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					    MH/DD/SA
Provider Operations
      Manual



                         Wake County
       Local Managing Entity
              (LME)
Effective July 1, 2007
Revised 12-01-07
TABLE OF CONTENTS

Introduction                                                                  Page
                   Preface                                                     1
                   Organizational Structure                                    2
                   Wake County Mission, Vision & Guiding Principles            4
                   Wake County Human Services Mission Statement                5
                   Roles of Wake County LME and Providers                      6

Section I          Provider Relations
              1    Technical Assistance and Problem Resolution                 1
              2    Notification of Changes                                     2
              3    List of Contacts                                            3
              4    Provider Application for Non-Medicaid Contracts             6

Section II      State and Federal Requirements
              1 State and Federal Requirements                                 1
              2 NC-TOPPS Users Guide and Frequently Asked Questions            4
              3 Substance Abuse Prevention and Treatment (SAPT) Block          12
                Grants Requirements
              4 MHDDSA Services Eligible For Medicaid Transportation           14
              5 Notice Regarding the False Claims Act and Whistleblower        18
                Protections

Section III     Authorization Process
              1 Referral and Acceptance                                        1
              2 Authorization Policy and Principles                            4
              3 Developmental Disabilities Eligibility and Authorization of    6
                Services
              4 Mental Health and Substance Abuse Authorization                11
                Process
              5 Procedures For Direct Enrolled Behavioral Health               15
                Outpatient Providers
              6 Non-Medicaid Appeal Rights                                     17

Section IV         Claims and Reimbursement
               1   Human Services Fee Policy And Principles                    1
               2   MH/DD/SA Fee Procedure                                      4
               3   Reimbursement Rate Table                                    16
               4   Child Residential Service Codes                             21
               5   General Billing Requirements                                22
               6   Accounting For Time When Providing MH/DD/SA Services        24
               7   Non-Medicaid Claims Submission                              25
               8   Non-Medicaid Timely Filing Requirements                     26
               9   Non-Medicaid Services Payment Processing                    28
              10   Medicaid Payment Processing                                 31
              11   Medicaid Billing Codes Specific To WCHS                     33
              12   Fund Balances, Over-Realized Receipts, & Year End           34
                   Settlement For Contract Providers
             13 Claims & Reimbursement Specific to CAP-MRDD           35

Section V        Provider Documentation Submission Requirements
               1 Required Consumer Record Information                 1
               2 Consumer Record Rules Regarding Adoptions and Name   4
                 Changes
               3 Other Required Medical Record Procedures             6
               4 Consumer Enrollment Procedure                        8
               5 Target Population Eligibility                        10
               6 Transfers                                            12
               7 Discharges                                           14
               8 Child to Adult Transition Planning Guidelines        15
               9 Licensure Rule Waiver Requests                       17

Section VI      Quality Improvement and Performance Monitoring
              1 Best Practices Guidelines                             1
              2 Consumer Rights                                       3
              3 Complaints                                            5
              4 Quality Management and Quality Improvement            9
              5 Incident Review                                       11
              6 Staff Competencies                                    14
              7 Research Conducted Through Wake County                17
              8 Provider Monitoring                                   19
              9 Provider Sanctions                                    23
             10 Appeal of Findings from Monitoring, Complaint         27
                Investigations or Audits
             11 Withdrawal of Endorsement                             29
             12 Consumer Engagement and Empowerment                   30

Section VII       Service Provision Policies and Procedures
              1   Lead Provider                                       1
              2   Person Centered Plan                                3
              3   Psychiatric and Medical Services                    6
            3.1   Medication and Drugs, General Statement             6
            3.2   Prescription and Administration of Medication       7
            3.3   Dispensing, Packaging, Storage and Labeling of      9
                  Medication
            3.4   Psychotropic Medication                             10
            3.5   Medication Education                                13
              4   Medical Emergencies                                 15
              5   Psychiatric Emergencies                             17
              6   Crisis Intervention                                 18
              7   Housing Support Requirements for MH/SA Providers    20
              8   Residential Treatment Requirements for CMH/SA       23
                  Providers

Section VIII      Glossary
                                                     Wake County LME Provider Manual
                                                                           INTRODUCTION

Preface

This manual is a binding part of the contract between Wake County Local
Managing Entity (LME) and providers of state funded MH/DD/SA services, and
the Memorandum of Agreement between Wake County LME and direct
enrolled providers of enhanced MH/DD/SA services funded by Medicaid.

This manual does not include information about DHHS endorsement procedures
that take place prior to any agreement with a Medicaid Provider. Rather, it
includes only information pertinent to the performance of the Agreement or
contract, whichever applies. Each procedure or policy is designated either as
informational only or a requirement. For requirements, the type(s) of provider it
pertains to is indicated at the top of the page in the information box.

Section
1. Name of Policy or Procedure
Effective Date: specified here                 Version Date: indicates latest change date
 Informational Only       Requirement         Reference: to State/Fed regulations or statutes
Defines content of the section
Requirement Applies to Provider Type:
   Medicaid Basic Svc (Direct Enrolled)           CAP/MRDD
   Medicaid Basic Svc (Not Direct Enrolled)       Cat. A Licensed Facilities
   Medicaid Enhanced Svc                          Cat. B Comm Based Providers
   Non-Medicaid Contracted Svcs                   Cat. C Institutions/Facilities
   ICF-MR                                         Cat. D Lic/Cert. Outpatient/Day Svcs

Provider Types are defined as follows:

Medicaid Basic Svc – Provider of Medicaid Basic Services (outpatient) enrolled
with DMA.
Medicaid Enhanced Svc – Provider of Medicaid MHDDSA Services other than
outpatient services. These require endorsement and DMA enrollment.
Non-Medicaid Contracted Svcs – Providers who have a contract with Wake
County LME to provide Non-Medicaid services, also known as IPRS services.
ICF-MR – Intermediate Care Facility for persons with Mental Retardation
CAP/MRDD – Medicaid waiver Community Alternatives Program for persons with
Mental Retardation or Developmental Disabilities.
Cat. A Licensed Facilities - facilities licensed pursuant to G.S. 122C, Article 2, except
for hospitals; these include 24-hour residential facilities, day treatment and outpatient
services.
Cat. B Comm Based Providers - community-based providers not requiring State
licensure, including, but not limited, to CAP-MR/DD service providers and homes for one
adult.
Cat. C Institutions/Facilities - hospitals, state-operated facilities, nursing
homes, and adult care homes/family care homes that don‘t require licensure
under G.S. 122-C.
Cat. D Lic/Cert. Outpatient/Day Svcs – individuals providing only outpatient or day
services and are licensed or certified to practice in the State of North Carolina.


                                  Introduction – Page 1
                                                          Wake County LME Provider Manual
                                                                               INTRODUCTION



     Introduction
     1. Organizational Structure
     Effective Date: July 1, 2005                   Version Date: 7/1/07
      Informational Only Requirement              Reference:

     Wake County Human Services:
                                          Wake County
                                          Government


                                              Wake
                                             County
                                             Human
                                            Services
                                            (WCHS)




Administration       Compliance/         Project Mgmt           Community                WCHS Local
  Service            Credentials/              &                 Affairs &              Managing Entity
  Divisions          Accreditation       Development           Communication              (LME) for
& Operations                                                                              MH/DD/SA
                                                                                           Services


                                  Wake County Human Services

     Wake County Human Services is the consolidation of programs and services formerly
     carried out by several separate departments and offices: Social Services, Public Health,
     Mental Health/Developmental Disabilities/Substance Abuse (MH/DD/SA) services, Job
     Services, Child Welfare, Housing, and Transportation.

                             Wake County Local Management Entity

     Wake County‘s Local Managing Entity (LME) has overall responsibility for
     conceptualizing, developing and managing clinical and programmatic aspects of the
     publicly funded MH/DD/SA services system. Wake County LME functions include
     screening, triage and referral, 24/7 facility-based crisis services, care coordination,
     utilization review and management, quality management, provider and community
     development, consumer rights and claims processing and payment.




                                      Introduction – Page 2
                                                                                           Wake County LME Provider Manual
                                                                                                                               INTRODUCTION


Wake LME Organizational Chart

            WCHS
            Board

                                                                David Cooke
                                                               County Manager
                                       Joe Durham
        David Filipowski
                                      Deputy County
         Board Chair
                                        Manager
                                                               Ramon Rojano
                                                               Director WCHS
                                                               & Area Authority

                     LME Oversight

                                                                                                                   Director Project       Community Affairs
                                                                    Medical                  Director of
                                                                                                                  Management and               And
                                                                    Director                Administration
                   Wake County LME                                                                                  Developmemt            Communications




                                                                   Tim Isley
                     Crystal Farrow                                                       Marianne Iavarone
                                                                Physician, Chief
                     Director, LME                                                         Financial Offier
                                                                 of Psychiatry



                                             Deborah Andrews
Chris Wassmuth
                                                Executive
CIT Coordinator
                                                Assistant


     Vacant
EBP Coordinator
Sr. Psychologist



                                                           Greta Gill                                         Miki Jaeger
 Willie Sanders            Tammy Strickland                                            Larry Fuller                                   Patricia Coleman
                                                       Child Residential /                                      Quality
 Access / Crisis           Care Coordination                                       Utilization REview                                   Operations
                                                        System of Care                                        Management



    Screening,                                                                                    Jeff Hildreth
                               Adult Care              Carlyle Johnson
      Triage                                                                                      DD Services
                              Coordination            Adult Mental Health
   And Referral                                                                                     Director



                                                         Sandy Mangum
      Crisis                   Child Care
                                                           Executive
     Services                 Coordination
                                                           Secretary



                                Geriatric                 Beth Nelson
                             Speciality Team             Child MH / SA




                                                        DeDe Severino
                                                          Adult SA




                                                      Introduction – Page 3
                                                  Wake County LME Provider Manual
                                                                       INTRODUCTION




Introduction
2. Wake County Mission, Vision & Guiding Principles
Effective Date: February 1, 2001            Version Date: N/A
 Informational Only Requirement           Reference:

                              Wake County’s Mission

    To ensure the delivery of quality public services and to improve the economic,
educational, social, and physical quality of the community, we are committed to service
 excellence and embrace new approaches to more effectively and efficiently meet the
                        ever-changing needs of our customers.

                                        Vision

           Wake County will be a great place to live, work, learn, and play.

   It will be a place where people are self-sufficient, enrich their lives, respect
nature, appreciate their heritage, participate in government, and plan for a better
                                    tomorrow.


                            Values / Guiding Principles

                                  Customer Service

                                      Teamwork

                            Professionalism and Integrity

                                      Openness

                                     Leadership

                             Continuous Improvement




                              Introduction – Page 4
                                                    Wake County LME Provider Manual
                                                                          INTRODUCTION


Introduction
3. Wake County Human Services Mission Statement
Effective Date: February 1, 2001               Version Date: 07/01/07
 Informational Only Requirement              Reference:

Mission Statement
Wake County Human Services in partnership with the community will anticipate and
respond to the public health, behavioral health and the economic and social needs of
Wake County residents. We will coordinate and sustain efforts that assure safety,
equity, access and well-being for all.

Outcomes

   1.  Women and families will have healthy, planned births.
   2.  Families will support their children‘s successful development.
   3.  Children will be ready for school.
   4.  Children and youth will be successful in school.
   5.  Children and vulnerable adults will not experience abuse or neglect.
   6.  Youth will make healthy decisions.
   7.  Children removed from their parents will have a permanent home.
   8.  The elderly and individuals with severe, chronic disabilities will live as
       independently as possible.
   9. Parents will financially and medically support their minor children.
   10. People will find and maintain employment.
   11. People will have safe, affordable housing.
   12. Individuals, families, and communities will have improved physical and
       behavioral health.




                                Introduction – Page 5
                                                        Wake County LME Provider Manual
                                                                               INTRODUCTION


Introduction
4. Roles of Wake County LME and Providers
Effective Date: July 1, 2004                      Version Date: 7/1/06
Informational Only  Requirement                 Reference:
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)              CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)         Cat. A Licensed Facilities
 Medicaid Enhanced Svc                            Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                    Cat. C Institutions/Facilities
 ICF-MR                                          Cat. D Lic/Cert. Outpatient/Day Svcs

A. Role of Wake County LME

In its role as assuror, Wake County LME commits to the following:
1. Promoting the inclusion and integration of persons with disabilities in the community;
2. Ensuring services are of high quality, are delivered in a culturally competent manner
     and positively influence consumer outcomes;
3. Providing leadership, with community partners, in the development of a
     comprehensive, accessible system of care;
4. Creating mechanisms to ensure financial feasibility for providers to implement
     evidence-based and best practice services;
5. Funding and prioritization of Wake County residents in need of MHDDSA services,
     within available funding limits;
6. Providing eligibility determination and service referral for all DD consumers through
     the Single Portal process, and oversight of the process for consumers of MH and SA
     services;
7. Ensuring that consumers and families are educated and aware of their choices
     regarding service provision, including types of treatment as well as providers;
8. Providing utilization review to ensure the use of the most appropriate, least restrictive
     services;
9. Ensuring the most efficient and effective use of public funds; and,
10. Conducting needs assessment, at both individual and community levels.

B. Role of Providers

In partnership with Wake County LME, the Providers‘ roles in the provision of services
include:
1. Providing services within standards of best practice and funding requirements;
2. Promoting the inclusion and integration of persons with disabilities in the community;
3. Developing and implementing individualized goals and strategies, in coordination
    with a Person Centered Plan;
4. Promoting the development of natural supports for the consumer;
5. Continual assessing and reviewing of consumer progress and appropriateness of
    goals, and making adjustments to services in response to changes;
6. Managing agency operations to produce efficient and effective services; and
7. Participating in quality improvement activities and making changes accordingly.




                                     Introduction – Page 6
                                                     Wake County LME Provider Manual 2008
                                                                               SECTION I




SECTION I Provider Relations
1. Technical Assistance and Problem Resolution
Effective Date: January 1, 2006                    Version Date: 11/01/08
Informational Only  Requirement                  Reference:
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)               CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)          Cat. A Licensed Facilities
 Medicaid Enhanced Svc                             Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                      Cat. C Institutions/Facilities
ICF-MR
                                                    Cat. D Lic/Cert. Outpatient/Day Svcs

Technical Assistance:
The LME will offer training and technical assistance regarding the provision of publicly
funded MH/DD/SA services for the residents of Wake County.

The LME has the right to charge the usual and customary fee for additional staff
attendance or scheduling additional trainings to meet Provider demand. The LME shall
also mandate Provider attendance at selected Clinical Sessions of which the Provider
bears the cost, whether LME sponsored or offered by outside Parties. The Provider shall
also bear the cost of all trainings related to licensure or accreditation activities. The
Provider must be able to demonstrate to the LME its application of training information.

The LME is not required to provide any technical assistance that would be considered a
normal operational procedure of a service provider. The LME is not required to provide
technical assistance to a provider who has not assimilated previous technical assistance
into its provider infrastructure.

Problem Resolution/Disputes and Appeals:

If problems arise between the Provider and the LME in the delivery of services, the
parties shall attempt whenever possible to resolve these problems informally in a
reasonable and timely manner.

The Provider agrees to notify the appropriate Wake County LME Provider Community
Development Team (PCDT) Services Director within ten (10) business days should a
contract disagreement arise between the Provider and Wake County LME. A meeting
between the Services Director (or designee) and the Provider shall be arranged. Should
this meeting not resolve the disagreement, then the Director of the LME (or designee)
and the Provider shall attempt to resolve the disagreement. Should the disagreement
still not be resolved, the issue will be referred to the Director of Wake County Human
Services for further attempts to resolve the disagreement.

In the event that informal resolution is not appropriate or is unsuccessful, the process
outlined in GS 122C-151.4 shall be followed.




                                        Section I - Page 1
                                                     Wake County LME Provider Manual 2008
                                                                               SECTION I


SECTION I Provider Relations
2. Notification of Changes
Effective Date: July 1, 2004                       Version Date: 07/01/07
Informational Only  Requirement                  Reference:
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)               CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)          Cat. A Licensed Facilities
 Medicaid Enhanced Svc                             Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                      Cat. C Institutions/Facilities
 ICF-MR
                                                    Cat. D Lic/Cert. Outpatient/Day Svcs

Medicaid Providers – shall notify DMA of changes of address using DMA Forms
found at: www.dhhs.state.nc.us/dma/form.

All Providers shall notify Wake County Human Services Contracts Management
(see Section I.3 List of Contacts for staff name/address) within twenty-four (24)
hours of:
1. Any changes in ownership, including mergers, or business address.
2. Any changes in the name, address, e-mail address or telephone numbers of
    the primary agency contact person(s).
3. Any legal or governmental action initiated against the Agency, including but
    not limited to an action: (1) for negligence, (2) for violation of law, or (3)
    against any license, certification or accreditation, which if successful, might
    impair the ability of the Provider to carry out the duties and obligations
    assumed under this contract.
4. Insolvency or pending bankruptcy by the Provider.
5. Any other condition or occurrence that might impair the ability of the Provider
    to carry out the duties and obligations assumed under this contract.
6. Any changes in location of service records shall be made in writing to Wake
    County Human Services. This mandate shall survive the terms of the
    contract.
7. When discontinuing providing a category of service, when it involves
    discharging or transferring Wake County consumers.




                                        Section I - Page 2
                                                   Wake County LME Provider Manual 2008
                                                                             SECTION I


SECTION I Provider Relations
3. List of Contacts
Effective Date: July 1, 2004                      Version Date: 07/01/07
 Informational Only Requirement                 Reference:

WAKE COUNTY LME Directory

 Area Authority/Human Services
                                  Ramon Rojano            919-212-7302     rrojano@co.wake.nc.us
 Director
                                  Carmen Vazquez-                          Carmen.Vazquez@co.wake.
    Administrative Assistant                              919-212-7302
                                                                           nc.us
                                  Hankerson

 LME Director                     Crystal Farrow          919-250-3100     cfarrow@co.wake.nc.us

                                                                           Deborah.andrews@co.wake
    Administrative Assistant      Deborah Andrews         919-250-3152
                                                                           .nc.us
 Provider and Community Development Team
    Consultants to providers and LME staff
    Management of the Purchase of Service budget(s)
    Community collaboration projects
    Provider recruitment and endorsement
    System planning and conceptualization
      CPAC and CFAC support
     Adult Mental Health           Carlyle Johnson   919-250-3123          cjohnson@co.wake.nc.us

    Adult Substance Abuse         DeDe Severino           919-250-1534     dede.severino@co.wake.nc.
                                                                           us
    Developmental Disabilities    Jeff Hildreth           919-857-9108     jhildreth@co.wake.nc.us

    Child Mental Health and
    Substance Abuse
       Outpatient Services       Beth Nelson             919-212-8452     enelson@co.wake.nc.us
       System of Care
          Implementation, Child   Greta Gill              919-212-9494     ggill@co.wake.nc.us
          Residential Treatment
          Services
 Screening, Triage and Referral   Willie Sanders          919-250-3137     wasanders@co.wake.nc.us
    Phone screening and
      referral
    Walk-In screening, triage
      and referral
    Full assessments as
      needed including
      scheduled assessments
    Crisis intervention
      treatment services as
      needed
    Eligibility determination




                                  Section I - Page 3
                                                        Wake County LME Provider Manual 2008
                                                                                  SECTION I

Quality Management                      Miki Jaeger           919-856-5646   miki.jaeger@co.wake.nc.us
         Monitors services of licensed and non-licensed providers
         Receives and reviews incident reports
         Provides endorsement reviews
         Assists in complaint mediation
         Letters of support for residential services

      Administrative Assistant          Delilah Pearce        919-856-6508   Delilah.pearce@co.wake.nc.
                                                                             us
Care Coordination                       Tammy Strickland      919-212-8356   tstrickland@co.wake.nc.us
Engage – Stabilize – Motivate – Link
   Adult and Child Care Coordination Teams for consumers transitioning from hospitals and
     residential settings to outpatient providers;
   Crisis response for on-site assessments;
   Crisis stabilization (non-residential);
   Clinical quality of care for high utilizers of services;
   Intensive case management (for consumers who cannot find a clinical home in 1-2 weeks);
   Rapid Response – disasters, Critical incident Stress Debriefing (CISD);
   Outreach; brief therapy for non-target populations
   Person Centered Plan reviews

      Administrative Assistant          Michele Crenshaw      919-250-1076   Michele.Crenshaw@co.wak
                                                                             e.nc.us
      Child Care Coordination           Vickie Boviall        919-212-8386   vboviall@co.wake.nc.us
      Adult Care Coordination           Stephanie Williams    919-250-4498   sfwilliams@co.wake.nc.us
Utilization Review                      Larry Fuller          919-250-3120   Larryfuller@co.wake.nc.us
          Authorization and re-authorization of IPRS-funded MH/SA services.
          Consultation with service providers
          Consumer advocates regarding level of care criteria
          Post payment reviews.
Operations Support                      Patricia Coleman      919-212-9296   Patricia.coleman@co.wake.
                                                                             nc.us
         Administrative processing of authorizations
         Fee Application verification
         Budget management support
         State IPRS and CDW reporting

  Data Support Specialist-MHSA          Stacy Salva           919-212-8407   stacy.salva@co.wake.nc.us
  Data Support Specialist-MHSA          Candis Alston         919-212-9329   calston@co.wake.nc.us
  Data Support Specialist-MHSA          Paula Snelling        919-250-3158   psnelling@co.wake.nc.us
  Data Support Specialist-MHSA          Vacant                919-212-8420
  Data Support Specialist-MHSA          Lourie Craver         919-250-1272   lcraver@co.wake.nc.us
  Data Support Specialist-DD            Mary Anne             919-857-9383   mbaltazar@co.wake.nc.us
                                        Baltazar
  Data Support Specialist-DD            Sandra Conrad         919-856-6453   Sandra.conrad@co.wake.nc
                                                                             .us
Contracts Management
Assists providers with contract         Phil Goerger          919-212-0490   pgoerger@co.wake.nc.us
process                                 Eric Thanos           919-212-0489   eric.thanos@co.wake.nc.us
Service Billing and Payment
Billing Accounts Receivable             Alice Wilkerson       919-212-7817   awilkerson@co.wake.nc.us
Accounts Payable                        Kathy Watson          919-250-1146   kwatson@co.wake.nc.us




                                       Section I - Page 4
                                                Wake County LME Provider Manual 2008
                                                                          SECTION I



Other Contacts:

 Name             Resource                 Phone #        Email Address
 Brian Gunter     Consumer Affairs         919-212-7155   bkgunter@co.wake.nc.us
 Dena Hansley     Consumer Records         919-212-7038   Dena.Hansley@co.wake.nc.us

 Tim Wildfire     Information System       919-212-7938   tim.wildfire@co.wake.nc.us
                  Business Consultant
 EPSDT            MHSA- Larry Fuller       919-250-3120    Larryfuller@co.wake.nc.us
                  DD-Patti Beardsley       919-857-9111   pbeardsley@co.wake.nc.us

Addresses:

All Non-Medicaid Billing Submission
       Attn: Alice O. Wilkerson, Billing Unit
       WCHS
       23 Sunnybrook Rd Suite 169
       Raleigh, NC 27610

Medicaid Claims Submission AND
Medicaid and Non-Medicaid Claims Processing/Payment:
      Attn: Cynthia Henderson, Accounts Payable
      WCHS
      23 Sunnybrook Rd Suite 169
      Raleigh, NC 27610


MH/SA Authorization & Consumer Enrollment
     Attn: Data Support Specialists
     WCHS LME
     3010 Falstaff Rd
     Raleigh, NC 27610
     Fax: 919-250-3761

DD Authorization and Consumer Records
      Attn: (Staff or Dept. Name)
      WCHS LME Development Disabilities
      401 E. Whitaker Mill Rd.
      Raleigh, NC 27608




                                   Section I - Page 5
                                                     Wake County LME Provider Manual 2008
                                                                               SECTION I


SECTION 1 Provider Relations
4. Provider Application for Non-Medicaid Contracts
Effective Date: 11/1/07                   Version Date: 11/1/07
Informational Only  Requirement         Reference:
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)               CAP/MRDD
Medicaid Basic Svc (Not Direct Enrolled)           Cat. A Licensed Facilities
Medicaid Enhanced Svc                              Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                      Cat. C Institutions/Facilities
ICF-MR                                             Cat. D Lic/Cert. Outpatient/Day Svcs


Purpose: To describe the process by which providers apply for a new contract or
expansion of scope of an existing contract with the Wake County Local Managing Entity
to receive state and county-funded (Non-Medicaid) services. Requests for Non-
Medicaid contracts will be considered based upon the LME‘s assessment of community
needs and capacity, as well as availability of funds.

Procedure:

    1. Provider must first be endorsed (if it is an enhanced service) and direct enrolled
       with Medicaid (both basic and enhanced services) if the service is to be billed
       through IPRS. This does not apply to IPRS-only services, such as Developmental
       Therapy.
    2. Provider should contact the appropriate Provider Community Development Team
       (PCDT) Service Director(s) to request contract for specific services with specific
       age/disabilities. (See Section 1.3 List of Contacts)
    3. PCDT will review each request as a team in order to coordinate efforts for different
       age/disability groups.
    4. Evaluation of requests for non-Medicaid contracts will consider current capacity
       and network service needs, provider experience with specific populations and
       services, and provider references and monitoring history (including Wake LME‘s
       experience with provider, feedback from other LMEs, history of complaints and
       sanctions, and other sources of information).
    5. PCDT Service Director(s) or their designee will meet with the provider and
       conduct a site visit.
    6. PCDT Service Director(s) or their designee will recommend contract initiation or
       deny the request and offer technical assistance to the provider.




                                        Section I - Page 6
                                                     Wake County LME Provider Manual 2008
                                                                               SECTION II


SECTION II Requirements
1. State and Federal Requirements
Effective Date: July 1, 2005                       Version Date: 7/01/07
Informational Only  Requirement                  Reference:
Requirement Applies to Provider Type:
 Medicaid Basic Svc (Direct Enrolled)             CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)         Cat. A Licensed Facilities
Medicaid Enhanced Svc                             Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                     Cat. C Institutions/Facilities
 ICF-MR
                                                    Cat. D Lic/Cert. Outpatient/Day Svcs

The following information includes rules, regulations, standards, and other
information pertinent to Providers of MH/DD/SA services. These documents
change based on legislative action, change in federal and state policy, and state
procedures. The Providers should routinely check these items for updates on
requirements. If a Provider has problems obtaining or understanding the
information referenced in this section, they should contact the appropriate PCDT
Services Director (see List of Contacts).

State web links for Providers of MH/DD/SA Services:

General Rules for MHDDSAS
http://www.ncdhhs.gov/mhddsas/statspublications/manualsforms/aps/apsm30-01-6-
06.pdf

Confidentiality Rules
http://www.ncdhhs.gov/mhddsas/statspublications/manualsforms/aps/apsm45-
1confidentialityrules1-1-05total.pdf

Client Rights Rules
http://www.dhhs.state.nc.us/mhddsas/statspublications/manualsforms/aps/apsm95-
2clrights7-03.pdf

Service Records Manual
http://www.dhhs.state.nc.us/mhddsas/statspublications/manualsforms/aps/apsm-45-
2servrecord9-03.pdf

Incident and Death Response System
State Memo 2.9.06
http://www.dhhs.state.nc.us/mhddsas/statspublications/manualsforms/incidentdeathrepo
rtformchanges2-9-06memo.pdf

Guidelines
http://www.dhhs.state.nc.us/mhddsas/statspublications/manualsforms/dhhs-incident11-
18-04manual-total.pdf

QM02 guidelines


                                       Section II - Page 1
                                                        Wake County LME Provider Manual 2008
                                                                                  SECTION II

     http://www.dhhs.state.nc.us/mhddsas/statspublications/manualsforms/incidentreportingc
     hanges-dhhsreportqm02rev1-06.pdf

     QM02 form
     http://www.dhhs.state.nc.us/mhddsas/statspublications/manualsforms/forms/dhhsinciden
     tdeathreport-formqm02-rev3-8-06.dot\

     QM11 Provider Quarterly Incidents Report
     http://www.dhhs.state.nc.us/mhddsas/statspublications/manualsforms/forms/providerqtrr
     eport-formqmQM11rev1-06.doc

     CAP/MR
     http://www.dhhs.state.nc.us/mhddsas/cap-mrdd/operations/index.htm


     If no web access, for State documents contact:
     Mail Service Center, 3015
     Raleigh, NC 27699
     (919) 715-1294

REQUIREMENT                                             SUGGESTED              WEB SITE
Federal level                                           ACCESS
                                                                               http://www.dol.gov/elaws/dr
Drug Free Workplace Act of 1988 as revised              Library-Federal Laws   ugfree.htm

Section 503 and 504 of the Rehabilitation Act of 1973   Library-Federal Laws   http://www.dol.gov/dol/com
                                                                               pliance/compliance-
                                                                               majorlaw.htm#eeo
                                                                               www.eeoc.gov
Civil Rights Act of 1964                                                       http://www.eeoc.gov/policy/
                                                        Library-Federal Laws   vii.html

Non-Profit Agencies-Conflict of Interest 1993 Session
Laws: Chapter 321, Section 16                           Library-Federal Laws   www.dol.gov
                                                                               http://thomas.loc.gov/bss/d
Public Law 99-319, May 1986                             Library-Federal Laws   099/d099laws.html
Protection and Advocacy for Mentally Ill Persons                               Search for 99-320
 Title I Protection and Advocacy Systems                                      http://www4.law.cornell.edu
 Title II ReinStatement of Rights for Mental Health                           /uscode/42/ch114.html
    patients
                                                                               http://thomas.loc.gov/bss/d
Public Law 100-509 Protection & Advocacy for            Library-Federal Laws   100/d100laws.html
Mentally Ill                                                                   Search for 100-509
                                                                               http://www.oxfordhouse.org
Individual Amendments Act of 1988, October 1988                                /fairhouse.html
                                                                               http://thomas.loc.gov/bss/d
Public Law 101– 496 Developmental Disabilities                                 101/d101laws.html
Assistance and Bill of Rights Act of 1990               Library-Federal Laws   Search for 101-496
42 CFR Part 2 Confidentiality Regulations                                      Federal Regulations
45 CFR Part 160 & 164 HIPAA Standards for               Library-Federal Laws   search:
Privacy of Health Information                                                  http://www.gpoaccess.gov/c
                                                                               fr/index.html




                                         Section II - Page 2
                                                        Wake County LME Provider Manual 2008
                                                                                  SECTION II

Office of the Inspector General (Exclusions – ―Lower-   Library-Federal Laws   http://oig.hhs.gov/fraud/excl
tier Transactions and disbarment‖)                                             usions.html
Pro-children Act                                        Library-Federal Laws   http://www.ed.gov/legislatio
Section 1041-1044 of the Educate America Act of                                n/GOALS2000/TheAct/intro
1994 prohibiting smoking in areas used by children.                            .html
Americans with Disabilities Act                         Library-Federal Laws   http://www.usdoj.gov/crt/ad
                                                                               a/adahom1.htm

Other
North Carolina Council of Community MH/DD/SAS                                  www.nc-council.org
Programs

Wake County Human Services & LME
Wake County LME Website                                                        http://www.wakegov.com
                                                                               /humanservices/lme/defa
                                                                               ult.htm
Local Business Plan                                                            Go to Wake County LME
                                                                               website and link to Local
                                                                               Business Plan
Services Index                                                                 http://68.236.68.112/ly/wak
                                                                               ectysid/defaultindex.htm
Smartworks – for accessing WCHS forms                                          http://www.smartworks.c
  1. From website, click on the ―Login‖ link                                   om/
  2. In the login page, type the Username:
      WCPROVIDER and Password ―forms‖



    NOTE: Web addresses are subject to change.




                                         Section II - Page 3
                                                     Wake County LME Provider Manual 2008
                                                                               SECTION II



SECTION II Requirements
2. NC-TOPPS Users Guide and Frequently Asked Questions
Effective Date: 11/01/07                           Version Date: 11/01/07
Informational Only  Requirement                  Reference:
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)              CAP/MRDD
Medicaid Basic Svc (Not Direct Enrolled)          Cat. A Licensed Facilities
 Medicaid Enhanced Svc                            Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                     Cat. C Institutions/Facilities
ICF-MR                                             Cat. D Lic/Cert. Outpatient/Day Svcs

PURPOSE: To provide information on how and when the State-mandated NC-TOPPS
form must be completed.

FREQUENTLY ASKED QUESTIONS


1.       For which clients is an NC-TOPPS Assessment required?

NC-TOPPS Interviews are required for 100% of consumers ages 6 and above who have:
        Been formally admitted to the LME by having an open record with a unique LME-
         assigned Consumer Record Number and
        Begun receiving mental health and/or substance abuse services from a publicly
         funded source (such as State funds, Medicaid funds, Health Choice, etc.). See
         Section V for details.
Further requirements and exclusions are noted below. Any LME or provider agency
interested in using NC-TOPPS for consumers not in the required populations will need to
contact Kathryn Long or Jaclyn Johnson (see NC-TOPPS Contacts, Section XI).

               Consumers Receiving Only Medicaid-Funded Services
NC-TOPPS Interviews are required for all adults and children ages 6 years and above
who are receiving:
    community support services (8 hours unmanaged and all managed) or
    other Medicaid managed services (i.e. services requiring prior authorization) for any
     mental health and/or substance abuse issues.
NC-TOPPS Interviews are not required for consumers receiving only:
    Crisis services (mobile crisis, 24-hour crisis bed, facility-based crisis program or
     respite)
    Detoxification services
    Psychiatric inpatient services
    Developmental disability services and supports
    Unmanaged outpatient therapy and/or medication management (8 visits for adults;
     26 visits for children)



                                       Section II - Page 4
                                                  Wake County LME Provider Manual 2008
                                                                            SECTION II


  Consumers Receiving Services Funded Through IPRS Only or Both IPRS and
                                      Medicaid
NC-TOPPS Interviews are required for all adults and children ages 6 years and above
who are enrolled in an IPRS target population and receiving:
    any mental health and/or substance abuse services or
    outpatient therapy and/or medication management services, if enrolled in IPRS
     target populations other than AMSRE.
NC-TOPPS Interviews are not required for consumers enrolled only in one or more of
the following IPRS target populations:
    Adult MH Stable Recovery Population (AMSRE)
    Crisis Services Populations (AMCS, ASCS, CMCS, CSCS)
    Assessment Only Populations (AMAO, ASAO, CMAO, CSAO)
    Substance Abuse Prevention Populations (CSIP, CSSP)
    Developmental Disability Populations (All populations beginning with AD or CD)
In addition, NC-TOPPS Interviews are not required for consumers receiving only one or
more of the following services, regardless of target population membership:
    Crisis services (mobile crisis, 24-hour crisis bed, facility-based crisis program or
     respite)
    Detoxification services
    Psychiatric inpatient hospitalization services

   Consumers Receiving Developmental Disability (DD) Services and Supports
Consumers who receive DD services and supports as well as MH and/or SA services
require a NC-TOPPS only when the services are predominantly either MH or SA. The
LME will determine whether the NC-TOPPS is appropriate for each MH/DD or SA/DD
consumer. (See Section VIII for more information.) Consumers in the Mental
Retardation/Mental Illness (ADMRI) target population are not required to have NC-
TOPPS Interviews.
NOTE: The Developmental Disability Consumer Outcomes Inventory (DD-COI) was
discontinued, as of April 1, 2007 and is no longer required for any consumer. The
Mental Health and Substance Abuse COI (MH/SA-COI) and Early Intervention COI (EI-
COI) were discontinued previously.
Source: NC-TOPPS SFY 2007 – 2008 IMPLEMENTATION GUIDELINES
FOR SUBSTANCE ABUSE AND MENTAL HEALTH CONSUMERS, Version 4.0, Effective July 1,
2007


2.      Who should complete the NC-TOPPS?

Only one set of NC-TOPPS Interviews is completed for each consumer during a
particular episode of care. However, NC-TOPPS Interviews should capture all
services a consumer receives during an episode of care. If the consumer is being
treated by multiple provider agencies, the QP from the clinical home who is
responsible for the consumer‘s PCP is also responsible for ensuring that all
involved provider agencies are consulted and informed when completing NC-


                                    Section II - Page 5
                                                Wake County LME Provider Manual 2008
                                                                          SECTION II

TOPPS Interviews. If the consumer signs a consent for sharing the NC-TOPPS
information with other provider agencies involved in his or her care, the clinical
home QP is responsible for providing those other provider agencies with copies
of the NC-TOPPS Interviews.
For Mental Health clients, the WCHS ―Lead Provider‖ should complete the NC-TOPPS.
This is the same agency that is responsible for coordinating the Unified Service Plan.
The WCHS Provider Manual defines the Lead Provider as follows:

Lead Provider (Clinical Home) Responsibilities: When multiple referrals are made at
Intake/Evaluation, or if additional services are later accessed by the initial service
provider, the designated lead provider (aka Clinical Home) is responsible for the
development of a Person Centered Plan. The following hierarchy will determine which
provider is designated as the lead provider with responsibility for the on-going
coordination, implementation, monitoring and updates of the plan:

1. Community Support Provider, or other ―Clinical Home‖ (eg. ACTT, Community
   Support Team)
2. Intensive In-Home, MST
3. Therapist, for consumers without community support or other ―clinical home‖
4. Residential provider
5. Day program provider (PSR, Day Treatment, PH, SAIOP, SACOT)
6. Any remaining provider

In special situations, lead provider responsibility can be negotiated amongst the
consumer‘s providers.

Communication amongst service providers in completing the NC-TOPPS is encouraged.


3.   What happens when a client’s “lead agency” or clinican changes during a
WCHS treatment episode?

When the consumer‘s clinical home changes, the QP at the current clinical home must
complete a Transfer Interview and the QP at the new clinical home must complete a new
Initial Interview. This allows a provider agency to evaluate the outcomes for the
individuals it has served.

4.     What Client ID do I use for WCHS clients?

Use the six digit Wake County client ID. NC-TOPPS will not accept dashes, so fill in the
client ID as follows:

Wake County Client ID         NC-TOPPS Client ID
11-22-33                      112233
01-02-03                      010203

5.     What does my agency have to do about privacy notices and consents?

NC-TOPPS falls under the ―audit or evaluation exception‖ of the federal laws cited
above. This clause allows collection and sharing of consumer-identifying information with


                                 Section II - Page 6
                                                Wake County LME Provider Manual 2008
                                                                          SECTION II

state or local government agencies for the purpose of evaluating the quality and
effectiveness of services. Consumers must be informed of this by including NC-TOPPS
on the Notice of Privacy to consumers in accordance with HIPAA regulations.

For consumers with multiple provider agencies, the consumer must also specifically
consent for the provider agency to share NC-TOPPS information with other provider
agencies serving the consumer before the provider agency can send any NC-TOPPS
information to those provider agencies.

The Division cannot ―redisclose‖ to the consumer‘s LME any information that the Division
receives from the provider agency which identifies an individual as a substance abuse
consumer, until the substance abuse consumer signs a written consent form. Therefore,
the provider agency must request the consumer to sign a consent form authorizing
redisclosure of their identifying information from:
      The Division to the consumer‘s LME
      The clinical home provider agency to each other provider agencies serving the
        consumer
If the consumer signs a consent, the Division will share individual-identifying information
with the consumer‘s LME in accordance with 42 CFR, Part 2, HIPAA and NC Statute. If
the consumer does not consent, the Division will not share any information identifying
the individual as a substance abuse consumer with the LME.

The clinical home provider agency may only share consumer-identifying information with
those provider agencies explicitly named on the signed consent form.
The consent form must be renewed at least annually. An example of a consent form can
be found on the NC-TOPPS website at
https://nctopps.ncdmh.net/ci0708/ConsentExample.pdf

Source: NC-TOPPS SFY 2007 – 2008 IMPLEMENTATION GUIDELINES
FOR SUBSTANCE ABUSE AND MENTAL HEALTH CONSUMERS, Version 4.0, Effective July 1,
2007

6.     Is it required to print the NC-TOPPS assessment and place it in consumer's
chart?

Yes

7.    When will I get notification that a 3 month, 6 month, 12 month, or other 6
month update is due for a consumer?

The tracking system, which is located on your main menu page in the top right corner
named 'Updates Needed', is set up to notify the clinician 2 weeks prior to an Update
being due.




