct link to
the Implementation Updates on the Division’s website is the link to the provider’s section of the
Division’s website
s%20Manual%20-%20Revisions%2015%20January%20..pdf is a direct link to services definitions for
state funded services on Division’s website

Resources at DMA: is a direct link to clinical coverage policy 8A, which
includes service definitions for enhanced services, found on DMA’s website is the provider’s section of DMA’s website

Other Resources:
    NCTOPPS info can be found at

      NCSNAP info can be found at

Value Options is Value Options’ homepage is the direct link to the provider’s section of
Value Options website

                                        Page 62 of 89 is the direct link to
Value Options network specific section for NC Medicaid


The Guilford Center – visit the Guilford Center website at to obtain
information related to MH/DD/SA training or contact Anne Gable at or
call (336-641-7473).

The UNC-CH School of Social Work Behavioral Healthcare Resource Program is a source of
information for training related to mental health and substance abuse service definitions and person
centered planning (919-843-3018)

The UNC-CH Developmental Disabilities Training Institute (DDTI) provides training for professionals
and paraprofessionals whose primary focus is developmental disabilities (and dual diagnosis of a
developmental disabilities and a mental health issue). (919-966-5463)

The North Carolina Evidence Based Practices Center (NCEBPC) at Southern Regional AHEC is
dedicated to the support of evidence based mental health practices, treatments, and interventions.
They offer training, consultation, and other assistance to help practitioners and administrators make
the changes required by ongoing mental health reforms in North Carolina. (910-678-7305)

Training information is also posted on the North Carolina Division of Mental Health, Developmental
Disabilities and Substance Abuse Services Web site. Go to their website and click on Providers of
MH/DD/SA Services on the left side menu. Then scroll down to “training”. View their Question and
Answer section for good information. They have a conference calendar posted on their website, too.

The North Carolina Area Health Education Center (and local Greensboro
Area Health Education Center are sources of professional healthcare training. (336-

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                                                         RECORD COMPLIANCE AUDIT
                                                                     Attachment A
Provider Name: _________________________________________                                        Client Initials: ___________________
Contract Administrator: __________________________________                                      Record Number: _______________________
Reviewer’s Signature: _____________________________________                                     Date of Review: _______________________

Procedure Code _______________________________         Date of Event _______________      Cost Center _______________     Units Billed _______________

Diagnosis in HSIS __________________________________________________________________             IPRS Populations ________________

                                          COMPLIANCE INDICATOR                                                          YES          NO         NA
   1.  Do the face sheet and emergency information documentation meet requirements (10A NCAC 27g .0206)?
   2.  Does the chart document guardianship (if applicable)?
   3.  Is NCSNAP or NCTOPPS present, if required?
   4.  Does the CCA include summary, diagnosis and service recommendation?
   5.  Does the CCA have several blanks or short answers? (if yes, red flag for clinical review)
   6.  Was the CCA completed prior to the Complete PCP or treatment plan?
   7.  Has the Tx plan been written or goal reviewed within a year of event?
   8.  Are goal target dates no more than 12 months in duration?
   9.  Does an intervention in the Tx plan name the specific service?
   10. Does the agency administer medications? If yes, is MAR available and complete for month audited?
   11. Did client, parent or guardian sign Tx plan before service date or on review date?
   12. Is there a service note for the event billed?
   13. Does the note relate to a current goal in the service plan? (if no, red flag for clinical review)
   14. Does the note reflect the staff intervention? (if no, red flag for clinical review)
   15. Do all paid events during audit period have corresponding service notes?
   16. Is documentation available proving at least one staff currently on site is certified in CPR and First Aid?
   17. Does duration match units billed?
   18. Is the service note signed by the person who delivered the service AND is signature on note identifiable (or
       on signature file) and with degree, licensure or job title?
   19. Is signature of staff within required 7-day timeline for billable late entries? (Chapter 8-1 to 8-5 of
   20. Name the staff member who performed the service.

   21. Does staff providing service have credentials and meet staffing patterns required by service definition?

                                                                  Page 83 of 89
   22. Are Client’s Name and Record Number on all pages?
   23. Are errors properly corrected?

                                                          Page 84 of 89
                                                                STAFF CREDENTIALS AND TRAINING
                                                                                              Attachment B
                                                                                                                                                                                        Revised 8/29/2011
                                                                                    HEALTH                            BLOOD                              CLIENT   AGENCY
                                                               CRIMINAL              CARE                MED          BORNE                 3    FIRST RIGHTS and ORIENTA
              STAFF NAME                         EXCL                                                                                CPR                                                        NCI
                                                                 CHECK             REGISTRY             ADMIN         PATHO                       AID CONFIDENT TION for
                                                                                    CHECK                             GENS2                              IALITY    STAFF

Agency policy requires privileging or credentials? ____________________________

Staff name and whether privileged or credentialed as required by agency policy. Supervision plan for associate professional and paraprofessionals and whether documented according to plan.



  Please see Section 6.e. here: for requirements.
  Required annually
  For CPR and First Aid, see
%20mental%20health%2C%20community%20facilities%20and%20services/subchapter%20g/subchapter%20g%20rules.html section .0202 for requirements
                                                                                          Page 85 of 89
HHS/OIG List of Excluded Individuals/Entities (found at for the Federal Exclusion Check for the Health Registry check

                                                               Page 86 of 89
                                             Attachment C

                   ISSUE                                AUDIT CONSEQUENCE

PCP/CAP Plan not properly signed and/or        Payback for the audit service required to the
deleted by consumer/guardian, QP, etc.         beginning of the fiscal year or to the end of
                                               the previous plan, whichever is later.
 Service not included in PCP or appropriate Payback for the audited service to beginning
service plan, or target dates for goals do not of the fiscal year or the last plan which
cover date of audited event.                   included the service with valid goal target
Problem with a daily periodic service note, Payback for specific event being audited.
such as: intervention not included,
intervention does not match goal in service
plan, signature not included, duration of
service not included, service not named.
Missing daily periodic service note.
Problem with or missing monthly summary Payback for the whole month of services that
note.                                          is supposed to be reported on in the monthly
Problem with or missing quarterly              Payback for the whole quarter of services that
summary note.                                  is supposed to be reported on in the quarterly
All events on EOB do not have                  Payback for missing event or events.
corresponding service notes in the chart.
Issues with or incomplete training/staff       Payback for all events billed by clinician from
credentialing.                                 beginning of fiscal year or expiration of
                                               audited training, whichever is less.
Non-person-centered (canned) service           Payback per period covered by note.
Non-person-centered (canned) PCC or            Payback to beginning of year or treatment
CAP Plan                                       plan date, whichever is later.

Revised 3/9/2008

                                          Page 87 of 89
                       PAYBACK SCHEDULE GUIDELINES
                     For audits of events paid within contract term
                                          Attachment D

First Audit: Payback the first $500 of actual calculated payback, plus 10% of calculated payback
above $500. First audit payback only may be taken from overearnings, if applicable.

Second Audit: Payback the first $500 of actual calculated payback, plus 20% of calculated payback
above $500

Third Audit: Payback the first $500 of actual calculated payback, plus 30% of calculated payback
above $500

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                          Agency IPRS Copay Policy Checksheet
                                             Attachment E

1. Does Agency document application of sliding fee scale?     Yes   No

2. Does Agency document fees collected?                       Yes   No

3. Does Agency document fee expenditure?                      Yes   No

4. Does Agency expend fees to benefit program?                Yes   No

5. Does Agency have written policy and procedures to govern
  IPRS copay requirements?                                    Yes No

6. Does Agency utilize approved fee scale?                    Yes No

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