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 and again on September 20, 2011. ValueOptions provides prior authorization for mental health and substance abuse services except for recipients who reside in the Durham, Eastpointe, and Piedmont LME catchment areas.

Provider communication regarding the Medicaid Program can be found at www.ncdhhs.gov/dma/index.htm. Service Definitions can be found at www.ncdhhs.gov/dma/mp/index.htm.

Effective October 1, 2011, providers must submit authorization requests to ValueOptions electronically using the ValueOptions ProviderConnect web portal.  Authorization requests submitted by means other than ProviderConnect on/after October 1, 2011 will be returned Unable to Process.

Providers are encouraged to submit any current clinical information to support the medical necessity of the request in addition to the required documentation outlined by the Division of Medical Assistance. Additional documentation may consist of Child and Family Team notes, summary of Care Review, copies of assessments/evaluations, etc.

Request Formats

1. ITR

All requests for authorization must be submitted via ProviderConnect.

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)
  Child/Adolescent Discharge Plans via Implementation Update #85
• Partial Hospitalization
• Facility Based Crisis
• Community Support Team
• Intensive In-Home
• MST
• ACTT
• Psychosocial Rehabilitation
• Day Treatment
• SAIOP
• SACOT
• 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 Treatment

2. ORF2

All requests for authorization must be submitted via ProviderConnect.

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

• Outpatient Services
• Mobile Crisis

3. CTCM

All requests for authorization must be submitted via ProviderConnect.

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

• Non-CAP/TCM-IDD

Non-CAP/TCM-IDD requests must be submitted under the Outpatient Level of Service, Developmental Disability Type of Service on ProviderConnect with the CTCM form attached.

• CTCM Form (Excel) | CTCM Form (Word)

4. Psychological/Neurological Testing

All requests for authorization must be submitted via ProviderConnect.

You are required to complete the Psychological/Neurological Testing form for all Psychological/Neurological Testing services.

• Psychological/Neurological Testing Request Form (Word)

Psychological/Neurological Testing requests must be submitted under the Outpatient Level of Service, Mental Health Type of Service, Outpatient Level of Care, Psych Testing Type of Care on ProviderConnect with the Psychological/Neurological Testing form attached.

Authorization Processes

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:

• www.ncdhhs.gov/mhddsas/providers/personcenteredthinking/index.htm
• Child/Adolescent Discharge Plans via Implementation Update #85

Outpatient Services

For recipients under 21, the first 16 visits of the calendar year are unmanaged and do not require preauthorization. For recipients 21 and over, the first 8 visits of the calendar year are unmanaged and do not require preauthorization. If in doubt whether or not a recipient has exhausted the unmanaged visits, submit a request for authorization to ValueOptions.

Service Orders are required to be submitted with all outpatient service requests. The service order is required to be updated annually.

A Psychological/Neurological Testing Form is required with all requests for testing.

Enhanced Services

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

Link to PCP Information:

• www.ncdhhs.gov/mhddsas/providers/personcenteredthinking/index.htm

Criterion 5 Transition Services

ValueOptions prior authorizes Criterion 5 transition services for children eligible for Medicaid who are 1) age 17 and under; 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.

Out-of-State Placement Service

ValueOptions makes medical necessity determinations regarding applications for Out-of-State placement for NC Medicaid recipients under age 18 for Level IV and Psychiatric Residential Treatment Facilities (PRTF). Contact ValueOptions at 1 (888) 510-1150 extension 292466 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 date of service. Applicable medical records must be either attached to the Retrospective ProviderConnect request or sent to ValueOptions via US mail to:

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

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: www.ncdhhs.gov/mhddsas/implementationupdates/Archive/2009/update053/implementationupdate_53final2-2-09.pdf .

EPSDT Services

ValueOptions conducts medical necessity reviews for recipients under the age of 21, when  services are requested that are not covered in the NC State Plan. Service limitations on scope, amount, or frequency described in the coverage policy may not apply if the service is medically necessary.

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

Link to PCP Information:

• www.ncdhhs.gov/mhddsas/providers/personcenteredthinking/index.htm

Non-CAP DD/Targeted Case Management

The following are the required documents for non-CAP TCM submissions:

Non-CAP TCM Requests

• PCP update page/Action plan with goals reviewed/dates and signature page dated within 90 days
  Or
  Current PCP with review dates and matching signature page dated within 90 days
  Or
  Annual rewrite of PCP with signature page dated within 90 days
• CTCM
• Initial TCM request requires NC-SNAP and comprehensive Clinical Assessment (current psychological) be submitted with Complete PCP and CTCM.
• NC SNAP (4 pages and Summary Report/Supplemental Information sheet) should be submitted annually thereafter with annual rewrite of PCP
• For concurrent requests there must be a current PCP in the ValueOptions system.

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 using ValueOptions ZixMail Encryption System. Instructions for sending an encrypted email are on the template and are also on the PDF document below.

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 in place. Please see the descriptions of each form below and select as appropriate.

Provider Change Attestation Form

Use the Provider Change Attestation Form (pdf) to request provider change only for those Medicaid recipients who have appealed an adverse decision, or whose provider agency is going out of business, or are changing providers for another service with an authorization period of six months or more.

Provider Change Due to Error or Merger

Use the Error/Merger Provider Change Request Form (Excel) to request a change in provider number to a completed authorization if correcting a previous submission error or due to a merger/acquisition. 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 service to ValueOptions Customer Service at PSDCustomerService@valueoptions.com.

Provider Training Opportunities

Effective October 1, 2011, providers must submit authorization requests to ValueOptions electronically using the ValueOptions ProviderConnect web portal. See the August 2011 Medicaid Bulletin and Implementation Update.

Providers can view recorded webinars and download ProviderConnect training documents to learn how to submit authorization requests electronically via ProviderConnect. The training documents are:

Click on one of the recorded webinars below to participate in a self-paced tutorial.

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.

Links