North Carolina Health Choice

Note: Topics to the left do not apply to NC Health Choice for Children. All links for additional NC Health Choice information are identified below as you scroll down this page.

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

ValueOptions is a clinically focused company driven by the premise that delivering rather than denying care is the key to both optimal clinical outcomes and cost-effective care.

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 Health Choice for Children

(NC Health Choice)

Beginning in October 1998, ValueOptions entered into an agreement with the State of North Carolina to provide utilization review services for children in the state of North Carolina whose parents' income was up to 200% of poverty level. Utilization review includes the precertification of care based on medical necessity criteria and is required prior to the start of treatment in almost all instances (exceptions are as specified below in the bulleted list). Clinical care managers at ValueOptions who review authorizations requests are masters' level clinicians. These clinicians evaluate all mental health and substance abuse admissions and continuing treatment for medical necessity for the following levels of care: inpatient, residential treatment centers, partial hospital programs, intensive or structured outpatient treatment programs; Level II - IV group homes including therapeutic foster care; certain behavioral health enhanced services (referred to as Special Services); as well as outpatient treatment after the first 26 unmanaged visits each fiscal year (July 1 - June 30).

NC Health Choice Special Services:

The special services listed below are available to children with special health care needs covered under NC Health Choice:

• Community Support - Children-Adolescents - billing codes H0036 HA (individual) and H0036 HQ (group)
• Day Treatment - billing code H2012 HA
• Intensive In-Home Services - billing code H2022
• Multisystemic Therapy - billing code H2033
• Targeted Case Management - billing code T1017HI (this service is for DD clients only)
• Level II therapeutic foster, family type - billing code S5145
• Level II group home, program type - billing code H2020
• Level III group home (all bed capacities) - billing code H0019
• Level IV group home (all bed capacities) - billing code H0019
• Diagnostic Assessment - billing code T1023 (only one diagnostic assessment is allowed per fiscal year without pre-certification)
• Mobile Crisis - billing code H2011 (only the first 32 units are allowed per episode without pre-certification; ValueOptions may authorize up to an additional 96 units in the 2 consecutive days following the initial 32 units)

For all services listed above, pre-authorization by ValueOptions will be required of NC Health Choice providers prior to the first date of service. Authorizations for continuing stay/treatment by ValueOptions will also be required of NC Health Choice providers on or before the last date of any previously authorized period. Local Management Entities may not provide authorization for any of the above services. Authorization from the Health Choice team at ValueOptions alone is necessary to be considered for reimbursement by Health Choice for behavioral health special needs benefits.

Respite Care - Contact 800-753-3224 for information (nursing, community, and institutional based)

Provider Forms

You are required to complete the ITR prior to the start of the service:

• Inpatient Services
• Residential Treatment Center Services (PRTF-like service)*
• Residential Service (levels II-IV) including therapeutic foster care*
• Partial Hospitalization
• Community Support*
• Intensive In-Home*
• MST*
• Day Treatment*
• IOP*

* these services require the Health Choice addendum be submitted with the ITR

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

• Outpatient Services
• Mobile Crisis
• Diagnostic Assessment

You must complete the Health Choice Targeted Case Management (TCM) Request for Authorization Form for all TCM requests.

Provider Forum

Deficit Reduction Act