                                  Section II - Page 7
                                                      Wake County LME Provider Manual 2008
                                                                                SECTION II

8.      What codes are used to enroll a clinician?
The following table lists the codes to be used to enroll a Mental Health clinician in NC-
TOPPS:

NC-TOPPS Clinician                WCHS Contract Provider              WCHS Internal Provider-
Enrollment Data Item                                                  Support staff will enroll
                                                                      Internal clinicians
Clinician ID                      Assign your own Clinician ID's      Please use your four digit
                                  Each clinician should have a        Unicare provider code
                                  separate ID
LME Name                          WCHS                                WCHS
LME Code                          33081                               33081
Reporting Unit Number             Wake County Program Code            Wake County Program Code
                                  (A list for contract programs is
                                  appended)
Attending Provider Number         Your agency‘s WCHS                  Use ―WCHS‖
                                  Attending Provider Code, in
                                  the format WKCxxxx
                                  (A list for contract providers is
                                  appended)

9. I love this stuff! Where can I learn more?

From the NC-TOPPS home page (http://nctopps.ncdmh.net) click on the ―Training and
Support‖ link on the left of the page. Then select ―SFY 07-08 NC-TOPPS Implementation
Guidelines (Version 4.0, July 1, 2007).‖

10.   Have there been any significant changes to the NC-TOPPS requirements or
assessments for the new Fiscal Year?

         There is now a requirement that clients sign privacy notices that include NC-
          TOPPS, and request that Substance Abuse clients sign a consent to share NC-
          TOPPS with the LME and other providers.

         By May 23, 2008, every provider agency must be enrolled with a National
          Provider Identifier (NPI). NC-TOPPS will also be adopting the NPI at that time.
          Provider agencies should begin using the NPI as soon as one has been
          assigned.

         There have been changes and improvements to the Web-based system.


11.       Who are the Contacts for NC-TOPPS?

For information about WCHS NC-TOPPS policies and procedures contact:

David Peterson,WCHS LME
919-856-6412
David.Peterson@co.wake.nc.us

Tim Wildfire,WCHS Operations



                                     Section II - Page 8
                                                 Wake County LME Provider Manual 2008
                                                                           SECTION II

919-212-7938
tim.wildfire@co.wake.nc.us

Tammy Bonas, WCHS LME
919-856-5649
tammy.bonas@co.wake.nc.us

For information about NC-TOPPS statewide:
Main contacts
 Kathryn Long        kathryn_long@ncsu.edu           919-515-1310    NCSU Center for Urban
                                                                     Affairs and Community
                                                                     Services
 Jaclyn Johnson      jaclyn_johnson@ncsu.edu         919-515-1310    NCSU Center for Urban
                                                                     Affairs and Community
                                                                     Services

Other contacts
 Marge Cawley        cawley@ndri-nc.org              919-863-4600    National Development and
                                                         x223        Research Institutes (NDRI)
 Mindy McNeely       mindy_mcneely@ncsu.edu          919-515-1310    NCSU Center for Urban
                                                                     Affairs and Community
                                                                     Services
 Gail Craddock       craddock@ndri-nc.org            919-863-4600    National Development and
                                                         x226        Research Institutes (NDRI)
 Shealy              shealy.thompson@ncmail.net      919-733-0696    NC DMH/DD/SAS
 Thompson
 Spencer Clark       spencer.clark@ncmail.net        919-733-4670    NC DMH/DD/SAS
 Ward Condelli       ward.condelli@ncmail.net        919-733-0696    NC DMH/DD/SAS

Clinician passwords, NC-TOPPS Website, and general project questions: Kathryn
Haynes Long, or Jaclyn Johnson
NC-TOPPS Quarterly Feedback Reports: Gail Craddock
Questions regarding NC-TOPPS policy issues: Marge Cawley and Spencer Clark



BASIC NC-TOPPS USER INSTRUCTIONS

I.       Logging in to NC-TOPPS

      1. Open you web browser (eg. MS Explorer, Netscape, Firefox)
      2. In the address bar, use this address- http://nctopps.ncdmh.net

II.      Doing an NC-TOPPS Assessment

1.       Click on ―NC-TOPPS Website Submission‖ at the left side of the web page.
2.       Enter you Clinician ID and Password
         Clinician ID- For Internal WCHS staff- Unicare Provider Code




                                   Section II - Page 9
                                                Wake County LME Provider Manual 2008
                                                                          SECTION II

                        For Contract Programs- ID used to register as NC-TOPPS
                        Clincian
                        (for Training, enter ―training‖)
        Password-       Will be assigned by NC-TOPPS
                        (for Training, enter ―training‖)
3.      A list of incomplete assessments will appear.
        a. To enter a new assessment, Look for ―Begin New Interview‖ at the top of the
             web page. Click on the appropriate type of assessment- ―Initial‖,
             ―Transfer/Complete Episode‖ or ―Update‖
        b. To edit an assessment that you had begun, but had not completed, locate the
             incomplete assessment and click on ―Edit.‖ This will bring you to the
             beginning of the assessment. The previously entered values will be
             displayed. (To save and escape, click ―Main menu‖)
        c. For a convenient view of the information entered on an incomplete
             assessment, locate the ―Consumer Record Number‖ aka LME client number
             and click on ―Confirm Report‖. This screen will show all of the items on the
             assessment, and will highlight any missing or incomplete data items. After all
             corrections have been made, click on ―Confirm Data‖ at the bottom of the
             page.
4.      To view a list of updated assessments that are due, click on ―Updates Needed‖ at
the top of the web page.
5.      Navigating through an assessment
There are four main ways that items are entered:
    o ―Click‖ boxes- just click on the selection
    o X boxes for multiple selections- click on the box to select, click again to de-select
    o Data boxes- type in the appropriate number
    o Drop-down boxes- Click on the correct drop-down item.


Navigate from screen to screen using the                                     buttons at the
bottom of the screen. Data is stored when you go to the next screen.
6.     If you click on ―Next‖ and nothing happens, you have probably found a required
item that cannot be skipped…. Complete the item to move forward with the assessment.
7.     When you reach the end of the assessment, a summary of the assessment will
be displayed, with missing items highlighted.
       a. To exit the assessment without completing, click on ―Main Menu‖ at the top of
            the web page. All data will be saved and the assessment will appear on your
            ―incomplete‖ list
       b. To edit items that are incomplete or missing, click on the item name. After
            correcting the item, you‘ll need to click through the rest of the assessment to
            get to the end again, or click on ―Main Menu‖, select the client, and click on
            ―Confirm Report‖ to get to the end.
       x. To fail to save the data on a page – The Browser              buttons at the
          top of the screen in the frame of the browser window will take you to the
          previous page, the data entered on the current page is lost.

8.     To complete an assessment
       a. From the ―Assessment Summary‖ page that appears at the end of the
          assessment, or from the ―Confirm Report‖ option, click on ―Confirm Data‖ at



                                 Section II - Page 10
                                                Wake County LME Provider Manual 2008
                                                                          SECTION II

          the bottom of the screen. A window will pop-up confirming that you have
          submitted the report.
       b. Next, a window will appear with the banner message ―Print This Page Now‖.
          Use the Browser print icon to print this page. A copy of the completed
          assessment must be filed in the consumer record.

           If a printer is not available, you can click on ―File‖, ‖Save Page As‖. Include
                the client number and assessment date in the name of the saved file for
                easy identification.

           Assessments can be printed later from the ―Main Menu‖, too. Click ―Print
              Interview Report‖ at the top right of the Main Menu. Follow the prompts to
              print a report of a past assessment.

III.   To Enroll as a New Clinician

1.     Open you web browser (eg. MS Explorer, Netscape, Firefox)
       In the address bar, use this address- http://nctopps.ncdmh.net
2.     Before you can complete an official NC-TOPPS assessment, you must be
enrolled as a clinician in NC-TOPPS. To enroll as a clinician:

For Internal WCHS staff:

3I.     WCHS support staff will enroll you as a NC-TOPPS clinician. Your clinician ID
will be your 4 digit Unicare provider ID. You will be sent your user ID and password by
e-mail.

For WCHS Contract programs

3C.   Contract agency staff with enroll as a NC-TOPPS clinician by using the Web
based NC-TOPPS system. Click on ―New Clinicians Enrolling For Website Submission.‖

For WCHS contract clinicians, use these codes when you enroll:
Clinican ID- Assign your own Clinician ID. Each clinician has a separate ID
LME Name-                            WCHS
LME Code-                            33081
Reporting Unit Number-               WCHS Program Code
Attending Provider Code-             Agency attending provider code-WKCxxxx.

You will be sent your user ID and password by e-mail.


***NOTE: If you have already received a NC-TOPPS id and password and need to add
or change your LME and/or provider information, do NOT fill out this form. Instead,
please contact Jaclyn Johnson at jaclyn_johnson@ncsu.edu or Kathryn Long at
kathryn_long@ncsu.edu to make the appropriate changes. Thank you.




                                 Section II - Page 11
                                                    Wake County LME Provider Manual 2008
                                                                              SECTION II



SECTION II Requirements
3. Substance Abuse Prevention and Treatment (SAPT) Block Grant Requirements
Effective Date: July 1, 2005            Version Date: 11/01/07
Informational Only  Requirement       Reference:
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)             CAP/MRDD
Medicaid Basic Svc (Not Direct Enrolled)         Cat. A Licensed Facilities
Medicaid Enhanced Svc                            Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                    Cat. C Institutions/Facilities
ICF-MR                                            Cat. D Lic/Cert. Outpatient/Day Svcs

Any agency that provides substance abuse prevention and/or treatment services for
children, adolescents or adults through a contractual agreement with Wake County LME
receives state and/or federal block grant funding and is therefore required to adhere to
specific stipulations.

     1. Providers who receive safe and drug free schools (Governor‘s 30%) funds must:
            Target selective and indicated populations (CSSP, CSIP)
            Coordinate efforts with WCPSS Safe and Drug Free Schools initiative
            Utilize approved evidence based prevention curricula
            Submit mid-year and end of year reports
            Adhere to any other contractual agreements between the LME and the
               provider

     2. Providers who receive substance abuse prevention block grant and/or funds
        must:
            Target selective and indicated populations (CSSP, CSIP)
            Utilize approved evidence based prevention curricula
            Implement other prevention activities utilizing the following strategies:
               information dissemination, education, alternatives, problem identification
               & referral, community-based processes, environmental
            Submit mid-year and end of year reports
            Adhere to any other contractual agreements between the LME and the
               provider

     3. Providers who receive MAJORS funds must:
            Coordinate substance abuse treatment services with the Department of
               Juvenile Justice and Delinquency Prevention (DJJDP – Juvenile Court
               Counselors)
            Assess all participating youth and families utilizing the MAJORS
               Assessment System (MAS)
            Submit all required MAS data quarterly
            Submit required monthly reports
            Adhere to general block grant requirements (e.g. TB screening, etc.)

     4. Priority Admission Preference




                                      Section II - Page 12
                                               Wake County LME Provider Manual 2008
                                                                         SECTION II

       Providers must have a policy in place that assures priority admission preference
       to the following populations regardless of client‘s age:
            Pregnant, injecting drug users
            Pregnant women
            Injecting drug users
       Providers must also choose a method to advertise or publicize this policy, such
       as PSAs, postings, etc.

   5. Universal Tuberculosis (TB) Screening
      Providers must have a policy in place that assures that all child and adult
      substance abuse consumers are screened for TB. This policy should address
      screening, referral for testing (if indicated), follow-up and case management. It is
      recommended that a brief TB evaluation be a component of the clinical
      assessment. Documentation of the screening, results and follow-up activities, if
      necessary, must be kept in a standard location in the consumer‘s medical record.

   6. Injecting Drug Users
      Providers must have a policy in place that assures that consumers who are
      injecting or IV drug users are admitted for services within seven (7) days of the
      request for treatment. In addition, interim services must be provided within 48
      hours.

   7. Women‘s Set-Aside
        Providers of substance abuse treatment services to women must evaluate the
        following during screening or assessment:
              Pregnancy status
              Need for medical care
              Need for case management/community support services
              Need for transportation assistance
        Additionally, if the woman has children, the following must be evaluated:
              Need for primary pediatric care
              Need for behavioral health treatment services
              Need for child care services (in order for the woman to participate in
                substance abuse treatment)
These issues should be addressed and kept in a standard location in the consumer‘s
medical record. Providers of treatment services to women must also assure the
provision of gender-specific treatment.




                                Section II - Page 13
                                                    Wake County LME Provider Manual 2008
                                                                              SECTION II


SECTION II Requirements
4. MHDDSA Services Eligible For Medicaid Transportation
Effective Date: 12/20/06                 Version Date: 12/20/06
Informational Only  Requirement        Reference:
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)             CAP/MRDD
Medicaid Basic Svc (Not Direct Enrolled)         Cat. A Licensed Facilities
Medicaid Enhanced Svc                            Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                    Cat. C Institutions/Facilities
ICF-MR                                            Cat. D Lic/Cert. Outpatient/Day Svcs


In October 2006 the State Division of Medical Assistance changed the rules for
MHDDSA services that qualify for Medicaid transportation funding. An update to these
rules was published in December 2006. This has resulted in changes in the Wake
County Human Services approval process for authorizing Medicaid transportation for
MHDDSA services.

In December 2006, the State reconsidered the implications of these rules, and issued
―Implementation Bulletin #21‖ which re-instates at least some of the transportation
accessibility of services.

This document is intended to clarify the new state rules for clients and providers.

Three conditions must be met to qualify for Medicaid funded transportation to a
MHDDSA service:

1.    The client must be Medicaid eligible on the date of service. Clients who receive
both Medicaid and Medicare (known as full-benefit dual eligibles) ARE eligible for
Medicaid transportation. Clients whose only benefit is to receive payment of their
Medicare premium (known as MQB or Medicare Savings Program) are NOT eligible, as
the Medicaid does not cover any services, only premiums.

2.       The service must be a Medicaid covered service, and

3.       The cost of transportation cannot be included in the Medicaid reimbursement rate
for the service. In the October rules, most enhanced benefit services were made
ineligible for transportation, as the cost of transportation was said to be included in the
rate. In the December rules, enhanced benefit services are again eligible, with the
exception of Community Support. CAP MRDD Waiver Day Support and Supported
Employment Services are not eligible for Medicaid transportation reimbursement.


The charts below specify the services that are eligible for Medicaid transportation
services. The changes between the October and the December rules are highlighted in
red.




                                      Section II - Page 14
                                            Wake County LME Provider Manual 2008
                                                                      SECTION II

MHDDSA Services Eligible for Medicaid Transportation

  State   Service Description                            Eligible for
  Code                                                    Medicaid
                                                       Transportation
 90772 Medication Administration                             Yes
 90801 Clinical Intake                                       Yes
 90802 Interactive Evaluation                                Yes
 90804 Individual Therapy (20-30 min)                        Yes
 90805 Individual Therapy (20-30 min) MD                     Yes
 90806 Individual Therapy (45-50 min)                        Yes
 90807 Individual Therapy (45-50 min) MD                     Yes
 90816 Individual Therapy (30 min)                           Yes
 90817 Individual Therapy (30 min) MD                        Yes
 90818 Individual Therapy (50 min)                           Yes
 90819 Individual Therapy (50 min) MD                        Yes
 90846 Family Therapy wo/patient                             Yes
 90847 Family Therapy w/patient                              Yes
 90853 Group Therapy                                         Yes
 90862 Medication Check – Individual                         Yes
 96101 Psychological Testing (per hour)                      Yes
 96111 Developmental Testing – Extended                      Yes
 H0001 Behavioral Health Assessment                          Yes
 H0004 Behavioral Health Counseling and Therapy              Yes
H0004:HQ DMH Outpatient Treatment Group                      Yes
H0004:HR DMH Outpatient Tx Family Therapy w/ Client          Yes
         DMH Outpatient Tx Family Therapy w/o                Yes
H0004:HS
         Client
         Alcohol and/or Drug Services; Group                Yes
 H0005
         Counseling by Clinician
 H0031 Mental Health Assessment                             Yes
H0012:HB SA Non-Medical Community Residential               No
         Treatment – Adult
 H0015 SA Intensive Outpatient Program                      YES
 H0019 Behavioral Health Long Term Residential               No
         (level 3, <5 bed)
 H0019 Behavioral Health Long Term Residential              No
         (level 3, 5+bed)
 H0019 Behavioral Health Long Term Residential              No
         (level 4, <5 bed)
 H0019 Behavioral Health Long Term Residential              No
         (level 4, 5+ bed)
 H0020 Opioid Treatment (Medicaid Only)                     YES
 H0035 Partial Hospitalization MH Tx – Child, min. 3        YES
         hrs
 H0035 Partial Hospitalization MH Tx – Adult, min. 3        YES
         hrs



                              Section II - Page 15
                                           Wake County LME Provider Manual 2008
                                                                     SECTION II

  State   Service Description                          Eligible for
  Code                                                  Medicaid
                                                     Transportation
H0036:HA Community Support Individual-Child                 No
H0036:HB Community Support Individual-Adult                 No
H0036:HQ Community Support Group                            No
 H0040 Assertive Community Treatment Team                   No
 H0046 Residential Level 1                                  No
H2012:HA Day Tx, Behavior Health – Child                   YES
 H2014 Developmental Therapies- Profes. Individ.            No
H2014:HM Developmental Therapies- Paraprofessional          No
         Individual
H2014:HQ Developmental Therapies- Profes. Group            No
H2014:U1 Developmental Therapies- Paraprofessional         No
         Group
H2015:HT Community Support Team                            No
 H2017 Psychosocial Rehabilitation                        YES
 H2020 Therapeutic Behavioral Service Level 2              No
 H2022 Intensive In-home                                   No
 H2033 Multi-systemic Therapy                              No
 H2035 SA Comprehensive Outpatient Program                 No
 S5145 Foster Care Therapeutic Child Level 2               No
T1017:HI Targeted Case Management-DD                       No
 T1023 Diagnostic Assessment                              YES
 YA125 Hourly Respite - CTSP Only                          No
 YA230 Psychiatric Resid. Treatment Facility               No
 YA232 Room & Board Level III (1-4 beds)                   No
 YA233 Room & Board Level III (5+ beds)                    No
 YA234 Room & Board Level II (Age 5 or <)                  No
 YA235 Room & Board Level II (Age 6-12)                    No
 YA236 Room & Board Level II (Age 13 or >)                 No
 YA237 Room & Board Level IV (1-4 beds)                    No
 YA238 Room & Board Level IV (5+ beds)                     No
 YA254 Ther. Leave -Resid Level II -Ther Hme               No
 YA255 Ther. Leave -Resid Level II -Grp Hme                No
 YA256 Ther. Leave -Resid Level III(1-4 Beds)              No
 YA257 Ther. Leave -Resid Level III( 5+ Beds)              No
 YA258 Ther. Leave -Resid Level IV(1-4 Beds)               No
 YA259 Ther. Leave -Resid Level IV(5+ Beds)                No
 YA370 Specialized Summer Program                          No
 YM050 Personal Care                                       No
 YM645 Long-term Vocational Supports                       No
 YM686 Guardianship                                        No
 YM700 Independent Living-MR/MI                            No
 YM811 Supervised Living – 1 Resident                      No
 YM811 Superv. Living – 1 Resident Therap. Leave           No
 YM812 Supervised Living – 2 Resident                      No


                             Section II - Page 16
                                         Wake County LME Provider Manual 2008
                                                                   SECTION II

State   Service Description                            Eligible for
Code                                                    Medicaid
                                                     Transportation
YM812   Superv. Living – 2 Resident Therap. Leave          No
YM813   Supervised Living – 3 Resident                     No
YM813   Superv. Living – 3 Resident Therap Leave           No
YM814   Supervised Living – 4 Resident                     No
YM814   Superv. Living – 4 Resident Therap Leave           No
YM815   Supervised Living – 5 Resident                     No
YM816   Supervised Living – 6 Resident                     No
YP010   Hourly Respite – Individual                        No
YP011   Hourly Respite – Group                             No
YP020   Personal Assist – Individual                       No
YP610   Developmental Day (inc. Before/After)              No
YP620   ADAP/ADVP                                          No
YP630   Supported Employment – Individual                  No
YP640   Supported Employment – Group                       No
YP660   Day Activity                                       No
YP710   Supervised Living – Low                            No
YP710   Supervised Living – Low Ther Leave                 No
YP720   Supervised Living – Moderate                       No
YP720   Intensive Supervised Living                        No
YP720   Intensive Supervised Living- Ther Leave            No
YP730   Community Respite                                  No
YP740   Family Living – Low                                No
YP750   Family Living – Moderate                           No
YP760   Group Living – Low                                 No
YP760   Group Living – Low Ther Leave                      No
YP770   Group Living – Mod A                               No
YP770   Group Living – Mod B                               No
YP770   Group Living – Mod A Ther Leave                    No
YP770   Group Living – Mod B Ther Leave                    No
YP780   Group Living – Hi                                  No
YP780   Group Living – Hi Ther Leave                       No
YP830   YP830 Alcohol/Drug Assessment non-                 No
        licensed SA professional
YP831   Behavioral Health Indiv. Counseling non-          No
        licensed SA professional
YP832   Behavioral Health Group Therapy non-              No
        licensed SA professional
YP833   Family Therapy with Client non-licensed SA        No
        professional
YP834   Family Therapy without Client non-licensed        No
        SA professional
YP835   Alcohol/Drug Group Counseling non-licensed        No
        SA professional




                           Section II - Page 17
                                                     Wake County LME Provider Manual 2008
                                                                               SECTION II



SECTION II Requirements
5. Notice Regarding The False Claims Act And Whistleblower Protections
Effective Date: 10/24/07                  Version Date: 10/24/07
Informational Only  Requirement         Reference: see list at end of procedure
Requirement Applies to Provider Type:
 Medicaid Basic Svc (Direct Enrolled)             CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)         Cat. A Licensed Facilities
 Medicaid Enhanced Svc
                                                   Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs
                                                   Cat. C Institutions/Facilities
ICF-MR
                                                    Cat. D Lic/Cert. Outpatient/Day Svcs

NOTICE

       The Wake County Human Services Department, (WCHS), hereby notices and
holds all contractors, subcontractors, agents and any other business associate who
provide or furnish healthcare items or services for WCHS, who provide billing or coding
services, or who are involved in the monitoring of healthcare provided by WCHS,
responsible for compliance with federal and state laws that prohibit the making of false
claims and for otherwise conducting our affairs lawfully. We are providing you with this
Notice as one of our contractors, subcontractors, agents and any other business
associate, in order to comply with our obligations under federal and state law.

        The information in this Notice is an overview of some of the wrongful ―false
claims‖ activity that the federal and state governments are monitoring in the healthcare
profession and the laws that govern such wrongful activity. This Notice is not intended
as a comprehensive outline for every law that concerns healthcare providers. As a
health care provider it is your responsibility to review and know all laws, rules and
regulations that may apply to your activities and to ensure compliance with such laws.

FEDERAL/STATE FALSE CLAIMS AND OTHER STATE RELATED LAWS

The Federal False Claims Act aids the federal government in combating fraud and
recovers losses due to fraud committed in federal programs, such as Medicare and
Medicaid. Violations of the False Claims Act can include ―knowingly‖: (1) submitting a
false claim for payment, (2) making or using a false record or statement to obtain
payment for a false claim, (3) conspiring to make a false claim or get one paid, or (4)
making or using a false record to avoid payments owed to the U.S. Government.

The term ―Knowingly‖ is defined under this act as a person who: (1) has actual
knowledge that the information is false; (2) acts in deliberate ignorance of the truth or
falsity of the information; or (3) acts in reckless disregard of the truth or falsity of the
information.

The False Claims Act does not require an element of intent by the person to commit
fraud. A person engages in an act knowingly by showing either: (1) actual knowledge,
(2) deliberate ignorance of the truth or falsity of the information, or (3) reckless disregard
of the truth or falsity of the information.




                                       Section II - Page 18
                                                 Wake County LME Provider Manual 2008
                                                                           SECTION II


The False Claims Act contains provisions which permit individuals with information
concerning fraud involving government programs to file a lawsuit on behalf of the
government. If the lawsuit is successful, the individual may be eligible to receive a
portion of the recoveries received by the government.

Penalties:     Violations of the federal false claims act can result in penalties of not less
               than $5,500.00 and not more than $11,000.00 per claim (subject to
               inflationary increases), plus three times the amount of damages that the
               government sustains.

North Carolina has enacted a Medical Assistance Provider False Claims Act. This act
provides that it shall be unlawful for any provider of medical assistance under the
Medical Assistance Program to: 1) knowingly present, or cause to be presented to the
Medical Assistance Program a false or fraudulent claim for payment or approval; or 2)
knowingly make, use or cause to be made or used a false record or statement to get a
false or fraudulent claim paid or approved by the Medical Assistance Program.

A medical provider that violates this provision may be liable for a civil penalty up to
$10,000.00, plus three times the amount of damages sustained by the Medical
Assistance Program for each separate cause of action. A medical provider who violates
this act is also subject to pay for any investigatory and court costs, in addition to interest
on the amount of damages for violations of this act.

The North Carolina Medical Assistance Provider False Claims Act ―is to be interpreted
and construed to be consistent with the Federal False Claims Act, 31 U.S.C. §3729, et.
seq., and any subsequent amendments to that act.‖

Unlike the Federal False Claims Act, a cause of action may be brought only by the North
Carolina Attorney General‘s Office. A private citizen may not bring a cause of action
under this act.

North Carolina also enacted statutes that provide for criminal penalties for Medicaid
fraud. The Medicaid Assistance Provider Fraud statute provides that a violation of this
statute by a medical assistance provider is a Class I felony. This type of fraud includes:
(1) fraudulent applications where a Medicaid provider willfully and knowingly makes or
causes to be made a false statement or representation of a material fact in an
application for payment or an application for Medicaid eligibility, or that allows a provider
to remain eligible or to qualify to provide Medicaid services; and (2) concealment of a
relevant fact by a provider who knowingly and willfully conceals or fails to disclose a fact
or event that effects entitlement to Medicaid payment or the amount of Medicaid
payments received.

The Medicaid Fraud by Recipient statute provides that violation of this statute by a
recipient is a Class I felony, where the amount wrongfully obtained exceeds $400.00
(four hundred dollars), otherwise it is punishable as a Class 1 misdemeanor. This type
of fraud includes: (1) fraudulent application by a Medicaid recipient where the patient
knowingly and willfully, with intent to defraud, makes or causes to be made a false
statement or representation of a material fact in an application for payment or an
application for Medicaid eligibility; and (2) concealment of fact affecting a Medicaid
recipient‘s eligibility where an applicant or recipient of Medicaid or a person acting on his


                                  Section II - Page 19
                                                Wake County LME Provider Manual 2008
                                                                          SECTION II

or her behalf knowingly and willfully conceals or fails to disclose a fact or event that
effects entitlement to Medicaid payment.

The Medicaid Card Fraud statute provides that a person who is guilty of Medicaid card
fraud maybe punished as a Class I felony. A person is guilty of this type of fraud when
that person knowingly and willfully, with intent to defraud obtains or attempts to obtain or
assists, aids, or abets another person to obtain any money, service or anything of value
to which the person is not entitled as a Medicaid recipient; or when that person
deliberately misuses a Medicaid identification card.

Examples of potential False Claims include:

   1.      Failure to obtain payment from beneficiaries who may have other primary
           payment sources;
   2.      Failure to refund overpayments made by a federal or state healthcare
           program;
   3.      Participating in kickbacks, bribes or rebates in exchange for referring goods,
           facilities, services or items that are reimbursed by government programs;
   4.      Altering, falsifying, destroying, or concealing medical records, income and
           expenditure reports or any other records that support reimbursement;
   5.      Making inaccurate, false or improper entries in medical records, cost reports
           and any other records used to support reimbursement;
   6.      Billing for services that were not documented or misrepresenting the services
           that were provided;
   7.      Billing for services that were not medically necessary or for services that fail
           to meet professionally recognized standards for healthcare;
   8.      Billing for non-covered service or characterizing a non-covered service, item
           or cost in a way that leads to reimbursement from a government program;
   9.      Double billing, which means to bill more than once for the same service or
           item;
   10.     Charging rates in excess of established Medicare or Medicaid rates;
   11.     Accepting a gift, money, donation or other compensation as a condition of
           admission or continued stay in the facility;

FEDERAL QUI TAM “WHISTLEBLOWER” ACTIONS

There is a private cause of action under the False Claims Act. A person, who is called a
Qui Tam Relator under this act, may bring a civil action for any false claim in the name of
the United States government. The federal government may review a complaint brought
by a Qui Tam Relator and the disclosure of substantially all of the material evidence and
information the person possesses to decide whether to intervene. If the federal
government intervenes, then the federal government may proceed with a cause of action
under the False Claims Act, and the person who originally brought the action, the Qui
Tam Relator, may receive from 15% to 25% of the proceeds of the action or settlement
of the claim. If the federal government does not proceed with a cause of action and Qui
Tam Relater continues with the action or settles the claim, he or she may receive an
amount from 25% to 30% of the proceeds of the action or settlement. The Qui Tam
Relator may also receive an amount for reasonable expenses, including reasonable
attorney fees and costs incurred in connection with bringing the lawsuit.




                                 Section II - Page 20
                                                Wake County LME Provider Manual 2008
                                                                          SECTION II

FEDERAL AND STATE WHISTLEBLOWER PROTECTIONS

Federal and state laws protect individuals who investigate or report possible false claims
made by their employer against discharge or discrimination in employment because of
such investigation. Employees who are discriminated against based on whistle blowing
activities may sue for acts of retaliation in court for damages. Under either the federal or
state law, any employer who violates whistleblower protection laws is liable to the
employee for (1) reinstatement of the employee‘s position without loss of seniority, (2)
two times the amount of lost back pay, (3) interest and compensation for any special
damages, and such other relief necessary to make the employee whole.

POLICIES AND PROCEDURES FOR DETECTING AND PREVENTING FRAUD,
WASTE AND ABUSE

WCHS Department in its commitment to excellence and compliance with all laws and
regulations that apply to health care has implemented the following policy:

If you are an employee, volunteer, vendor, agent or contractor with WCHS, you must:

1)     Exercise good faith and honesty in all dealings and transactions.
2)     Observe all laws and regulations that govern WCHS, including requirements of
       Medicare, Medicaid and other federal healthcare programs. Maintain complete
       and accurate medical records and submit complete and accurate claims for
       services provided.
3)     Provide accurate and truthful information for all transactions.

You may contact one of the following resources available if you have any knowledge or
concern regarding a potential false claim:
    Speak with your supervisor or another manager.
    If the manager is not available, or you are not comfortable speaking with him/her,
      or you believe the matter has not been adequately resolved, contact the Wake
      County Internal Auditor. You may report the incident anonymously.

WCHS Department policy strictly prohibits retaliation, in any form, against any individual
making a report, complaint, or inquiry in good faith. Retaliation is subject to discipline,
up to and including dismissal from employment or termination of business or contractual
relationship with WCHS.

To report instances of suspected fraud, abuse or waste, please contact the following:

Wake County Internal Auditor
Wake County Finance Department
337 S. Salisbury Street
Raleigh, NC 27601
(919) 856-6120
(919) 856-6880 (fax)




                                 Section II - Page 21
                                               Wake County LME Provider Manual 2008
                                                                         SECTION II

AUTHORITY

This policy is enacted pursuant to Section 6032 of the Deficit Reduction Act of 2005.

(1)    The federal Civil False Claims Act, Section 3279 of Chapter 31 of the United
       States Code.
(2)    The North Carolina Medical Assistance Provider False Claims Act, N.C. GEN.
       STAT. §108A-70.10, et seq.
(3)    North Carolina Medical Assistance Provider Fraud, N.C. GEN. STAT. §108A-63
(4)    North Carolina Medical Recipient Fraud, N.C. GEN. STAT. §108A-64
(5)    Wake County Human Resources Administrative Manual, Section 602.1, 603.1,
       604.1, 605.1




                                Section II - Page 22
                                                                 Wake County LME Provider Manual 2008
                                                                                          SECTION III


SECTION III Authorization Process
1. Referral and Acceptance
Effective Date: July 1, 2004                         Version Date: 7/1/07
Informational Only  Requirement                    Reference:
Requirement Applies to Provider Type:                CAP/MRDD
 Medicaid Basic Svc (Direct Enrolled)               Cat. A Licensed Facilities
 Medicaid Basic Svc (Not Direct Enrolled)
                                                     Cat. B Comm Based Providers
Medicaid Enhanced Svc
 Non-Medicaid Contracted Svcs                       Cat. C Institutions/Facilities
ICF-MR                                               Cat. D Lic/Cert. Outpatient/Day Svcs

Purpose:
To describe the process by which Wake County LME makes referrals of consumers who are
eligible for services reimbursable by or through Wake County LME to network Providers, and to
establish procedures and timeframes within which the Provider is required to process Wake
County LME referrals for admission and to initiate services.

Principles:
    Informed Choice of Providers: Consumers will be informed of appropriate and
      available providers in the Wake County LME Provider network that meet their
      specific needs, such as subspecialty, locations, and hours of availability.
    Prompt Acceptance/Admission: Providers shall make a determination of whether
      the individual is appropriate for their services and admit or deny as quickly as
      possible, so that treatment is not delayed. The timeframes in the grid below are
      considered maximums.
    Adverse Selection: The Provider shall be prohibited from arbitrarily declining,
      refusing to serve or rejecting a specific consumer for authorized services. In the
      event that a Provider declines a referral, refuses to serve or rejects a specific
      consumer, the Provider shall give specific reasons that demonstrate the denial is not
      arbitrary. In all cases of adverse selection, the Provider must provide timely
      reasons, and where applicable, notice to ensure that continuity of care can be
      optimized. Refusal to accept a referral based upon the individual’s source of
      reimbursement may constitute adverse selection. The LME may consider
      information regarding adverse selection in its evaluation of the Provider.
    Waiting Lists: When necessary, Wake County LME will maintain a waiting list for
      the services it funds; Providers shall not maintain their own waiting list for Wake
      County LME referrals.

Procedure for Wake County LME referrals to Network Providers:
   1. Wake County LME will present the consumer who requests services with an informed
      choice of service providers. This list shall include providers of basic services that have
      registered with Wake County LME, providers of enhanced services who are endorsed by
      Wake County LME, and other services under contract with Wake County LME, to provide
      the requested service. Consumers will sign an Acknowledgement of Consumer Choice
      form to indicate their decision.
   2. When Wake County LME and the consumer decide to make a referral to a Provider, the
      Referral Coversheet shall be used as a tracking mechanism for the referral, and a
      reference as to which documentation is being included with the referral. A medical record
      number is assigned to the consumer prior to the referral, if not already assigned.

                                             Section III - Page 1
                                                           Wake County LME Provider Manual 2008
                                                                                    SECTION III

   3. Referring staff shall indicate which information is being included with the referral packet,
      and which information the Provider is required to complete and return.
   4. The decision to accept a referral indicates that the consumer meets the Provider‘s
      admission criteria and the Provider has capacity to initiate services for the individual
      within the required timeframe.
   5. The Provider shall indicate whether or not they accept the referral by faxing the completed
      Referral Coversheet to the referring staff within the required timeframe (see table below).
      The Provider must also notify the individual/family of acceptance/non-acceptance of the
      individual within the timeframe specified.
   6. All referral information for those consumers not accepted must either be shredded or
      returned to Wake County LME, and shall not be kept by the Contract Provider.
   7. If the Provider accepts the individual and the individual chooses the Provider, then
      services shall commence within the required timeframe.
   8. The Provider is to submit the information checked as ―Required for Enrollment‖ to the
      Wake County LME Data Support Specialists within 10 business days of admission
      of the individual.
   9. If the Provider is not able to begin services within the maximum number of days indicated
      below, the Provider shall notify the referral source at the LME, so that the LME can let the
      consumer know of other service options.

                                         Acceptance/ Non-           Initiation of Services*
                                     Acceptance (Maximum #         (Maximum # of days from
    MHSA Service                     of days from referral date)          referral date)
    Behavioral Health
    Outpatient, Diagnostic               3 calendar days              7 calendar days
    Assessment, Community
    Support and all other
    enhanced services not
    listed below
    Vocational and
    Psychosocial                        30 calendar days              60 calendar days
    Rehabilitation Services
    Residential                         30 calendar days              90 calendar days

    Developmental Disability
    Service
    Targeted Case                        3 business days              7 business days
   Management
    Developmental Therapy                7 business days             15 business days
    and Personal Care
    Vocational                          15 calendar days              30 calendar days
    Residential                         30 calendar days              45 calendar days

Note: Services should be made available to consumer within this number of days, unless
instructed otherwise by LME.

Eligibility Procedure for Developmental Disability Services:
    1. All persons over the age of three with developmental disabilities seeking publicly funded
          services must apply through Wake Co. Human Services‘ DD Access & Entry (also known
          as Single Portal) (401 E. Whitaker Mill Rd., Raleigh, NC 27608).



                                     Section III - Page 2
                                                         Wake County LME Provider Manual 2008
                                                                                  SECTION III

   2. Referral is made by completing an ‗Application for Services for Persons with
      Developmental Disabilities‘. Applications are available at Smartworks.com or by calling
      856-6400. Applicant/guardian signature and a signed copy of an evaluation by an
      appropriately licensed professional who has diagnosed the applicant‘s developmental
      disability is required.
   3. Eligibility for Developmental Disability Services and Target Population assignment must be
      determined by the LME – DD Services Access & Entry prior to referral or authorization of
      services.
   4. Eligible applicants are reviewed by the Single Portal Interagency Planning Committee for
      recommendations regarding service availability and community resources with notification
      in writing to the applicant/guardian of those recommendations and waiting list status.


Procedure for Referrals between Network Providers:
Providers must present the consumer who requests services that are reimbursed by
Medicaid or other public funds with an informed choice of service providers. This list shall
include providers of basic services that have registered with Wake County LME, and
providers of enhanced services who are endorsed by Wake County LME, to provide the
requested service. Consumers will sign an Acknowledgement of Consumer Choice form to
indicate their decision. The consumer must be informed that non-Medicaid public funds may
not be available for requested services, in addition to eligibility criteria that must be met.

The list of registered and endorsed providers can be found on the web at:
http://www.wakegov.com/humanservices/providers/network/topics.htm

Referral Requirements When a Provider Closes, Merges, or Discontinues a Service:
Consumers must be assured informed choice of services when an agency closes, merges with
another agency, or otherwise goes out of business.

   1. Consumers must be informed when their provider agency is going to close or go out of
      business.
   2. Providers will clarify for consumers that they are enrolled for services with the agency that
      is closing, and provide them with a choice of agencies they can be transferred to for
      continued services.
   3. The closing agency must complete discharge paperwork on all consumers, and transfer
      the NC-TOPPS to the receiving agency.
   4. The agency that accepts the referral must complete the admission process and
      paperwork, even if the direct care provider(s) are the same as in the first agency.
   5. Providers must request new authorizations from Value Options (Medicaid) and Wake LME
      (IPRS).
   6. Acknowledgement of Consumer Choice forms should be signed by the consumer and a
      copy placed in both the discharged chart and in the new chart.
   7. The closing provider should release appropriately requested records to facilitate a good
      transition.
   8. Per Section I Procedure 2, Notification of Changes, providers must inform Wake County
      LME of closures, merges, and discontinued services.




