North Carolina Medicaid

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 per calendar year).  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 (including Early Periodic Screening and Diagnostic Treatment (EPSDT)), CAP/MR/DD services and quality assurance reviews for all Medicaid Consumers.

Exception: ValueOptions does not conduct utilization review for recipients who reside in the Piedmont catchment area (Rowan, Union, Cabarrus, Stanley, and Davidson counties) except for quality assurance reviews for CAP/DD services and retrospective reviews.

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.

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

Inpatient (General and Free Standing Hospitals)

PRTF

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.ncdhhs.gov/mhddsas/pcp.htm

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 for individuals age 21 and older beginning with the 9th visit per calendar year. If in doubt whether or not a Consumer has reached their "unmanaged" visit limit, please go ahead and submit a request for authorization to ValueOptions.

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.ncdhhs.gov/mhddsas/pcp.htm

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 individuals who do not have verifiable, active Medicaid at the time of admission to a service but who subsequently are approved for Medicaid covering the time of service. Applicable medical records must be sent to ValueOptions either via fax at (919) 461-0679 or US mail at:

ValueOptions, Inc.
Retrospective Review Department
P.O. Box 13907
RTP, NC 27709-13907

Please note that ValueOptions has 60 days to review the requests upon receipt of complete information.  To ensure prompt processing, please provide both the beginning date and the ending date of the period you would like reviewed.

For more information, see http://www.dhhs.state.nc.us/mhddsas/servicedefinitions/servdefupdates/implementationupdate_53final2-2-09.pdf.

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.ncdhhs.gov/mhddsas/pcp.htm

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:

The following are the required documents for DD submissions to ValueOptions for a review to be initiated:

CNR(CAP)

• POC/PCP with signatures and cost summary
• MR2
• CTCMs
• NC SNAP (all 4 pages and the Summary Report and Supplemental Information sheet)
• For equipment/supplies – Justification/Assessment, Dr order or prescription, price quote (2 quotes required for Home modifications/Aug com/Vehicle Adaptation)
• Proof of insurance for Vehicle Adaptation

Initial POC (CAP)

• PCP with signatures and cost summary
• MR2 with prior approval date and number
• CTCMs
• NC SNAP (all 4 pages and the Summary Report and Supplemental Information sheet)
• Current Psychological Evaluation
• For equipment/supplies – Justification/Assessment, Dr order or prescription, price quote (2 quotes required for Home modifications/Aug com/Vehicle Adaptation)
• Proof of insurance for Vehicle Adaptation

Revision (CAP)

• PCP update with signatures and cost summary
• CTCMs
• For equipment/supplies – Justification/Assessment, Dr order or prescription, price quote (2 quotes required for Home modifications/Aug com/Vehicle Adaptation)
• Proof of insurance for Vehicle Adaptation

TCM Request

• PCP update page with signatures (Must be a current PCP in the ValueOptions system)
• CTCM
• Initial request requires Comprehensive Clinical Assessment (i.e. current Psychological Evaluation, Diagnostic Assessment) or a goal to obtain one
• NC SNAP (all 4 pages and the Summary Report and Supplemental Information sheet) submitted with initial request and annually

Provider change

• Cost Summary
• CTCM to discharge previous provider
• CTCM to add new provider

Provider Forum

Links

Customer Service/Provider Relations

Providers may submit consumer-specific inquiries to Customer Service on-line 24/7 via ProviderConnect. Such inquiries will receive an electronic response that will appear in the Inbox of Your Message Center on ProviderConnect. Providers may also contact ValueOptions Customer Service for routine inquiries at 888.510.1150 between the hours of 8:00 a.m. and 6:00 p.m.

For requests to research multiple authorizations, providers may use the template found at the link below. E-mail it to Customer Service at PSDCustomerService@valueoptions.com as a password protected file per the instructions on the template.

Regarding inquiry escalation, a provider not satisfied with a response to, or the handling of, an inquiry should gather the pertinent information, call Customer Service, and simply ask to speak to a Customer Services supervisor to resolve the issue.

ValueOptions Provider Relations continues to deliver provider training and address systematic or recurring service issues.

Provider Number Changes to Completed Authorizations

Upon request, ValueOptions will change provider numbers on authorizations already in place. Such is typically related to an agency merger/acquisition or to correct a previous submission error. Changing a provider number on an authorization requires voiding the old authorization, building a new authorization with the new provider number, attaching relevant inquiries and reviews into the inquiry, documenting the basis of the activity, and creating and mailing an authorization letter to the provider that corresponds to the new authorization. The fee is $9.70 for each authorization changed.

In order to request such changes, providers must complete the Provider Change Request Form located below and mail a hard copy of the completed form along with a check payable to ValueOptions Inc. for the appropriate amount to:

ValueOptions, Inc.
PSD Provider Relations
P.O. Box 13907
RTP, NC 27709-3907

The requested changes will be completed within ten business days after receipt of the check and completed form and DMA approval to proceed (extraordinary volumes may require longer). Providers may e-mail questions about this new service to ValueOptions Customer Service at PSDCustomerService@valueoptions.com.

For additional information see:
http://www.dhhs.state.nc.us/mhddsas/servicedefinitions/servdefupdates/dmadmh1-14-09update52.pdf.

Provider Training Opportunities

Learn how to submit Enhanced Service as well as Concurrent Residential (Group Home & Therapeutic Foster Care) requests to ValueOptions electronically via ProviderConnect.

Register for an upcoming Webinar by clicking on the link for the date you/your staff want to attend. You will receive a confirmation email with instructions for joining the Webinar once you complete the registration process. On the day of the Webinar, you will login to a website to view the presentation AND dial into a conference call for the audio portion. Training sessions are scheduled for Wednesday mornings from 10am-12pm. Space is limited, reserve your seat now.

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.