ProviderConnect is A ValueOptions® Web Site

North Carolina Medicaid

Important Numbers:


NC Medicaid Toll Free Number

1.888.510.1150

Medicaid other MH/SA Fax Number

919.461.0599

Medicaid Developmental Disabilities Fax Number

919.461.0669

Research Triangle Park, NC

The ValueOptions North Carolina Service Center (NCSC) in Morrisville, NC has been part of the mental health and substance abuse services delivery system in North Carolina since 1992.

Since its inception, ValueOptions has provided utilization management services based on our belief that the most effective treatment is that which is appropriate to the needs of the person being served, easily accessible, provided by competent practitioners, and conducive to family involvement where possible. Treatment should be based upon best practices in the behavioral health care industry.

North Carolina Medicaid

Beginning January 1, 2002, ValueOptions, Inc. entered into an agreement with the North Carolina Division of Medical Assistance to provide utilization review services for over 1.3 million of the State's Medicaid recipients.

The State awarded a new contract to ValueOptions beginning June 1, 2006.  Under this contract, our employees will continue to manage admission and concurrent stays for all mental health and substance abuse services to hospitals and PRTF's (psychiatric residential treatment facilities), Criterion V services, post-payment services, retrospective reviews, out-of-state reviews, and outpatient services (after the first 26 visits for individuals under 21 years of age or after the first 8 visits for individuals age 21 and older).  In addition to the residential services ValueOptions already manages (Levels II-IV for >4 beds), our employees also conduct reviews for Levels I and II and all residential bed sizes.  Additionally, VO is responsible for conducting utilization review for enhanced behavioral health services, Early Periodic Screening and Diagnostic Treatment (EPSDT) services and quality assurance reviews for all Medicaid Consumers.

Exception: ValueOptions will only conduct quality assurance reviews for CAP/DD services and retrospective reviews for individuals whose Medicaid eligibility is in the Piedmont catchment area (Rowan, Union, Cabarrus, Stanley, and Davidson counties).

All provider communication regarding the Medicaid Program can be accessed by clicking on the Division of Medical Assistance link: Division of Medical Assistance - Publications and Reports, and looking specifically at the General and Special Bulletins published by DMA around the first of each month. Service Definitions can be accessed by clicking on Division of Mental Health, Developmental Disabilities and Substance Abuse Services link.

ValueOptions provides two forms for providers to use for requesting authorization. The forms can be downloaded and completed by hand and faxed to us or they can be completed on your PC and then printed out, signed and faxed to us at the fax numbers listed above.

Please note that we are piloting a web-based authorization request process with providers throughout the State. Once we receive satisfactory results of the pilot test, we willl open the process up to ALL providers. We appreciate your patience while we work to improve our authorization process.

1. ITR (Inpatient Treatment Report) Only Valid for NC

(Note: You have two options for completing the form:

You are required to complete the ITR for all of the following services:

  • Inpatient Services
  • PRTF Services
  • Residential Services (levels I-IV all bed sizes)
  • Partial Hospitalization
  • Facility Based Crisis
  • Community Support (adult, child, and team)
  • Intensive In-Home
  • MST
  • ACTT
  • Psychosocial Rehabilitation
  • Day Treatment
  • SAIOP
  • SACOP
  • SA Non-Medical Community Residential Treatment
  • SA Medically Monitored Community Residential Treatment
  • Ambulatory Detox
  • Non Hospital Medical Detox
  • Medically Supervised or ADATC Detox/Crisis Stabilization
  • Opioid Treament

2. ORF2 (Outpatient Review Form)

Note: You have two options for completing the form:

You are required to complete the ORF2 for all of the following services:

  • Outpatient Services
  • Mobile Crisis
The Authorization Processes - Based on Level of Care Being Requested:

Inpatient (General and Free Standing Hospitals)

PRTF

PRTF Certificate of Need Link:

Residential Services (Group Homes)

ValueOptions provides utilization review for all residential services regardless of bed size for individuals under 21 years of age.

A Person-Centered Plan is required for all residential services.

Link to PCP Information:
http://www.dhhs.state.nc.us/mhddsas/training/access-care/index.htm

Link to Intro PCP document:
http://www.dhhs.state.nc.us/mhddsas/training/access-care/introductorypcp7-11.07.doc

Link to Complete PCP document:
http://www.ncdhhs.gov/mhddsas/training/access-care/completepcp7-16-07.doc

Outpatient Mental Health and Substance Abuse Services

ValueOptions conducts utilization reviews for all outpatient services for individuals under 21 beginning with the 27th visit per calendar year and beginning with the 9th visit for individuals age 21 and older (each calendar year). If in doubt whether or not a Consumer has reached their "unmanaged" visit limit, please go ahead and contact ValueOptions for authorization. EDS will track the visits on the claims end and will not look at prior approval until the designated trigger points.

Please Note: Service Orders are required to be submitted for all outpatient services requests. The service order is required to be updated annually.

Enhanced Services

Beginning June 1, 2006 ValueOptions began conducting reviews for enhanced services such as Day Treatment for children and adolescents, Community Support, ACTT, Intensive In-Home, Mobile Crisis Mgmt, Opioid treatment, Partial Hospitalization, SA Comprehensive Outpatient Treatment, Facility Based Crisis, MST, Psychosocial Rehab, SAIOP, SA Non-Medical Community Residential Treatment, SA Medically Monitored Community Residential, Ambulatory Detox, Non Hospital Medical Detox, and Medically Supervised or ADATC Detox/Crisis Stabilization.