                                      Section III - Page 3
                                                                Wake County LME Provider Manual 2008
                                                                                         SECTION III


SECTION III Authorization Process
2. Authorization Policy and Principles
Effective Date: July 1, 2004                        Version Date: 7/1/07
Informational Only  Requirement                   Reference:
Requirement Applies to Provider Type:               CAP/MRDD
Medicaid Basic Svc (Direct Enrolled)               Cat. A Licensed Facilities
Medicaid Basic Svc (Not Direct Enrolled)           Cat. B Comm Based Providers
Medicaid Enhanced Svc                              Cat. C Institutions/Facilities
 Non-Medicaid Contracted Svcs                       Cat. D Lic/Cert. Outpatient/Day Svcs
ICF-MR

Policy:

Wake County LME and its Providers of Non-Medicaid Services will make every reasonable
effort to assure that Wake County consumers receive MH/DD/SA services determined to be
both medically necessary and reimbursable from the non-entitlement funds made available
by state and local government. Wake County LME will utilize an Authorization process to
target services for priority populations and to activate the provision of those services.

Authorization is a clinical and administrative process that assures that eligible consumers
receive needed services and that providers receive reimbursement for services from the
Local Managing Entity (LME).

The LME shall proactively manage all available funds for the purchase of MHDDSA
services through utilization management and the use of sound accounting practices.

Principles:

Authorization Requirement: All publicly funded Non-Medicaid (e.g., IPRS) services reimbursed
by Wake County LME require pre-authorization, with the following exception: Emergency
services (unanticipated service needs, the absence of which would be harmful to the consumer)
require authorization within 2 business days. Such services will be retroactively reviewed to
determine medical necessity and emergency status.

Clinical Authorization Principles: Services will meet the following:

    Services must be medically necessary or clinically indicated.
    Services will be rendered in the least restrictive, least intensive and most clinically appropriate
     level of care.
    Services will be provided by a Wake County LME contract Provider, and must meet Wake
     County LME accepted standards of care.
    The goals of services shall be to:
             o Stabilize consumers in crisis
             o Maximize consumers‘ improvement
             o Maintain stability for consumers with chronic conditions, and
             o For consumers with debilitating conditions, minimize the anticipated decline.




                                            Section III - Page 4
                                                         Wake County LME Provider Manual 2008
                                                                                  SECTION III

Fiscal Management Principles: Wake County LME has designated the Provider and
Community Development Team service directors to be responsible for the purchase of service
budgets. These staff shall be responsible for adhering to the following:

   Authorizations shall be managed to assure funds are not over-encumbered.
   Revenues shall be optimized.
   Authorizations and Budgets shall be managed to assure continuity of care for consumers.
   Services shall be authorized for individuals who meet medical/clinical necessity criteria, when
    there is funding available, utilizing the Clinical Authorization Principles.
   When there is insufficient funding to meet the service needs of a MHDDSA population, the
    service manager shall utilize a published process for prioritizing the authorization of new
    consumers/services.
   Covered services shall include all those services for which there is State, Federal and local
    funding, which meet Wake County LME accepted standards of care.

Conditions for Payment: An authorization does not guarantee payment, but provides a
reasonable expectation of funding if all conditions are met. Payment is contingent on:

   The service meets the terms of the authorization.
   The consumer is eligible for the benefit on the date of service.*
   Federal, State and LME rules and contract provisions are met.
   The claim is submitted accurately and on a timely basis.
   There is no reduction of funds by the Federal, State or local funding source. Claims submitted
    before the date that a fund reduction is announced should be honored.

*Note: If a consumer is Medicaid eligible, the consumer is not eligible for IPRS coverage of
services that are also covered by Medicaid, unless an explicit exception is obtained.




                                      Section III - Page 5
                                                                 Wake County LME Provider Manual 2008
                                                                                          SECTION III




SECTION III Authorization Process
3. Developmental Disabilities Eligibility and Authorization of Services
Effective Date: July 13, 1998               Version Date: 7/01/07
Informational Only  Requirement                    Reference: NCAC 16A 0400
Requirement Applies to Provider Type:                 CAP/MRDD
Medicaid Basic Svc (Direct Enrolled)                 Cat. A Licensed Facilities
 Medicaid Basic Svc (Not Direct Enrolled)           Cat. B Comm Based Providers
 Medicaid Enhanced Svc                              Cat. C Institutions/Facilities
 Non-Medicaid Contracted Svcs                        Cat. D Lic/Cert. Outpatient/Day Svcs
 ICF-MR

Purpose: To clarify the service authorization process for persons over 3 years of age who have
developmental disabilities (DD) into the Wake County Human Services DD Service delivery
system.

Authorization Procedure for DD Services

The Service Authorization Request Form (SARF) is the form that the Lead Agency submits to
request authorization of non-Medicaid services provided by WCHS contract providers. Lead
Agency designation for DD Services is outlined in Section VII Service Provision Policies and
Procedures – 1. Lead Provider.

Lead Agency’s Responsibilities
   1. The Lead Agency completes the appropriate version of the Service Authorization Request
      Form (SARF). There are two versions of the SARF specific to the DD target populations
      served:
          a. Child/Adult SARF (Target Populations: CDSN, ADSN)
          b. DD/MI SARF (Target Population: ADMRI)
   2. If not currently designated as ADMRI, the Lead Agency must receive prior approval from
      DD Resource & Supports to change a consumer to this target population.
   3. The Lead Agency is responsible for completing and submitting the appropriate SARF
      which outlines all services provided by contract agencies.
   4. The Lead Agency submits a copy of the complete Unified Person Centered Plan (UPCP)
      along with the SARF when:
          a. the initial request for a non-Medicaid service is made
          b. the annual Unified Person-Centered Plan is developed in the consumer‘s birth
              month
          c. a new service is being requested or if there is a change in the plan.
   5. The Lead Agency completes and submits a Developmental Therapy Step-Down Plan
      along with the SARF at the time of the quarterly reauthorization request for developmental
      therapy. If requesting more than 4 hours/day, this must be indicated and justified on the
      Developmental Therapy Step-Down Plan.
   6. The Lead Agency will submit all other required documentation as identified in the table
      below along with the SARF.
   7. Lead Agency will submit the Child/Adult SARF and required documentation at least 10
      business days prior to the requested reauthorization effective date.
   8. Lead Agency will submit the DD/MI SARF and all accompanying documents as listed on
      the SARF by the 1st day of the consumer’s birth month.

                                             Section III - Page 6
                                                        Wake County LME Provider Manual 2008
                                                                                 SECTION III

 9. Revision to authorized services -The Lead Agency completes and submits a SARF
     indicating the specific service authorization for revision when there is a change in service
     prior to the end of the current authorization. The Lead Agency will include justification for
     any additional hours of service requested.
 10. Early ending of authorized services - the Lead Agency completes the Early Ending of
     Authorized Service form when a service is terminated prior to the ending date of the
     current authorization. The Lead Agency submits this form to Data Support. A revised
     authorization mailer will be generated for the contract agency indicating the change in
     service.


 Documentation Packet to be Submitted to the Data Support Specialists

 Initial Service Request        Quarterly Reauthorization       Annual Reauthorization
  Consumer Enrollment           Service Authorization          Unified Person
      form                         Request Form (SARF)             Centered Plan (UPCP)
  Unified Person                  for all services              Service Authorization
      Centered Plan (UPCP)         authorized quarterly            Request Form (SARF)
  Service Authorization           such as Developmental         Application for Reduced
      Request Form (SARF)          Therapy, Personal               Fee
  Application for Reduced         Care, and Personal            NC-SNAP
      Fee                          Assistance
  NC-SNAP                       Developmental Therapy
  Target Population*              Step-Down Plan
                                 Unified Person
                                   Centered Plan (UPCP)
                                   – ONLY if there has
                                   been a change.

 *Target Population only needs to be sent in when a consumer with DD is changing from
 CDSN to ADSN (age 18). The Target Population needs to be completed on their date of birth
 and a revised Service Authorization Request Form (SARF) must be submitted to change the
 funding source.


How to Complete the Service Authorization Request Form (SARF)

    Requested authorization/reauthorization effective dates on the SARF are related to the
     birth month of the consumer when the annual Unified Person-Centered Plan is developed.
         o Example of initial authorization request: Consumer has a scheduled start date of
            August 27 at an ADVP. The Lead Provider submits the SARF and Unified Person-
            Centered Plan. The beginning effective date of ADVP on the SARF is August 27th
            and the end date is the last day of the consumer‘s birth month (example:
            November), thus the initial authorization request will be from August 27th to
            November 30th.
         o Example of reauthorization request: Example: Consumer‘s birth month is
            November. The Unified Person-Centered Plan is developed in November. The
            ADVP service needs to be reauthorized. The Lead Agency completes and submits
            the SARF with the effective dates of the reauthorization from December 1st to
            November 30th of the following year. The Unified Person-Centered Plan and SARF
            are submitted to Data Support.


                                    Section III - Page 7
                                                          Wake County LME Provider Manual 2008
                                                                                   SECTION III

      In all instances, the requested duration of the service shall be the shortest time frame
       possible to achieve the consumer‘s goals. If sufficient justification exists within the Unified
       Person-Centered Plan, non-Medicaid services may be requested for the following
       timeframes:

Child/Adult DD (CDSN, ADSN target populations)

Service                      Timeframe             Authorization Standard
Residential                  1 year                 daily
ADVP                         1 year                35 hours/week
Long Term Vocational         1 year                36 hours/year
Support
Developmental Day            3 months              30 hours/week for summer
                                                   10 hours/week for after school
Personal Care                3 months              varies but maximum is
                                                   20 hours/week
Developmental Therapy        3 months              based upon UPCP – up to a maximum 15
                                                   hours/week
Targeted Case                3 months              5 hours/month for 1 month when writing a
Management                                         new or annual service plan, then 2
                                                   hours/month


DD/MI (ADMRI target population)

Service                      Timeframe             Authorization Standard
Adult Day Activity           1 year                Per consumer needs as identified in UPCP
*Behavior Plan               3 months for          Development: maximum 20 hrs
Development, Behavior        development,          Monitoring: 2 hours/month
Plan Monitoring              1 year for
                             monitoring
Developmental Therapy        3 months              Per consumer needs as identified in the
(paraprofessional and                              UPCP
professional)
*Individual Therapy          1 year                Per consumer needs & recommendation of
                                                   therapist
Personal Assistance          3 months              Per consumer needs as identified in UPCP
Residential                  1 year                 daily

   * Must initially be requested through ValueOptions prior to requesting non-Medicaid funding of
   these services.

Review of Service Requests & the Generation of the Authorization
       DD Resource & Supports reviews and approves all non-Medicaid service authorization
          requests from Lead Agencies.
       DD Resource & Supports may utilize Care Coordinators to follow-up with Lead
          Providers and Contract Providers when there are questions or concerns with regards
          to a service request or a unified person-centered plan.
       DD Resource & Supports will withhold approval of an authorization request until the
          Lead Provider and/or Contract Providers address all concerns.


                                      Section III - Page 8
                                                          Wake County LME Provider Manual 2008
                                                                                   SECTION III

          Upon approval of the service(s) outlined on the Service Authorization Request Form
           (SARF), authorization mailer(s) is/are generated by Data Support Specialists. The
           authorization mailers are either held for pick-up on the second floor receptionist‘s office
           at the Community Services Center (401 E. Whitaker Mill Road) or mailed directly to the
           contract agencies identified on the SARF depending upon the specification of each
           contract agency.
          A copy of the SARF with all of the authorization numbers entered is returned to the
           Lead Agency to serve as confirmation of the approval of service(s) and generation of
           the mailer(s).
          The computer-generated mailer is the authorization for service and shall remain with
           each contract provider.

Responsibilities of the Contract Provider
1) The contract provider may not bill Wake County LME for:
   a) services that are not authorized
   b) services that fall outside of the authorized dates of service
   c) services that exceed the number of units within the authorized period
   d) services that were rendered but do not address the approved Unified Person Center Plan
        goals.
   e) Developmental Therapy exceeding 4 hours/day without prior approval
2) Services that fall into the above categories will not be paid.
3) If services cannot be carried out as authorized, the contract provider must notify the Lead
   Agency. The Lead Agency must notify DD Resource & Supports.

Discharge Approval
All discharges from services are subject to review and approval by WCHS DD Services.
Discharge from services should be a planned process based on changes in the consumer‘s level
of need for that particular service and should be included as part of the Unified Person Centered
Plan process. Prior to provider-initiated discontinuation of a service to any consumer within the
authorized period, the contract provider must notify the Case Manager and DD Resource &
Supports in writing, with two weeks prior notice for periodic services, four weeks prior notice for
day services and a 60-day notice for residential services.

Contact Information:

       DD Resource & Supports
       401 E. Whitaker Mill Road
       Raleigh, North Carolina 27608

       Patti Beardsley
       E-mail: pbeardsley@co.wake.nc.us
       Phone: (919) 857-9111
       Fax: (919) 856-5674

       Tammy Ramirez
       E-mail: tammy.ramirez@co.wake.nc.us
       Phone: (919) 857-9115
       Fax: (919) 856-5674




                                      Section III - Page 9
                                               Wake County LME Provider Manual 2008
                                                                        SECTION III

Data Support Specialists:

Consumer Last Name A-K
Sandra Conrad
E-mail: sandra.conrad@co.wake.nc.us
Phone: (919) 856-6453
Fax: (919) 856-5674

Consumer Last Name L-Z
MaryAnne Baltazar
E-mail: mbaltazar@co.wake.nc.us
Phone: (919) 857-9383
Fax: (919) 856-5674




                            Section III - Page 10
                                                                Wake County LME Provider Manual 2008
                                                                                         SECTION III


SECTION III Authorization Process
4. Mental Health and Substance Abuse Authorization Process
Effective Date: 7/1/06                              Version Date: 11/1/07
Informational Only  Requirement                   Reference:
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)               CAP/MRDD
Medicaid Basic Svc (Not Direct Enrolled)           Cat. A Licensed Facilities
Medicaid Enhanced Svc                              Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                      Cat. C Institutions/Facilities
ICF-MR                                              Cat. D Lic/Cert. Outpatient/Day Svcs

Non-Medicaid services reimbursed by Wake County LME require prior authorization from Wake
County LME. The LME shall respond to properly completed and submitted routine Non-Medicaid
service authorization requests within 14 calendar days; and urgent requests within one business
day.

Procedures for Authorization of Non-Medicaid Services

Initial Authorizations:
A provider may receive an initial authorization for services for a consumer in one of two ways: 1)
with a referral after the consumer has been screened and assessed by WC LME, or 2) by
requesting an authorization from the WC LME Utilization Review Team. The procedures are
described below:
1) Referrals from WC LME follow the Referral and Acceptance Procedure in this manual.
    a) The referral will come with a Referral Coversheet, clinical information, the consumer‘s
         IPRS Target Population Eligibility and Fee Application status. The Authorization Mailer is
         faxed separately to the Provider‘s business office of choice. (Referrals from Wake County
         Human Services, NOT the LME, include a referral only, and no authorization. These are
         treated like item #2 below.)
    b) The Provider must submit a Consumer Enrollment form to the LME UR Team within 10
         business days of admission, and prior to initial service billing.
2) If the consumer contacts the Provider directly, the Provider must complete the following forms
    in order to request an authorization for services for eligible clients/services from WC LME.
    The Provider will send in the following completed paperwork to the WC LME Data Support
    Specialists (3010 Falstaff Rd, Raleigh, NC 27610). These forms are available on
    Smartworks.com.
          Clinical assessment
          Release of Information form, for release of this information to Wake County LME,
             required for all consumers with a substance abuse diagnosis
          Demographic form
          Consumer Enrollment form
          MH/SA Clinical Services Request form
          Service plan or Introductory Person Centered Plan, including Crisis Plan (optional if
             less than 30 days since admission)
          ASAM (if consumer has SA diagnosis)
          Target Population Eligibility form
          Fee Application and supporting documentation.



                                            Section III - Page 11
                                                        Wake County LME Provider Manual 2008
                                                                                 SECTION III

   a) Upon receipt of complete and accurate paperwork requesting services authorization, WC
       LME will:
        Verify Fee Application data, which indicates the consumer‘s county of residence and
           financial eligibility for publicly funded services.
        Verify IPRS Target Population eligibility. IPRS Eligibility is determined based on
           Target Population eligibility and the consumer‘s eligibility for a reduced fee. NOTE:
           IPRS Target Population eligibility does not guarantee services will be authorized for
           reimbursement by WC LME, as IPRS funds are limited and responsibility for
           administering the funds lies with WC LME.
        Determine level of care needed, based on clinical information. WC LME UR Team will
           use the current NCDMHDDSAS Enhanced Benefit Services for Mental Health and
           Substance Abuse Entrance Criteria, North Carolina Division of Medical Assistance
           Clinical Coverage Policies #8a, and other best practices criteria.
        Respond to the Provider either Authorizing services that were determined appropriate,
           denying the authorization request, or requesting additional information.
   b) The Authorization Mailer is sent or faxed to the Provider as formal notification of duration
       and volume of services authorized. The Mailer also indicates the WC LME Medical
       Record for the consumer, which must be used on Non-Medicaid claims.
3) Additionally, a provider may request an authorization for a current consumer to receive a new
   service, either from their own agency or another provider.
   a) The authorization request should include the supporting documentation listed under
       ―Continuing Authorizations‖ below.
   b) In order to request child residential treatment services, the Provider must make an
       appointment to present the case to WC LME UR in person.
   c) If the authorization is being requested for a Provider other than the requesting Provider,
       the UR Team will fax the requesting Provider a ―Receipt of Request for Services‖ form
       showing that medical necessity had been reviewed and approved. The Receipt does not
       constitute an authorization. The Provider must follow the procedure in # 2 above to
       request an authorization.
4) When transferring a consumer to another agency (when the referring agency still has a
   current authorization):
   a) The referring agency contacts their assigned UR Care Manager to request a transfer of
       authorized services, providing written documentation explaining the reason for the transfer
       and effective date of the transfer. The referring agency submits a Contract Discharge
       Data Form with the above-mentioned written documentation.
   b) The UR Care Manager will provide the referring agency a ―Receipt of Initial Request for
       Services‖.
   c) The referring agency will provide a copy of this receipt to the accepting agency.
   d) The accepting agency will complete the bottom section of this Receipt (including Provider
       Name, Start Date of Service, and Service) and fax it to the LME UR Team at 250-3761,
       along with a Consumer Enrollment Form.
   e) Upon receipt of these forms, the UR Care Manager will then generate an authorization for
       that service to the accepting agency.
   f) Note: A current, completed Fee Application will need to be on file.


Continuing Authorizations:
The Provider is responsible for submitting a reauthorization request for consumers who need
services beyond the initial authorization to LME UR care managers 10 business days before the
end of the prior authorization period. The request should include:
   a) MH/SA Clinical Services Request form


                                     Section III - Page 12
                                                          Wake County LME Provider Manual 2008
                                                                                   SECTION III

   b)   Service plan or complete Person Centered Plan, including Crisis Plan, if changed
   c)   ASAM (SA clients), if changed
   d)   Target Population Eligibility form, if changed or annual update is due
   e)   Fee Application (if annual update is due or income/residency changes)
   f)   Other supporting information as required for the specific service being requested

Child Residential Treatment Room and Board Procedure: Clinical home service providers will
often assist families with the application process for residential treatment services for children and
adolescents. It is imperative that the clinical home provider designee, who facilitates referral
for residential treatment, orients the family to the changes in room and board funding policy
established in Communication Bulletin #064 and begin the process by assisting the family with the
application for Supplemental Security Income (SSI). Once the application process is begun the
residential treatment provider must follow up with the family. According to the Communication
Bulletin #64:

Providers requesting authorization of state funds for room and board shall submit
documentation to the LME to verify that the child is not in DSS custody, that application for
SSI has been denied through the first appeal, and that the family’s total gross monthly
income is at or below 200% of the federal poverty level. See Section IV. Procedure 2.,
MHDDSA Fee Procedures.

When SSI is already established for a consumer the residential treatment provider shall verify the
monthly benefit. The residential treatment provider may request room and board from the LME if
the monthly benefit is less than the allowable $603.00 per month.

Emergency Authorization Requests

All publicly funded Non-Medicaid (e.g., IPRS) services reimbursed by Wake County LME require
pre-authorization. Emergency requests for services require authorization by the LME within one
business day.

If an authorization request is perceived to be a clinical emergency, follow the guidelines below. A
request is considered to be a clinical emergency if the client is experiencing an acute crisis with a
resulting increase in symptoms and is in imminent danger of severe consequences without
immediate intervention. Each Care Manager has the responsibility to determine what
constitutes a clinical emergency, taking the client‘s safety and the safety of others into
consideration.

To make an emergency request for authorization:
   1. Call the LME to alert that an emergency authorization is being requested. Contact your
      agency‘s Care Manager first. If the Care Manager is not available, then contact your
      agency‘s Data Support Specialist. If the Data Support Specialist is not available, then call
      250-3100 (the receptionist‘s desk), and that person will find someone who can assist you.
   2. Fax the authorization request to UR at 250-3761. On the fax coversheet, in bold, large
      letters, write ―emergency request‖ and provide a brief explanation as to why this is a
      clinical emergency. In order to receive an authorization, the following paperwork must be
      in place: the Consumer Enrollment Form, Demographic Form and Target Population
      Form. (Otherwise, a ―Receipt for Initial Request for Services‖ will be sent by UR in lieu of
      an authorization mailer).




                                      Section III - Page 13
                                                         Wake County LME Provider Manual 2008
                                                                                  SECTION III

Emergency authorization approval will be determined based upon clinical criteria. Payment can
be made only if all required documentation is received (the same documentation that is required
for routine authorizations) and the client meets financial criteria for Non-Medicaid funds.


Wake County LME Utilization Review Team contact information:

Call (919) 212-9398 or 212-7029 for an appointment to present a request for an initial child
residential treatment authorization.

Wake County LME Utilization Review Team
3010 Falstaff Road
Raleigh, NC 27610
Fax: (919) 250-3761

See Section I.3 List of Contacts for Data Support Specialist contact information.




                                     Section III - Page 14
                                                                 Wake County LME Provider Manual 2008
                                                                                          SECTION III


SECTION III Authorization Process
5. Procedures For Direct Enrolled Behavioral Health Outpatient Providers
Effective Date: September 1, 2005                    Version Date: 7/1/06
Informational Only  Requirement                    Reference:
Requirement Applies to Provider Type:
 Medicaid Basic Svc (Direct Enrolled)               CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)           Cat. A Licensed Facilities
Medicaid Enhanced Svc                               Cat. B Comm Based Providers
Non-Medicaid Contracted Svcs                        Cat. C Institutions/Facilities
ICF-MR                                               Cat. D Lic/Cert. Outpatient/Day Svcs

Purpose:
Behavioral Health Outpatient Providers who are direct enrolled with Medicaid must register with
Wake County LME in order to receive Medicaid referrals from the LME.

Registration of Direct Enrolled Behavioral Health Outpatient Providers

Agencies
Multi Specialty Agencies who do not have IPRS (non-Medicaid) contracts must register their direct
enrolled clinicians by submitting the Agency Direct Enrolled Provider Registration Form along with
the Independent Practitioner Form for each therapist. Wake County LME staff will contact the
provider for further information if needed.

Independent Practitioners
Independent Practitioners who are direct enrolled with Medicaid should complete and submit the
Independent Practitioner Direct Enrolled Provider Registration Form. If providers would like to
receive referrals from the LME, they must agree to the expectations listed on the registration
application. Once applications are processed and approved, you will receive a Memorandum Of
Agreement (MOA). This MOA does not guarantee referrals, but must be in place in order to use
the LME as a Medicaid referral source. For billing non-Medicaid services you must have an IPRS
contract in place.


B. Referral of Medicaid Recipients to Wake County Registered Direct Enrolled Medicaid
Behavioral Outpatient Providers

Medicaid Recipients Under The Age Of 21
Services provided to Medicaid recipients under the age of 21 require a referral by a Carolina
ACCESS Primary Care Provider (PCP), a Medicaid-enrolled psychiatrist, or the Local Managing
Entity (LME) (see North Carolina Medicaid Special Bulletin – January 2005). Initial
approval/referral comes through Child Mental Health Intake Assessment and Referral Services
(see contact info sheet). DMA regularly sends Wake County LME a list of clients seen by Direct
Enrolled Providers using the Wake County LME as the referral source. Wake County LME is
required to review the list to verify that all clients have been referred or approved through the LME
process outlined below. Any referrals not approved by WC LME are reported to DMA, which may
require payback for services to clients not referred.




                                             Section III - Page 15
                                                            Wake County LME Provider Manual 2008
                                                                                     SECTION III

Medicaid Recipients Age 21 And Over
Services provided to recipients age 21 and over may be self-referred or referred by any source.
However, when the recipient is referred by the Wake County LME, the procedures below will be
followed.

Medicaid Referrals From Wake County LME
Wake County LME will make referrals after either a face-to-face evaluation or a telephone
screening.
    a) When Wake County LME completes a telephone screening only,
       i) For adults, the provider will be contacted directly by the consumer.
       ii) For those under 21, the Provider will receive the Screening/Referral form (outlines
            basic demographic information and reason for requesting services), and the Referral
            Coversheet.
    b) When Wake County LME completes a face-to-face evaluation, the Provider will receive a
       full assessment packet, including the Screening/Referral and Referral Coversheet forms,
       with the referral.
    c) The Referral Coversheet will designate that the referral is an ―approved referral‖.
    d) The Provider will need to return the Referral Coversheet within the established timeframes
       to indicate the date of the first appointment, so that Wake County LME can confirm the
       Provider is accepting the client.
    e) Wake County LME will make all referrals based on screening/assessment results along
       with informed consumer choice to determine the most appropriate service matching for the
       family.
    f) Wake County LME staff will verify Medicaid prior to the initial referral. It is the responsibility
       of the provider to ensure that the Medicaid eligibility remains in effect.
    g) The provider is responsible for obtaining any reauthorizations through ValueOptions,
       following the criteria determined by DMA.

Approval Of Medicaid Recipient Self-Referrals
   a) WC LME reserves the right to require that the client come in for a face-to-face interview
      with Wake County LME before providing the referral.
   b) If a consumer/parent/guardian contacts a provider directly to obtain services for an
      individual under age 21, AND a referral is needed from the LME, the provider can either:
           o Refer the consumer/parent to Wake County LME to go through the process
              described above; or
           o Complete the Clinical Screening/Referral Form and fax it to Wake County LME
              (919-212-7024). The initial appointment date should be indicated on the Clinical
              Screening Form. Provider will receive an approval letter.
           o Wake County LME will verify Medicaid prior to giving the referral approval number
              but the provider is responsible for on-going verification.
   c) If the consumer is 21 years old or older, no referral is required.
   d) The provider is responsible for obtaining any reauthorizations through ValueOptions,
      following the criteria determined by DMA.




                                       Section III - Page 16
                                                                Wake County LME Provider Manual 2008
                                                                                         SECTION III


SECTION III Authorization Process
6. Non-Medicaid Appeal Rights
Effective Date: July 1, 2007                        Version Date: 7/1/07
Informational Only  Requirement                   Reference:
Requirement Applies to Provider Type:
 Medicaid Basic Svc (Direct Enrolled)              CAP/MRDD
Medicaid Basic Svc (Not Direct Enrolled)           Cat. A Licensed Facilities
Medicaid Enhanced Svc                              Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                      Cat. C Institutions/Facilities
ICF-MR                                              Cat. D Lic/Cert. Outpatient/Day Svcs

Appeals of LME Utilization Management decisions regarding Non-Medicaid funded
services:

Any LME Utilization Review decision to reduce, terminate, or otherwise deny payment for a
requested Non-Medicaid funded service is subject to an appeal request for a Clinical
Reconsideration Review if the consumer or legal representative is not in agreement with the
decision contained in the authorization letter. Non-Medicaid funded services are not an
entitlement; therefore, please be advised that filing a request for an appeal in no way
guarantees the consumer the specified service regardless of the outcome of the review.
Payment can be denied for services based on limitations of Non-Medicaid funding.

A request for an appeal of a clinical decision regarding Non-Medicaid funded services may be
filed either by the consumer, a legally responsible person, or any other individual who does not
have a conflict of interest. Although a service provider is deemed to have a financial conflict of
interest in a decision that would reduce or deny payment to that provider for a requested service,
it is an expectation that service providers will advise consumers of their right to file an appeal, and
may assist consumers in the process. Consumers, their legal representatives or service providers
may contact the Wake LME Utilization Review Team directly if they have any questions regarding
the appeal request process. The Clinical Reconsideration Review will be based on the following
criteria:

          The decision described in the letter is not consistent with established service definitions.
          The decision described in the letter is not clinically appropriate to the complainant‘s
           situation

The LME UR Team must receive the appeal request in writing within 10 days of the date of the
letter or other notification denying, reducing, or terminating Non-Medicaid funded services. A
Clinical Reconsideration Review will be completed by the LME Utilization Review Program
Manager or designated licensed UR staff within 5 days from receipt of the appeal request, and
may uphold or overturn the original decision. In cases in which the reviewer overturns the original
decision, the requested services may be authorized in those instances when Non-Medicaid
funds will be made available for such services, and an authorization letter will be issued
stating the date on which the denied service shall be authorized or the date on which the
suspended, reduced or terminated service shall be partially or fully reinstated. Phoning a UR
Care Manager or the UR Program Manager to request an ―expedited clinical review‖ will facilitate
appeals regarding emergency services.



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                                                       Wake County LME Provider Manual 2008
                                                                                SECTION III

Appeals to the North Carolina Division of Mental Health, Developmental Disabilities and
Substance Abuse Services:

This Non-Medicaid Appeals Process applies only to utilization management decisions that
have been through the local LME appeal/complaint process:

NC General Statute 143-B-147 (a) § 10.35.(a) required the adoption of rules permitting Non-
Medicaid eligible clients to appeal utilization management decisions made by an Area
Authority/County Program (LME) to the Division of Mental Health, Developmental Disabilities and
Substance Abuse Services. According to the statute, “the purpose of the appeal process is to
ensure that mental health, developmental disabilities, and substance abuse services are delivered
within available resources, to provide an additional level of review independent of the area
authority or county program (i.e.: LME) to ensure appropriate application of and compliance with
applicable statutes and rules, and to provide additional opportunities for the area authority or
county program to resolve the underlying complaint.” Please refer to Communication Bulletin #63
(―Non-Medicaid Appeal Process‖) located on the Department of Health and Human Services
website (www.ncdhhs.gov/mhddsas) for instructions and forms.




                                    Section III - Page 18
                                                                Wake County LME Provider Manual 2008
                                                                                         SECTION IV

SECTION IV Claims and Reimbursement
1. Human Services Fee Policy and Principles
Effective Date: July 1, 2005                        Version Date: 6/14/05
Informational Only  Requirement                   Reference: G.S. 122C-146
Requirement Applies to Provider Type:               CAP/MRDD
Medicaid Basic Svc (Direct Enrolled)               Cat. A Licensed Facilities
 Medicaid Basic Svc (Not Direct Enrolled)          Cat. B Comm Based Providers
 Medicaid Enhanced Svc
 Non-Medicaid Contracted Svcs                      Cat. C Institutions/Facilities
ICF-MR                                              Cat. D Lic/Cert. Outpatient/Day Svcs

Wake County Human Services (WCHS) and its contract Providers provide a range of physical and
behavioral health services, many of which may be mandated by state contracts, grants, or
participation in federal initiatives, or may be targeted to the needs of specific populations. WCHS
is committed to keeping these services within the reach of all Wake County residents including the
medically indigent and needy.

Policy: This policy applies to publicly funded physical health, mental health,
developmental disabilities, and substance abuse services provided by or reimbursed
through Wake County Human Services (WCHS) and the Wake County Local Managing
Entity.

     1. WCHS Services and its contract Providers will make every reasonable effort to
        collect appropriate reimbursement for the cost of providing services from
        individuals, insurance and other third parties.
     2. However, no individual will be denied services solely because of an inability to pay.
     3. Public funds (State, Federal and local) shall be utilized as the payor of last resort.
        Cost avoidance and post-payment recovery methods will be utilized to ensure
        public funds are the payor of last resort.
     4. Contract Providers agree to accept WCHS’ reimbursement rates for services.
     5. Contract and internal Providers shall utilize WCHS’ rules for establishing consumer
        residency and the consumer’s financial liability for services. The consumer’s
        financial liability for services shall be based on verified income and dependents.
     6. Consumers shall not be charged for services when State/Federal rules prohibit fees.

PRINCIPLES AND DEFINITIONS:
A. WCHS shall accomplish Cost Avoidance in two ways:
      1.    WCHS shall not purchase services that are both available in the community and
            reimbursed through first and/or third party payors. Consumers with third party
            coverage and/or sufficient personal funds shall be referred to community providers to
            the extent that services are available.
      2.    When WCHS contracts with community providers to serve consumers, the provider
            shall be reimbursed at the established rate less the amount of the consumer‘s liability.
B. The consumer‘s financial capacity to pay for services rendered will be determined through an
   Ability to Pay Assessment, which sets standards for determining and verifying income and
   number of dependents. The consumer‘s ability to pay shall be reassessed when income or
   dependents changes, and at least annually.
C. The Sliding Fee or Co-Pay Schedule shall establish the consumer‘s liability for services and
   is set by WCHS for its internal and contracted services not covered by Medicaid (Medicaid
   rules specify the consumer‘s liability for Medicaid-covered services).


                                             Section IV - Page 1
                                                            Wake County LME Provider Manual 2008
                                                                                     SECTION IV

       1.     The Sliding Fee Scale shall ensure that consumer fees are reasonable, given the
              family‘s income and dependents, and a combination of the service cost and the typical
              frequency and timeframe over which the service is provided. Under this principle,
              fees charged to consumers eligible for the sliding fee scale for acute, short term
              services are likely to be a higher proportion of the cost of the service than the fees for
              intensive, long-term services.
        2.    WCHS shall set the Sliding Fee Scale, which will result in a co-pay amount, or a
              percentage of the full cost of services, based on the criteria above.
        3.    The consumer‘s fee shall vary depending on the combination of income and number
              of dependents. Persons living close to or below prevailing federal poverty level shall
              have the lowest fees.
D.   Only Wake County residents are eligible for fee reductions according to the Sliding Fee
     Scale. County of residency shall be verified according to criteria set forth by WCHS.
E.   Payment Schedules may be arranged between the Provider Agency and the consumer,
     allowing the consumer to pay a portion of their total fees each month, according to rules
     established by the Provider.
F.   Fee Modifications shall be available for individuals due to financial hardship or clinical
     reasons. Fee modifications can result in further reductions of the consumer‘s fee or no fees.
     WCHS must approve modification to the consumer‘s liability for services.
G.   Third Party Payors shall be billed for covered services rendered. WCHS and the Provider
     Agency shall verify Medicaid, Medicare and/or other third party insurance coverage. WCHS
     and its contract Providers will comply with the rules and regulations of Medicaid, Medicare,
     and other third-party coverage applicable to each service.
H.   The Provider Reimbursement Rate Table shall list the rates at which contract Providers are
     reimbursed for services. Rates will be set by WCHS at the prevailing applicable State rates;
     in the absence of a State-wide rate, a reasonable rate shall be set based on the cost of
     providing the service. Exceptions to Statewide rates shall require approval by WCHS, and
     higher rates will only be allowed if State rates differ significantly from Provider costs and there
     are other funds available.
I.   The Consumer Fee Table shall specify the fees for services charged to consumers who are
     not eligible for a fee reduction – that is, those who are not a resident of Wake County, who did
     not complete the Ability to Pay Assessment, or who have an income too high for the Sliding
     Fee Scale. These rates are based on reasonable customary charges, State determined rate,
     market factors and/or cost, unless WCHS‘ Revenue and Services Director determines the
     service meets one of the following criteria for exclusion:
        1.    The service is primarily a service to the community; or
        2.    The service is primarily necessary due to government requirements; or
        3.    Due to the disability of the target population, the needed service would likely be
              refused if there were a charge.
        4.    The cost of the service relative to the earned income of consumers of that service
              would be prohibitive.
J.   Refusal to Pay: If a consumer has an ability to pay, but refuses to do so after reasonable
     collection efforts, the Provider is required to provide or arrange for emergency services and to
     ensure continuity of care per relevant State laws, standards of care and WCHS principles
     regarding transfers of consumers receiving services.

RESPONSIBILITIES:
A. WCHS Responsibilities:
    1.  Carry out the policies and principles delineated herein, including maintaining and
        updating related procedures.


                                        Section IV - Page 2
                                                       Wake County LME Provider Manual 2008
                                                                                SECTION IV

     2.   Establish and maintain the Sliding Fee Scale, including updates as the Federal
          Poverty Guidelines are revised or other conditions change.
     3.   Establish and maintain the Provider Reimbursement Rate Table and Consumer Fee
          Tables as rates and procedure/service definitions change.
     4.   Ensure the Ability to Pay Assessment is applied equitably and according to set
          criteria.
     5.   Process requests for Fee Modifications in a timely manner.
B. Provider Responsibilities It is the responsibility of internal and Contracted Provider
   Agencies to:
     1.   Carry out these policies and principles with regard to services/consumers funded by
          WCHS.
     2.   Assess the consumer‘s Ability to Pay according to WCHS‘ established criteria and
          procedures, and to provide supporting documentation as requested.
     3.   Establish and carry out first and third party collection procedures, including, but not
          limited to:
                  a. Establishing a consumer Financial Agreement that specifies the consumer‘s
                      financial liabilities and payment procedures;
                  b. Obtaining appropriate releases and pursuing third party reimbursement;
                      and
                  c. Submitting requests for Fee Modifications to WCHS, and, if applicable,
                      establishing Payment Schedules.




                                     Section IV - Page 3
                                                               Wake County LME Provider Manual 2008
                                                                                        SECTION IV


SECTION IV Claims and Reimbursement
2. MH/DD/SA Fee Procedures
Effective Date: May 1, 2006                        Version Date: 11/1/07
Informational Only  Requirement                  Reference: G.S. 122C-146
Requirement Applies to Provider Type:              CAP/MRDD
Medicaid Basic Svc (Direct Enrolled)              Cat. A Licensed Facilities
Medicaid Basic Svc (Not Direct Enrolled)          Cat. B Comm Based Providers
Medicaid Enhanced Svc                             Cat. C Institutions/Facilities
 Non-Medicaid Contracted Svcs                      Cat. D Lic/Cert. Outpatient/Day Svcs
ICF-MR


Purpose: To implement procedures consistent with the WCHS Fee Policy and Principles, that are
equitable for consumers, and are reasonable for both large and small Providers to carry out.

Overview:
1. WCHS and Providers of services subsidized by WCHS shall utilize the standardized fee
    application and determination process.
2. Consumers shall be charged co-pays according to the uniform Co-Pay Schedule for services
    authorized/subsidized by WCHS.
3. WCHS will not authorize services for individuals who are able to pay full cost according to
    the income guidelines, or for those who do not accurately complete the Fee Application.
4. Providers are to collect co-pays from consumers.
5. Contract Providers will be reimbursed for authorized Non-Medicaid services at the full rate
    for authorized services, less the amount of the established co-pay for the service provided.

Sections covered below:
   A. Responsibilities
   B. Guidelines for Obtaining Financial Information from Consumers
   C. Procedure For Processing Fee Applications
   D. Consumer Payment Options
   E. Fee Application & Co-Pay Schedule Frequently Asked Questions
   F. Consumer Co-Pay Schedule
   G. Income Guidelines
   H. Fee and Consumer Enrollment Forms List


A. Responsibilities:
 It is the responsibility of Wake County LME to administer the MHDDSA Co-Pay Schedule,
and to verify the consumer‘s eligibility for public funding of services.
 It is the responsibility of the Consumer to provide information required on the Fee Application
in order to be eligible for services subsidized by WC LME. The consumer is responsible for
paying the Provider the appropriate fees or co-pays for services rendered, and to inform their
provider and Wake County LME of changes in county of residency, income, dependents and
insurance coverage.
 It is the responsibility of the Provider to support the consumer in obtaining benefits, with a
priority on obtaining Medicaid coverage if the consumer meets eligibility criteria. It is also the
Provider‘s responsibility to explain to the consumer the expected cost of services specified in


                                            Section IV - Page 4
                                                          Wake County LME Provider Manual 2008
                                                                                   SECTION IV

their Person Centered Plan, and to make a reasonable effort to collect fees or co-pays from
consumers with an ability to pay.

