Alliance is responsible for conducting routine monitoring of agencies and solo practitioners providing outpatient mental health services to individuals. Through the monitoring process we have learned that many LIPs are not aware of current requirements for practitioners serving individuals with Medicaid. It is Alliance’s hope that the following information will serve as a regulatory tool kit, including standardized information and resources, to assist you in complying with and keeping up-to-date with regulations.
You, as the provider of services to Medicaid beneficiaries, are ultimately responsible for adhering to all federal and state laws and regulations, administrative rules, state policies and contractual obligations. While there are multiple sources of requirements, it is the provider’s responsibility to follow the most stringent requirements, including the code of ethics of your professional licensure.
This page provides links to external resources and sample forms and other information. All forms need to be adapted to reflect the nuances of your practice. We gave provided prompts in red to indicate where you will add your unique provider information and processes. For example, one of the requirements is to notify individuals in writing of their rights as well as your practice’s rules that individuals are expected to follow and possible penalties for violating the rules. This notification of rules and possible penalties is for your protection as well. What will happen if someone frequently misses appointments without adequate notification? Will you give them a warning? How many missed appointments do you allow before they are discharged from your services? Are guns allowed on your premise? If not, what will happen if someone brings a fire arm onto the premises? You need to develop your rules for your practice, give a written copy of those rules to the individual or legally-responsible person (LRP), and have a mechanism by which you can validate that they have received it. This is often in the form of a signature and date on an acknowledgment of receipt of the information.
The State of North Carolina has made changes to the provider monitoring process. As stated in the LME-MCO Communication Bulletin #J254, while providers who are fully accredited by an accrediting body (CQI, COA, CARF, The Joint Commission) will no longer require a “routine” monitoring, the every two-year post-payment review will continue. As a result of this change some items were added to the post-payment review for ALL agencies (accredited and non-accredited) and licensed independent practitioners. Those items are:
Is there evidence the provider agency meets the access standards related to appointment availability (emergency, urgent and routine need)?
Is there evidence the provider agency meets the access standards related to Office Wait Time (scheduled, walk-ins and emergency)?
Is there evidence the provider agency provides physical access, reasonable accommodations, and accessible equipment for enrollees with physical or mental disabilities?
The question regarding coordination of care has been moved from the routine monitoring tool to the post-payment tab.
The following websites contain federal and state requirements and information on how those requirements are to be applied. Please keep in mind that website information may periodically change and the links may become inactive. If so, please search the web for the name of the manual or policy/regulation. By using the below links, or searching the web, you ensure that you are always reviewing the current version.
DHHS Review Tools for LIPs – Once you download and open the tool, look along the tabs at the bottom, click on the guidelines tab and download both the Review Tool Guidelines and the Post-Payment Review Tool Guidelines. These are helpful as they give you the references from which the rules are obtained and an explanation of how you might demonstrate compliance with some rules.
Network Contract between Alliance Behavioral Healthcare LME/MCO and your practice
The templates included below are for guidance only and in no way warrant your agency’s compliance with applicable law, policy or your contract. YOU ARE NOT REQUIRED TO USE THESE TEMPLATES. If you choose to use any of them, you will need to edit them before use. Guidance notes to help you do so are set out throughout the template. During the editing process, you should delete those guidance notes. Square brackets in the body of the document indicate areas that require editorial attention. By the end of the editing process, there should be no square brackets left in the body of the document. If you have any doubts about the editing or use of this template, you should seek professional legal advice.
Access and Information Center (800) 510-9132 We want to make it easy for you to get the services or information you need. You can call the Alliance Access and Information Center toll-free 24 hours a day.
Provider HelpDesk (919) 651-8500 Representatives are available 8:30am-5:15pm Monday-Friday to answer provider questions about authorization, billing, claims, enrollment and credentialing, the Alpha Provider Portal or other issues.
Confidential Fraud and Abuse Line
(855) 727-6721 You are encouraged to report matters involving Medicaid fraud and abuse. If you want to report fraud or abuse, you can remain anonymous.