A Person-Centered Plan is required for all enhanced services.

Link to PCP Information:
http://www.dhhs.state.nc.us/mhddsas/training/access-care/index.htm

Link to Intro PCP document:
http://www.dhhs.state.nc.us/mhddsas/training/access-care/introductorypcp7-11.07.doc


Link to Complete PCP document:
http://www.ncdhhs.gov/mhddsas/training/access-care/completepcp7-16-07.doc

Criterion V Transition Services

ValueOptions coordinates the process to provide reimbursement of hospital services for children eligible for Medicaid who are 1) under age 17; 2) no longer meet criteria for continued acute stay; and 3) there is a clear absence of appropriate community based services available if discharge were to occur.

For questions regarding Criterion V services, please contact ValueOptions at 1-888-510-1150.

Out-of-State Placement Service

ValueOptions reviews and makes determinations regarding applications for Out-of-State placement for NC Medicaid recipients under age 18 for Level IV and Psychiatric Residential Treatment Facilities (PRTF). In addition, ValueOptions ensures compliance with Federal and State guidelines and monitor progress through on going involvement with respective treatment teams. Contact ValueOptions: 1-888-510-1150 ext 292621 for information and the Out of State Packet.

Retrospective Reviews

ValueOptions conducts retrospective reviews for inpatient and PRTF services for individuals who apply for Medicaid either during or after an admission. In addition, ValueOptions conducts retrospective reviews for outpatient, residential and enhanced services if the reason for delay is due to Medicaid eligibility. For inpatient services, medical records must be sent to ValueOptions within 30 days from the date of discharge if the consumer applies for Medicaid during an admission, and within 4 months of Medicaid application date if the consumer applies for Medicaid after the date of discharge to be considered for review. For all other services, the medical records must be sent to ValueOptions to be considered for review if Medicaid changed the individual's eligibility retroactively and the eligibility falls within the dates of service being requested.

The mailing address is:
ValueOptions, Inc.
Retrospective Review Department
P.O. Box 13907
RTP, NC 27709-13907

EPSDT Services

ValueOptions conducts reviews for Consumers under the age of 21, when additional services may be requested even if they do not appear in the NC State Plan or when coverage is limited to those over 21 years of age.  Service limitations on scope, amount, or frequency described in the coverage policy may not apply if the service is medically necessary.

Note: Any denial, reduction, suspension or termination of a service requires notification to the recipient and/or legal guardian about their appeal rights.

A Person-Centered Plan is required to be updated for all EPSDT requests.

Link to PCP Information:
http://www.dhhs.state.nc.us/mhddsas/training/access-care/index.htm

Link to Intro PCP document:
http://www.dhhs.state.nc.us/mhddsas/training/access-care/introductorypcp7-11.07.doc

Link to Complete PCP document:
http://www.ncdhhs.gov/mhddsas/training/access-care/completepcp7-16-07.doc

CAP/Targeted Case Management

Beginning September 1, 2006 ValueOptions began conducting reviews for designated services related to Developmental Disabilities and Substance Abuse Services for all Medicaid recipients except for those who reside in the Piedmont Catchment area (Cabarrus, Davidson, Rowen, Stanley, and Union Counties). This includes Targeted Case Management services for CAP MR/DD and non- CAP recipients, authorization of services on initial Plans of Care (POC) as well as performance of the Continued Need Review (CNR).

For further information, please review the DMA June Special Bulletin at http://www.dhhs.state.nc.us/dma/bulletin/UR.pdf

You have two options for completing the form:

You are required to complete the CTCM for all of the following services:

  • Plan of Care (POC) initial review
  • Continued Need Review (CNR)
  • Targeted Case Management (TCM)
  • Plan Revisions
  • Discreet Services: 
    • Home and Community Supports
    • Residential Supports
    • Respite
    • Personal Care
    • Day Supports
    • Supported Employment

Plan of Care/Continuous Need Review (POC/CRN)

Include with each request:

  • Plan of Care/CNR
  • Service Order signed by appropriate discipline
  • Signed MR2
  • Supporting Assessments
  • SNAP score
  • Cost Summary

Targeted Case Management (TCM)

Include with each request:

  • Person Centered Plan (if not CAP, use POC)
  • Service Order, properly signed by MD, Ph.D., PA or NP

Discreet Services: Discreet Services are those services which are Provider specific, and do not include equipment or modifications. To request discreet services, follow the guidelines below:

  • A separate CTCM form must be submitted for each service if different providers are delivering the services. If same provider delivers multiple services, up to 3 requests can go on one form.
  • The Case Manager submits the original or initial request along with the Patient Centered Plan (PCP)
  • The individual provider can submit JUST the CTCM on the concurrent request if there are no changes.  In these cases the PCP is not required to be resubmitted.

Provider Forum

Links

Provider Relations

The ValueOptions Provider Relations Team delivers provider training and addresses systematic or recurring issues not resolved through providers' routine contact with ValueOptions Customer Service.  (Routine inquiries should be directed to Customer Service at 888.510.1150).

You may conveniently email your questions or concerns to Provider Relations at PSDProviderRelations@valueoptions.com.  Provider Relations will research your inquiry and respond to you.  For consumer-specific questions requiring sharing of PHI, or for requests to research multiple authorizations, please enter the consumer-specific information into the template found at the link below and e-mail it to Provider Relations as a password protected file per the instructions on the template.

Reports

For questions regarding NC Medicaid specific information contained on this web page please contact the NC Public Sector Provider Service Department 1-888-510-1150.

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