B. Guidelines For Obtaining Financial Information From Consumers:

Initial Phone Contact:
    1. The screener should ask the caller if they have private insurance, and if so instruct the
         caller to contact their insurance company to find out what services and providers are
         covered.
    2. If the caller doesn‘t have private insurance, or knows their insurance does not cover
         MH/DD/SA services, the screener should inform the caller that there are fees for
         MH/DD/SA services, and of the application process for a reduced fee.
    3. If a referral is made, or an internal appointment is made that is more than 4 business
         days out, or the screener sends the consumer/guardian the Fee Application.
    4. If an internal appointment is made that is less than 4 business days out, the Screener
         reviews with the consumer the documentation the consumer must bring to apply for a
         reduced fee.

Initial Face-to-Face Contact, non-crisis situation
Step 1. Determine if consumer      - If the consumer has insurance coverage, the insurance
has private insurance coverage (if coverage is primary; public funds may not be utilized. The
no private insurance coverage,     consumer should be referred to their insurance carrier for
go to step 2)                      network providers if the Provider of this initial contact is not
                                   in their network.
                                   - If the consumer‘s insurance coverage does not cover
                                   needed services, obtain insurance information and
                                   proceed with step 2.
Step 2. Determine if the           - Ask for a copy of their Medicaid Card.
consumer has current Medicaid      - If they don‘t have one, check Medicaid eligibility online
eligibility, and the responsible   when access is available.
County. If Medicaid or             - If the consumer has a current Medicaid card, use the
HealthChoice eligible, complete    indicated County of Residence. If the consumer has
this step and then skip to Step 4. moved to Wake in the last 8 weeks and is in the process of
                                   transferring their Medicaid to Wake, the consumer can be
                                   considered a Wake County resident.
                                   - If the Medicaid County is other than Wake, Medicaid
                                   services may require authorization from the indicated
                                   County.
                                   Note- If Medicaid eligible (including HealthChoice) the
                                   consumer may also be eligible for WC LME subsidy of
                                   Non-Medicaid Services, if medically necessary and
                                   authorized. If authorization of non-Medicaid covered
                                   services is to be requested for a Medicaid eligible
                                   consumer, Target Population Eligibility is required.
Step 3. Complete Fee Application Staff should indicate ―est.‖ by all estimates
with consumer as accurately as
possible, using estimates where
necessary:




                                      Section IV - Page 5
                                                           Wake County LME Provider Manual 2008
                                                                                    SECTION IV

3.a. Verify address and county        If not a Wake County resident, explain that they are not
                                      eligible for a reduced fee and need to contact their
                                      County‘s LME to access public services. (Exception-
                                      CASP programs that receive special regional funding.)

3.b. Estimate eligibility Non-        - If consumer is estimated to be above 400% of poverty,
Medicaid reduced fee                  staff should inform the consumer that they are not likely to
                                      be eligible for public subsidy of services. If they are
                                      concerned that they are unable to afford services, have
                                      them complete both the Fee Application and the Financial
                                      Hardship form. Inform the consumer that they also have
                                      to meet clinical eligibility criteria.
                                      - If consumer is estimated to be at or below 400% of
                                      poverty, inform consumer of the service authorization
                                      request process. If initial services are authorized, services
                                      beyond 45 days are contingent on completion and
                                      verification of the Fee Application. Give consumer copy
                                      of Application with required documentation highlighted,
                                      and emphasize it is due in 15 days.
                                      - If consumer brought documents necessary to verify
                                      income, complete Fee Application and have signed by
                                      consumer/responsible party. Give copy to consumer, and
                                      submit with authorization request according to the
                                      procedure below. Inform the consumer that public funding
                                      for their services is contingent on their meeting clinical
                                      criteria, as well as verification of their Fee Application data.
                                      Be sure that they are clear that if the information on their
                                      Fee Application is false, they will be responsible for the full
                                      cost of services rendered.
Step 4. Have the consumer/
responsible party sign your
agency‘s Financial Agreement
and, if they have insurance,
Medicaid or Medicare, the Third
Party Agreement to cover
services specific to this Provider.


C. Procedure For Processing Fee Applications:

All requests for non-Medicaid authorizations (new and continuing) require that the consumer be
financially eligible for publicly subsidized services. The Fee Application is the means used to
determine the consumer‘s financial eligibility. The procedure for processing the Fee Application is
as follows:

   1. Wake County will attempt to determine financial eligibility for publicly funded services for
      new consumers who are seen at Wake‘s Crisis and Assessment Services (CAS).
      However, the financial information may be incomplete, and the referral is made to ensure
      services are initiated in a timely manner.
   2. The Lead Provider is responsible for ensuring that the Fee Application is completed and
      submitted on all Non-Medicaid consumers for whom an authorization is being requested


                                       Section IV - Page 6
                                                        Wake County LME Provider Manual 2008
                                                                                 SECTION IV

     from Wake County LME. The Fee Application is submitted to the Data Support
     Specialists. Lead Providers shall ensure that the Fee Application is completed annually
     and when the consumer‘ income, dependents or residency changes.
3.   In order for the Fee Application to be considered ―Complete‖:
          a. The application must be filled in completely
          b. The application must be signed by the consumer/guardian
          c. The required documentation must be submitted (see back of Application)
                    i. One proof of residency
                   ii. Proof of income for adults in family
4.   If an incomplete application is received:
          a. WCHS staff will send the provider the ―Notice That Non-Medicaid Service
               Authorization Request Can Not Be Processed‖.
          b. The authorization request will be held until the Application (or other missing
               information) is complete.
5.   If the Application is ―complete‖, and an authorization is granted, the authorization is
     effective:
          a. For new client authorization requests, the authorization will be effective with the
               admission date. Initial authorizations can be authorized retroactively up to 45
               days from the receipt of the complete application, or to the initial date of service,
               whichever is shorter.
          b. For continuing Authorization requests, the authorization will be effective no earlier
               than the date that the ―complete‖ Application was received. Thus, if the previous
               Fee Application is over a year old, and
                    i. the application is complete prior to the end of the previous authorization,
                       then the authorization will be effective continuously.
                   ii. the complete application is received after the previous authorization
                       expires, there will be a gap in the authorization.
6.   If the Fee Application is attached and complete, or it has been previously verified, the
     authorization request shall be processed as usual. Wake County Data Support
     Specialists will notify the Provider of the consumer‘s eligibility for Co-Pay Group A or B on
     a Fee Application Verification form when a Fee Application is processed, and also on the
     authorization mailer when a service is authorized.
7.   The consumer‘s eligibility for a Co-Pay can also be viewed on the Financial Caseload
     report that Wake LME distributes monthly.
          a. The financial caseload indicates the date the Fee Application was verified. If the
               information was incomplete, it will indicate the date the Fee Application was
               estimated. Estimated applications will still require verification, and the missing
               information will be required.
          b. If the Fee Application verified date is present, the ―Total # Supported‖ (dependents)
               and ―Annual Income‖ will be displayed. The ―Co-Pay‖ column indicates if the
               consumer falls in Co-Pay Group A, B, or Full Fee.
8.   The first column on the report indicates the Lead Provider with an ―L‖. If the consumer is
     open to only one program/provider, that provider is the Lead Provider. If the consumer is
     open to two or more Provider agencies, the Provider that is highest on the Lead Provider
     hierarchy is the lead provider (see Wake County LME Provider Manual procedure VII.1,
     Lead Provider). When a consumer is being served by more than one agency, it is
     important that the agencies discuss and coordinate completion of the application.
     Although it is the responsibility of the Lead Agency to ensure the application is completed,
     it will certainly be accepted if it is submitted with the secondary agency‘s authorization
     request.



                                    Section IV - Page 7
                                                         Wake County LME Provider Manual 2008
                                                                                  SECTION IV

   9. If a consumer has Medicaid, and you are requesting authorization for a non-Medicaid
       service, a Fee Application is not required. The exception to this rule is for Child Room and
       Board, in which case the application is required.
   10. Criteria for eligibility for public subsidy of Child Room and Board for recipients of
       Residential Treatment have been established by the State:
            a. The consumer‘s gross family income is at or below 200% of poverty, AND the
               consumer has applied for SSI and received two denials, OR
            b. The consumer‘s gross family income is at or below 200% of poverty AND SSI has
               been approved at less than the full rate. In this case, Room and Board can only be
               authorized up to the monthly amount ($603 less the amount of the SSI).
       See the Room and Board Authorization Request form for instructions.
   11. The consumer‘s eligibility for public subsidy of services shall be re-assessed when their
       income, county of residency, insurance coverage, or number of dependents changes, and
       at least annually with the PCP or Service Plan.
   12. The payment to the provider shall be reduced by the co-pay amount for applicable
       services for consumers in Co-Pay Group B. For consumers who have third party
       coverage other than Medicaid, the insurance must be filed prior to billing WCHS for the
       uncovered portion of the service cost (see procedure IV.9 Non-Medicaid Services
       Payment Processing).


D. Consumer Payment Options

1. Payment Deferment: Sometimes, for clinical reasons, it may not be therapeutic for a
consumer to receive a billing statement for a temporary period of time. A payment deferment can
be requested; fees for services are not discontinued, however. Billing statements shall resume at
a later date inclusive of fees that have accrued. Payment Deferment may be arranged within a
Provider agency, without WC LME approval.

2. Payment Schedule: At the time that a client‘s fee is assessed, or as requested, a Payment
Schedule may be arranged. This schedule will allow the client to pay a minimum amount per
month. The payment schedule should specify the largest monthly payment the client can afford.
This payment schedule will be reassessed at least annually. Payment Schedules may be
arranged within a Provider agency, without WC LME approval.

3. Fee Modification: A consumer‘s co-pay/fee may be modified or waived for the reasons of
financial hardship and/or clinical concerns. Requested fee modifications must be approved by the
requesting party‘s clinician‘s supervisor and requires approval of the WC LME.

Fee Modification due to clinical reasons may be granted in instances when the expected cost of
services, and the consumer‘s mental illness or addiction makes it unlikely he/she would continue
in services, or receive the course of treatment necessary to:
 keep the consumer and/or others he/she has contact with safe from harm (this may include
   women who are pregnant and currently using alcohol and/or other drugs, as well as individuals
   who are IV drug users and/or have a communicable disease such as TB, AIDS, etc.), OR
 maintain the consumer in the community (prevent hospitalization).


Fees may also be waived for individuals under the age of 18 who are requesting substance abuse
or mental health treatment without the consent or knowledge of their parent(s) or legal guardian(s)
and have inadequate financial resources of their own. These waivers are also requested on the
Clinical Exception form.


                                     Section IV - Page 8
                                                     Wake County LME Provider Manual 2008
                                                                              SECTION IV


Co-Pay/Fee Modification due to financial hardship may be granted in two situations:
1. When the consumer/family has medical expenses that, when deducted from their gross
   income, results in an income less than 400% of poverty, or
2. When the consumer/family has paid 5% of their gross income for MHDDSA services in a
   calendar year.

The Fee Modification Request forms must be submitted to Wake County LME for approval.
Instructions for accessing forms are found in the last section of this procedure.




                                   Section IV - Page 9
                                                          Wake County LME Provider Manual 2008
                                                                                   SECTION IV


E. Fee Application & Co-Pay Schedule Frequently Asked Questions (from the Consumer‘s
perspective)

Question                                    Answer
Why do I have to pay for services?          State law requires that the County charge fees when
                                            the individual has an ability to pay. (See NC General
                                            Statute 122C-146)
I didn‘t have a fee before, why do I        With Mental Health reform, the State has been
have one now?                               implementing a lot of changes in how mental
                                            health/substance abuse/developmental disabilities
                                            services are administered. In the past, some programs
                                            charged fees and some did not. This new Co-Pay
                                            schedule ensures that all programs that receive public
                                            funding charge the same co-pays for the same
                                            services.
On the Fee Application, who all should      Do include your immediate family members (minors
be counted in the Family Size?              include parents and minor siblings, adults include
                                            spouses and minor children). Do not include adult
                                            children, parents of adult consumers, or other unrelated
                                            people who live with the family, unless they are the
                                            parent of a minor child who is counted.
On the Fee Application, whose income        Include the income of all the adults that are included in
should be included?                         the Family Size. Income should be gross income
                                            (before taxes – not your take-home income). Annual or
                                            monthly amounts are preferred over hourly.
My income has changed or was not            Please get with your service provider to complete a new
correctly verified previously.              Fee Application. Be sure to bring proof of income and
                                            residency:
                                            Proof of Income: 2 most recent pay stubs, Form 1040
                                            or 1040ez (most recent) or W-2, plus proof of other
                                            sorts of income, like Social Security, VA benefits,
                                            unemployment, etc.
                                            Proof of Residency: Utility bill address, bank statement
                                            address, rental agreement, motor vehicle registration.
I fall in Co-Pay Group B, receive           If you have high medical or related bills, you can
Behavioral Health Outpatient Services,      complete a Financial Hardship form to request zero co-
and can‘t afford the co-pay.                pay. You can get a copy of the form from your service
                                            provider. You will need to prove your expenses with
                                            copies of your bills. You will be notified if your request
                                            is approved by mail from the WCHS business office.




                                       Section IV - Page 10
                                                              Wake County LME Provider Manual 2008
                                                                                       SECTION IV

Question                                       Answer
I don‘t have any regular income, except        If you earn any income, on the Fee Application,
I am sometimes paid for odd jobs, so I         estimate what you earn in an average month on the
don‘t have any pay stubs or tax forms.         ―Income from Self Employment‖ line. On the second
How do I prove my income?                      page, write in "None" by the Proof of Income
                                               documents list. Sign the form attesting to the accuracy
                                               of what you have reported. If you falsify your income,
                                               and it is discovered later, you will be responsible for the
                                               full cost of services provided. If Wake County does not
                                               find evidence of income when verifying your application
                                               against data reported by employers, you will not need
                                               to submit additional documentation. However, if you
                                               have recently been receiving an income but lost your
                                               job, we will need proof of the change in your income
                                               (that is, a termination letter or Income/Residency
                                               Confirmation Letter) because the income reported by
                                               your previous employer will differ from what you
                                               reported on your Fee Application.
My income is over 400% of poverty –            Your service provider sets the fees for full cost or self-
what will services cost?                       pay consumers, not the County. Please talk to your
                                               service provider.
My income is over 400% of poverty,                   If you have high medical and related expenses,
and I can‘t afford full fee.                            you can apply for a Financial Hardship
                                                        exception. If approved, WCHS may subsidize
                                                        your services, and you may only be responsible
                                                        for the co-pay. You can get a copy of the form
                                                        from your service provider (or offer to mail a
                                                        copy to them). You will need to prove your
                                                        medical expenses with copies of your bills. You
                                                        will be notified if your request is approved.
                                                     If you are not eligible for a Financial Hardship
                                                        exception based on medical expenses, you can
                                                        apply for a hardship when your mental
                                                        health/substance abuse/developmental
                                                        disabilities services cost 5% of your gross family
                                                        income in a calendar year. For example, a
                                                        family with a gross annual income of 50,000
                                                        may be eligible for an exception when their out
                                                        of pocket mental health expenses reach $2,500
                                                        (5% of $50,000).
                                                     You can also talk to your provider about a
                                                        payment plan to spread the cost of your services
                                                        over time.
What happens if I don‘t pay?                   Each service provider sets their own payment and
                                               collection procedures. Please contact your service
                                               provider for that information.
Can I still receive services if I don‘t        That is between you and your service provider. Service
pay?                                           providers are not required to continue providing
                                               services to someone who has an ability to pay, but
                                               refuses to do so.



                                          Section IV - Page 11
                                                            Wake County LME Provider Manual 2008
                                                                                     SECTION IV

Question                                     Answer
Why do mental health/substance               State, federal and local tax dollars are not sufficient to
abuse/developmental disabilities             pay for everyone who needs mental health/substance
services cost?                               abuse/developmental disabilities services, so public
                                             money is reserved for those who are least able to pay
                                             on their own.
Do I have to pay at the time of my visit?    Please contact your service provider for that
                                             information.
I filled out the Fee Application, but I      There may be a couple of reasons for this:
have not yet been approved for a Co-              Your application has not yet been verified by
Pay.                                                 Wake County LME.
                                                  Or, your Fee Application was missing required
                                                     documentation, or the information appeared
                                                     inconsistent. For example, proof of income of
                                                     each adult in the family is required.
Most common reasons Fee                           There are two adults listed, and income
Applications are considered                          documents were only provided for one adult.
incomplete:                                       The income listed on the Fee Application is
                                                     different from what was reported by your
                                                     employer.
                                                  Income from a second job, or self-employment,
                                                     was omitted from the Fee Application.
                                                  No or incomplete proof of income.
                                                  No proof of residency. Only Wake County
                                                     residents are eligible for services subsided by
                                                     WCHS. (There are a few regional CASP funded
                                                     programs that allow consumers to reside in
                                                     other counties –Southlight Wakeview or
                                                     Perinatal, and WCHS Deaf Program, Hilltop
                                                     Home).
Why do I need to submit a Fee                Wake County contracts with 150 private and nonprofit
Application to Wake County to get low        community agencies and therapists to provide mental
cost services?                               health/substance abuse/developmental disabilities
                                             services for eligible consumers. Public (taxpayer)
                                             funding for services is managed by Wake County.
I had a job but I lost it, so I no longer    Contact your service provider and complete a new Fee
make the income reported by my               Application with your current income and attach a
employer.                                    termination letter from your employer.
Where can I send the application and         Please submit it to your service provider, or to the
documentation?                               Wake County address on the form.




                                        Section IV - Page 12
                                                                Wake County LME Provider Manual 2008
                                                                                         SECTION IV

F. Consumer Co-Pay Schedule
The Co-Pays listed below apply to Non-Medicaid services authorized by Wake County LME. Clinical or
Financial Hardship exceptions may be requested for consumers with fees. Consumers may also apply for
Financial Hardship when their out-of-pocket cost has reached 5% of their gross income for the calendar
year.
Co-Pay Schedule
Based on the consumer‘s family gross income and family size, relative to the Federal Poverty Guidelines.
                          Financial Level Groupings:
                                                               Co-Pay Group B
                              Co-Pay Group A                                                     Full Fee
                                                            Income above 200% of
                            Income at or below                                                Income above
Service Category:                                           Poverty, up to 400% of
                               200% Poverty                                                  400% of Poverty
 (defined below)                                                   Poverty
      Behavioral Health
                                      $0                     $5.00 per service event              Full Fee
            Outpatient
     Intensive Services               $0                                $0                        Full Fee
      Substance Abuse
                                      $0                           $ 50 per day                   Full Fee
    Inpatient and Detox
   Child Room & Board                 $0                             Full Fee                     Full Fee
Service Categories
Behavioral Health Outpatient                Intensive Services
Individual Therapies                        Adult Day Vocational Program (ADVP)
Group Therapies                             Assertive Community Treatment Team (ACT)
Family Therapies                            Child Day Treatment
Medication Evaluation/Check                 Child Residential Treatment (.1700/1300)
Psychological Testing                       Community Support
Medically Supervised Observation            Community Support Team
Assessment/ Evaluation 90801                DD Personal Assistance
                                            DD Personal Care
                                            DD Targeted Case Management
Services with Specific                      Developmental Day
Co-Pays                                     Developmental Therapies
Detox                                       Diagnostic Assessment
Substance Abuse Inpatient                   Intensive In-Home Services
Child Room and Board in Residential         Long Term Vocational Support
Treatment                                   Multi-systemic Therapy
                                            Partial Hospitalization
                                            Physician‘s charges, meds and lab work are included in the client‘s
                                            per diem for Detox and Substance Abuse Inpatient
                                            Psychosocial Rehabilitation
                                            Substance Abuse Comprehensive Outpatient Treatment
Involuntary Commitment                      Substance Abuse Intensive Outpatient Program
Evaluations and Screenings are              Supervised & Group Living, SA Halfway House (.5600 etc)
not charged to the consumer.                Supported Employment
The consumer is not eligible for public subsidy of service cost when:
 The consumer‘s household income is over 400% of poverty (exceptions may be requested).
 The consumer is not a Wake County resident (exception for special regional ―CASP‖ service recipients).
 The consumer refused to apply for Reduced Fee.
 The Fee Application was incomplete.
 The consumer does not meet diagnostic and clinical criteria.
 Eligible consumers may not receive authorization if funding is unavailable or there is a waiting list for
  services.
                       THIS CO-PAY SCHEDULE IS SUBJECT TO CHANGE.



                                           Section IV - Page 13
                                                           Wake County LME Provider Manual 2008
                                                                                    SECTION IV


G. Income Guidelines
Based on Federal Poverty Guidelines (source: Federal Register January 24, 2007)


                                                 Co-Pay Group B:
                     Co-Pay Group A                                                Full Fee
Persons in                                    Income above 200% of
                   Income at or below                                        Income above 400% of
  Family                                      Poverty, up to 400% of
                      200% Poverty                                                 Poverty
                                                     Poverty
     1                 0 to $20,420             $20,421 to $40,840                Above $40,840
     2                 0 to $27,380             $27,381 to $54,760                Above $54,760
     3                 0 to $34,340             $34,341 to $68,680                Above $68,680
     4                 0 to $41,300             $41,301 to $82,600                Above $82,600
     5                 0 to $48,260             $48,261 to $96,520                Above $96,520
     6                 0 to $55,220            $55,221 to $110,440                Above $110,440
     7                 0 to $62,180            $62,181 to $124,360                Above $124,360
     8                 0 to $69,140            $69,141 to $138,280                Above $138,280
     9                 0 to $76,100            $76,101 to $152,200                Above $152,200
     10                0 to $83,060            $83,061 to $166,120                Above $166,120

―Persons in Family‖ includes immediate family only – adults and children.
―Income‖ equals the gross income for all adults in the family.

―Full Fee‖ consumers should contact their service provider regarding fees for services and
payment options.




                                      Section IV - Page 14
                                                            Wake County LME Provider Manual 2008
                                                                                     SECTION IV

H. Fee and Consumer Enrollment Forms List


 REGISTRATION FORMS                        When used:                                   Smartworks
                                                                                        Form #
 Demographic Form                          Required at intake, if not already           HS 2965
                                           completed when referred by WCHS
 Consumer Enrollment                       Required at intake                           HS 2953
 WCHS Financial Agreement                  Required at intake – Community               HS 2954
                                           Providers should use their own version
 WCHS Third Party Release                  Required when consumer has                   HS 524
                                           insurance and insurance is added or
                                           changed - Community Providers should
                                           use their own version
 Fee Application                           Required at intake and annually when         HS 3238
                                           consumer does not have Medicaid
 Income / Residency Confirmation           Required for non-Medicaid consumers          HS 3253
 Letter                                    whose income has changed recently or
                                           need proof of residency
 Adult Medicaid Screening                  Required for Non-Medicaid consumers          HS 3378
                                           when Provider is billing for Benefit
                                           Eligibility Screening service
 Child Medicaid Screening                  Required for Non-Medicaid consumers          HS-3419
                                           when Provider is billing for Benefit
                                           Eligibility Screening service
 Financial Hardship - Fee                  May be used to request a fee reduction       HS 3254
 Modification Request
 Clinical Exception - Fee                  Clinician may use to request a fee           HS 3255
 Exception Request                         reduction
 WCHS Payment Schedule                     May be used, if requested, to allow          HS 3256
 Agreement                                 consumer to pay their balance over
                                           time – Community Providers should use
                                           their own version
 Address Update                            Used to update WCHS computer when            HS 533
                                           the consumer‘s address changes

To get these forms, go to www.smartworks.com. Click on SMARTworks 6.0 Login in the upper
right hand section.
        User Name: wcprovider
        Password: forms

Click on Browse Catalogs, choose the catalog MH/DD/SA Internal Providers or Wake County
Providers, and then click on forms. The forms are listed in number order. You can browse to
find your form,
        OR
Click on Product Search and type in part of the name in Description to find the form.

Click on the printer icon beside the form to view it. After it pulls up the form, click on the printer
icon on the toolbar to print it.




                                       Section IV - Page 15
                                                                 Wake County LME Provider Manual 2008
                                                                                          SECTION IV


SECTION IV Claims and Reimbursement
3. Reimbursement Rate Table
Effective Date: July 1, 2006                         Version Date: 12/1/07
Informational Only  Requirement                    Reference: G.S. 122C-146
Requirement Applies to Provider Type:                CAP/MRDD
Medicaid Basic Svc (Direct Enrolled)                Cat. A Licensed Facilities
 Medicaid Basic Svc (Not Direct Enrolled)           Cat. B Comm Based Providers
Medicaid Enhanced Svc                               Cat. C Institutions/Facilities
 Non-Medicaid Contracted Svcs
                                                      Cat. D Lic/Cert. Outpatient/Day Svcs
ICF-MR

Procedure:
1. Services are only reimbursable when the Provider is licensed, certified, or accredited to
    provide that service, the Provider has received consumer-specific authorization per contract
    Authorization requirements, AND the Provider has accurately completed required Consumer
    Enrollment paperwork.
2. Non-Medicaid services are billed on the WCHS Service Billing Form or the NON-MEDICAID
    BEHAVIORAL HEALTH OUTPATIENT Direct Enrolled Provider Claim Form, and are
    reimbursed at the listed rates. Non-Medicaid services must be billed using the WCHS Non-
    Medicaid Billing Code (first column). Rates are subject to change based on State and
    Medicaid rate changes and changes in availability of funds. Individualized rates may be
    negotiated in special circumstances.
3. Medicaid services should be billed directly to EDS using the State code, at the Provider‘s
    Usual and Customary Rates.
4. The Provider is responsible for ensuring that the services meet Medicaid and IPRS
    definitions.

CPT Code Services:

   Non-    Service Description                          MD          Lic-Cert*       Nurse      PhD
Medicaid &                                              Rate          Rate          Rate      Psych
State Code                                                                                     Rate

   90772      Medication Administration                $16.62         #N/A          #N/A       #N/A

   90801      Clinical Intake                         $133.58        $100.19       $113.54    $133.58

   90802      Interactive Evaluation                  $141.64        $106.23       $120.40    $141.64

   90804      Individual Therapy (20-30 min)           $56.85        $42.64        $48.32     $56.85

   90805      Individual Therapy (20-30 min) MD        $74.17         #N/A          #N/A       #N/A

   90806      Individual Therapy (45-50 min)           $82.94        $62.20        $70.50     $82.94

   90807      Individual Therapy (45-50 min) MD       $104.69         #N/A          #N/A       #N/A

   90816      Individual Therapy (30 min)              $55.28        $41.46        $46.99     $55.28

   90817      Individual Therapy (30 min) MD           $61.01         #N/A          #N/A       #N/A


                                             Section IV - Page 16
                                                                 Wake County LME Provider Manual 2008
                                                                                          SECTION IV

   Non-    Service Description                          MD          Lic-Cert*   Nurse         PhD
Medicaid &                                              Rate          Rate      Rate         Psych
State Code                                                                                    Rate

   90818       Individual Therapy (50 min)             $83.02        $62.27     $70.57       $83.02

   90819       Individual Therapy (50 min) MD          $87.63         #N/A      #N/A         #N/A

   90846       Family Therapy wo/patient               $80.89        $60.67     $68.19       $80.89

   90847       Family Therapy w/patient                $99.33        $74.50     $81.33       $99.33

   90853       Group Therapy                           $27.94        $20.95     $22.62       $27.94

   90862       Medication Check - Individual           $55.48         #N/A      #N/A         #N/A

   96101       Psychological Testing (per hour)        $80.51        $60.38     #N/A         80.51

   96111 Developmental Testing - Extended       $120.20              $90.15     #N/A         120.20
* Lic-Cert includes LPA, LPC, LCSW, LMFT, CCS, and LCAS


Behavioral Health Outpatient H-Code Rates

                                                                                  Other QP*
WCHS Non-
                  State                                                          Rate (Billed
 Medicaid                          Service Description
Billing Code      Code                                           Direct Enrolled   through
                                                                 Provider Rate       LME)
    602          H0001  Behavioral Health Assessment                 $22.00         $15.40
                        Behavioral Health Counseling and
    604         H0004                                                 $22.00        22.00
                        Therapy
   8004        H0004:HQ DMH Outpatient Treatment Group                 $8.11        $8.11
                        DMH Outpatient Tx Family Therapy
   8002        H0004:HR                                               $22.00        $22.00
                        w/ Client
                        DMH Outpatient Tx Family Therapy
   8003        H0004:HS                                               $22.00        $22.00
                        w/o Client
                        Alcohol and/or Drug Services;
   8013         H0005                                                  $8.11        $5.68
                        Group Counseling by Clinician
   8001         H0031 Mental Health Assessment                        $22.00        $15.40

* ―Other QP‖ are practitioners that do not qualify for direct enrollment.

Note: MD‘s cannot bill Behavioral Health Outpatient H-codes




                                             Section IV - Page 17
                                                              Wake County LME Provider Manual 2008
                                                                                       SECTION IV

Service Code and Rate Table
(See above for Behavioral Health Outpatient Codes and Rates)
 WCHS Non-           State    Service Description                           Unit            WCHS
Medicaid Billing     Code                                                                Max. Rate for
    Code                                                                                   FY07-08
      776          H0012:HB SA Non-Medical Community Residential          1 day (limit          $145.50
                                                                             to 30
                            Treatment - Adult                               day/yr)
      608           H0015   SA Intensive Outpatient Program                 1 event              $131.93
     8501           H0019   Behavioral Health Long Term Residential         1 day
                            (level 3, <5 bed)                                                      252.38
     8502           H0019 Behavioral Health Long Term Residential           1 day
                            (level 3, 5+bed)                                                       205.64
     8503           H0019 Behavioral Health Long Term Residential           1 day
                            (level 4, <5 bed)                                                      342.15
     8504           H0019 Behavioral Health Long Term Residential           1 day
                            (level 4, 5+ bed)                                                     342.15
      609           H0020 Opioid Treatment (Medicaid Only)                  event                 $19.17
     8103           H0035 Partial Hospitalization MH Tx - Child, min. 3    1 event               $121.69
                            hrs
     8104           H0035 Partial Hospitalization MH Tx - Adult, min. 3    1 event               $121.69
                            hrs
     8020          H0036:HA Community Support Individual-Child              15 min                 $12.82
                                                                                         before 12/1/2007
     8070           H0036: Community Support Individual- Child -QP          15 min                 $12.82
                    HA:U3                                                                         starting
                                                                                                12/1/2007
     8071           H0036: Community Support Individual- Child- non         15 min                 $12.82
                    HA:U4 QP                                                                      starting
                                                                                                12/1/2007
     8022          H0036:HB Community Support Individual-Adult              15 min                 $12.82
                                                                                         before 12/1/2007
     8075           H0036: Community Support Individual-Adult-QP            15 min                 $12.82
                    HB:U3                                                                         starting
                                                                                                12/1/2007
     8076           H0036: Community Support Individual-Adult-non           15 min                 $12.82
                    HB:U4 QP                                                                      starting
                                                                                                12/1/2007
     8024          H0036:HQ Community Support Group                         15 min
                                                                                                   $4.12
     8105           H0040    Assertive Community Treatment Team              1 day               $323.98
                                                                            (4/mo)
     8508           H0046 Residential Level 1                                1 day                 $53.59
     8101          H2012:HA Day Tx, Behavior Health - Child                 1 hour                 $31.25
     8026           H2014 Developmental Therapies- Profes. Individ.         15 min                  $8.34
     8025          H2014:HM Developmental Therapies-                        15 min                  $6.01
                            Paraprofessional Individual
     8028          H2014:HQ Developmental Therapies- Profes. Group          15 min                  $5.00
     8027          H2014:U1 Developmental Therapies-                        15 min                  $2.01
                            Paraprofessional Group
     8030          H2015:HT Community Support Team                          15 min                $16.52
     8012           H2017 Psychosocial Rehabilitation                       15 min                 $2.90
     8507           H2020 Therapeutic Behavioral Service Level 2            1 day                $136.04
     8040           H2022 Intensive In-home                                 1 day                $190.00


                                         Section IV - Page 18
                                                              Wake County LME Provider Manual 2008
                                                                                       SECTION IV

 WCHS Non-          State     Service Description                           Unit            WCHS
Medicaid Billing    Code                                                                 Max. Rate for
    Code                                                                                   FY07-08
     8050           H2033     Multi-systemic Therapy                        15 min               $23.54
     8107           H2034     SA Halfway House                               1 day               $55.29
     8106           H2035     SA Comprehensive Outpatient Program         1 hour (4 hr           $45.76
                                                                           minimum)
     8506           S5145     Foster Care Therapeutic Child Level 2          1 day                $95.40
     8015          T1017:HI   Targeted Case Management-DD                   15 min                $22.66
     8016           T1023     Diagnostic Assessment                         1 event              $169.06
     7125           YA125     Hourly Respite - CTSP Only                    15 min                 $5.00
     7230           YA230     Psychiatric Resid. Treatment Facility          1 day               $465.01
     7232           YA232     Room & Board Level III (1-4 beds)              1 day                $20.10
     7233           YA233     Room & Board Level III (5+ beds)               1 day                $20.10
     7234           YA234     Room & Board Level II (Age 5 or <)             1 day                $13.00
     7235           YA235     Room & Board Level II (Age 6-12)               1 day                $14.66
     7236           YA236     Room & Board Level II (Age 13 or >)            1 day                $16.33
     7237           YA237     Room & Board Level IV (1-4 beds)               1 day                $20.10
     7238           YA238     Room & Board Level IV (5+ beds)                1 day                $20.10
     7280           YA254     Ther. Leave -Resid Level II -Ther Hme          1 day                $95.40
     7281           YA255     Ther. Leave -Resid Level II -Grp Hme           1 day               $136.04
     7282           YA256     Ther. Leave -Resid Level III(1-4 Beds)         1 day               $252.38
     7283           YA257     Ther. Leave -Resid Level III( 5+ Beds)         1 day               $205.64
     7284           YA258     Ther. Leave -Resid Level IV(1-4 Beds)          1 day               $342.15
     7285           YA259     Ther. Leave -Resid Level IV(5+ Beds)           1 day               $342.15
     7370           YA370     Specialized Summer Program                    15 min                 $3.58
     8029           YM050     Personal Care                                 15 min                 $3.36
      778           YM645     Long-term Vocational Supports                 15 min                $11.21
      639           YM686     Guardianship                                   1 unit       Client Specific
      810           YM700     Independent Living-MR/MI                       1 day        Client Specific
      821           YM811     Sup Living – 1 Res- Level A                    1 day                330.00
     9821           YM811     Sup. Living – 1 Res Level A Therap. Leave      1 day                330.00
      822           YM811     Sup Living – 1 Res- Level B                    1 day                370.00
     9822           YM811     Sup. Living – 1 Res Level B Therap. Leave      1 day                370.00
      823           YM811     Sup Living – 1 Res- Level C                    1 day                380.00
     9823           YM811     Sup. Living – 1 Res Level C Therap. Leave      1 day                380.00
      812           YM812     Supervised Living – 2 Resident                 1 day               $161.99
     9812           YM812     Superv. Living – 2 Resident Therap. Leave      1 day               $161.99
      813           YM813     Supervised Living – 3 Resident                 1 day               $116.15
     9813           YM813     Superv. Living – 3 Resident Therap Leave       1 day               $116.15
      814           YM814     Supervised Living – 4 Resident                 1 day                $93.17
     9814           YM814     Superv. Living – 4 Resident Therap Leave       1 day                $93.17
      815           YM815     Supervised Living – 5 Resident                 1 day                $77.67
      816           YM816     Supervised Living – 6 Resident                 1 day                $68.83
      115           YP010     Hourly Respite – Individual                   15 min                 $5.00
      117           YP011     Hourly Respite – Group                        15 min                 $1.67
      684           YP020     Personal Assist – Individual                  15 min                 $4.46
      663           YP610     Developmental Day (inc. Before/After)         15 min                 $2.50
      660           YP620     ADAP/ADVP                                     15 min                 $1.25
      644           YP630     Supported Employment – Individual             15 min                $11.21
      662           YP640     Supported Employment – Group                  15 min                 $2.53
      630           YP660     Day Activity                                  15 min                 $3.75


                                          Section IV - Page 19
                                                            Wake County LME Provider Manual 2008
                                                                                     SECTION IV

 WCHS Non-         State   Service Description                          Unit        WCHS
Medicaid Billing   Code                                                          Max. Rate for
    Code                                                                           FY07-08
      751          YP710   Supervised Living – Low                      1 day            $28.92
     9751          YP710   Supervised Living – Low Ther Leave           1 day            $28.92
      752          YP720   Supervised Living – Moderate                 1 day            $55.11
      757          YP720   Intensive Supervised Living                  1 day           $180.23
     9757          YP720   Intensive Supervised Living- Ther Leave      1 day           $180.23
      781          YP730   Community Respite                            1 day           $214.38
      761          YP740   Family Living – Low                          1 day            $50.00
      763          YP750   Family Living – Moderate                     1 day            $52.03
      771          YP760   Group Living – Low                           1 day            $55.29
     9771          YP760   Group Living – Low Ther Leave                1 day            $55.29
      772          YP770   Group Living – Mod A                         1 day            $70.95
      775          YP770   Group Living – Mod B                         1 day            $75.48
     9772          YP770   Group Living – Mod A Ther Leave              1 day            $70.95
     9775          YP770   Group Living – Mod B Ther Leave              1 day            $75.48
      773          YP780   Group Living – Hi                            1 day           $141.51
     9773          YP780   Group Living – Hi Ther Leave                 1 day           $141.51
      625          YP830   YP830 Alcohol/Drug Assessment non-           15 min           $15.40
                           licensed SA professional
      626          YP831   Behavioral Health Indiv. Counseling non-     15 min          $22.00
                           licensed SA professional
     8017          YP832   Behavioral Health Group Therapy non-         15 min            $8.11
                           licensed SA professional
     8018          YP833   Family Therapy with Client non-licensed      15 min          $22.00
                           SA professional
     8019          YP834   Family Therapy without Client non-licensed   15 min          $22.00
                           SA professional
     8014          YP835   Alcohol/Drug Group Counseling non-           15 min            $5.68
                           licensed SA professional
     8060           NA     Benefits Eligibility Screening               15 min            $5.00




                                       Section IV - Page 20
                                                                Wake County LME Provider Manual 2008
                                                                                         SECTION IV


SECTION IV Claims and Reimbursement
4. Child Residential Service Codes
Effective Date: Jan. 1, 2004                        Version Date: 7/1/06
Informational Only  Requirement                   Reference:
Requirement Applies to Provider Type:               CAP/MRDD
Medicaid Basic Svc (Direct Enrolled)               Cat. A Licensed Facilities
Medicaid Basic Svc (Not Direct Enrolled)           Cat. B Comm Based Providers
 Medicaid Enhanced Svc                             Cat. C Institutions/Facilities
 Non-Medicaid Contracted Svcs
                                                     Cat. D Lic/Cert. Outpatient/Day Svcs
ICF-MR

Where to Bill and Code Ranges:

Consumer Eligibility:             Treatment             Tx Ther. Leave*             Room&Board

Medicaid       CTSP/       Medicaid: H0019, S5145, Medicaid: H0019,            IPRS: YA232, YA233,
               CMSED       H2020,H0046 via         S5145,H2020,                YA234, YA235, YA236,
                           HCFA/NCECS              H0046 via UB92              YA237
                                                   WITH RC 183
Medicaid     Child (non- Medicaid: H0019, S5145, Medicaid: H0019, S5145,       not covered by State
               CTSP)     H2020, H0046 via        H2020, H0046 via UB92
                         HCFA/NCECS              WITH RC 183


Medicaid     In Custody Medicaid: H0019, S5145, Medicaid: H0019, S5145,        WCHS DSS
                (CTSP   H2020, H0046 via        H2020, H0046 via UB92
             CMSED and HCFA/NCECS               WITH RC 183
                 Non)
NonMed         CTSP/       IPRS: H0019, S5145,     IPRS: YA254-YA259           IPRS YA232-YA238
               CMSED       H2020, H0046
* 45 day max on Ther Leave per year

See Reimbursement Rate Table for codes to use when submitting IPRS (non-Medicaid) services
for reimbursement.




                                            Section IV - Page 21
                                                                 Wake County LME Provider Manual 2008
                                                                                          SECTION IV


SECTION IV Claims and Reimbursement
5. General Billing Requirements
Effective Date: July 1, 2004                         Version Date: 6/27/06
 Informational Only Requirement                    Reference:
Requirement Applies to Provider Type:                CAP/MRDD
Medicaid Basic Svc (Direct Enrolled)                Cat. A Licensed Facilities
 Medicaid Basic Svc (Not Direct Enrolled)           Cat. B Comm Based Providers
 Medicaid Enhanced Svc
 Non-Medicaid Contracted Svcs                       Cat. C Institutions/Facilities
ICF-MR                                               Cat. D Lic/Cert. Outpatient/Day Svcs

Purpose: To describe rules and guidelines for staff who provide MHDDSA services to follow
when billing for time spent providing services for or on behalf of consumers.

Billing rules/guidelines:
    1) The consumer must be enrolled in the Provider‘s program according the Consumer
        Enrollment procedure.
    2) It is the responsibility of each staff member to accurately document and bill for all services
        they render. Contract Providers must also ensure that the service is authorized prior to
        billing (see Authorization Procedure).
    3) Time spent in preparation, documentation, and travel is not included with the billable
        service, unless specified otherwise in the definition.
    4) Services may only be provided to a consumer who has been admitted and signed a
        consent for treatment, unless the service is specified as a non-open consumer service
        (e.g., Assertive Outreach).
    5) All service activities must be recorded in the consumer record, or in the case of non-open
        consumers, in a pending file.
    6) For billing non-Medicaid services, each billable service has a service code that must be
        utilized on WCHS Service Reporting Form. These codes are specific to the WCHS
        computer system, and in many cases differ from state-wide codes.
    7) Services provided in groups must be recorded using a group service code.
    8) Staff should never bill for the same period of time to more than one consumer, unless
        utilizing a group service code.
    9) Time spent providing services (i.e., the number of hours/minutes) should be recorded
        according to the procedure Accounting For Time When Providing MH/DD/SA Services.
    10) If two or more staff provide a service together to a single consumer, the staff person with
        the higher credentials should indicate their Provider Code as the primary provider of the
        services. Unless specifically allowed in the service definition, in no case shall both staff
        bill separately for the same intervention with the same consumer, as double-billing would
        occur.
    11) Providers shall ensure that services are billed according to the service definitions and
        requirements specific to the funding source (e.g., Medicaid, NCDMHDDSA).
    12) Services billed to Medicaid must meet Medicaid requirements. These rules are generally
        the same of the NC DMH/DD/SA rules, with a few additions. Basic rules include:
             a. the service must be medically necessary;
             b. the service must be ordered by an appropriately credentialed professional;
             c. the documentation must support the type of service billed;
             d. the documentation must follow documentation requirements:
                      i. the service relates to the goals in the consumer‘s plan;

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                                                   Wake County LME Provider Manual 2008
                                                                            SECTION IV

                 ii. the documentation includes the staff intervention;
                iii. the documentation includes the consumer response/status;
                iv. the note is appropriately signed and dated.
        e. the documentation supports the duration of service billed;
        f. the staff providing the service must be appropriately privileged or trained.
13) Generally, a sample of WCHS services billed to Medicaid are audited on an annual basis.
    Services that do not meet requirements will result in a payback of funds. Such a payback
    could also be assessed for other services provided to the same consumer or staff member
    in addition to the ones sampled. See also ―Authorization Policy & Principles‖ and
    ―Provider Sanctions‖.




                                Section IV - Page 23
                                                                 Wake County LME Provider Manual 2008
                                                                                          SECTION IV


SECTION IV Claims and Reimbursement
6. Accounting for Time When Providing MH/DD/SA Services
Effective Date: July 1, 2004                         Version Date: 6/20/04
Informational Only  Requirement                    Reference:
Requirement Applies to Provider Type:                CAP/MRDD
Medicaid Basic Svc (Direct Enrolled)                Cat. A Licensed Facilities
 Medicaid Basic Svc (Not Direct Enrolled)           Cat. B Comm Based Providers
 Medicaid Enhanced Svc
 Non-Medicaid Contracted Svcs                       Cat. C Institutions/Facilities
ICF-MR                                               Cat. D Lic/Cert. Outpatient/Day Svcs

Purpose: To describe the way staff should account for their time when providing billable mental
health, developmental disability, and/or substance abuse services.

Procedure:

1. In the progress note, reflect the actual length of the service in one-minute increments, e.g., 1
   hr. 22 min. For services over 2 hours in length, it is advisable to indicate the length of time for
   each discreet intervention, to assist in justification of the length of time billed.

2. On the service reporting form, and Medicaid Claim forms, convert this time to the unit of
   measure specific to the service (e.g., 15 minute unit, 1 hour unit, event, or bed day).


3. When the same service is provided by the same provider more than once to one individual on
   the same day, write the total amount of time to be converted to units. For example, three ten
   minute Case Management services sum to one 30 minute service on the Service Reporting
   Form.


4. When billing services that are reported in 15-minute units, convert the length of service by
   rounding down. For example:

         □   1 to 14 minutes = 0 units
         □   15 to 29 minutes = 1 unit
         □   30 to 44 minutes = 2 units
         □   45 to 59 minutes = 3 units
         □   60 to 74 minutes = 4 units

5. CPT code services must also be rounded down.

6. All services that are billed require a progress note.

7. The content of the note should be reflective of the amount of time billed. There are three
   ways that the accuracy of the amount of time billed are monitored: 1) internal monitoring by
   supervisors; 2) external audits; and 3) consumers who receive invoices for services.




                                             Section IV - Page 24
                                                                Wake County LME Provider Manual 2008
                                                                                         SECTION IV


SECTION IV Claims and Reimbursement
7. Non-Medicaid Claims Submission
Effective Date: June 1, 2005                        Version Date: 7/1/06
Informational Only  Requirement                   Reference:
Requirement Applies to Provider Type:               CAP/MRDD
Medicaid Basic Svc (Direct Enrolled)               Cat. A Licensed Facilities
Medicaid Basic Svc (Not Direct Enrolled)           Cat. B Comm Based Providers
Medicaid Enhanced Svc                              Cat. C Institutions/Facilities
 Non-Medicaid Contracted Svcs                       Cat. D Lic/Cert. Outpatient/Day Svcs
ICF-MR


The Non-Medicaid Service Reporting Form is to be used to report all non-Medicaid services
funded by WC LME EXCEPT FOR Behavioral Health Outpatient Services provided by Direct
Enrolled providers (see below). The form is designed to include all services provided to a
consumer in a 15-16 day period representing the first or second half of the month. Multiple
services and consumers can be reported on the same form, but each form can contain services
from only one Fund Source. The billing must be completed on a computer using Excel software,
as this produces row and column totals. Instructions can be found on a tab in the WCHS Non-
Medicaid Service and Adjustment Forms spreadsheet, which can be found on the Wake County
LME website:
http://www.wakegov.com/humanservices/localmanagemententity.htm

Direct Enrolled providers of Behavioral Health Outpatient services must report their services
separately from other non-Medicaid services authorized by WC LME. This is due to State
requirements for reporting attending provider numbers, and for paying specialty-specific rates.
Providers may report these services using paper HCFA 1500 claim forms, or using WCHS‘ Non-
Medicaid Service Reporting form for Direct Enrolled Behavioral Health Outpatient services is
found on a tab in the same Excel workbook as the Non-Medicaid Service Reporting Form.
Providers submitting claims using the paper HCFA 1500 form must contract the WCHS Accounts
Receivable section manager Alice O. Wilkerson to obtain format and content approval prior
submission of claims. Timely filing requirements are the same (see Timely Filing procedure).
Form instructions can be found on a tab in the WCHS Non-Medicaid Service and Adjustment
Forms spreadsheet.




                                            Section IV - Page 25
                                                                Wake County LME Provider Manual 2008
                                                                                         SECTION IV


SECTION IV Claims and Reimbursement
8. Non-Medicaid Timely Filing Requirements
Effective Date: July 1, 2006                        Version Date: 10-1-07
Informational Only  Requirement                   Reference:
Requirement Applies to Provider Type:               CAP/MRDD
Medicaid Basic Svc (Direct Enrolled)               Cat. A Licensed Facilities
Medicaid Basic Svc (Not Direct Enrolled)           Cat. B Comm Based Providers
Medicaid Enhanced Svc                              Cat. C Institutions/Facilities
 Non-Medicaid Contracted Svcs                       Cat. D Lic/Cert. Outpatient/Day Svcs
ICF-MR

Purpose: To ensure non-Medicaid billing is received on a timely basis, so that Wake County
LME can pro-actively manage limited public funds and ensure priority populations receive needed
MH/DD/SA services.

Procedure:
1) Prompt Pay: Payment shall be made within 48 days of receipt of Service Reporting Forms
   that are completed accurately and submitted by the Final Deadline.
2) Timely Filing Due Date: Date by which WCHS must receive billing in order for most efficient,
   prompt payment. The Due Date is 5 pm on the 5th working day of the following month. For
   services provided early in the month, early filing is encouraged and appreciated. For
   admissions in the last five days of the month, claims may be submitted with the following
   month‘s claims.
3) Late, incomplete, and/or incorrect submissions will fall outside the normal payment
   processing schedule and so are not subject to payment within 48 days. Late submissions
   may not be processed until the following month‘s payment processing. Late billing requires
   a “Time Limit Over-ride” form in order to request processing. The “Reason for
   Request” must be detailed and specific! Time limit over-ride requests will be
   considered based on justification and availability of funds.
4) Final Deadline: Date by which WCHS must receive billing for that Service Month in order for
   services to be reimbursed within Prompt Pay timeline. This date is the last day of the
   subsequent month, or, if it falls on a weekend, the previous Friday. For example, dates of
   service for August 2007, received after October 31, 2007, would not be eligible for
   reimbursement until the end of the Fiscal Year, and then only if funds are available.
5) *End of Year (EOY) Deadlines: End of the fiscal year closing sometimes necessitates earlier
   Final Deadlines for April through June services. If required, early Final Deadlines for April,
   May and/or June services will be announced with sufficient notice.
6) Intensive Periodic Services: Providers who choose to report Intensive Periodic services on
   the alternative schedule (two times a month with a two week lag) are not subject to the Timely
   Filing Due Date. Final and End of Year Deadlines DO apply.

FY 2007-08 Due Dates and Deadlines
Service Month         Timely Filing Due Date                  Final Deadline
July 2007             August 8, 2007                          September 28, 2007
August 2007           September 10, 2007                      October 31, 2007
September 2007        October 8, 2007                         November 30, 2007
October 2007          November 7, 2007                        December 31, 2007
November 2007         December 7, 2007                        January 31, 2008


                                            Section IV - Page 26
                                                    Wake County LME Provider Manual 2008
                                                                             SECTION IV

Service Month          Timely Filing Due Date      Final Deadline
December 2007          January 8, 2008             February 29, 2008
January 2008           February 7, 2008            March 28, 2008
February 2008          March 7, 2008               April 30, 2008
March 2008             April 7, 2008               May 30, 2008
*April 2008            May 7, 2008                 June 30, 2008
*May 2008              June 6, 2008                July 31, 2008
*June 2008             July 8, 2008                August 29, 2008
Non-Medicaid      Attn: Alice O. Wilkerson, Billing Unit
Billing must be   Wake County Human Services
submitted to:     23 Sunnybrook Rd Suite 169, Raleigh, NC 27610




                                  Section IV - Page 27
                                                                Wake County LME Provider Manual 2008
                                                                                         SECTION IV


SECTION IV Claims and Reimbursement
9. Non-Medicaid Services Payment Processing
Effective Date: May 1, 2005                         Version Date: 7/1/07
Informational Only  Requirement                   Reference:
Requirement Applies to Provider Type:               CAP/MRDD
Medicaid Basic Svc (Direct Enrolled)               Cat. A Licensed Facilities
Medicaid Basic Svc (Not Direct Enrolled)           Cat. B Comm Based Providers
Medicaid Enhanced Svc                              Cat. C Institutions/Facilities
 Non-Medicaid Contracted Svcs                       Cat. D Lic/Cert. Outpatient/Day Svcs
ICF-MR

Purpose: To outline the processing of payment for IPRS-defined services that are not Medicaid
eligible, and are funded by Wake County LME, either by authorization or a contract that does not
require authorization.

Procedure For Authorized Services:
1. Contract Providers are to report all authorized non-Medicaid services on the Non-Medicaid
   Service Reporting Form, according to WCHS instructions, utilizing correct codes.
2. Non-Medicaid Service Reporting Forms for all dates of service in the month are due to WCHS
   Program Area Accounting Staff on the 5th working day of the following month. See the Non-
   Medicaid Timely Filing Requirements procedure. In some cases, service documentation
   (progress notes) may be required for quality monitoring.
3. Incomplete or inaccurately completed forms, and services for consumers who have not had
   opening paperwork submitted, a copy will be returned to the Contract Provider with a Non-
   Medicaid Service Billing Denial letter within 18 days of receipt, with the denied services
   indicated. Eligible services may be resubmitted according to the procedure found below.
4. WCHS‘ automated system will adjudicate claims to ensure units do not exceed authorized
   units and the Provider‘s contract is valid.
5. Providers are reimbursed at the their billed rate, or Wake County LME’s maximum rate,
   whichever is lower, LESS the established Co-Pay for the consumer, for the service
   billed.
6. A standard Explanation of Benefits (EOB) will be generated and sent to the Provider.
7. A Request for Payment is submitted to Wake County Finance for processing. Requests for
   Payment are processed through Wake County‘s centralized Finance office.
8. Audits may be done by WC LME for additional verification of billed services against consumer
   authorizations. Overpayments found through this audit process may result in payback.

When Consumers have Third Party Coverage Other Than Medicaid:
Consumers who have third party coverage may be eligible for authorization and payment for
services from Wake County LME, if they meet income and clinical eligibility requirements.
However, Wake County LME is the payor of last resort, and reimbursement will only occur only
after the services have been denied or only partially funded by the third party coverage. Attach
the EOB showing the denial or partial payment to your Wake County claim. Wake County will
reimburse only for difference between the full rate, and the third party coverage, and the
consumer‘s Wake County co-pay.



Special Procedure for Limited Services Not Subject to Authorization:

                                            Section IV - Page 28
                                                         Wake County LME Provider Manual 2008
                                                                                  SECTION IV

A very limited number of contracts for IPRS-defined services do not require authorization from
WCHS. Agencies are required to report units on the Non-Medicaid Service Reporting Form, and
are required to follow the processing rules as stated above; with the exception that item 5 does
not apply. These providers earn up to X/12‘s of their contract maximum on a year-to-date basis
each month, where X indicates the number of months reported year-to-date. For example, in a
$120,000 contract, the Contract Provider may have ytd earnings of up to 3/12‘s ($30,000) for July
to September services, based on units provided times the contracted rate.

Billing Errors, Re-Billing and Adjustments:
1) Providers will be notified of denials in one of two ways:
    a) WCHS’ Billing Unit reviews the Non-Medicaid Service Reporting Form and finds one of
        the types of errors listed below. The Billing Unit sends the Provider a Non-Medicaid
        Service Billing Denial letter within 18 days of submission.
        i) The data or codes were inaccurate or incomplete,
        ii) The consumer‘s opening paperwork was not received or was erroneous,
        iii) The client/service does not have an appropriate WC LME Non-Medicaid authorization.
        iv) The service is an apparent duplicate (the same client/service/date was already
             submitted).
        v) The services were not submitted with the required timelines.
    b) WCHS’ Accounts Payable (AP) staff send the Provider an Explanation of Benefits (EOB)
        that includes denials where the number of units billed exceeds the units authorized (Denial
        code 02 or 03).
2) Depending on the type of denial, the Provider may be able to correct the problem and
    resubmit the service for reimbursement (see table below). There are three types of forms
    that are used to correct denied submissions:
    a) WCHS Re-Bill Form – For re-submission of Non-Medicaid services for reimbursement that
        were denied by the Billing Unit on a Non-Medicaid Service Billing Denial letter for all
        reasons except duplicate service or missed deadlines.
    b) WCHS Adjustment Form - For correcting services previously billed with incorrect units.
    c) WCHS Time-Override Request – For special circumstances which would allow services to
        be billed after the final filing deadline.
3) These forms can be found in the file WCHS NonMedicaid Svc and Adjustment Form.xls, on
    the tabs located at the bottom of the spreadsheet.
4) PLEASE NOTE: The Final Deadlines delineated in Procedure 9 apply to submissions of
    WCHS Re-Bill and Adjustment forms.

Issue/problem                             Solution
Non-Medicaid Claim is denied by           Provider can re-submit the claim on a WCHS
WCHS Billing Dept. because                Re-Bill form once the error is corrected
- the client was not open,                (opening paperwork has been submitted, they
- the service was not authorized,         have requested and received an authorization
due to a coding error, or                 for the service, or the coding is corrected).
- units exceed authorized units.




                                     Section IV - Page 29
                                                          Wake County LME Provider Manual 2008
                                                                                   SECTION IV

Issue/problem                              Solution
Apparent Duplicate Service: If more        It is the responsibility of the Provider to
than one Non-Medicaid claim on             combine units on one line of the Service Billing
Service Billing Reporting Form is          form when the client receives the same service
received for the same                      more than once on the same day (regardless of
                                           whether the same or different staff were
client/date/service/provider agency
                                           involved). If a service is denied as a duplicate
combination, with the same or a
                                           that should have been combined with the first
different number of units, WCHS Billing
                                           (i.e., the client actually did receive the same
Dept will deny the second one as
                                           service twice in one day), then the Provider
duplicate.
                                           can correct the units submitted by completing
                                           a WCHS Adjustment Form with the total
                                           number of units indicated.
Provider discovers error—Provider          Provider to use the WCHS Adjustment Form to
billed the wrong service code, wrong       indicate original and corrected billing. If the
number of units, or realizes they should   change results in payback, Provider should
not have billed the service, AND they      include payment with the form.
have not received a WCHS Denial
letter.
Late Billing of Non-Medicaid               If more than 60 days has elapsed since the
Services due to Special                    month the service was delivered, the Provider
Circumstances: Provider billed             should submit billing on a WCHS Re-Bill Form
services to private insurance first but    and attach a WCHS Time Over-Ride Request,
had to wait to receive the insurance       and the insurance denial (if applicable). If the
EOB or denial to submit with the           late billing is being submitted for the first time,
Service Billing Reporting Form; or other   use the normal Non-Medicaid Service
legitimate special circumstance.           Reporting Form instead of the Re-Bill Form,
                                           and be sure to include the Time Over-Ride
                                           Request and other required documentation.
WCHS EOB Denial 02 or 03: Denial           Provider may request that Authorization Staff
on EOB indicates no units available or     authorize extra units.
exceeds authorized units. (This              If granted, Authorization staff will send the
procedure is the same for Medicaid              Authorization Mailer to the Provider.
and Non-Medicaid services.)                  Provider must contact WCHS Accounts
                                                Payable (A/P) rep and send or fax a
                                                request (919-250-3943) to the WCHS A/P
                                                Unit to pay the service, including a copy of
                                                the Authorization and the EOB where the
                                                service was denied.
                                             WCHS A/P will pay offline (for Denial
                                                codes 03) or with the next Provider
                                                payment (Denial code 02).




                                     Section IV - Page 30
                                                                 Wake County LME Provider Manual 2008
                                                                                          SECTION IV


SECTION IV Claims and Reimbursement
10. Medicaid Payment Processing
Effective Date: July 1, 2004                         Version Date: 4/21/05
Informational Only  Requirement                    Reference:
Requirement Applies to Provider Type:                CAP/MRDD
Medicaid Basic Svc (Direct Enrolled)                Cat. A Licensed Facilities
 Medicaid Basic Svc (Not Direct Enrolled)           Cat. B Comm Based Providers
 Medicaid Enhanced Svc
                                                     Cat. C Institutions/Facilities
Non-Medicaid Contracted Svcs
                                                      Cat. D Lic/Cert. Outpatient/Day Svcs
ICF-MR

Purpose: To outline the processing of Contract Provider payment for Medicaid-covered services
authorized and billed under Wake County Human Service‘s Medicaid Billing Provider number.

Procedure:
1) Contract Providers electronically submit claims for authorized Medicaid services directly to
    EDS using NCECS or proprietary software.
2) Contract Providers billing under WCHS‘ Billing Provider Number are responsible for correctly
    using the following codes on their claims. Incorrect coding will delay payment.
    a) Billing Provider Code (3404931), DO NOT USE Alpha Suffixes
    b) Patient Account Number (WCHS‘ 6 digit Medical Record Number [without dashes or
        spaces] followed by the authorizing Program Area code). See Medicaid Billing Codes
        procedure.
    c) Rendering/Attending Provider Code (WKCXXXX, where XXXX has been assigned by
        WCHS to each Contract Provider). Obtain from WCHS Contracts staff.
3) The Contract staff completes claims submission using required codes. The Contract Provider
    shall retain a detailed hardcopy of submitted claim data. All Providers shall submit a
    hardcopy of claim detail to the WCHS Accounts Payable, with the last 5 digits of the
    Authorization Number indicated, so that WCHS staff can determine if all submitted claims
    were paid.
4) In some cases, service documentation (progress notes) may be required for quality
    monitoring.
5) WCHS Accounting staff receive a Remittance Advice (RA) listing Medicaid payments from
    EDS. WCHS Accounting staff use the RA to determine payment amounts per agency, which
    are processed through Wake County‘s central Finance office.
6) WCHS Accounting staff will verify that services fall within authorized ranges; unauthorized
    services will either be denied on that Explanation of Benefits (EOB), or deducted from
    subsequent payments for Medicaid services.
7) Payment will be generated within 48 days of the RA date. Payments for claims lacking the
    required codes are exempt from this prompt payment requirement, as those claims will require
    extra steps to determine the correct provider.
8) WCHS Accounting staff will distribute an EOB report to each agency. For Denial Codes 02
    and 03, see section at end of this procedure.
9) Payment is sent separately by Wake County‘s Finance office.
10) When the consumer has other third party insurance, Medicaid is secondary and should be
    submitted as a hardcopy claim directly to EDS, and a copy to WCHS Accounting.
11) When a Contract Provider determines that a service was billed and paid in error, they shall
    complete an EDS Adjustment Form and submit that form and required attachments to WCHS
    Accounts Payable staff. WCHS Accounting will submit to EDS for processing.

                                             Section IV - Page 31
                                                          Wake County LME Provider Manual 2008
                                                                                   SECTION IV

12) Contract Provider staff are responsible for correcting errors that results in Medicaid denials or
    overpayments, and for resubmitting denied claims when appropriate.
13) Questions regarding payment for Medicaid services should be directed to the WCHS
    Accounting staff of the program area that authorized the service.



WCHS EOB Denial 02 or 03:
If the denial on WCHS EOB indicates no units available or exceeds authorized units, the
Provider may request that Authorization Staff authorize extra units.
1. If the authorization is granted, WCHS Authorization staff will send the Authorization
   Mailer to the Provider.
2. Provider must contact WCHS AP rep and send or fax a request (919-250-3943) to the WCHS
   AP Unit to pay the service, including a copy of the Authorization and the EOB where the
   service was denied.
3. WCHS AP will pay offline (for Denial codes 03) or with the next Provider payment
   (Denial code 02) if appropriate paperwork is included and it is received within 30 days.




                                      Section IV - Page 32
                                                                 Wake County LME Provider Manual 2008
                                                                                          SECTION IV


SECTION IV Claims and Reimbursement
11. Medicaid Billing Codes Specific to WCHS
Effective Date: July 1, 2004                         Version Date: 6/10/04
Informational Only  Requirement                    Reference:
Requirement Applies to Provider Type:                CAP/MRDD
Medicaid Basic Svc (Direct Enrolled)                Cat. A Licensed Facilities
 Medicaid Basic Svc (Not Direct Enrolled)           Cat. B Comm Based Providers
 Medicaid Enhanced Svc
                                                     Cat. C Institutions/Facilities
Non-Medicaid Contracted Svcs
                                                      Cat. D Lic/Cert. Outpatient/Day Svcs
ICF-MR

                              Medicaid Services Billing Codes
                                 For use on HCFA Claims

Must be submitted electronically to EDS via NCECS or proprietary software.
            Contact EDS at 800-688-6696 for NCECS training.
                     Field                                   Instructions for Provider
Billing Provider Number (HCFA Box 33               3404931 only – NO Suffix
Grp #; NCECS Provider Information/
Provider No. field)
Patient‘s Account No (HCFA Box 26;                 6 digit WCHS Medical Record Number, no
NCECS Patient Information/Account                  spaces or dashes, plus Authorizing Program
Number field)                                      Area Code found in table below.
Attending Provider Code (HCFA Box 33    Attending Provider Code: WKCxxxx
PIN#; NCECS Rendering/Attending         (specific to your agency, assigned by WCHS;
Provider No field)                      obtain from WCHS Contract staff)
NOTE: Detailed hardcopy of claims must be printed and a copy submitted to WCHS. It is
recommended that the Provider also keep a copy for their files.

Failure to utilize proper codes may result in delayed payment!

Program Area Code – For
use on Medicaid Claims
Patient Acct # field                Description
DD                                  Developmental Disabilities
MI                                  MR/MI
CT                                  CMSED/CTSP
CH                                  Child Mental Health
CSA                                 Child Substance Abuse
MAJ                                 CSA Majors
ASA                                 Adult Substance Abuse
AMH                                 Adult Mental Health




                                             Section IV - Page 33
                                                                 Wake County LME Provider Manual 2008
                                                                                          SECTION IV


SECTION IV Claims and Reimbursement
12. Fund Balances, Over-Realized Receipts, & Year End Settlement for Contract
Providers
Effective Date: October 1, 1996                      Version Date: 10/01/07
Informational Only  Requirement                    Reference:
Requirement Applies to Provider Type:                CAP/MRDD
Medicaid Basic Svc (Direct Enrolled)                Cat. A Licensed Facilities
 Medicaid Basic Svc (Not Direct Enrolled)           Cat. B Comm Based Providers
 Medicaid Enhanced Svc
 Non-Medicaid Contracted Svcs                       Cat. C Institutions/Facilities
ICF-MR                                               Cat. D Lic/Cert. Outpatient/Day Svcs

Purpose: To apply existing WCHS Board policy regarding fund balances, over-realized receipts,
and year-end settlement procedures for contract Providers.

Procedure:
1) If the Wake County LME contracts with a Provider for the purchase of service on a unit
    reimbursement basis and the following conditions are met:
    a) The unit reimbursement rate has taken into consideration Division cost finding rate and the
        Medicaid rate; and
    b) The Wake County LME is satisfied that the unit of service rate is reasonable; and
    c) Payment is based on services delivered;
Then, there will be no year-end settlement procedures and no fund balance/over-realized receipt
policy.
2) The contract Provider is responsible, however, for keeping an audit trail and for submitting an
    annual financial audit and compliance report, if applicable.
3) If the basis for funding in a contract with a contract Provider is total cost or grant basis, each
    contract must contain language that specifies whether or not and how year-end settlement
    procedures shall apply. This may be based on any terms of allocation or award from the
    Division that comes to Wake County, or it may be based on conditions set by Wake County
    LME.




                                             Section IV - Page 34
                                                                Wake County LME Provider Manual 2008
                                                                                         SECTION IV


SECTION IV Claims and Reimbursement
13. Claims and Reimbursement Specific to CAP-MR/DD
Effective Date: 9/1/07                              Version Date: 7/12/07
Informational Only  Requirement                   Reference:
Requirement Applies to Provider Type:                CAP/MRDD
Medicaid Basic Svc (Direct Enrolled)               Cat. A Licensed Facilities
Medicaid Basic Svc (Not Direct Enrolled)           Cat. B Comm Based Providers
Medicaid Enhanced Svc                              Cat. C Institutions/Facilities
Non-Medicaid Contracted Svcs                        Cat. D Lic/Cert. Outpatient/Day Svcs
ICF-MR

Purpose: Outline processing of Contracted Provider payment (TCM agencies) for Medicaid-
covered services (Home Health items and CAP-MR/DD funded items (Specialized Equipment and
Supplies (T1999), Home Modifications, Vehicle Modifications, Augmentative Communication
Devices, Individual/Caregiver training and Education, Transportation).

Procedure:

        Providers cannot bill for any DME product. Only authorized DME distributor can bill for
         those types of items.
        All waiver items must be approved by ValueOptions (VO) prior to ordering.
        Contractors are responsible for having all the needed information. With audits, if
         information is not available and appropriate, vendor is responsible for payback.
        Contractors are responsible for getting insurance denials, as appropriate, and submitting
         with invoices for WCHS to bill Medicaid.
        Contractors pay vendors of their choice and submit billing to Wake County LME. The
         Invoice must include the total number of units, appropriate code and signed off by QDDP.
         Submit invoice with TCM signature, Code and date, verifying received and paid.
        Wake County LME will reimburse the Provider within 45 days of receipt of funds from
         Medicaid.
        Any denials will be re-submitted to contractors to assist with any corrections.

The following items are to be kept by the contractors for audit purposes:

1. Home Health Items:
       Prescription from doctor noting item, reason for item (medical necessity), how many
           units needed, and how often can be refilled. Need for items should also be in the
           treatment plan. Does not require VO approval.
2. Specialized Equipment and Supplies (T1999 items):
    Requires VO authorization
    Evaluation by appropriate therapist (OT/PT)
    Prescription from doctor noting item, medical necessity reason. Physician can write
      statement of medical necessity on therapist evaluation and sign with credentials and date.
    Quote from vendor and no older than 30 days at time of ordering. If older, vendor can
      verify is still current and needs to be noted and signed on quote as such.
    If consumer has insurance, contractor will need to receive denial of item before Medicaid
      will pay out. Denial must be submitted with invoice.


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                                                                                  SECTION IV

       Invoice must be signed off by TCM, verifying item received and accepted with date with
        correct code.
3.    Vehicle Modifications:
      Requires VO authorization
      Quote from appropriate therapist/vehicle adaptation specialist with the information required
        in the Service Records Manual (APSM 45-2) and CAP-MR/DD manual.
      When work is completed and paid, invoice submitted with TCM signature, code, and date.
4.    Home Modifications:
      Requires VO authorization prior to starting work
      Quote from appropriate vendor with the required information in the Service Records
        Manual (APSM 45-2) and CAP-MR/DD manual.
      When work is completed and paid by contractor, invoice submitted with TCM signature,
        code, and date, verifying received and paid.
5.    Augmentative Communication Devices:
      Requires VO authorization
      Quote from appropriate vendor with the required information in the Service Records
        Manual (APSM 45-2) and CAP-MR/DD manual.
      Make sure speech therapist is certified in North Carolina.
      When item is received and paid by contractor, invoice submitted with TCM signature,
        code, and date, verifying received and paid.
6.    Individual/Caregiver Training and Education:
      Requires VO authorization
      If attending conference, must submit receipt from payment for conference with TCM
        signature, code, and date. Remember, billing must be billed in 15 minute units to
        determine how many hours add up to the amount of registration.
      Maintain records of the required information noted in the CAP-MR/DD manual.
7.    Transportation:
      Requires VO authorization
      Assure required information is maintained from the CAP-MR/DD manual.
      Assure limitations are adhered.




                                     Section IV - Page 36
                                               Wake County LME Provider Manual 2008
                                                                        SECTION V


SECTION V Provider Documentation Submission Requirements
1. Required Consumer Record Information
Effective Date: July 1, 2004               Version Date: 7/01/07
Informational Only  Requirement          Reference: APSM 45-2 & 45-2A, Clinical
                                           Policy 8a
Requirement Applies to Provider Type:      CAP/MRDD
Medicaid Basic Svc (Direct Enrolled)      Cat. A Licensed Facilities
 Medicaid Basic Svc (Not Direct Enrolled) Cat. B Comm Based Providers
 Medicaid Enhanced Svc
 Non-Medicaid Contracted Svcs             Cat. C Institutions/Facilities
ICF-MR                                     Cat. D Lic/Cert. Outpatient/Day Svcs

Purpose: To provide an overview of the required components of the consumer record
of persons who received publicly funded mental health, developmental disability or
substance abuse treatment.

Information Required To Be Submitted To Wake County LME
For each person receiving services from Wake County LME Contract and Medicaid
Providers, the following information must be submitted to Wake County LME. (See also
Section III.3 and 4, Authorization procedures.)



Forms Required at Admission       Medicaid                   Non-Medicaid
                                  Basic Svc,    Enhanced     Referred  Agency
                                  Not Direct    Service      with      requests
                                  Enrolled                   Auth.     Auth.
WCHS Demographic Screening *           Y             Y                     Y
WCHS Consumer Enrollment *             Y             Y            Y        Y
WCHS MH/SA Clinical Services                                      Y        Y
Request (MH/SA only)
WCHS Target Population                               Y                        Y
Eligibility
WCHS Fee Application                                            If not        Y
                                                              complete
Release of Information for             Y             Y           Y            Y
consumers with Substance Abuse
diagnosis
Service plan or Person Centered                                               Y
Plan
ASAM (SA only)                                                                Y
NC-SNAP (DD Consumers Only)                          Y                        Y
Clinical Assessment and other
clinical information needed for                                               Y
authorization purposes (see
Section III procedure 3 and 4).




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                                                                           SECTION V


Forms Required when                  Medicaid                    Non-Medicaid
due/updated                          Basic Svc,    Enhanced      Referred  Agency
                                     Not Direct    Service       with      requests
                                     Enrolled                    Auth.     Auth.
WCHS Contract Agency                    Y           Y                 Y        Y
Discharge Data form (at
discharge)*
Service plan or Person Centered                   (upon           Y             Y
Plan                                             request)
WCHS Target Population                              Y             Y             Y
Eligibility (annually)
NC-SNAP (DD Consumers Only)                         Y             Y             Y
(annually)
 *Per the Medicaid MOA and IPRS Contract, these forms contain data required for
 submission to CDW for State Reporting.

Note: Medicaid BHO Direct Enrolled providers do not need to send any consumer
information to Wake County LME, unless they need a referral from WC LME (See
Section III. Procedure 5.)

Additional Information Required To Be Part Of The Consumer Record:

1) Consents & Releases: (completed fully, then signed, dated, & witnessed)
   a) Consent to Treatment (must grant permission to seek emergency care from a
       hospital or physician)
   b) Consumer Acknowledgement of Receipt of HIPAA Notice of Privacy Practices
   c) Consent to Release Information – Federal confidentiality regulations (42 CFR
       Part 2) require that programs that provide substance abuse diagnosis, treatment,
       or referral for treatment strictly maintain the confidentiality of these consumer
       records. Disclosure of information is permissible if the consumer has signed a
       valid consent form that has not expired or been revoked. Please see 42 CFR
       2.31 for the elements required in a valid consent form, as well as for a description
       of the exceptions to this requirement.
   d) Acknowledgement of Receipt of Consumer Rights Information
   e) Emergency information for each consumer which shall include the name,
       address and telephone number of the person to be contacted in case of sudden
       illness or accident and telephone number of the consumer ‘s preferred physician
   f) Third Party Release (to include private insurance carrier, public benefits and
       entitlements)
2) Acknowledgement of Consumer Choice
3) NC-TOPPS (Lead Agency shall complete as required by the State for Mental Health
   and Substance Abuse clients effective July 1, 2005).
4) Person Centered Plan (required for Enhanced services) or Service Plan (required for
   basic services).
5) Documentation of mental illness, developmental disabilities or substance abuse
   diagnosis coded according to the DSM-IV and documentation of physical disorders
   according to the ICD-9, including subsequent amendments and editions. All 5 axes
   required.




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                                              Wake County LME Provider Manual 2008
                                                                       SECTION V

6) Order for Services: for all services to be provided, signed by the appropriate
   professional.
7) Service Notes
8) Other elements may be required or clinically relevant depending upon the services
   received (e.g. Medication Administration Record).
9) Allergies: Any known or suspected allergies or adverse reactions, or the absence of
   such, must be prominently noted in the record (preferably on the front cover of the
   record).

Consumer record information must be maintained in an organized manner and in a
confidential and secure location.

Health Insurance Portability & Accountability Act (HIPAA) Requirements

Providers shall provide a summary of consumer rights regarding the use, storage, and
handling of personal health information according to HIPAA.

A HIPAA Notice of Privacy Practices (NOPP) form should be reviewed with each
consumer/legally responsible person. After reviewing the NOPP, Providers should
request that consumers sign a HIPAA Acknowledgement form that states that they
received a NOPP. WCHS samples of these forms can be found on
www.Smartworks.com




                                Section V - Page 3
                                                    Wake County LME Provider Manual 2008
                                                                             SECTION V


SECTION V Provider Documentation Submission Requirements
2. Consumer Record Rules Regarding Adoptions and Name Changes
Effective Date: July 1, 2001          Version Date: July 1, 2006
Informational Only  Requirement     Reference: NC GS Chapter 48
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)              CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)         Cat. A Licensed Facilities
 Medicaid Enhanced Svc                            Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                     Cat. C Institutions/Facilities
ICF-MR
                                                   Cat. D Lic/Cert. Outpatient/Day Svcs

Providers must follow either this procedure or referenced rules/statutes.

Purpose:
To describe the steps that must be taken with regard to the consumer‘s record
when a consumer is adopted.

A. Adoption Name Change Procedure:
When the adoption has been finalized:

1) The old record shall be closed, using adoption date as the discharge date.
   a) Medical Records staff shall place a paper in the front of the current and
      discharged file advising the viewer to ―SEE RECORDS MANAGER
      BEFORE RELEASING ANY INFORMATION‖. Per NCGS Chapter 48
      Article 9, no person or entity shall release information that reasonably
      could be expected to lead directly to the identity of an adoptee, an
      adoptive parent of an adoptee, an adoptee‘s parent at birth, or an
      individual who, but for the adoption, would be the adoptee‘s sibling or
      grandparent, except upon order of the court. Non-identifying information
      may be released according to NCGS Chapter 48 Article 9 and 10.
   b) The discharged file remains on-site with the Medical Records department
      supporting the program where the consumer is active for future
      reference.
2) A new consumer number shall be issued, with the new name.
   a) If the consumer was issued a new Social Security Number, a new
      screening form must be completed.
   b) Copies can be made of the following forms (the original name and
      client number must be covered and no longer visible; the new name
      and client number should be added in it‘s place):
           (1) Admission Assessment, Service Plan, CE form, demographic
               screening form, Order for Service, and (for Early Intervention) I/T
               Data form.
           (2) New releases/consents shall to be signed by new legal guardian
               (if applicable).
3) A new file is made using new name and client number.
   a) a) A paper is placed in front of new file advising about adoption, with the
      following statement: ―DOCUMENTS IN THIS RECORD HAVE BEEN
      CARRIED FORWARD FOLLOWING ADOPTION. THEREFORE,


                                       Section V - Page 4
                                                Wake County LME Provider Manual 2008
                                                                         SECTION V

        COPIES OF ORIGINAL DOCUMENTS HAVE BEEN BROUGHT
        FORWARD WITH NAME AND NUMBER CHANGES INTO THE
        CURRENT RECORD.‖
4) Staff are to provide Consumer Records staff with the following information to
   initiate the process described above:
   a) Legal documentation of adoption;
   b) New Demographic Screening form
   c) Note explaining this is an adoption.
5) Consumer Records staff will:
   a) Change the Consumer Enrollment form and Person Centered
        Plan/Service Plan (copy with new name and client number).
   b) Use the date of adoption and discharge all screens under old record
        number.
   c) Open the consumer under the new record number-using day after
        discharge.
   d) Discharge the old record, as this number will never be re-used. Do NOT
        place the consumer on inactive status.
6) WCHS will use the UniCare software ―CNOS‖ screen to reflect the adoption
   by showing both old and new numbers. Agencies that do not have access to
   the UniCare software and ―CNOS‖ screen, can utilize an Administrative file—
   which remains in the Medical Records room—to reflect both old/new
   names/numbers for easier reference. Because both the discharged file and
   new file will be kept on site, there‘s no need to copy the entire medical record
   (such as documentation from doctors and/or hospitals and evaluations). See
   the following example as one way to set up the Administrative file.

                                      ADOPTIONS

Old Name            Old Client Number         New Name           New Client Number




B. Name Changes Other Than Adoptions

Purpose:
To describe the process for reflecting name changes in the consumer‘s Medical Record
for reasons other than adoption.

Procedure:
   1. A copy of the document authorizing the name change, e.g., a court order, shall
      be obtained and placed in the front of the medical record.
   2. If a document is one we will continue to update (current medication sheet, Flow
      Sheet, etc.), change the name at the top of each page. This is done by drawing a
      single line through the name and writing the new name nearby.
   3. A name change form (see illustration) shall be completed and filed at the front
      of the chart on the left hand side. This form will show both the old and new
      names and shall be sent with any release of information.




                                  Section V - Page 5
                                                    Wake County LME Provider Manual 2008
                                                                             SECTION V


SECTION V Provider Documentation Submission Requirements
3. Other Required Medical Record Procedures
Effective Date: April 1, 2006           Version Date: January 31, 2006
Informational Only  Requirement       Reference:
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)              CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)         Cat. A Licensed Facilities
 Medicaid Enhanced Svc                            Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs
                                                   Cat. C Institutions/Facilities
ICF-MR
                                                   Cat. D Lic/Cert. Outpatient/Day Svcs

A. TELEWORKING

Each Provider shall have a policy and procedure that address employees that telework,
with the purpose of ensuring that consumer information is kept confidential and secure at
all times.

B. RECORD RETENTION

Reference: February 7, 2005 MEMORANDUM To Area Directors From Mike Moseley
regarding Medical Records

―Inherent in our system reform process is the need for various requirements, rules, and
manuals to be revised. This communication contains some preliminary medical record
policy guidance and clarification. This memorandum is just the beginning of a series of
written guidance that the Division of Mental Health, Developmental Disabilities, and
Substance Abuse Services will provide to the field with respect to medical records. The
Division has established a medical records work group which includes staff from LMEs
to provide assistance and input into the identification and resolution of medical record
issues. The work group will continue to meet to address and resolve additional medical
record issues.

The following guidance applies to area/county programs and service providers as
indicated below:
1. Area/county programs shall have access to all medical records for consumers in their
care or in the care of providers to whom the Area/county program has referred the
consumer for service.
2. Area/county programs shall have responsibility for all historical medical records. The
historical medical record is the record that was created when the area/county program
was a service provider in the pre-LME world.
3. The following guidance applies to all service providers in the area/county programs‘
provider community:
        a. Service providers must meet the requirements of the following:
                i. 42 CFR, Chapter 1, Part 2 Substance Abuse Confidentiality,
        b. 45 CFR, Parts 160 and 164 Health Insurance Portability and
        Accountability Act,
        c. Applicable statutory requirements in G.S. 122C,
        d. Service Records Manual, APSM 45-2,


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                                               Wake County LME Provider Manual 2008
                                                                        SECTION V

        e. Confidentiality Rules, APSM 45-1,
        f. Rules for Mental Health, Developmental Disabilities, and Substance
        Abuse Services, APSM 30-1,
        g. Client Rights Rules, APSM 95-2, and
        h. Record Retention Rules, APSM 10-3.
4. Service providers shall permit area/county programs access to medical records.
5. Service providers shall maintain records and documentation for all service provision,
including release and disclosure information.
6. Contract service providers and direct enrolled providers may opt to purchase the
management of their medical record and quality improvement functions, but may not
contract away the responsibility of documenting service provision. The contract service
provider and the direct enrolled provider are ultimately responsible for assuring that
medical records are properly protected and secured.
7. The contract service provider and the direct enrolled provider assume the cost
associated with records created and maintained during service provision as well as the
cost of returning records to the area/county program when the provider ceases
operations. The area/county program assumes the cost associated with the
maintenance and storage of historical records and records that are returned should the
service provider cease operation. ―


C. COUNTERSIGNATURES IN CONSUMER RECORDS
Reference: APSM 45-2
1) All documentation by Medical Students and Residents shall be countersigned by
   their designated supervisor.
2) Documentation in Physician Orders by Nurses, Physician Extenders, Students, or
   Residents shall be countersigned by a Physician within 48 hours.




                                 Section V - Page 7
                                                    Wake County LME Provider Manual 2008
                                                                             SECTION V


SECTION V Provider Documentation Submission Requirements
4. Consumer Enrollment Procedure
Effective Date: July 1, 2004                      Version Date: 7/1/06
Informational Only  Requirement                 Reference:
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)              CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)         Cat. A Licensed Facilities
 Medicaid Enhanced Svc                            Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs
                                                   Cat. C Institutions/Facilities
ICF-MR
                                                   Cat. D Lic/Cert. Outpatient/Day Svcs

PURPOSE: Providers must report the admission of consumers into treatment to Wake
County LME using the Consumer Enrollment (CE) Form. It is required for all consumers
receiving Non-Medicaid MH/DD/SA services funded by WC LME and/or Medicaid
enhanced services. The CE form serves the following purposes:
   1. to open a client to a specific program
   2. to specify the consumer‘s Lead Provider
   3. to assign a diagnosis
   4. for required State CDW reporting

The program/provider should list the specific diagnosis that is the focus of their treatment
(Primary Diagnosis). It may be the same diagnosis another provider is also addressing
or it may be different. There can be more than one diagnosis. The target population is
not program specific.

Timelines: The CE form shall be completed:
   a) upon initial admission
   b) when the primary diagnosis changes, and
   c) when the provider or MD changes (internal WCHS providers only)
Accurate and timely completion of this form is essential for WC LME to process Provider
payment for services.

ROUTING AND PERFORMANCE STANDARDS:

     1. Contract Providers:
            a. If the consumer is screened and referred by WC LME, and you received
                an Authorization with this referral, then the CE form should be submitted
                to the WC LME UR Team within 10 days of admission, and prior to claims
                submission.
            b. If the consumer was NOT referred by WC LME, the CE form should be
                submitted with the initial authorization request.
     2. CE updates should be submitted promptly as completed.
     3. Data Support Specialists will notify the provider if the form needs corrections.
     4. Providers shall correct CE forms with errors and resubmit (to the same location)
        within 5 business days of notification.




                                       Section V - Page 8
                                               Wake County LME Provider Manual 2008
                                                                        SECTION V


PROGRAM ENROLLMENT SECTION

   1. The Program Enrollment section must be completed to admit the consumer to
      the internal program or contract Provider for treatment.
   2. The Lead Agency should be indicated whenever a consumer is opened to a
      program. See Section VII Procedure 1, Lead Provider, to determine which
      provider is lead when the consumer is receiving services from more than one
      provider.
   3. If an evaluation is done and a decision is made not to open the consumer for
      ongoing treatment, the Open/Close Same Day box is checked.
   4. If a previous assessment is being used as a part of the admitting program‘s
      admission assessment, this should be indicated at the bottom of this section.
   5. Update Provider/MD is used by internal WCHS programs to indicate a change in
      primary therapist and/or supervising physician.
   6. The entire Program Enrollment section is left blank when updating diagnostic or
      population group information on a consumer that is already open to the
      program/provider.



PRIMARY DIAGNOSIS SECTION

     Only clinical staff qualified to do evaluations (either via privileging and/or by
     meeting competency standards) may establish diagnoses. Clinical staff other than
     those who determined the diagnosis may be responsible for recording the
     appropriate diagnoses on the CE form as described below.
    All established diagnoses should be documented in the diagnostic evaluation and
     the Unified Service Plan. Only those that are primary are reported on the CE
     form.
    The Consumer Enrollment (CE) form is the only way for diagnoses to get added
     and updated in the WCHS computer system.

Instructions regarding reporting diagnoses on the Consumer Enrollment (CE) form:

   1. Clinicians should list only the primary diagnoses, i.e., those that are the focus of
      treatment for that program, on the CE form.
   2. There has to be at least one diagnosis indicated for each program providing
      services, and more than one should be listed if there is more than one diagnosis
      that is the focus of treatment.
   3. DSM-IV-TR codes should be used. The diagnoses can be axis 1, 2 or 3.
   4. Each time there is any change in primary diagnosis, the clinician should indicate
      Update at the top of the form, and list all primary diagnoses for that consumer on
      the CE form, so that there will be no ambiguity whether a particular diagnosis is a
      change or in addition to previously reported diagnoses. Data entry staff will
      discontinue any previously reported diagnoses that are not included on the CE
      form.
   5. If the consumer has a substance abuse diagnosis, the SA History section must
      be completed.




                                 Section V - Page 9
                                                   Wake County LME Provider Manual 2008
                                                                            SECTION V


SECTION V Provider Documentation Submission Requirements
5. Target Population Eligibility
Effective Date: July 1, 2004                      Version Date: 7/1/07
Informational Only  Requirement                 Reference:
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)              CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)         Cat. A Licensed Facilities
 Medicaid Enhanced Svc                            Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs
                                                   Cat. C Institutions/Facilities
ICF-MR
                                                   Cat. D Lic/Cert. Outpatient/Day Svcs

Purpose:
To describe the process by which IPRS Target Population eligibility is determined and
reported to WC LME, to ensure accuracy and maximize earnings of State funding. IPRS
Target Populations are based on a combination of consumer clinical and demographic
characteristics, and reflect the populations determined by the State of North Carolina to
be the highest priority for receiving MH/DD/SA public funding.

Procedure:
1) Target Population Eligibility is required for consumers that are subsidized with non-
   Medicaid funding, or that receive Medicaid Enhanced Services.
2) Target Population eligibility should be determined:
   a) During the first full assessment or at admission,
   b) As new diagnoses/eligibility is determined,
   c) When a child turns 18, AND
   d) At least annually.
3) Initial Target Population eligibility, and changes to Target Population eligibility, must
   be reported to WC LME on the disability-specific Target Population Eligibility forms
   (CMH/SA, AMH/SA, and DD). Annual updates that do not result in a change of
   eligibility do NOT have to be submitted on the Target Population form.

Population Group rules:
   1. Population Group definitions/criteria can be obtained from the NC Division of
      MHDDSA website (http://www.dhhs.state.nc.us/mhddsas/), under IPRS, Target
      Populations.
   2. Target Population Eligibility is required for consumers that are subsidized with
      non-Medicaid funding. The LME delegates the responsibility for determination
      and re-determination of eligibility to Providers when service planning originates at
      a provider agency and at least annually to determine whether the consumer
      continues to meet their target population eligibility requirements. Do NOT
      resubmit a target population eligibility form if no change in eligibility has occurred.
      Verification of Target Population Eligibility is the responsibility of the LME. The
      LME has final decision making authority over interpretation of the Target
      Population eligibility criteria, and whether the consumer meets that criteria.
   3. The consumers‘ diagnosis, along with functional levels and other criteria,
      determines the IPRS Population Group(s) for which they are eligible. Thus, the
      Population Group indicated on the Eligibility form must be supported by one of



                                      Section V - Page 10
                                               Wake County LME Provider Manual 2008
                                                                        SECTION V

     the diagnoses clinically determined (see the Division‘s website, IPRS,
     Diagnosis/Target Populations table).
4.   Some Population Groups may not co-occur with others, as specified on the NC
     Division of MHDDSA website, under IPRS, Target Populations, Concurrency.
     Other populations groups that indicate characteristics such as deafness or TANF
     eligibility should co-occur.
5.   If the non-Medicaid consumer is ineligible for a Target Population Group, they
     are not eligible for public funding.
6.   Responsibility for Population Group eligibility determination is as follows:
          a. Most consumers are only enrolled in one program, so that program is
               responsible for eligibility updates.
          b. For consumers that are enrolled in more than one program and/or
               Provider agency, the Lead Provider is responsible for determining
               eligibility (as well as coordinating Service Plan or PCP updates).
          c. If a consumer is served by more than one disability area (MH, DD,
               SA), eligibility must be determined in each disability area. For example, if
               a consumer is receiving services from two mental health programs and
               one substance abuse program, two population groups are needed. The
               MH program higher in the hierarchy should do the MH eligibility
               determination, and the SA program should complete and submit the SA
               population group eligibility.
7.   DO NOT record a population group on the Target Population Eligibility form
     unless you have done the assessment and determined the appropriate
     Population Group – i.e., if the population group was determined and
     reported at an earlier time or by another provider, and this is not an update
     (annual or due to changes), DO NOT re-record the previously determined
     Population Group eligibility.
8.   Responsibility for verification of Target Population eligibility falls with the
     LME. The Utilization Review Team will verify Target Population eligibility
     with each authorization request, and may require that the Provider submit
     additional clinical information to support eligibility.




                               Section V - Page 11
                                                   Wake County LME Provider Manual 2008
                                                                            SECTION V


SECTION V Provider Documentation Submission Requirements
6. Transfers
Effective Date: July 1, 2004                      Version Date: 7/1/06
Informational Only  Requirement                 Reference:
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)              CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)         Cat. A Licensed Facilities
 Medicaid Enhanced Svc                            Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs
                                                   Cat. C Institutions/Facilities
ICF-MR
                                                   Cat. D Lic/Cert. Outpatient/Day Svcs

Purpose:
To describe the process by which a provider transfers clinical responsibility for consumer
services to a different provider.

Principles:
 Continuity of Care: Once a consumer has engaged in treatment/services, the
   Provider is obliged to continue services until the consumer no longer needs the
   service, chooses to discontinue services, or is actively engaged in appropriate
   alternative services.
 Informed consumer choice: Consumers who wish to transfer their care should
   be informed of available providers who can fully meet their needs
 Transfers: Providers transferring consumers to another program should not
   discharge the consumer until the transferring Provider has ensured that the
   consumer has engaged with the receiving Provider and is receiving the full
   array of services required. For example, if the referring provider is providing
   psychiatric services, this provider will continue psychiatric services until the
   receiving provider has initiated psychiatric treatment.
 Confirmation of transfer: Both providers will maintain consistent
   communication to ensure satisfactory transition of care for the consumer.


Procedure Transfer of Consumers between Providers:

     1. The current provider shall utilize the Referral Coversheet to formally initiate the
        transfer. Personal communication between the referring and receiving Providers
        is encouraged when conditions warrant it. These documents will ensure the
        receiving Provider has sufficient information to commence the process of
        acceptance determination.
     2. The Receiving Provider shall follow the acceptance procedures required in the
        Referral and Acceptance procedure.
     3. Some clients will have a two-step process for transfer that will include initiation of
        some clinical services at intake followed by the completion of the full array of
        services over a period of time (e.g., intake for therapy followed by psychiatry
        intake at a later date). In these circumstances, the receiving provider will notify
        the transferring provider when all services have been transitioned satisfactorily.
        Both providers will collaborate to ensure transfer of Medicaid and Non-Medicaid
        authorizations.


                                      Section V - Page 12
                                           Wake County LME Provider Manual 2008
                                                                    SECTION V

4. If the consumer is not successfully transferred to the Receiving Provider, either
   by consumer choice or the Provider‘s non-acceptance, the Transferring Provider
   will make all reasonable attempts to re-engage the consumer and/or refer to an
   appropriate alternative Provider.




                            Section V - Page 13
                                                   Wake County LME Provider Manual 2008
                                                                            SECTION V


SECTION V Provider Documentation Submission Requirements
7. Discharges
Effective Date: July 1, 2004                      Version Date: 10/1/07
Informational Only  Requirement                 Reference:
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)              CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)         Cat. A Licensed Facilities
 Medicaid Enhanced Svc                            Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs
                                                   Cat. C Institutions/Facilities
ICF-MR
                                                   Cat. D Lic/Cert. Outpatient/Day Svcs

Purpose: To establish procedures and timeframes within which the Provider is required
to provide notification of termination of services.

Procedure:
1. The provider must notify the consumer and all other involved providers in writing of
    the intent to discharge.
2. The provider must also notify the appropriate Wake County LME PCDT Service
    Director when one of the following is true:
    a.     It is against the wishes of the consumer/family, or
    b.     It is in contradiction to the service plan.
3. Notification must be in writing, prior to discharge and include the rationale. See
    Notification timeframes below.

                                                 Notification of Discharge
                                              (minimum # of calendar days prior
Population/ Service                                  to discharge date)

Residential                                                  60*


All other services                                           30*

*Unless decertified by Value Options, which only gives 14 days notice.

4.    A Contract Agency Discharge Data Form must be completed and a copy of it
      submitted to the WC LME Data Support Specialist where the services were
      authorized within 10 business days of the discharge. Other population-specific
      rules regarding coordination of the discharge may apply.




                                      Section V - Page 14
                                                   Wake County LME Provider Manual 2008
                                                                            SECTION V


SECTION V Provider Documentation Submission Requirements
8. Child to Adult Transition Planning Guidelines
Effective Date: January 15, 2005           Version Date: 7/01/06
Informational Only  Requirement          Reference:
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)              CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)         Cat. A Licensed Facilities
 Medicaid Enhanced Svc                            Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs
                                                   Cat. C Institutions/Facilities
ICF-MR
                                                   Cat. D Lic/Cert. Outpatient/Day Svcs

Purpose: To ensure clinical concerns and administrative requirements are addressed
when a child receiving MHDDSA services transitions to adulthood.

Guidelines:

Transition activities should begin for children receiving mental health and substance
abuse services as they reach seventeen to determine the following:

        Need for continuation of services beyond the eighteenth birthday
        Willingness to participate in services
        Eligibility for adult target populations
        Available resources
        Need for application or re-application for financial benefits
        Need for adult guardianship

Medicaid eligible children have options for continuation of outpatient services based
on medical necessity. Referral for outpatient adult services should begin six months
prior to the eighteenth birthday. Transitioning children with complex, intensive treatment
needs will be tracked within the LME as the service continuum is managed.

Child Mental Health Residential Treatment services can continue based on medical
necessity in two instances. Children already placed in Level II and III Residential
Services can remain in placement six months to a year beyond the eighteenth birthday
subject to continued Medicaid eligibility. Residential Treatment Facilities are no longer
licensed for the 18 to 21 year old age group. Providers of residential treatment services
can request a waiver through the Division of Health Services Regulation to continue
services to Medicaid eligible consumers beyond the timeframe stated above. Providers
shall notify the Wake County LME PCDT Child Residential Treatment services director
and submit a copy of the written waiver request to the LME. Children in Wake County‘s
custody, placed in Level II Therapeutic Foster Care licensed through Child Welfare, can
remain in placement through age twenty. Placements are subject to continued Medicaid
eligibility and voluntary placement agreement with Child Welfare.

IPRS eligible children must meet an adult target population for continuation of IPRS
funded adult services. Additional funding such as Supplemental Security Income (SSI)
and Special Assistance (SA) are often necessary for consideration of very limited
residential services.


                                      Section V - Page 15
                                               Wake County LME Provider Manual 2008
                                                                        SECTION V


Children who have both developmental and mental health disabilities and who are
expected to have long-term service needs should be referred for appropriate disability
specific services by age seventeen. Children with severe developmental disabilities are
usually identified by DD Single Portal at an earlier age and continue with DD services.

In some instances children with substance abuse treatment needs qualify for an
adult substance abuse target population. However, for transitioning children that do not
meet adult target populations, other community resources can be explored.

Administrative procedures must also be completed in addition to consideration of
clinical needs and consumer preferences. The consumer or legal guardian must
participate in service planning and sign the plan. When a consumer will receive adult
services from an agency other than their current provider the transfer/discharge
procedures outlined in this manual must be followed. Other tasks that must be
completed as appropriate include the following:

      New consents (e.g. Treatment, HIPAA, Financial, Release of Information)
      ASAM, NCSNAP, NCTOPPS
      DD Adult Eligibility Checklist
      Target Population Eligibility forms for non-Medicaid funded services
      Adult guardianship proceedings when necessary




                                Section V - Page 16
                                                   Wake County LME Provider Manual 2008
                                                                            SECTION V


SECTION V Provider Documentation Submission Requirements
9. Licensure Rule Waiver Requests
Effective Date: July 1, 2007                      Version Date: 07/11/07
Informational Only  Requirement                 Reference:
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)              CAP/MRDD
Medicaid Basic Svc (Not Direct Enrolled)          Cat. A Licensed Facilities
 Medicaid Enhanced Svc                            Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                     Cat. C Institutions/Facilities
ICF-MR                                            Cat. D Lic/Cert. Outpatient/Day Svcs

Purpose: To ensure that waiver requests are timely and filed according to
administrative rules.

Procedure: If during the course of service delivery it becomes necessary to request a
waiver for licensure rules providers shall utilize the process outlined in Subchapter 27G-
Rules for Mental Health, Developmental Disabilities, and Substance Abuse Facilities and
Services- Section .0800 – Waivers and Appeals. Additionally, a copy of the waiver
request shall be submitted to the appropriate service director within the LME at the same
time as it is sent to the Director of the Division of Health Services Regulation.




                                      Section V - Page 17
                                                         Wake County LME Provider Manual 2008
                                                                                  SECTION VI


SECTION VI Quality Improvement and Performance Monitoring
1. Best Practices Guidelines
Effective Date: July 1, 2004           Version Date: 06/09/04
Informational Only  Requirement      Reference:
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)          CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)     Cat. A Licensed Facilities
 Medicaid Enhanced Svc                        Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                 Cat. C Institutions/Facilities
 ICF-MR                                       Cat. D Lic/Cert. Outpatient/Day Svcs

Wake County‘s Local Managing Entity will identify, approve and support practices that accomplish
integrated Human Services outcomes. Efforts to define and shape best practice will evolve
gradually over the next five years.

The five service characteristics that focus Wake County Human Services work are:
              Community Based
                 Features partnerships with neighborhoods and communities to build the capacity
              of residents to address their needs and improve their quality of life.
              Outcome Driven
                 Attention is directed towards the assessment of the agency according to the
              results it achieves and not the specific "products" or "units" it produces.
              Prevention Focus
                 Any measures that promote or maintain physical, behavioral, social health and/or
              forestall the onset of any undesirable consequence or event.
              Family Centered
                 The priorities and choices of the family, as it defines itself, drive the delivery of
              services.
              Culturally Competent
                 The ability of individuals and systems to respond respectfully and effectively to
              people of all cultures in a manner that recognizes, affirms, and values the worth of
              individuals, families, and communities and protects and preserves the dignity of each.

and the five components of quality performance are:
              Effectiveness of strategies, measurable progress towards desired outcomes
              Inclusion of customers and partners in planning and/or evaluating services
              Accuracy in documentation, calculation, calibration or financial practices
              Appropriateness or relevance of assessment, intervention and follow-up
              Efficiency of operations, use of resources and business practices

These will serve as the foundation for implementing Best Practice work.

The LME adopts the best practice definition of ―behavioral health practice that is generally accepted
as a successful intervention currently believed to improve consumer outcomes.‖ This may include
science and evidence based practice, as well as, emerging or promising clinical practice models.
Best Practice indicators include compliance with accrediting bodies, licensure and professional
standards in addition to achievement of consumer outcomes.


Best practices are not limited to clinical treatment models. It includes philosophies and practices
such as
                                        Section VI - Page 1
                                                     Wake County LME Provider Manual 2008
                                                                              SECTION VI


Family Psycho-education, Unified Service Planning, Person/Family Centered principles, use of
ASAM criteria, Personal Outcomes, the System of Care model, health information management and
medical records to name but a few. Further, the scope of best practice crosses system initiatives
and includes, for example, child welfare and community health practices that through collaboration
and system integration impact mental health service delivery, the lives of consumers and our
Providers.




                                    Section VI - Page 2
                                                                    Wake County LME Provider Manual 2008
                                                                                             SECTION VI




  SECTION VI Quality Improvement and Performance Monitoring
  2. Consumer Rights
  Effective Date: July 1, 2004           Version Date: 7/1/07
  Informational Only  Requirement      Reference: APSM 95-2
  Requirement Applies to Provider Type:
   Medicaid Basic Svc (Direct Enrolled)                    CAP/MRDD
      Medicaid Basic Svc (Not Direct Enrolled)             Cat. A Licensed Facilities
      Medicaid Enhanced Svc                                Cat. B Comm Based Providers
      Non-Medicaid Contracted Svcs                         Cat. C Institutions/Facilities
      ICF-MR                                               Cat. D Lic/Cert. Outpatient/Day Svcs
  x
  xPrinciples:
  x
       Consumers of MH/DD/SA services shall be fully informed of their rights.

       Consumers of MH/DD/SA services should understand how to resolve complaints, grievances,
        or other disputes with Providers directly. Consumers should also be informed of the option of
        reporting complaints directly to external advocacy resources as well as to the LME Quality
        Management Team.

       Consumers of MH/DD/SA services should understand how information about their treatment
        will be used and disclosed, and understand when their written authorization is required for
        disclosure.

       Consumers of MH/DD/SA services shall be informed of their right to appeal decisions that
        reduce, terminate, or suspend Medicaid-funded MH/DD/SA services.

   Requirements:
   All Providers are expected to comply fully with clients rights provisions contained in
   Title 10A NC Administrative Code (NCAC) Subchapter 26B- Consent for Release, and

   Clients Rights in Community MH/DD/SA Services (APSM 95-2) including:
   Title 10A NC Administrative Code (NCAC)
   Subchapters:
27C-     Procedures and General Information
27D-     General Rights
27E-     Treatment or Habilitation Rights
27F-     24 Hour Facilities
27G-     Rules for MH/DD/SA Services

   A. Rights Summary

   Providers shall review a summary of MH/DD/SA consumer rights with the consumer and/or legally
   responsible person on a regular basis. Ideally this review should be done as soon after admission to
   a service as practicable, and be reviewed with the consumer and/or legally responsible person
   annually. All clients should sign a form acknowledging the receipt of the written summary and
   review of clients‘ rights.

   The LME expects provider agencies to hold their staff accountable to the highest ethical
   standards. Providers shall develop procedures to ensure the review of informed consent and
                                                  Section VI - Page 3
                                                     Wake County LME Provider Manual 2008
                                                                              SECTION VI


consumer choice issues with consumers when initiating referrals for new services. A signed copy
of the Acknowledgement of Consumer Choice form shall be maintained in the consumer‘s medical
record. Additionally providers shall document in personnel records the orientation of new staff and
annual in-services for existing staff members regarding informed consent and consumer choice
procedures.

B. Human/Clients’ Rights Committees

The Wake County LME or the Wake County Human Rights Committee may require a Provider
to form its own Human/Clients‘ Rights Committee according to the following policy:

Criteria for Requiring Providers to Form Human Rights Committees

The Wake County LME or the Human Rights Committee of the Wake County Human Services
Board of Directors reserves the right to require any Provider to formulate a Human Rights
Committee under any or all of the following circumstances:
1. When a Provider assumes responsibilities for a range of client services which may include
   physician and other medical services, psychotherapy, other supportive counseling or
   personal assistance services, and case management services;
2. When a Provider delivers services in a 24 hour treatment and/or residential setting;
3. When as a result of a review of a client grievance by the Human Rights Committee of Wake
   County, it is determined:
   a. that a clients‘ rights violation has occurred or may be reasonably concluded to have
       occurred; or
   b. that a human rights committee would facilitate the promotion, protection, and/or review of
       alleged violations of clients rights;
4. When a Provider utilizes therapies or other interventions for which the formation of such a
   body is required by State or local standards, regulations, or policies.

Human Rights Committees shall consist of a majority of non-board or non-governing body
members.

Each applicable disability shall be represented on the committee.

One-third of the committee members shall be consumers or family members of consumers,
unless exempted from this requirement by the Human Rights Committee.

Staff who serve on the committee shall be non-voting members.




                                   Section VI - Page 4
                                                           Wake County LME Provider Manual 2008
                                                                                    SECTION VI



SECTION VI Quality Improvement and Performance Monitoring
3. Complaints
Effective Date: July 1, 2004           Version Date: 11/01/07
Informational Only  Requirement      Reference: APSM 30-1, 10NCAC
                                       27G.0606 and .607
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)               CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)          Cat. A Licensed Facilities
 Medicaid Enhanced Svc                             Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                      Cat. C Institutions/Facilities
ICF-MR                                             Cat. D Lic/Cert. Outpatient/Day Svcs



Purpose:
Per the rules found in APSM 30-1, 10ANCAC 27G.0606 AND .0607, the Wake County LME will
attempt to mediate complaints for all MH/DD/SAS provider types and to investigate complaints for
Category A and Category B Providers within the Wake catchment area except for ICF/MR
facilities.

For the purposes of this policy a complaint is an expression of concern in writing or orally
regarding rights, services or administrative issues that the complainant perceives as a
problem. Any consumers or Providers who have a complaint concerning the provision of publicly
funded MH/DD/SA services in Wake County should call:

  Wake County LME
  Quality Management Team
  2321 Crabtree Boulevard
  Raleigh, NC 27604
  919-856-5345

Providers are expected to have a process and procedure for addressing complaints. In regards to
complaints, consumers should be informed that they may contact any of the advocacy services
listed below at any time. This information should be prominently posted in areas available to
consumers and should be readily available to all workers/employees.

  Wake County Human Services
  Consumer Rights Program
  PO Box 46833
  Raleigh, NC 27620-6833
  919-212-7155

  Carolina Legal Assistance
  1010 Richardson Drive
  Raleigh, NC 27603
  919-733-9840




                                         Section VI - Page 5
                                                      Wake County LME Provider Manual 2008
                                                                               SECTION VI
 NC Division of MH/DD/SA Services
 Advocacy/Customer Service/Community Rights
 3009 Mail service Center
 Raleigh, NC 27699-3009
 919-715-3197


 NC Division of Health Service Regulation (formerly Facility Services)
 2711 Mail Service Center
 Raleigh, NC 27699
 919-855-4500

Procedures:
In order to respond to complaints received concerning the provision of public services, the Wake
County LME will attempt to resolve issues of concern through informal dialogue and agreement
between parties. Both consumers and providers are encouraged to resolve issues between
themselves before seeking resolution through the LME.

The Quality Management Team may be called upon by other regulatory/oversight agencies to
assist and/or coordinate complaints and investigations.

Potential Rights Violations:

When a potential rights violations is received by the Wake LME Quality Management Team that
the complainant (either consumer or Provider) has not been able to resolve the following will
occur:
    1. The LME Quality Management Team will receive information and review the complaint
       thoroughly.
    2. The LME Quality Management Team will notify the complainant within 5 days of receipt of
       the complaint and whether the complaint will be addressed directly by a conflict resolution
       process (informal review) or by conducting an investigation of the allegation(s).

Conflict resolution process
The complainant will be offered the option of accessing the provider‘s internal complaint process
or conflict resolution services offered by Wake LME Quality Management Team.
    1. Consumers are not required to participate in the provider‘s conflict resolution process or
        complaint process before submitting a complaint to QM Team.
    2. If the issue is resolved either by the provider‘s or the QM Team‘s conflict resolution
        process, the QMT will document the results.
    3. The informal review will be completed within 10 days after QM Team receives the
        complaint.
    4. If issue is not resolved, the complainant may file a complaint to the Wake LME Director
        within 10 days from the date of the completion of the conflict resolution process.
    5. If a need for an investigation is revealed during conflict resolution, the QM Team will begin
        the investigation or refer the matter to the appropriate State or local government agency.
    6. The Wake LME Director‘s decision shall be dated and mailed to the complainant by the
        LME QM Team within 15 days from receipt of the complaint.

Investigation
When an investigation is required, the QM Team must follow the following protocol:


                                    Section VI - Page 6
                                                     Wake County LME Provider Manual 2008
                                                                              SECTION VI
   1. Complete the complaint investigation within 30 days of the date of the receipt of the
       complaint.
   2. Submit a report of investigation findings to the complainant, the provider and to the
       consumer‘s home LME, if different.
   3. If a rights violation is found, the QM Team will require a Plan of Correction to be submitted
       by the provider within 10 days from the date the provider receives the complaint
       investigation report.
   4. The QM Team will review and respond to the provider‘s Plan of Correction with approval
       or a description of additional required information to the provider within 10 days of receipt
       of the Plan of Correction.
   5. If a Provider does not send in a Plan of Correction within the 10-day period, the QM
       Team will call the provider by telephone. If the provider does not respond within 48 hours,
       the QM Team will notify the Provider via certified mail. If there is no response to the
       certified mail within 5 days of mailing, then the QM Team will follow the recommendation
       to suspend referrals procedure found in section VI.9 and will also file a complaint with the
       Division of Health Service Regulation if the Provider is licensed.
   6. If a Plan of Correction is required, it shall be implemented in a timely manner not to
       exceed 60 days from the date of the complaint investigation report. The QM Team shall
       verify that the corrected actions cited in the investigation report were implemented no later
       than 60 days from the date the Plan of Correction is approved.
   7. Once a Plan of Correction is received the QM Team will review the plan and notify the
       provider within 10 days of receipt of the plan if it is accepted. A Provider will be given a
       total of three opportunities to submit an acceptable Plan of Correction. If the third
       submission is unacceptable, the LME make take actions up to and including withdrawal of
       endorsement.
   8. If there are unresolved issues from the corrective plan that may compromise the health
       and safety of current or future consumers and/or continuity of care the Wake County LME
       will immediately notify the appropriate agencies (i.e. DSS, DHSR.)
   9. The complainant who disagrees with the results of the QM Team‘s actions may file a
       complaint to the Wake LME Director within 10 days from the receipt of the QM Team
       investigation report or the QMT team approval of the provider‘s corrective action plan. The
       complaint is limited to the complaint record and allegations that the investigation and/or
       corrective actions are inadequate or not completed in a timely manner.
   10. The Wake LME Director shall notify the complainant within 5 days from receipt of the
       complaint whether the complaint meets the above criteria. If the complaint is accepted by
       the Wake LME Director, the QM Team shall send the LME Director‘s written decision
       within 15 days from receipt of the complaint to: 1) uphold the investigation findings and
       corrective action plan 2) return the investigation findings and corrective action plan to the
       QM Team for a reinvestigation, 3) uphold the investigation findings and corrective action
       plan with specified changes.

Complaints regarding Administrative Issues and Service Quality

A consumer, legally responsible person, staff, or any other individual without a conflict of
interest may file a complaint regarding administrative issues or service quality. The Wake
LME QM staff must assist a complainant who requests assistance in filing the complaint
and also provide consumer information materials describing the complaint process and
how to contact advocacy groups.

When QM Team receives a complaint regarding administrative or service quality, it will be
reviewed and documented as follows.

                                   Section VI - Page 7
                                                      Wake County LME Provider Manual 2008
                                                                               SECTION VI
           1. QM Team will acknowledge receipt of the complaint the same or next business day
              following the date the complaint was received. The QM Team shall describe the
              informal review process to address the specific complaint and provide contact
              information to the complainant for questions regarding the complaint.

           2. Review Levels
                 a. Level I: Informal Review Process: The QM Team will contact the
                    complainant within 10 days of the receipt of the complaint and ensure that
                    there is full opportunity provided for complainant to represent his/her
                    concerns. A decision regarding the complaint shall be dated and mailed to
                    the complainant by QM Team within 2 days of the date the review was held.
                 b. Level II: A complaint regarding a Level I decision must be received orally or
                    in writing within 10 days of the date indicated on the Level I written decision
                    letter. The QM Team will acknowledge receipt of the complaint the same or
                    next business day following the date the complaint was received. The Wake
                    LME Director will review the complaint. The QM Team shall send the LME
                    Director‘s written decision to the complainant within 10 days from the date
                    the complaint was received by QM Team. The letter shall be mailed not
                    later than the next day following the Level II review decision.

If serious issues of health and safety and/or continuity of care are evident, the QM Team may
refer the complaint to DMH/DD/SAS, DHSR, DSS or other agencies responsible for oversight.
When a complaint is referred to the State or local government agency responsible for the
regulation and oversight of the Provider, QMT staff shall send a letter to the complainant informing
them of the referral and to the Provider against whom the complaint has been made.

The Quality Management Team will contact the State or local government agency to which the
QM Team made the referral within 120 days of the date that the complaint was received to
determine the actions taken in response to the complaint.

To appeal any findings of a complaint investigation please see Procedure VI.10 in this section.




                                   Section VI - Page 8
                                                           Wake County LME Provider Manual 2008
                                                                                    SECTION VI



SECTION VI Quality Improvement and Performance Monitoring
4. Quality Management and Quality Improvement
Effective Date: July 1, 2004            Version Date: 01/01/07
Informational Only  Requirement       Reference: APSM 30-1, 10NCAC
                                        27G.0201
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)               CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)          Cat. A Licensed Facilities
 Medicaid Enhanced Svc                             Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                      Cat. C Institutions/Facilities
ICF-MR                                             Cat. D Lic/Cert. Outpatient/Day Svcs


  Purpose:
  The purpose of Quality Management and Quality Improvement is to involve consumers, Providers
  and the community in the ongoing evaluation and improvement of services.

  Objectives:
     o Promote participation of consumers and staff to define quality, identify opportunities for
         improvement and solve problems
     o Provide coordination and direction for efforts aimed at evaluating the
         effectiveness, appropriateness, and quality of services
     o Provide a process for adjusting services, policies and procedures in response to findings
     o Provide a process for measuring the success of these adjustments
     o Establish and maintain high standards of effective and efficient consumer services
         and supporting operations
     o Satisfy requirements of funding sources, regulating bodies and community standards

  Five guiding principles address the content of continuous quality improvement activities:
      o Effectiveness of strategies, measurable progress towards desired outcomes
      o Appropriateness or relevance of assessment, intervention and follow-up
      o Inclusion of customers and partners in planning and/or evaluating services
      o Accuracy in documentation, calculation, calibration or financial practices
      o Efficiency of operations, use of resources and business practices

  Procedures:
  A Provider is expected to implement and follow its own policy as well as comply with applicable
  standards and statutes regarding continuous quality improvement, innovation and assurance of
  quality services. Service Providers may be asked to submit documentation of their agency's
  QM/QA activities.

  Providers shall demonstrate a Continuous Quality Improvement (CQI) process by identifying a
  minimum of three improvement projects acted upon per year. Project and results will be
  reported to the Area Authority/County Program (LME) in any quarter of completion. The CQI
  Project report format is posted at:
        www.wakegov.com/humanservices/lme/quality managementteam




                                         Section VI - Page 9
                                                    Wake County LME Provider Manual 2008
                                                                             SECTION VI
 According to North Carolina Administrative code
 http://www.ncdhhs.gov/mhddsas/statspublications/manualsforms/aps/apsm30-01-6-06.pdf
 quality assurance and quality improvement activities are evidenced by the presence of the
 following:
     Composition and activities of a quality improvement/assurance committee
     Written quality improvement/assurance plan
     Methods for monitoring and evaluating the quality and appropriateness of consumer
        care, including delineation of consumer outcomes and utilization of services
     Strategies for improving consumer care

The following elements will be reviewed to assure Quality Improvement and Quality Management
functions:
   1. Quality improvement committee with specified composition and activities
   2. Written quality assurance and quality improvement plan and evidence of
        implementation
   3. Monitoring and evaluation of individual outcomes and utilization of services for quality &
        appropriateness of care
   4. Implementation of improvements in the individual's services & supports


Other areas that also relate to the provision of quality service such as Incident Reporting,
Research, and Staff Competency Determination (formerly known as Credentialing and Privileging)
are addressed elsewhere in this manual.




                                  Section VI - Page 10
                                                         Wake County LME Provider Manual 2008
                                                                                  SECTION VI


SECTION VI Quality Improvement and Performance Monitoring
5. Incident Review
Effective Date: November 1, 2004                   Version Date: 07/01/07
Informational Only  Requirement                  Reference: 10A NCAC 27G.0600, 10A
                                                   NCAC 27E .0104
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)               CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)          Cat. A Licensed Facilities
                                                   Cat. B Comm Based Providers
 Medicaid Enhanced Svc
 Non-Medicaid Contracted Svcs                     Cat. C Institutions/Facilities
 ICF-MR                                           Cat. D Lic/Cert. Outpatient/Day Svcs

Purpose:
An Incident Review system is intended to safeguard individual consumer health and safety as well
as public safety. The Local Managing Entity expects that our community of Providers has an
Incident Review system in place and that there is evidence that the following objectives and
requirements are met.

Objectives:
    Identify and reduce potential or actual risk situations involving consumers, staff,
       and visitors.
    Identify areas for correction and improvement.

PROCEDURES:

A. General Incident and Death Response Requirements:
1. Providers will at all times follow the current state guidelines for responding to and reporting
   incidents and death. The Division of MHDDSAS published ―DHHS Incident and Death Form
   Manual‖ and Forms QM02 and QM04. They can be found on the Internet at :
   http://www.ncdhhs.gov/mhddsas/statspublications/manualsforms/index.htm. This website includes
   criteria for determining level of response to incidents, links to the current reporting forms as
   well as specific instructions for completing forms QM02 and form QM04.
2. FORM QM-02
   All Providers of 122-C licensed and non-licensed services (except hospitals) must use the
   DHHS Incident and Death Report (Form QM 02) to report Level II and III incidents involving
   any person receiving publicly funded mental health, development disabilities, and/or
   substance abuse services as required by 10A NCAC 27G .0600. This form replaces the
   Critical Incident and Death Reporting Form (QM01) and the Report of Death to DHHS form.
3. FORM QM04
   Providers must attach the DHHS Restrictive Interventions Details Report (Form Q04), or a
   form with comparable information, to the DHHS Incident and Death Report (Form Q02) when
   reporting Level II or III incidents involving use of restrictive interventions. This form may also
   be used to comply with the documentation requirements in 10A NCAC 27E .0104 for all use of
   restrictive interventions involving any person receiving mental health, developmental
   disabilities, and/or substance abuse services.
4. FORM Q11 (updated January 2006)
   LevelI Incident Quarterly Review Report Form (Q11) must be submitted according to
   guidelines provided by the North Carolina Department of Health and Human Services and as
   set forth in 10ANCAC27G.0600.


                                        Section VI - Page 11
                                                      Wake County LME Provider Manual 2008
                                                                               SECTION VI
5. According to administrative rule 10A NCAC 27G.0201 (which can be found at
   http://www.ncdhhs.gov/mhddsas/statspublications/manualsforms/aps/apsm30-01-6-06.pdf
Provider Agencies are responsible for:
   a. Review of all fatalities of active consumers being served in provider-operated or
        contracted residential programs at the time of death
   b. Reporting of any incident, unusual occurrence or medical error. (Any “unusual
       occurrence” not covered on the DHHS Incident and Death Report (Q02) )
7. Incident Reports are confidential quality assurance documents. Do not file incident reports in
   the consumer medical record. The staff directly involved with the incident shall enter a brief
   progress note into the consumer record describing the event, action taken and the consumer‘s
   condition. No mention of the Incident Report is to be made in the consumer record.
8. Level I incidents must be documented according to the provider‘s own policy/procedures and
   reported in summary to the Wake County contacts as specified at the end of this document
   (see B.1.b.)

B. Specific Wake County Reporting Requirements for all Age/Disability Consumers:

         ALL LEVEL III INCIDENTS MUST IMMEDIATELY BE REPORTED BY TELEPHONE TO:
         LME MEDICAL DIRECTOR
         919-250-3102
1. All Providers and Provider Agencies are to follow the state guidelines for reporting Level II and
III incidents including timelines and to whom incidents are to be reported.
      a.         Fax all Level II and III Incident Reports to:
             LME QM Team
             (Telephone 919-856-6407, Fax 919-856-5321).
      b.         Level I Incident Quarterly Review Report Form (Q11) must be submitted to LME
             QM Team (Telephone 919-856-6407, Fax 919-856-5321) according to guidelines
             provided by the North Carolina Department of Health and Human Services and as set
             forth in 10A NCAC 27G.0600.

For further explanation please consult the DHHS Incident and Death Response System
Manual and also see January 2006 incident reporting updates available at the
Division’s web site:
http://www.ncdhhs.gov/mhddsas/statspublications/manualsforms/index.htm

C. Monitoring of Provider Incident Processes:
1. Providers will be monitored for compliance with Incident reporting procedures.
a.             Report of critical incidents within 72 hours to Wake County LME
b.             Documentation of restrictive intervention in the individual's record, including
    frequency, duration, intensity of behavior, rationale, description of intervention,
    accompanying positive interventions and signatures
c.             Documentation of restrictive intervention in the individual's record, including
    frequency, duration, intensity of behavior, rationale, description of intervention,
    accompanying positive interventions and signatures
d.             Report of critical incidents within 72 hours to Wake County LME
        Suggested Sources of Evidence:
                    Documents - (record sample) service notes, incident reports
                    Consumer interviews- incidents and response
                    Staff interviews - occurrence & documentation of incidents




                                    Section VI - Page 12
                                                      Wake County LME Provider Manual 2008
                                                                               SECTION VI
e.              Documentation of restrictive intervention in the individual's record, including
     frequency, duration, intensity of behavior, rationale, description of intervention,
     accompanying positive interventions and signatures




                                    Section VI - Page 13
                                                         Wake County LME Provider Manual 2008
                                                                                  SECTION VI


SECTION VI Quality Improvement and Performance Monitoring
6. Staff Competencies
Effective Date: July 1, 2004                       Version Date: 3/10/06
Informational Only  Requirement                  Reference: G.S. 122C-26, APSM 30-1
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)              CAP/MRDD
Medicaid Basic Svc (Not Direct Enrolled)           Cat. A Licensed Facilities
 Medicaid Enhanced Svc                            Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                     Cat. C Institutions/Facilities
ICF-MR                                            Cat. D Lic/Cert. Outpatient/Day Svcs

Purpose:

Staff Competency Determination (formerly known as Privileging and Credentialing) is a formal
process to assure that Providers have adequate knowledge, skills and abilities to provide services
to consumers. All Providers and Independent Practitioners involved in the provision or
supervision of treatment/habilitation/ rehabilitation services to consumers must be competent to
provide those services.

As of this writing staff competency determination rules have not been finalized, but these new
rules are intended to replace a privileging system with a competency-based system that is based
on knowledge, skills and abilities. During the transition, Providers must have either a
Competency based process or a Privileging and Credentialing process in place.

Procedure:

1. Providers shall have policies and procedures to ensure that staff is competent to provide
   services and that appropriate supervision is provided, as required by APSM 30-1. Credentials
   verification and privileging/competency determination shall be conducted prior to delivery of
   services.

2. Providers will be responsible for documenting and verifying competency/credentials of all
   their employees. Credentials verification shall be based on primary source verification of
   provider credentials (i.e., training, experience, licensure) and competence. Providers will be
   responsible for documenting and verifying credentials at the time of employment and
   keeping updated records of licensure.

3. Independent Medicaid Direct Enrolled providers are responsible for providing
    documentation verifying credentials.

4. Physicians shall have their credentials verified with the National Practitioner‘s Data Bank.

5. Providers shall be privileged or determined to be competent to work with specific age and
   disability groups based on their knowledge, skills and abilities to provide services to those
   groups. Competency/privileging must be established for each age and disability group that is
   served by a given Provider. For example, a Provider may be designated as a Qualified
   Provider (QP) for one population and Associate Professional (AP) for another if his/her
   knowledge, skills and abilities for the latter population do not qualify them for QP status.



                                        Section VI - Page 14
                                                     Wake County LME Provider Manual 2008
                                                                              SECTION VI
 6. Both privileging and competency systems must ensure that Associate Professionals and
    Paraprofessionals have written, individualized supervision plans to ensure the development of
    knowledge, skills and abilities required by the specific population served. These plans must
    contain the number of hours per month of supervision, by whom and for whom. Further,
    there must be documentation that these supervisory sessions occurred. Records of
    competency/privileges/credentials and supervision plans must be retained by each Provider.
    Providers are expected to be cognizant of the limitations of their training and experience and
    seek consultation or supervision as appropriate regardless of privileging/competency status.

The following items related to competency can be found in APSM 30-1and would be expected to be
evident in the Provider‘s policies and procedures:

10A NCAC 27G .0104    Staff Definitions
and 10A NCAC 28A
.0102
10A NCAC 27G .0202(a) Written job description for the director and each staff position
                      in the staff member's file which includes:
                      (1) minimum qualifications
                      (2) the duties and responsibilities
                      (3) staff and supervisor signatures

10A NCAC 27G             The director, each staff member or any other person who
.0202(b)(1,2)            provides care or services to consumers:
                         (1) is at least 18 years of age;
                         (2) is able to read, write, understand and follow directions;

10A NCAC 27G .0202       Director, staff members and others who provide services &
(b)(3)                   supports to individuals on provider's behalf meet minimum
                         level of education, competency, work experience, skills and
                         other qualifications for the position.

10A NCAC 27G             No substantiated NC Health Care Personnel Registry findings
.0202(b)(4)              of abuse or neglect for the director, staff members and others
                         who provide services & supports to individuals on provider's
                         behalf

10A NCAC 27G .0202(c) Disclosure of applicants' criminal convictions


10A NCAC 27G .0202 (d) Staff are licensed, registered or certified in accordance with
                       applicable state laws for the service provided.

10A NCAC 27G .0202(e) Documentation of employees' qualifications, including training,
                      experience licensure, registration or certification

10A NCAC 27G .0202 (f) Continuing education shall be documented.




                                  Section VI - Page 15
                                                   Wake County LME Provider Manual 2008
                                                                            SECTION VI
10A NCAC 27G             Employee training programs, including training on:
.0202(g)(2,3,4)          - consumer rights and confidentiality;
[Also 27D .0204]         - how to meet the mh/dd/sa needs of the individual as
                         specified in the treatment/habilitation plan; and
                         - infectious diseases and bloodborne pathogens

10A NCAC 27G .0202(h) Need to review per 2005 audit
10A NCAC 27G .0202 (i) Agency develops and implements procedures for identifying,
                       reporting, investigating and controlling infectious and
                       communicable diseases of personnel and consumers.

10A NCAC 27G .0203(a- Demonstration of knowledge, skills and abilities required by
b) and .0204(c)       population served by qualified professionals, associate
                      professionals and paraprofessionals

10A NCAC 27G .0203(f) Individualized supervision plan for each associate professional

10A NCAC 27G .0203(g) Supervision of associate professionals by a qualified
                      professional

10A NCAC 27G .0204(b) Supervision of paraprofessionals by an associate professional
                      or qualified professional

10A NCAC 27G .0204(f) Individualized supervision plan for each paraprofessional




                                 Section VI - Page 16
                                                            Wake County LME Provider Manual 2008
                                                                                     SECTION VI


SECTION VI Quality Improvement and Performance Monitoring
7. Research Conducted Through Wake County
Effective Date: Dec. 1, 2000                       Version Date: 3/10/06
Informational Only  Requirement                  Reference: NCAC T10:14V.0208 Research
                                                   Review Board, Code of Federal Regulations
                                                   Title 45 Part 46 Protection of Human Subjects
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)                 CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)            Cat. A Licensed Facilities
 Medicaid Enhanced Svc                               Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                        Cat. C Institutions/Facilities
 ICF-MR                                              Cat. D Lic/Cert. Outpatient/Day Svcs


Purpose:
Providers must act to limit the likelihood of any increased risk associated with participation in
research. Providers must be able to assure that any increased risk is justified by the benefits
which might be derived from the research.

Each provider agency must have a process to protect consumers, families and staff when
research is conducted.

Procedure:

Any research which calls for the participation of Wake County LME consumers must
conform to this procedure.

All research must be approved by an Institutional Review Board, which is a committee that
conforms to requirements of 45 CFR 46; and gives consideration to the risks to the subjects, the
anticipated benefits to the subjects and others, the importance of knowledge that may reasonably
be expected to result, the informed consent process to be employed, the provisions to protect the
privacy of subjects; and additional safeguards for vulnerable populations (e.g., children, pregnant
women, mentally disabled persons, or economically or educationally disadvantaged persons).

Providers shall engage in a research project only after they have given proper consideration to:
   □ the risks to the consumers, staff, agency, and community,
   □ the anticipated benefits to the subjects, agency, and community including the
   □ importance of the knowledge which may reasonably be expected to result, and;
   □ the consent process to be employed for participation.
   □ the ability of consumers to withdraw from participation

No research shall be permitted that would result in the public disclosure of consumer or staff
identified information.

No research shall be conducted without approval from the Wake County LME PCDT. Prior to
initiating research activities, providers must submit a request to the appropriate PCDT Services
Director.




                                         Section VI - Page 17
                                                      Wake County LME Provider Manual 2008
                                                                               SECTION VI
Definitions:
Research involves an individual in an activity which involves a trial or special observation. It must
also:
    (a) place the individual at a risk which is greater than one they would normally experience; or
    (b) must involve the provision of a service which is expected to be less effective than that
        which would be provided without the trial or special observation, or
    (c) is meant to serve the purpose of the research (i.e., confirm or disprove an hypothesis, or
        explicate some principle or effect) rather than primarily benefit the individual, or
    (d) could result in public disclosure of person-identified information.

Increased risk include physical, psychological, social or financial harm or cost; being provided with
a service which is expected to be less effective than would otherwise be provided without the trial
or special observation; or public disclosure of person identified information.




                                    Section VI - Page 18
                                                                    Wake County LME Provider Manual 2008
                                                                                             SECTION VI


SECTION VI Quality Improvement and Performance Monitoring
8. Provider Monitoring
Effective Date: July 1, 2004                                Version Date: 12/05/06
Informational Only  Requirement                           Reference: 10 NCAC 27G.0600
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)      CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)  Cat. A Licensed Facilities
 Medicaid Enhanced Svc                     Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs             Cat. C Institutions/Facilities
ICF-MR                                    Cat. D Lic/Cert. Outpatient/Day Svcs
Purpose: To define the ways in which Wake LME assures the quality of MH/DD/SA services
provided to Wake County consumers.

 Wake County‘s Local Management Entity provides regular training and technical assistance
 opportunities to meet the identified needs of the MH/DD/SA Provider community. By forming
 cooperative, supportive and collaborative relationships with service providers, the quality of
 services to Wake County consumers is enhanced. A proactive rather than punitive approach to
 service quality is utilized and open dialogue with Providers is encouraged to assure that the
 appropriate training and technical assistance is available. Service Providers can benefit by being
 proactive in seeking assistance and training to avoid problem areas later.

 As a result of Senate Bill 163, rules were adopted surrounding the monitoring of facilities and
 services. The bill provides Local Managing Entities with the authority to monitor and oversee
 licensed and unlicensed MH/DD/SAS services provided in the catchment area. These rules are
 available on the web at
 http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/ByChapter/Chapter_122C.html
 They are also found in APSM 30-1, 10ANCAC 27G.0602.

 The Quality Management Team of the WC LME takes responsibility for the three (3) areas that
 these rules focus on:
    1. Mediation of complaints for all MH/DD/SAS provider types and investigation of
        complaints for Category A and Category B providers. See Complaints procedure.
    2. Review of Critical Incident Reports from Category A1 and Category B2 providers. See
        Incident Report Procedure.
    3. Monitoring of providers for compliance with ―Quality Indicators,‖ which are a limited set
        of licensure, client rights and confidentiality rules as defined in 10A NCAC 27G .0602(8).
        The procedures are outlined below.

 Provider Monitoring
 The purpose of monitoring is to ensure the consistency, quality and effectiveness of care, assist
 Providers with quality improvement activities, and promote attainment of consumer outcomes.

 All Providers need to be aware of the changes in monitoring through regular review of state
 websites as well as the Wake County LME website found at:
 http://www.wakegov.com/humanservices/lme/default.htm
 1 Category A - facilities licensed pursuant to G.S. 122C, Article 2, except for hospitals; these include 24-hour residential
 facilities, day treatment and outpatient services (facilities with license numbers MHL-XXX-XXX)
 2
   Category B - community based providers not requiring state licensure (unlicensed mh/dd/sas providers.)



                                            Section VI - Page 19
                                                       Wake County LME Provider Manual 2008
                                                                                SECTION VI


Under the 10A NCAC 27G .0600 an LME is authorized to assure the quality of services provided
within their catchment area whether a provider is contracted or not.

Frequency of monitoring is based on many factors, some of those being:
     Longevity and reputation of the Provider
     Results of reviews and status with other agencies that have oversight responsibility
   (DHSR or DSS of DMH/DD/SAS if applicable.)
     Critical Incident issues:
      o        Compliance with incident reporting system
      o        Number and severity of Level II or Level III incidents
      o        Providers‘ response to the incident
     Complaint issues:
      o        Number and type of complaints concerning a provider
      o        Providers‘ response to complaint
      o        Conclusion reached from investigation of complaint
     State inspection and review
     Accreditation status and results of accreditation agency reviews
     Compliance with the requirements of the provision of public services

A. Scheduled Monitoring Procedure:
    1. Thirty (30) days prior to the scheduled date for the monitoring, the Quality Management
       Team will send written notification to the Provider identifying the proposed monitoring date.
       The monitoring can be a site visit or a request for off site review of specific documents. If
       specific records are to be reviewed, the Provider will be told which records will be needed
       at least 5 business days prior to the monitoring. This may be through telephone
       communication, e-mail or the United States Post Office.
    2. Within 10 business days after the completion of the monitoring, the Quality Management
       team will complete a written Monitoring Results Report. This report may include
       recommendations and/or corrective actions. If there are health and safety issues that
       require immediate attention the provider will be informed at the time of the monitoring. If
       there is cause to immediately recommend suspension of referrals, the Wake LME Referral
       Suspension procedures will be followed. This may include informing other oversight
       agencies of the situation.
    3. A written Monitoring Results Report will either be sent to the provider via e-mail or
       discussed face-to-face at a scheduled meeting if warranted. The decision to either send a
       report or schedule a meeting to review the results will be made by the Quality
       Management Team based on the outcome of the review.
                 If a Provider does not attend the scheduled meeting or the e-mail is returned,
                    the QM Team will call the Provider by telephone. If the provider does not
                    respond within 48 hours, the QM Team will send the Provider a certified letter.
                    If there is no response to the certified letter within 5 days of mailing, then the
                    QM Team will follow the recommendation to suspend referrals procedure found
                    in section VI.9 and will also file a complaint with the Division of Health Service
                    Regulation if the Provider is licensed.
    4. The Provider, if required, is expected to complete a written corrective action plan and
       return it as directed on the Monitoring Results Report within 10 business days after receipt
       of that report. The Quality Management Team will be available to assist providers to
       complete a corrective action plan if needed.
             If a Provider does not send in a Plan of Correction within the 10 day period, the
                 QM Team will call the provider by telephone. If the provider does not respond

                                    Section VI - Page 20
                                                       Wake County LME Provider Manual 2008
                                                                                SECTION VI
                within 48 hours, the QM Team will send the Provider a certified letter. If there is no
                response to the certified letter within 5 days of mailing, then the QM Team will
                follow the recommendation to suspend referrals procedure found in section VI.9
                and will also file a complaint with the Division of Health Services Regulation if the
                Provider is licensed.

   5. Corrective action plans will be reviewed and approved. If a corrective action plan is not
      accepted and needs improvement, the Quality Management Team will work with the
      provider to assure completion.
                If no approved corrective action plan is completed after three (3) attempts then
                  the QM Team will follow the recommendation to suspend referrals procedure
                  found in section VI.9 and will also file a complaint with the Division of Health
                  Service Regulation if the Provider is licensed and the Division of Mental health
                  if appropriate. Failure to submit an acceptable Plan of Correction could lead to
                  withdrawal of endorsement.
   6. Timelines for implementing the corrections shall not exceed 60 days from the date the
      Provider receives the written Monitoring Results Report.
                If no implementation of the corrective action plan is completed after three (3)
                  attempts then the QM Team will follow the recommendation to suspend
                  referrals procedure found in section VI.9 and will also file a complaint with the
                  Division of Health Services Regulation if the Provider is licensed. Failure to
                  implement corrective actions could lead to withdrawal of endorsement.
   7. Results of service quality monitoring are reported to the Accountability Division of
      DMH/DD/SAS monthly. Results are also forwarded to other LME‘s whose consumers are
      also served by the provider.
   8. If there are unresolved issues from the corrective plan that may compromise the health
      and safety of current or future consumers, the WC LME will immediately notify the
      appropriate agencies (i.e. DSS, DHSR.) Failure to take appropriate corrective action
      can lead to a recommendation to suspend referrals, contract termination or in the future
      removal of a provider endorsement by the LME.
   9. If necessary the LME will refer results of monitoring to the appropriate state agencies.
      Category A providers will be referred to DHSR and Category B providers will be
      referred to DMH/DD/SAS in the following instances:
          Monitoring identifies an issues a State agency is required to review
          Corrective Acton Plans are not submitted to the LME within the designated timeframe
          Issues identified in monitoring are not corrected by the Provider in a timely manner.

Failure to take appropriate corrective action can lead to recommendation to suspend
referrals contract termination or withdrawal of endorsement by the LME.


B. Risk Monitoring Procedure:
In some instances, serious complaints, incident reports, or other concerns related to quality care
require that the Quality Management Team respond immediately. This response will not follow
the steps outlined for a scheduled monitoring.

   1. The Quality Management Team will contact the Provider and discuss the issue at hand.
      The setting for the review and the composition of the review team will be based on the
      concern that has triggered the monitoring. If other agencies are involved, the Wake LME
      team will work to coordinate with others who may also have concerns.



                                    Section VI - Page 21
                                                        Wake County LME Provider Manual 2008
                                                                                 SECTION VI
    2. If there is cause to immediately recommend suspension of referrals, the Wake LME
       Referral Suspension procedures will be followed. This may include informing other
       oversight agencies of the situation.
    3. Providers will be advised of results of the monitoring as soon as all information has been
       collected and reviewed. A written report will either be sent to the provider via e-mail and
       given to the Provider and discussed face-to-face at a scheduled meeting if the situation
       warrants. The decision to either send a report or schedule a meeting to review the results
       will be made by the Quality Management Team based on the outcome of the review.
                 If a Provider does not attend the schedule meeting or the Monitoring Results
                    report is returned, the QM Team will call the Provider by telephone. If the
                    provider does not respond within 48 hours, the QM Team will send the Provider
                    a certified letter. If there is no response to the certified letter within 5 days of
                    mailing, then the QM Team will follow the recommendation to suspend referrals
                    procedure found in section VI.9 and will also file a complaint with the Division of
                    Health Service Regulation if the Provider is licensed.
    4. The Provider may be required to complete a written corrective action plan and return it as
       directed on the Monitoring Results Report within the time frame noted on the report. The
       Quality Management Team will be available to assist Providers in completing a corrective
       action plan.
                 If no approved corrective action plan is completed after three (3) attempts then
                    the QM Team will follow the recommendation to suspend referrals procedure
                    found in section VI.9 and will also file a complaint with the Division of Health
                    Service Regulation if the Provider is licensed.
    5. Corrective action plans will be reviewed and approved. If a corrective action plan is not
       accepted and needs improvement, the Quality Management Team will be available to
       assist the Provider if requested.
                 If no approved corrective action plan is completed after three (3) attempts
                    then B.9 above can occur.
                 Timelines for implementing the corrections shall not exceed 60 days from the
                    date the Provider receives the written Monitoring Results Report but can occur
                    more quickly based on the severity of the issue to be corrected. If no
                    implementation of the corrective action plan is completed after three (3)
                    attempts then the QM Team will follow the recommendation to suspend
                    referrals procedure found in section VI.9 and will also file a complaint with the
                    Division of Health Services Regulation if the Provider is licensed.
    6. Results of service quality monitoring are reported to the Accountability Division of
       DMH/DD/SAS monthly. Results are also forwarded to other LME‘s whose consumers are
       also served by the Provider.
    7. The LME will refer results of monitoring to the appropriate state agencies; Category A
       providers will be referred to DHSR and Category B providers will be referred to
       DMH/DD/SAS in the following instances:
                 Monitoring identifies an issues a State agency is required to review
                 Corrective Acton Plans are not submitted to the LME within the designated
                    timeframe
                 Issues identified in monitoring are not corrected by the Provider in a timely
                    manner
Failure to take appropriate corrective action can lead to suspension, contract termination or
withdrawal of endorsement by the LME.




                                     Section VI - Page 22
                                                         Wake County LME Provider Manual 2008
                                                                                  SECTION VI


 SECTION VI Quality Improvement and Performance Monitoring
9. Provider Sanctions
Effective Date: July 1, 2006                       Version Date: 11/01/07
Informational Only  Requirement                  Reference: GS122C-111; 10A NCAC
                                                   27I.0307 (effective 7/1/04)
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)              CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)          Cat. A Licensed Facilities
 Medicaid Enhanced Svc                             Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                      Cat. C Institutions/Facilities
ICF-MR                                             Cat. D Lic/Cert. Outpatient/Day Svcs

 Purpose: Wake County LME strives to protect the safety and welfare of consumers by issuing
 sanctions to providers that violate rules and/or regulations. The purpose of this procedure is to
 define the situations that would result in sanctions from the Wake County LME, the sanctions that
 may be imposed, and the process utilized in imposing sanctions. Sanctions apply equally to
 WCHS programs and to network providers.

 Types of Sanctions:
    1. Payback: The process of returning payment for Non-Medicaid (IPRS) services to the
       Wake County LME.
    2. Recommendation for Suspension of referrals: In cases where the health, safety or
       welfare of consumer(s) is deemed at risk, the Wake County LME may recommend that
       referrals be suspended to a provider. Wake County LME will notify the State authorities,
       other providers, and other LME‘s of the recommendation for referral suspension.

These types of sanctions are detailed below.

1. PAYBACK OF NON-MEDICAID (IPRS) FUNDS:

Formal monitoring involves the use of a standardized audit instrument and procedures, and
typically targets a predetermined set of services.
There are four general types of deficiencies identified through monitoring which may result in
payback:
             1. Erroneous or fraudulent billing (unintentional or intentional) e.g., double billing, note
                does not meet billing criteria;
             2. Lack of documentation - e.g., service order, service plan, progress note, or staff
                competency;
             3. Insufficient documentation - e.g., the note doesn‘t reflect staff intervention, or the
                duration of time billed is not justified;
             4. Inadequate staff credentialing - i.e., staff lacks credentials to provide the service.
    Provider monitoring results must be reported on a timely basis to governmental oversight
    agencies, per statute or rule.
    Payback of Non-Medicaid IPRS funds must be made to the Wake County LME.




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                                                     Wake County LME Provider Manual 2008
                                                                              SECTION VI



2. RECOMMENDATION FOR SUSPENSION OF REFERRALS

Events and issues that could lead to the recommendation to suspend referrals to a provider can
be identified from any of the following:
        Monitoring events either scheduled or those related to complaints or concerns
            generated from many sources
        Incident Review
        Other LME‘s‘ communication to the Wake LME
        Public information not directly received by the LME or the Quality Management Team

The following are possible reasons for recommending an immediate suspension of referrals to the
provider:
   1. A serious risk is identified or discovered by Wake County LME teams regarding the health,
        safety, welfare or continuity of care of consumers and has been adequately investigated to
        indicate a recommendation of referral suspension is necessary to protect consumers.
   2. Another LME has recommended suspension of referrals and has forwarded pertinent
        information to Wake LME.
   3. Another oversight agency (DHSR, CPS, APS, DHHS etc.) has identified concerns that
        could immediately affect the health, safety or welfare of or continuity of care for
        consumers.
   4. A Provider is out of compliance with State and Provider Manual requirements due to
        failure to follow through with their plan of correction. (See Section VI.8 for specifics
        related to plans of correction.)

Recommendation to suspend referrals to a provider will result in Wake County LME taking the
following actions:
1.      Notifying the State authorities, other providers, and other LME‘s of the recommendation to
     suspend referrals until further notice.
     And possibly
2.      Holding any Non-Medicaid funds due to the provider,

 A. Procedure for implementing a Recommendation to Suspend referrals:

   1. The Quality Management Team, via email or phone, will forward the information leading to
       the recommendation to suspend referrals to a provider to the LME Director, PCDT Service
       Director and to members of the core LME Management Team for a decision.
        Based on the level of potential danger to consumers, the time allotted for this decision
           making process will vary and will be noted in the communication.
        If the situation is deemed appropriate for referral to WCHS Child Protective Services
           (CPS) or Adult Protective Services (APS), Division of Health Services Regulation
           (DHSR) or DMH/DD/SAS for further investigation the QM Team will do so. Results of
           investigations from these groups will be forwarded to the LME Director, PCDT
           Service Manager and the core LME Management Team.
   2. Appropriate members of the core LME Management Team will review the information and
       make a decision regarding the recommendation to suspend referrals.
   3. If a decision is made to recommend suspension of referrals to a provider, the PCDT
       Service Director connected to the provider will then:
        Notify QM Team of the decision to recommend suspension of referrals to the provider.



                                   Section VI - Page 24
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                                                                               SECTION VI
       Notify the Provider of this decision by telephone and in writing to give specific reasons
        for action as well as information regarding how the recommendation to suspend
        referrals of can be lifted.
  4. QM Team will:
       Notify all agencies that could refer to this provider, via email, of the recommendation
        that no referrals be made to this Provider until further notice. This notice will also be
        sent to the Division of Health Services Regulation, the Division of MH/DD/SAS, the
        Division of Medical Assistance, the Medicaid Utilization Review contractor (currently
        ValueOptions), the Wake County Attorney, and the Wake County Manager‘s office and
        all other LME Quality Management programs in the State.
       Facilitate the posting of the notice on Wake County LME‘s website

B. Procedure for Lifting Of Recommendation to Suspend Referrals:
  1. Upon receipt of a written Plan of Correction from the Provider, the QM Team will review
      and forward it to the LME Director, LME PCDT Service Director and the core LME
      Management Team who will also review the plan to decide if the plan is acceptable.
  2. If the Plan of Correction is accepted, the PCDT Service Director will notify the Provider
      in writing of the acceptance of the plan of corrections and the process for lifting the
      recommendation of referral suspension.
  3. If the Plan of Correction is not accepted, the PCDT Service Director will contact the
      Provider and work with them to create an acceptable plan.
       If no approved corrective action plan is completed after three (3) attempts then the
           QM Team will continue the recommendation to suspend referrals procedure found
           in section VI.9 and will also file a complaint with the Division of Health Service
           Regulation if the Provider is licensed.
  4. In order for the recommendation to suspend referrals be lifted the following must
      occur:
     a.) The provider has successfully completed the items on the Plan of Correction and the
            corrective actions have been reviewed by the LME to assure that all out of
            compliance issues have been rectified.
      If no implementation of the corrective action plan is completed after three (3) attempts
          then the QM Team will uphold the recommendation to suspend referrals procedure
          found in section VI.9 and will also file a complaint with the Division of Health Service
          Regulation if the Provider is licensed.
     b.) Other oversight agencies have communicated verbally or in writing that the
            allegations that led to suspension have:
            Not been substantiated, or have been adequately corrected
     c.) There are no currently unresolved pending complaints
  5. The results of the review of the corrective action plan will be communicated to the
      LME Director and the LME Management Team who can approve lifting the
      recommendation for suspension of referrals within 5 business days of the review.
  6. If the conditions in 4.) above have not been met then the LME will continue to work
      with the Provider towards completion so that the recommendation to suspend referral
      can be lifted.
  7. If the decision has been made to lift the recommendation for the suspension of
      referrals the PCDT Service Director connected to the provider will notify the
      Provider of the decision by telephone and in writing.
  8. QM Team will:
     a)      Notify by email of lifting of the recommendation for referral suspension. This notice
             will be sent to all of the entities originally notified of the recommendation to suspend
             referrals.


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                                              Wake County LME Provider Manual 2008
                                                                       SECTION VI
b)   Facilitate the posting of the notice of the lifting of the recommendation to suspend
     referrals on Wake County LME‘s website.




                            Section VI - Page 26
                                                      Wake County LME Provider Manual 2008
                                                                               SECTION VI


SECTION VI Quality Improvement and Performance Monitoring
10. Appeal of Findings from Monitoring, Complaint Investigations or Audits
Effective Date: July 1, 2006               Version Date: 1/01/07
Informational Only  Requirement          Reference: DMH/DD/SA Endorsement
                                           Policies, MOA
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)      CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)  Cat. A Licensed Facilities
 Medicaid Enhanced Svc                     Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                  Cat. C Institutions/Facilities
ICF-MR                                         Cat. D Lic/Cert. Outpatient/Day Svcs


It is the intent of Wake County LME to ensure a timely mechanism for Providers to appeal any
findings, sanctions or paybacks issued by LME Quality Management Team (QMT) as a result of a
provider monitoring, complaint investigation or audit.

Process Statement
All providers are afforded the opportunity to submit an appeal for the review of any findings,
sanctions and paybacks requested by Wake County LME by following the Appeals
Procedure. The Appeal process will not stop any sanctions or referrals to oversight
agency or a recommendation to suspend referrals.

Appeals Procedure
Upon receipt of any findings, sanctions or payback from Wake County LME that require a
corrective action or sanctions, the following procedures apply:

   1. A provider may appeal in writing to the LME QM Team Leader within 10 business days
       of receipt of findings. Appeals may be submitted along with corrective action plans of
       other results

   2. The LME QM Team Leader and other appropriate staff have 10 business days to review
       the appeal and uphold the appeal or deny it.
           a. If any or all parts of the appeal are upheld by the LME QM Team Leader,
              appropriate adjustments will be made to the findings report and returned to
              the contract provider.
           b. If the appeal is denied by the LME QM Team Leader, the corrective action
              plan and any payback will remain.

   3. When Provider receives the LME QM Team Leader‘s decision, the Provider may:
       a.    Accept the decision and comply with corrective actions as requested.
       b.    Reject the decision.

   4. If the provider wishes to appeal the findings further, a second appeal must be made
        in writing to the WC LME Director within 10 business days of the receipt of the first
        appeal decision by the QM Team.


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                                                                               SECTION VI
  5.   The LME Director and other appropriate staff have 10 business days to review the
       appeal and uphold the appeal or deny it.
         a. If any or all parts of the appeal are upheld by the LME Director, appropriate
              adjustments will be made to the findings report and returned to the contract
              provider.
         b. If the appeal is denied by the LME Director, the corrective action plan and any
              payback if applicable will remain.

  6.   If a Provider accepts the LME Director‘s decisions, a revised/final corrective action plan
       along with any payback if applicable is due within 10 days upon the completion of the
       appeals process.


If a Provider would like to appeal the decision of the Wake County LME Director, then the provider
may contact the Division of Mental Health/Developmental Disabilities/Substance Abuse Services at
(919) 715-3197.




                                   Section VI - Page 28
                                                  Wake County LME Provider Manual 2008
                                                                           SECTION VI


SECTION VI Quality Improvement and Performance Monitoring
11. Withdrawal of Endorsement
Effective Date: July 1, 2006                Version Date: 7/01/06
Informational Only  Requirement           Reference: DMH/DD/SA Endorsement
                                            Policies, MOA
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)       CAP/MRDD
Medicaid Basic Svc (Not Direct Enrolled)    Cat. A Licensed Facilities
 Medicaid Enhanced Svc                      Cat. B Comm Based Providers
Non-Medicaid Contracted Svcs               Cat. C Institutions/Facilities
ICF-MR                                     Cat. D Lic/Cert. Outpatient/Day Svcs


PURPOSE:
To assure that Providers of enhanced MH/DD/SA services funded by Medicaid meet all quality
standards.

PROCEDURES:
The Wake County LME may withdraw a Provider‘s endorsement and terminate the
Memorandum of Agreement for cause. The cause for termination will be documented in writing
describing the grounds for termination.

For more information on grounds for Endorsement withdrawal, please see Policy And
Procedures For Endorsement Of Providers Of Medicaid Reimbursable MH/DD/SA Services
at:
http://www.dhhs.state.nc.us/mhddsas/announce/2005archive.htm


A provider may terminate their agreement to provide enhanced MH/DD/SA services funded by
Medicaid any time by the provider after ninety (90) days upon written notice of termination.




                                Section VI - Page 29
                                                               Wake County LME Provider Manual 2008
                                                                                        SECTION VI



SECTION VI Quality Improvement and Performance Monitoring
12. Consumer Engagement and Empowerment
Effective Date: 7/01/07                Version Date: 7/1/07
Informational Only  Requirement      Reference: Enhanced Service Definitions
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)                   CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)              Cat. A Licensed Facilities
 Medicaid Enhanced Svc                                 Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                          Cat. C Institutions/Facilities
ICF-MR                                                 Cat. D Lic/Cert. Outpatient/Day Svcs

Every provider shall have mechanisms in place to engage consumers in the way they deliver
services. It is a best practice that consumers are represented on various committees and boards
related to service delivery, development, and quality improvement. This will be evident in
continuous quality improvement projects, response to consumer satisfaction surveys, and minutes
and attendance of committee and board meetings.

Providers are further encouraged to inform consumers of opportunities to serve on
Wake‘s Consumer and Family Advisory Committee (CFAC), which acts in an advisory
capacity to the LME.

The providers‘ consumer complaint policy and procedure shall meet the requirements of Section
VI. 3. It is best practice that providers ensure the process is easily understood and accessible to
consumers, and that education on the procedure occurs at least annually, with person centered
planning.




                                             Section VI - Page 30
                                                      Wake County LME Provider Manual 2008
                                                                              SECTION VII

SECTION VII Service Provision Policies and Procedures
1. Lead Provider
Effective Date: 7/1/07                   Version Date: 7/17/07
Informational Only  Requirement        Reference: Enhanced Service Definitions
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)              CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)         Cat. A Licensed Facilities
 Medicaid Enhanced Svc                            Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs
                                                   Cat. C Institutions/Facilities
ICF-MR
                                                   Cat. D Lic/Cert. Outpatient/Day Svcs

Purpose: To define which provider is considered the Lead Provider when a consumer
is receiving services from more than one provider, and to outline the responsibilities of
the Lead Provider.

The Lead Provider shall be reported to the LME on the Consumer Enrollment Form.

MH/SA Service System:
   For consumers receiving Basic Benefit services only, the Lead Provider is the
     Behavioral Health Outpatient therapist.
   For consumers receiving Enhanced Benefit services, the Lead Provider is the
     Clinical Home. The Clinical Home is any of the seven ―direct-admit‖ services, as
     defined by the State:
         1. Intensive In-Home
         2. Multisystemic Therapy
         3. Community Support Team
         4. Assertive Community Treatment Team
         5. Community Support Individual and Group (Child, Adult)
         6. Substance Abuse Intensive Outpatient Program
         7. Substance Abuse Comprehensive Outpatient Treatment
   The Lead Provider is responsible for the Service Plan (basic services), PCP
     (enhanced services), Crisis Plan, Target Population Eligibility form, NC TOPPS,
     Fee Application (for Non-Medicaid), facilitating consumer choice, and monitoring
     and implementation of the service plan. The Lead Provider is also the First
     Responder.
   If the only enhanced benefit service a consumer is receiving is not on the list
     above, then that service is responsible for the Person Centered Plan.
   Before a Lead Provider closes a child who is transferring to a ―non-direct admit‖
     service, such as Day Treatment or Child Residential, the provider should make
     due diligence in securing further authorization through an application for EPSDT.


Developmental Disabilities Service System:

The following hierarchy will determine which provider is designated as the lead provider
with responsibility for the on-going coordination, implementation, monitoring and updates
of the plan and authorizations for all services.

                      1. Targeted Case Management



                                      Section VII - Page 1
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                                                                          SECTION VII
                  2. Residential Provider
                  3. Day Program Provider
                  4. Any remaining provider

DD Lead Providers are responsible for Authorization requests, the NC-SNAP, Unified
Person Centered Plan, Crisis Plan, Fee Application, and Target Population Eligibility.

Before a Lead Provider closes a child who is transferring to a ―non-direct admit‖ service,
the provider should make due diligence in securing further authorization through an
application for EPSDT.




                                 Section VII - Page 2
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                                                                              SECTION VII


SECTION VII Service Provision Policies and Procedures
2. Person Centered Plan
Effective Date: March 20, 2006                    Version Date: 7/1/07
Informational Only  Requirement                 Reference: APSM 45-2, Clinical Coverage
                                                  Policy 8A
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)              CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)         Cat. A Licensed Facilities
 Medicaid Enhanced Svc                            Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs
                                                   Cat. C Institutions/Facilities
ICF-MR
                                                   Cat. D Lic/Cert. Outpatient/Day Svcs

Scope: This procedure applies to consumers of enhanced and intensive services,
including Community Support, Community Support Team, Intensive In-Home, MST,
ACTT, ADVP, group living, etc. It does not include consumers who receive only
Behavioral Health Outpatient, or short-term services such as crisis services, respite, and
Detox. (These latter services generally require a service plan that meets State
standards, documented in APSM 30-1 and APSM 45-2.)

Purpose:
This procedure will ensure that consumer‘s benefit from an individualized, person-
centered plan developed with the consumer/family, which reflects the strengths,
values, preferences and concerns of the consumer and family/significant others.
The plan shall be consumer-driven, coordinated, integrated, and non-duplicative.

This procedure provides guidelines for providers of Wake County Human Services LME
regarding the Person Centered Planning process and Lead Provider responsibility in the
initiation and on-going provision of MH/DD/SA services. These procedures reflect best
practice models for treatment planning and implementation. Clinical judgment is always
necessary to interpret procedures for consumers and families, and, to assist them in
determining the best course of action for situations that arise outside usual consumer
care.

         Lead Provider Responsibilities: Initial goals of treatment or comprehensive
         planning do not usually occur during crisis evaluation and intervention but rather
         as a part of the resolution to crisis events and linkage to services. An
         Introductory Person Centered Plan (PCP) shall be developed for consumers new
         to the MH/DD/SA system, or, consumers who have been discharged from all
         services for at least 60 days. If a consumer enters targeted case management or
         community support the QP can bill a maximum of 8 unmanaged hours to develop
         the introductory PCP to support the initial authorization request. All other direct
         admit enhanced services require prior approval before any services are billed.
         Prior to the end of the first authorization period the lead provider shall develop a
         comprehensive clinical assessment of the consumer‘s functioning and
         incorporate these findings in the Complete PCP. The Lead Provider is
         responsible for initiating the plan according to the mandated procedures for
         person centered plan development, ongoing linkage to other services as
         necessary, as well as the monitoring and updating of the person centered plan.


                                      Section VII - Page 3
                                                   Wake County LME Provider Manual 2008
                                                                           SECTION VII
        These procedures are expected to be implemented in a uniform manner for all
        consumers of enhanced services. Each consumer‘s person centered plan shall
        be reviewed as clinical needs change, at least annually when the review of
        medical necessity is due. The June 29,2007 revised Person-Centered Planning
        Instruction Manual, effective July 15, 2007, is available on the Division‘s web site
        located at:

                http://www.ncdhhs.gov/mhddsas/training/access-care/index.htm

Person Centered Plans must meet the minimum requirements as stated in the Service
Record Manual (APSM 45-2). Individual providers/agencies may adopt more stringent
requirements to meet the needs of their specific consumer population as long as these
requirements are documented.

1) Initial or Annual Person Centered Planning Process
     a) One Month Prior- One month prior to the consumer‘s annual review date found
        on the signature page, the Lead Agency for the consumer‘s services schedules
        the Person Centered Planning meeting. The meeting should occur at a mutually
        agreed upon location and time for all participants. Wake County Providers are
        required to attend and participate in all Person Centered Plan meetings.
        Notification of the meeting should preferably be issued in writing. The Child and
        Family Team shall convene the PCP meeting for recipients of Child Mental
        Health services.
     b) Two Weeks Prior- Two weeks prior to the meeting, the Lead Provider shall
        ensure that all participants are notified of its date, time and location.
2) Meeting Preparation
     Before the meeting, the Lead Provider shall orient the consumer, and family
     members when applicable to the planning meeting process. The discussion should
     inform the consumer and family members of the purpose of each part of the meeting
     agenda and any expectations of the consumer and others invited to attend. Each
     disability section has established models for person centered planning which will
     direct the flow of the PCP process. During the development of the introductory PCP
     or the review of a complete PCP, the consumer must be educated regarding all
     appropriate service options, from which they can give informed consent and make an
     informed choice of providers. Service providers shall not require consumers to
     receive multiple services from a sole provider.
3) Meeting Outcome - The Lead Provider:
     a) Completes the PCP documentation and facilitates signatures; and
     b) Provides copies of the finalized Person Centered Plan for all participants. If this
        cannot be accomplished at the meeting, each participant must receive copies of
        the complete PCP within 5 business days after the meeting date.
4)    Finalized Service Authorization Requests - Initial PCP service authorizations
     shall be completed by the Lead Provider. Once the Complete PCP has been
     authorized, subsequent service authorizations shall be the responsibility of each
     Provider according to authorization procedures outlined in Section III.




                                  Section VII - Page 4
                                                 Wake County LME Provider Manual 2008
                                                                         SECTION VII
5) Interim Changes to the Person Centered Plan - Additional services are generally
   accessed in response to a change in a consumer‘s clinical status and/or lack of
   progress towards initial goals. The lead provider shall engage the consumer,
   family/significant others, and other treatment providers in the person centered
   treatment process to change or develop any additional goals or strategies to meet
   the consumer‘s needs. Ideally these changes would occur in a meeting attended by
   all relevant parties. However, the PCP can be faxed to the new provider(s) and
   discussed via phone. If the new providers are in agreement with the plan they
   should sign off on the plan and return the signature page to the lead provider. The
   lead provider should call a meeting with the consumer and all providers to revise the
   plan if consensus cannot be reached by telephone. A copy of the plan should be
   submitted to all persons responsible for service authorization if changes are made in
   the plan that was submitted for initial authorization.
Discharge - If services by an agency are no longer needed due to goal/service plan
achievement, consumer move from the area, death, or any other reasons for
discharge/termination from services, the discharging agency shall submit a
Transfer/Discharge Summary form. The Transfer/Discharge procedures can be found in
Section V. Providers shall cooperate in the exchange of information during transition
among service providers according to established rules for release of information.




                                Section VII - Page 5
                                                      Wake County LME Provider Manual 2008
                                                                              SECTION VII


SECTION VII Service Provision Policies and Procedures
3. Psychiatric and Medical Services
3.1 Medication and Drugs, General Statement
Effective Date: July 1, 2004             Version Date: 3/10/06
Informational Only  Requirement        Reference: G.S. 90-21.5; 90-171.20(7),(8);
                                         90-171.44; 122C-26; 143B-147
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)              CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)         Cat. A Licensed Facilities
 Medicaid Enhanced Svc                            Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                     Cat. C Institutions/Facilities
ICF-MR
                                                   Cat. D Lic/Cert. Outpatient/Day Svcs

General Statement
Medication services include the prescribing, dispensing, administration, storage,
packaging, labeling, disposal, monitoring, review and control of medication and the
provision of education for those consumers who are placed on medication by providers
of Mental Health, Developmental Disabilities and Substance Abuse Services.

Procedure:

Providers that prescribe, dispense, administer, or store medication will maintain and
implement procedures in compliance with APSM 30-1 and the requirements of the
Provider Manual.

Providers will adhere to OSHA standards regarding blood-borne pathogens,
contaminated instrument disposal, and all other OSHA standards. All providers will
adhere to a universal blood and body fluid precaution protocol in the delivery of care.




                                      Section VII - Page 6
                                                      Wake County LME Provider Manual 2008
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SECTION VII Service Provision Policies and Procedures
3.2 Prescription and Administration of Medication
Effective Date: July 1, 2004              Version Date: 3/10/06
Informational Only  Requirement         Reference: G.S. 90-21.5; 90-171.20(7),(8);
                                          90-171.44; 122C-26; 143B-147
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)              CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)         Cat. A Licensed Facilities
 Medicaid Enhanced Svc                            Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs
                                                   Cat. C Institutions/Facilities
ICF-MR
                                                   Cat. D Lic/Cert. Outpatient/Day Svcs

Procedure:

1. Prescription of Legend Drugs:
   a. Only a psychiatrist or person authorized by state law shall be permitted to
        prescribe legend drugs.
   b. Prescription medication shall be administered in all MH/DD/SA programs only on
        the written or verbal order of an authorized prescriber.
   c. Only properly dispensed medication shall be administered. (See DISPENSING
        OF MEDICATION.)
   d. Physician assistants and nurse practitioners shall not prescribe psychotropic
        medication unless authorized by the North Carolina Board of Medical
        Examiners.
2. Administration of Prescription Medication
   a. Medication shall be administered in inpatient psychiatric services only by a
        psychiatrist, physician assistant, nurse, or nurse practitioner.
   b. In outpatient settings, medication may be administered by, or self-administration
        supervised by Service staff who have received instruction about each
        medication, dosage, time of administration, side effects, and contraindications
        from either the Service psychiatrist, or designee, or the consumer‘s parent or
        guardian.
3. Medication Administration Competency Requirements
   a. Medications shall be administered only by licensed persons, or by unlicensed
        persons trained by a registered nurse, pharmacist or other legally qualified
        person and deemed competent to administer medications.
   b. Non-medical staff administering prescription medication must be privileged and
        credentialed or deemed competent to do so.
   c. The recommendation for privileging/competency of a staff member to administer
        medication must be done by a psychiatrist.
4. Self-Administration of Medications
   a. A psychiatrist or person authorized to prescribe legend drugs shall approve the
        self-administration of prescription and over-the-counter (non-prescription)
        medication by consumers in inpatient programs, or minors or incompetent adults
        in residential programs.
   b. A parent of a minor or guardian for an incompetent adult shall obtain psychiatrist
        consent for the self-administration of prescription or over-the-counter (non-
        prescription) medication in outpatient, day treatment, or day activity programs.


                                      Section VII - Page 7
                                                 Wake County LME Provider Manual 2008
                                                                         SECTION VII
   c. A psychiatrist (or person authorized to prescribe legend drugs) shall approve the
      use of over-the-counter (non-prescription) medication for minors seeking
      treatment without parental consent.
   d. The competent adult consumer may self-administer prescription or over-the-
      counter (non-prescription) medication in outpatient, day treatment or day activity
      programs.
   e. Where applicable, consumers should receive training in the self-administration
      of medication.
5. Documentation Requirements
   a. Each medication prescribed by the medical services shall be documented in the
      consumer‘s record and signed by the prescriber.
   b. Consumer records for each agency or program will include documentation of all
      medication prescribed by the psychiatrist for that agency or program.
   c. Documentation of prescribed medication will include the consumer‘s name and
      record number, name, strength, and quantity of medication prescribed, date of
      prescription, number of refills, and instructions for administration.
   d. The prescriber will sign documentation of each medication prescribed.
   e. This information will be in a format that is readily available for review and
      transmission by fax to emergency medical personnel and other health care
      professionals.




                                Section VII - Page 8
                                                      Wake County LME Provider Manual 2008
                                                                              SECTION VII


SECTION VII Service Provision Policies and Procedures
3.3 Dispensing, Packaging, Storage and Labeling of Medication
Effective Date: July 1, 2004             Version Date: 3/10/06
Informational Only  Requirement        Reference: G.S. 90-21.5; 90-171.20(7),(8);
                                         90-171.44; 122C-26; 143B-147
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)              CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)         Cat. A Licensed Facilities
 Medicaid Enhanced Svc                            Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs
                                                   Cat. C Institutions/Facilities
ICF-MR
                                                   Cat. D Lic/Cert. Outpatient/Day Svcs

Procedure:

Medication shall be stored in a secure location that is in accordance with the state and
federal laws as well as the recommendations of the North Carolina Board of Pharmacy.
The medication container shall protect medication from light and moisture and shall be in
compliance with the Poison Prevention Packaging Act. In addition to other elements
required by APSM 30-1, medication containers shall include ancillary cautionary labeling
when indicated.

Only medical personnel (psychiatrists, nurses, nurse practitioners, and pharmacists)
authorized to prescribe, administer or dispense medication shall have access to stored
medication supplies (medication stock held prior to labeling). The lock on the
designated pharmacy dispensing area(s) in a building must have a lock unique to that
area. Only authorized medical personnel will be issued a key.

Space for storage shall be of sufficient size to allow for separate storage of each
consumer‘s medication and to prevent overcrowding.




                                      Section VII - Page 9
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SECTION VII Service Provision Policies and Procedures
3.4 Psychotropic Medication
Effective Date: July 1, 2004                       Version Date: 3/10/06
Informational Only  Requirement                  Reference: G.S. 90-21.5; 90-171.20(7),(8);
                                                   90-171.44; 122C-26; 143B-147
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)               CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)          Cat. A Licensed Facilities
 Medicaid Enhanced Svc                             Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs
                                                    Cat. C Institutions/Facilities
ICF-MR
                                                    Cat. D Lic/Cert. Outpatient/Day Svcs

A. Psychotropic Drug Administration and Informed Consent

Policy

Consent Requirements: Psychotropic medication may be prescribed or administered to
any adult consumer only after he/she has given voluntary consent to that specific
medication. Consent to a specific medication shall remain effective as long as the
consumer is receiving services, unless it is revoked by the consumer and/or guardian.
Exceptions to this requirement include: Disulfiram, Antipsychotics, Naltrexone and
Methadone, which must have written consents done at least yearly.

Procedure:
1) A consumer and/or guardian is considered to have given consent to medication after:
   a) A psychiatrist has discussed with the consumer and/or guardian the nature of
       his/her condition, the anticipated benefits of the medication prescribed and the
       risks and side effects of such medication, AND
   b) The consumer and/or guardian has given written or oral consent to the
       medication or, by affirmative behavior, has given evidence of his/her willingness
       to accept the medication.
2) Written consent is required for use of
   a) Disulfiram (Antabuse)
   b) Naltrexone (Revia)
   c) Methadone
   d) Antipsychotic (Neuroleptic) Drugs
3) Denial of Consent for Drug Therapy: The consent form should indicate refusal of
   consent when a consumer refuses treatment with antipsychotic medication and the
   psychiatrist judges that this denial implies risk of serious decompensation and/or
   hospitalization.
4) The guardian shall sign the written consent in cases of minors and incompetent adult
   consumers. The written consent should be renewed every 12 months.
5) Revocation of Consent: A consumer and/or guardian may revoke consent to a
   specific medication by stating or writing to any psychiatrist that he/she does not wish
   to take that medication. Each such refusal to take a specific medication shall be
   documented in the consumer record on the written consent if that is the case. If the
   consumer subsequently indicates a willingness to consent to such medication,
   he/she may do so, pursuant to procedures #1 and #2 above.


                                      Section VII - Page 10
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6) Emergency Exceptions to Consent and Medication Education Requirements:
   Psychotropic medications shall be administered in the inpatient unit to a voluntary or
   involuntary consumer without consent, if two psychiatrists certify that the medication
   is necessary to prevent a substantial likelihood of imminent, serious harm to the
   consumer or others. The administration of psychotropic medication in an emergency
   shall be documented in the consumer‘s medical record on the medication sheet and
   in a progress note. On an outpatient basis, consumers in those circumstances
   should be committed involuntarily to the hospital.


B. Tardive Dyskinesia

General Statement:
Since tardive dyskinesia is a condition which can develop in consumers who take
antipsychotic medication and, in some instances, may be permanent or irreversible, the
following precautions are required.

Policy:

Consumers or guardians shall be informed about the meaning and risks of tardive
dyskinesia as described in the medication education policy (see MEDICATION
EDUCATION).

Procedure:
Consumers shall be closely monitored with periodic (at least every six months)
screening and evaluation by a psychiatrist.

Appropriate documentation shall be made in the consumer‘s record including symptoms
noted and action taken.

While it is accepted that there is an association between antipsychotic (neuroleptic)
medication and abnormal movement disorders, it is also acknowledged that a clear
cause and effect relationship has not been established between medications and this
condition. There is also evidence that abnormal movement disorders similar to tardive
dyskinesia exist in psychotic consumers who have never been treated with neuroleptic
medications, and also some reason to believe that abnormal movement disorders
existed in consumers before the development of such medications. There is also
considerable personal cost to the consumer associated with the relapse to a psychotic
state for which these medications are given. Accordingly, decisions about decreasing or
discontinuing neuroleptic medications in consumers diagnosed as having tardive
dyskinesia must be made not simply on the basis on this condition but taking into
account the consumer‘s clinical history. In an attempt to balance the risks of abnormal
movement disorders with the risks of discontinuing antipsychotic (neuroleptic)
medications, the following guidelines should be followed:
1) A consumers receiving a score of ―2‖ on any item of the AIMS scale, by definition,
    has tardive dyskinesia. This will be entered as a problem on the treatment plan and
    a treatment plan will be developed. The frequency of AIMS examinations by the
    responsible psychiatrist may need to be increased, contingent upon the severity of
    the tardive dyskinesia and the clinical decision of the psychiatrist.
2) The consumer and/or guardian will be informed of the finding of tardive dyskinesia.
    Because of the uncertainties having to do with this condition, and due to variations in


                                Section VII - Page 11
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   the level of understanding of consumers, the actual information communicated to the
   consumer and the manner in which it is communicated will be determined by the
   responsible psychiatrist. It is the responsibility of each psychiatrist to keep informed
   about this condition.
3) The information given to the consumer and/or guardian, and the consumer‘s and/or
   guardian‘s response to this information, will be described in the progress notes.
   Quotes from each party are recommended. (It is recognized in certain
   circumstances that it may be difficult to communicate with the guardian; however, the
   psychiatrist and/or designee will attempt to do so.)
4) The consumer and/or guardian will be asked to sign a written consent form after this
   information has been given and he/she agrees in continuing the chemotherapy with
   antipsychotic medication.
5) The above steps are not to be considered a ―one-time procedure.‖ Education of the
   consumer and management of this condition must be an active and ongoing process
   in conjunction with the treatment of the mental illness. Psychiatrists are encouraged
   to request consultation from other program psychiatrists in cases that are severe or
   in which diagnostic uncertainty exists, as well as to consider consulting a neurologist.

Guidelines For The Use Of Psychotropics

Policy:

Psychotropic medications shall be used judiciously and in the lowest dosages possible
needed to treat a patient’s symptoms. When prescribing, the risks versus benefits need
to be considered by the psychiatrist.




                                Section VII - Page 12
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SECTION VII Service Provision Policies and Procedures
3.5 Medication Education
Effective Date: July 1, 2004                       Version Date: 3/10/06
Informational Only  Requirement                  Reference: G.S. 90-21.5; 90-171.20(7),(8);
                                                   90-171.44; 122C-26; 143B-147
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)               CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)          Cat. A Licensed Facilities
 Medicaid Enhanced Svc                             Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs
                                                    Cat. C Institutions/Facilities
ICF-MR
                                                    Cat. D Lic/Cert. Outpatient/Day Svcs

Policy:

In order for consumers to participate more fully and safely in their psychiatric treatment,
providers shall provide consumers with basic information regarding their medication.
This information should be sufficient to enable consumers or other responsible persons
to make informed consent, develop skills necessary for self-medication, have realistic
expectations of medication therapy, and to encourage compliance with the prescribed
regimen. For these reasons, medication education shall be available to all consumers
who are receiving medication regardless of age, sex, race, religion, social or economic
status, physical or mental ability.

Procedure:
1) Each consumer to be started or maintained on medication prescribed by
   psychiatrists of Wake County Human Services or its contract agencies shall receive
   individual or group education regarding prescribed medication. Education may be in
   oral or written form, but both are recommended
2) The psychiatrist, or psychiatrist‘s designee, shall assess each consumer‘s ability to
   self-administer medication as well as other factors that may affect drug therapy. In
   instances where the ability of the consumer to understand the medication education
   is questionable, a responsible person shall be provided with the opportunity to
   receive both written and oral instructions on behalf of the consumer.
3) The prescribing psychiatrist or other person approved by the psychiatrist shall
   provide the following written or oral (both modalities are strongly encouraged)
   information to the consumer or responsible person at a time deemed appropriate by
   the psychiatrist:
   a) The name, appearance of dosage regimen, intended use, and common side
       effects of the medication.
   b) Adverse reactions or uncomfortable side effects that should prompt calling a
       psychiatrist.
   c) Foods, drugs, or beverages that should be avoided/taken with medication.
   d) An alternative dosage regimen if a dose is missed.
   e) The expected length of the medication treatment.
   f) Refill Instructions.
   g) The proper place to store medication.
   h) The need to communicate and coordinate with other physicians of the consumer
       those medications prescribed by a psychiatrist.


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4) The medication education assessment and information provided shall be
   individualized for each consumer and documented in the consumer record.
5) Medication education shall be coordinated with the discharging or receiving program.
6) Medication education by non-M.D. clinical staff should be provided in the form of
   printed materials and training.




                               Section VII - Page 14
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SECTION VII Service Provision Policies and Procedures
4. Medical Emergencies
Effective Date: July 1, 2004                       Version Date: 3/10/06
Informational Only  Requirement                  Reference: G.S. 90-21.5; 90-171.20(7),(8);
                                                   90-171.44; 122C-26; 143B-147
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)               CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)          Cat. A Licensed Facilities
 Medicaid Enhanced Svc                             Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs
                                                    Cat. C Institutions/Facilities
ICF-MR
                                                    Cat. D Lic/Cert. Outpatient/Day Svcs

Policy:

Each Program shall implement a plan to be utilized in medical emergencies involving
consumers. Each Program shall comply with the following procedures.

Procedures:
1) Each Program shall maintain emergency information for each consumer which
   includes 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 consumer's preferred physician.
2) Upon consumer admission, each Program shall secure a signed statement from the
   parents of a minor consumer (with the exception of minor consumers seeking
   treatment/habilitation without parental consent), or the guardian of an adult
   adjudicated incompetent granting permission to seek emergency care from a hospital
   or physician.
3) During hours of operation of each treatment/habilitation Program, at least one staff
   member shall be available who is trained in basic first aid, cardio-pulmonary
   resuscitation, seizure management, and the Heimlich maneuver.
4) Each Program which includes water activities in its schedule shall assure that an
   individual who has successfully completed the basic rescue and water safety course
   is on the premises where the water activities occur.
5) Each Program shall have access to first aid supplies in each of its facilities.
6) If a consumer experiences what is determined to be a medical emergency, e.g., a
   medical problem that needs to be attended to immediately, a staff person will stay
   with the consumer until the consumer's condition becomes stable or medical staff
   takes responsibility for the care of the consumer and for the situation.
7) If there is a physician in the building, he/she needs to be notified immediately to
   assess the situation and consumer. If a physician is not in the building, or is not
   available, an R.N. needs to be notified immediately to assess the situation if he/she
   is in the building.
8) If there is no medical personnel in the building, the staff person(s) needs to evaluate
   the situation and, if needed, contact 911.
9) It is the responsibility of the staff members involved in a medical emergency to
   complete an incident report and follow the incident report protocol. The incident
   report should be completed immediately post incident and is to contain a complete



                                      Section VII - Page 15
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                                                                  SECTION VII
and accurate description of the emergency and actions taken. The consumer's
physician should be contacted as soon as possible after a medical emergency.




                         Section VII - Page 16
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SECTION VII Service Provision Policies and Procedures
5. Psychiatric Emergencies
Effective Date: July 1, 2004                       Version Date: 3/10/06
Informational Only  Requirement                  Reference: G.S. 90-21.5; 90-171.20(7),(8);
                                                   90-171.44; 122C-26; 143B-147
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)               CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)          Cat. A Licensed Facilities
 Medicaid Enhanced Svc                             Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs
                                                    Cat. C Institutions/Facilities
ICF-MR
                                                    Cat. D Lic/Cert. Outpatient/Day Svcs

Policy:

Providers seek to prevent psychiatric emergencies whenever possible through means
such as attending to consumers' needs promptly and professionally, and interviewing
potentially violent individuals through detection and prevention. When psychiatric
emergencies do occur, staff must respond immediately and intervene based on their
assessment of the situation. The first priority is to prevent injury, and the second is to
handle the situation in the least restrictive manner possible.

Procedure:

For the purpose of these procedures, a psychiatric emergency is defined as any incident
in which a person at a treatment program (whether or not a consumer) poses an
imminent danger to self, others or property, either by actions or stated intentions.

Each Program shall develop specific guidelines appropriate to its own structure.




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SECTION VII Service Provision Policies and Procedures
6. Crisis Intervention
Effective Date: July 1, 2004                       Version Date: 3/10/06
Informational Only  Requirement                  Reference: APSM 45-2
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)               CAP/MRDD
 Medicaid Basic Svc (Not Direct Enrolled)          Cat. A Licensed Facilities
 Medicaid Enhanced Svc                             Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs
                                                    Cat. C Institutions/Facilities
ICF-MR
                                                    Cat. D Lic/Cert. Outpatient/Day Svcs

Purpose:
Wake County Human Services Crisis and Assessment Services (CAS) staff and all
primary providers will strive to establish a close, collaborative relationship for handling
clinical emergencies. Whenever possible, the primary provider will take the lead in
handling emergencies involving open consumers. However, WC CAS staff will be
available to consult, assist, and when appropriate, take over the handling of clinical
emergencies. It is expected that the primary provider and the WC CAS staff on a case-
by case-basis, taking into the account the nature of the emergency, the needs of the
consumer, and the relative ability of either the primary provider or the WC Crisis staff to
meet the needs at the time, will negotiate these decisions.

Basic Principles to Successful Crisis Intervention

        A crisis is most likely to be resolved when the provider assisting the consumer
         has knowledge of the consumer and a positive working relationship with the
         consumer
        All interventions must maintain the dignity and respect of the consumer
        The individual‘s strengths and natural supports must be a primary focus
        All interventions must be solution focused and goal oriented
        ―Safety first‖ is an enduring principle
        Response must be timely
        Interactions are based upon cultural awareness and respect
        Clear communications should occur with all involved parties
        All services/supports are focused upon enhancing the ability to cope


 Crisis Assessment and Intervention – Roles and responsibilities of Wake County
  Human Services Crisis and Assessment Services staff and primary providers:

     1. WC CAS staff will handle emergencies in new consumers and former ―closed‖
        consumers.

     2. Emergencies with consumers who are open cases will be handled by the
        assigned primary provider whenever possible. If unable to handle the
        emergency, the provider will be available to consult with CAS staff as soon as
        possible, but usually within two to three hours. Providers will maintain current



                                      Section VII - Page 18
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   after hours contact/back-up information with WC Crisis and Assessment
   Services. Organizations that provide those services that require ―first responder
   crisis response‖ must provide crisis services on a 24/7/365 basis to recipients
   receiving services. Only individuals whose distress represents a clear and
   present danger to self or others following reasonable efforts, shall be referred to
   CAS for crisis services. The provider shall notify the individual and his/her
   support system of the process of accessing crisis/emergency services 24/7, both
   orally and in writing of the initial contact. The notification should include contact
   information for an alternate source of assistance in the event that the provider is
   not available.

3. Primary providers are expected to have working relationships with psychiatrists
   who have a reasonable ability to see consumers in a crisis situation or shortly
   after the crisis for immediate follow-up services.

4. Providers will prepare clear instructions for their consumers on medication issues
   and who to call and where to go in an emergency. These instructions will be
   designed to improve the system‘s response to emergency situations and to
   prevent medication emergencies. The instructions will emphasize the need to call
   the primary provider during working hours. Individuals with a history of multiple
   crisis episodes and/or who are at risk of future crisis should also have a crisis
   plan.

5. Providers may direct some consumers who call with emergencies to the CAS
   location if they think a hospitalization is likely or if for any reason it seems more
   prudent to handle a crisis situation there. The decision to handle a crisis at WC
   CAS does not mean the primary providers will not be involved. A copy of the
   consumer‘s treatment plan/crisis plan and any supporting clinical information that
   may be helpful, should be faxed to CAS whenever it is anticipated that a
   consumer may be seen at CAS and the provider is not immediately available.




                             Section VII - Page 19
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SECTION VII Service Provision Policies and Procedures
7. Housing Support Requirements for MH/SA Providers
Effective Date: July 1, 2006           Version Date: 7/1/06
Informational Only  Requirement      Reference:
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)               CAP/MRDD
Medicaid Basic Svc (Not Direct Enrolled)           Cat. A Licensed Facilities
 Medicaid Enhanced Svc                             Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                      Cat. C Institutions/Facilities
ICF-MR                                             Cat. D Lic/Cert. Outpatient/Day Svcs

Scope and Purpose: This procedure applies to providers of services for adult MH//SA
consumers who reside in government-funded housing and require assistance to enable
them to manage their symptoms and live independently in the community. This
procedure establishes requirements for providers to assist consumers in maintaining and
optimizing their housing status. These expectations support attainment of desired
consumer outcomes as well as compliance with requirements for receipt of federal,
state, and local housing funds.

Procedure: Providers of services for consumers in need of housing supports will assist
consumers in obtaining and maintaining housing. Providers will provide an appropriate
level of care and monitoring to assist consumers in reducing and managing their
symptoms, developing skills necessary to live independently, and participating in the
maintenance of their housing. Providers will collaborate with landlords, housing
developers and managers, governmental agencies, and other community housing
agencies to provide support for consumers who receive federal, state and local housing
funds. For consumers who reside in government-funded housing, providers will
participate in annual recertification procedures and will provide data as needed to
comply with funding requirements.

Specific expectations of providers are as follows:
   1. Conduct or arrange for a thorough assessment of consumer‘s desires, needs,
        strengths and limitations with regard to housing.
   2. Obtain signed releases from consumer to enable service providers to
        communicate with landlords and housing agencies
   3. Support consumer through the application and interview process for housing.
        Assist the client, as necessary, in completing required paperwork and
        accompany the client to meetings with landlords and housing agencies.
   4. Meet with the landlord at the lease signing and establish himself/herself as the
        client's contact, and educate the landlord regarding who to call in case of
        emergencies.
   5. Assist consumer in locating an apartment, placing utilities in their name,
        understanding their lease, identifying sources of furniture and moving into their
        apartment
   6. Assist consumer in orientation to apartment, including operation of
        heating/cooling and appliances, basic security precautions, basic cleaning and
        maintenance issues, how to access maintenance and repair services, how to



                                      Section VII - Page 20
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    access emergency medical and mental health services, and how to operate fire
    extinguishers and exit apartment in case of fire or emergency.
7. Assist the client in accessing community resources to ensure that basic
    household furnishings are supplied.
8. Orient consumer to their new neighborhood, locate bus stop and routes,
    Laundromat, grocery store, drug store, restaurants, employment opportunities,
    etc.
9. Help consumer with budgeting skills so that rent and utilities are paid in a timely
    manner.
10. Assist consumer in developing independent living skills as needed in areas of
    medication management, symptom management, shopping, cooking, cleaning
    and other areas.
11. Visit consumer a minimum of once per month at their home, assessing how they
    are caring for themselves and their apartment. The service provider will report to
    housing agency/landlord if the client fails to keep the apartment in a decent and
    safe manner, if the client does not cooperate with scheduling and keeping
    appointments for the once/month visits, and if maintenance problems are not
    addressed by the landlord in a timely manner.
12. Provide increased frequency of visits as needed during periods of increased
    symptoms/decompensation. Provide home visits as needed or requested to
    address concerns about consumer safety, clinical status, or housing
    maintenance issues.
13. Assist consumer in requesting help from property manager for any maintenance
    issues and negotiating and clarifying lease concerns
14. Provide 24 hour on call (first responder) response
15. Provide timely response (within 2 hours) to concerns raised by landlords, housing
    developers or other housing agencies or authorities.
16. Notify landlord, housing developers or other housing agencies of any emergency
    response to consumer (police, fire, rescue squad or EMT response) within 24
    hours.
17. Provide problem-solving assistance and communication in case of
    landlord/tenant concerns.
18. Ensure timely access to psychiatric services.
19. Respond to community concerns with sensitivity to both consumer and
    neighborhood concerns.
20. If required for HUD funding of housing, participate in Continuum of Care and
    Homeless Management Information System (HMIS) tracking. Provide data via
    web entry, as required for maintenance of HUD funding, in a timely and accurate
    manner.
21. Notify of transfers to other service providers and develop plans to ensure
    continuity of housing support services prior to completion of transfer.
22. Provide or arrange for provision of a face-to-face assessment and follow-up plan
    in response to warnings or other communication from landlords and housing
    agencies. Participate in meetings and planning efforts to address behaviors that
    place housing status in jeopardy.
23. Notify housing agency/landlord of any change in treatment status, including
    transfer and termination of services. In the event that consumer refuses services
    or services are otherwise suspended, provider will collaborate with housing
    agency/landlord to develop plan for continuity of supported housing services.
24. Notify housing agency/landlord if consumer vacates apartment.



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25. Assist consumer with transition to other housing in the event that consumer is
    evicted. Facilitate consumer‘s move, including termination of utilities, return of
    keys and removal of personal belongings.




                             Section VII - Page 22
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SECTION VII Service Provision Policies and Procedures
8. Residential Treatment Requirements for CMH/SA Providers
Effective Date: July 1, 2007             Version Date: 7/1/07
Informational Only  Requirement        Reference:
Requirement Applies to Provider Type:
Medicaid Basic Svc (Direct Enrolled)               CAP/MRDD
Medicaid Basic Svc (Not Direct Enrolled)           Cat. A Licensed Facilities
 Medicaid Enhanced Svc                             Cat. B Comm Based Providers
 Non-Medicaid Contracted Svcs                      Cat. C Institutions/Facilities
ICF-MR                                             Cat. D Lic/Cert. Outpatient/Day Svcs


Scope and Purpose: This procedure applies to providers of services for child and
adolescent consumers who will reside in residential treatment facilities for level II, III and
IV, as well as, level II therapeutic foster care and psychiatric residential treatment facility
services. System of Care values and principles are the recommended philosophical
base from which all services to children and adolescents are provided. This procedure
establishes requirements for use of system of care values and principles, especially as
providers assist consumers in accessing and receiving residential treatment services.

System of care is defined as a network of coordinated and integrated community
resources which support children and families with a full network of services and
supports to meet their needs based on their individual strengths. The values that that
make this approach distinctive include child-centered, family focused, family driven,
culturally competent, and community – based service delivery with:

         Needs driven plans vs. canned plans
         Strengths based approach vs. deficits based approach
         Partnership with families vs. power over families
         Recognizing the family‘s cultural values as a strength in the plan vs. fitting the
          family into existing service implementation strategies without regard for their
          culture
         Incorporating informal supports vs. only incorporating formal supports
         Family driven vision of outcomes vs. worker driven vision of outcomes
         Frequent evaluation of the PCP vs. PCP evaluation only at prescribed
          timeframes
         Use of most appropriate and least restrictive interventions vs. most readily
          available interventions

It is the expectation of the Wake LME that providers who refer consumers for residential
treatment services be prepared and available to support the consumer and parents
throughout the referral and placement process. Critical case management functions are
the responsibility of the clinical home, including the development or updating of the PCP
with the consumer‘s child and family team (CFT), participation in an admission activities
and conference, and, facilitation of the application for Supplemental Security Income
(SSI). The concepts above should be observable as the following procedure is
implemented.



                                      Section VII - Page 23
                                                 Wake County LME Provider Manual 2008
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Procedure: Providers will facilitate community based residential treatment service
delivery for all child and adolescent consumers of Wake County unless clinical
exceptions exist that require out of home community placement. The provider‘s qualified
professional shall facilitate the following process to arrange residential treatment
services:

1. A Child and Family Team (CFT) meeting is held to review clinical needs and
    progress including least restrictive treatment options already pursued, and to update
    the PCP to include new service implementation.
2. The desired outcome of the CFT is to attain consensus and confirm the need and
    type of residential placement required to address the consumer‘s clinical needs.
3. The QP re-confirms with family/guardian the type of residential treatment placement
    needed and their readiness to work with the QP to initiate the referral process.
4. The legal guardian applies for SSI with assistance from the QP when necessary.
    The Wake County Human Services guardian handles IV-E or SSI issues for children
    in Wake County‘s custody.
5. The QP contacts the CMH/SA Residential Services Director to submit a justification
    for out of home community placement and discuss contracted agencies in other
    counties.
6. The QP looks for available beds and facilitates consumer choice by matching the
    family‘s needs and preferences to the type of treatment needed.
7. The QP advises the chosen residential treatment provider to make arrangements
    with the guardian for room and board payment based on the state guidelines
    published in Communication Bulletin #064.
8. The QP receives the referral acceptance form, completes the ITR and submits the
    ITR and required PCP document to Value Options by fax, VO Provider Connect or
    Provider Link.
9. The agency receives VO confirmation if fax receipt confirmation option has been set
    on their fax machine.
10. The QP receives notification from VO of authorization or contacts VO if the
    authorization has not been received within a week of the start date.
11. The consumer is admitted to the residential treatment facility.
12. The residential treatment provider confirms the date of admission with VO.

OUT OF HOME COMMUNITY PLACEMENT

When attempting a placement outside of Wake County the referring provider must
submit a justification that includes:

      The consumer‘s name, medical record number, date of birth, legal guardian‘s
       name and address.
      The consumer‘s diagnosis and placement history.
      The reasons for seeking out of county placement.
      The referral source contact person‘s name, agency address, e-mail address and
       telephone number.

Referring providers are responsible for checking an agency‘s contract status prior to
facilitating an out of home community placement. Questions about agencies under
contract with Wake County and the out of home community placement process shall be
directed to the CMH/SA Residential Services Director prior to negotiating a placement.



                                Section VII - Page 24
                                                 Wake County LME Provider Manual 2008
                                                                         SECTION VII
The referring provider should send the summary to the CMH/SA Residential Services
Director at 3010 Falstaff Road, Raleigh, NC 27610.

The referring provider must also complete the Notification of Out Of Home Community
Placement form as required by the State, within three (3) days of placement. This form
must be submitted to all home and host parties as noted on the form. Receipt of this
form will be required prior to authorization of IPRS funds to support room and board
when applicable.

Psychiatric Residential Treatment Facility Services:

CERTIFICATE OF NEED

Consumers who are referred for Psychiatric Residential Treatment Facilities must be
certified for admission through the certificate of need (CON) process. The referring
provider must adhere to the procedures for establishing a certificate of need. Providers
should go to www.valueoptions.com/provider/contractspecific/ncmedicaid.htm to access
links regarding the CON process and the required form.

IPRS FUNDED PRTF SERVICES

The LME UM/UR staff are the point of contact for review of medical necessity for IPRS
funded PRTF services. Up to 60 days of IPRS funding may be accessed to support
PRTF placement when a 5045 Medicaid application is filed and placement needs are
immediate. Parents of consumers shall be made aware that this process affords the
opportunity for services while Medicaid reviews the application, usually a 45 day
process. This arrangement will only be extended based on the submission of a
complete Medicaid application. The parent is financially responsible for the placement
after 60 days.

This funding arrangement can only occur with PRTF facilities under contract with Wake
County. When Medicaid is awarded the PRTF facility will reimburse Wake County if
retroactive payments are received for previously paid invoices.




                               Section VII - Page 25

				
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