Authorization Information and Resources

Alliance Behavioral Healthcare authorizes an array of Medicaid and State-funded behavioral health services for individuals with intellectual and developmental disabilities who reside in Durham, Wake, Cumberland and Johnston counties.

For access to specific authorization information, benefit plans, guidelines and other resources, use the Authorization Information menu to your right.

All authorization requests must be submitted using the Alpha Provider Portal.

Consumer Eligibility and Enrollment

The following documents are provided here to clarify the requirements for enrollment and client update requests for consumer admissions in Alpha. Questions may be directed to the Provider Helpdesk at (919) 651-8500, Option 3.

AlphaMCS Access Request
Array of Services FY15
Benefit Plan Diagnosis Array FY15
Cumberland Hospital and Legal Immigrant Behavioral Health Authorizations
Federal Poverty Level
Helpful Enrollment and Client Update Tips
Medicaid Eligibility Categories
Target Populations FY15

Inpatient Out-of-Network Authorizations

Contact the Alliance Access and Information Center at (800) 510-9132 to determine if there is an in-network inpatient facility within your area. An Access and Information Center Clinician will assists you in finding an inpatient facility and can usually provide in-network options. If it is determined that an in-network facility is unavailable in your area and it is not feasible for the consumer to be transferred to an in-network facility, complete the Inpatient Out-of-Network Service Authorization Request and fax to the Alliance Utilization Management Department at (919) 651-8685.

The form must be submitted to Alliance within 72 hours of admission. An UM Care Manager will contact the requesting facility to discuss the plan of care and a member of the Alliance Provider Network Department will contact the facility to initiate a single case agreement and discuss the option and process for becoming an in-network provider.

No authorization for payment will be guaranteed.

Hospitalization

Psychiatric Residential Treatment Facilities (PRTFs)

Psychiatric Residential Treatment Facilities (PRTFs) provide non-acute inpatient facility care for NC Medicaid (Medicaid) beneficiaries under 21 years of age, and NC Health Choice (NCHC) beneficiaries’ ages 6 through 18 years of age who have a mental illness or a substance use disorder and need 24-hour supervision and specialized interventions.  Alliance only the Medicaid-funded PRTF service requests.

NC DMA provides Clinical Coverage Policy 8D-1 for PRTF level of care, which outlines Description of the Service, Eligibility Requirements, Entrance, Continued Stay, and Discharge Criteria, Prior Approval Requirements, and other requirements for PRTF level of care.

Under this Clinical Coverage Policy, in Section 5.3.1, it is noted that Federal Regulations require a Certificate of Need (CON) be completed on or prior to admission to a PRTF facility when the beneficiary is Medicaid eligible or Medicaid is pending.

The Federal Regulations citing the need for the CON and outlining the requirements for the CON can be found in the Code of Federal Regulations (CFR) Subpart D – Inpatient Psychiatric Services for Individuals Under Age 21 in Psychiatric Facilities or Programs.

The Certificate of Need form can be found on the NC DMA/DHHS PRTF Services page.

Medicaid and Non-Medicaid Benefit Plans

Alliance offers a range of helping services that are available to individuals without Medicaid coverage. Most state-funded services require prior authorization by Alliance and can be accessed by contacting the Alliance Access and Information Center. Part of the state-funded service eligibility process is based on  consumer or family levels of income, in addition to clinical needs. There are some crisis services available to consumers within the Alliance region that are available regardless of a consumer’s ability to pay.

Alliance has a limited amount of state funds to pay for treatment services. Therefore, service entry requirements and benefit maximums may be different than the Medicaid requirements for the same service.  At times, consumers seeking state-funded services may be placed on waiting list when:

  • Demand for service exceeds available resources (non-Medicaid funds only), or
  • Service capacity is reached as evidenced by no available provider for the state-funded service.

The Utilization Management (UM) Department is notified when providers report openings in service capacity, or funding for services becomes available. UM then works with providers to identify potential consumers from their waiting list. The provider and UM staff will consider the following factors when selecting waiting list consumers for services:

  • Service need (consumer meets medical necessity for service).
  • Risk factors such as health and/or safety issues.
  • Risk of hospitalization or a higher level of care if the need is not addressed.
  • Whether the resources identified are adequate to meet the consumer’s needs.
  • If other funding sources are available to meet the consumer’s need.
  • Length of time the consumer has been waiting.

Some state-funded services, such as Respite Care for Developmental Disabilities and Adult Developmental Vocational Program (ADVP), are not based on income.

Every consumer enrolled with Alliance is evaluated to determine their ability to pay for state-funded services. The combination of a consumer’s adjusted gross income and the number of dependents will show if they have the ability to pay. A consumer meets financial eligibility if the their household income is at or below 300% of the federal poverty level and they have no assets or third-party funding or insurance available to pay for services. If a consumer’s income exceeds this amount, the individual will be required to pay 100% of the cost for the state-funded services provided to him or her.

Non-Covered Services (EPSDT)

The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit entitles Medicaid beneficiaries under the age of 21 to medically necessary screening, diagnostic and treatment services within the scope of Social Security Act that are needed to “correct or ameliorate defects and physical and mental illnesses and conditions,” regardless of whether the requested service is covered in the NC State Plan for Medical Assistance. This means that children under 21 years of age can receive services in excess of benefit limits or even if the service is no longer covered under the State Plan. To request a service that is not covered by the State Plan that is covered under 1905(a) of the Social Security Act please fax the Non-Covered State Medicaid Plan Services Request Form for Recipients Under the Age of 21 to the Alliance Utilization Management Department at (919) 651-8685.

According to CMS, “ameliorate” means to improve or maintain the beneficiary's health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. Basic EPSDT criteria are that the service must be covered under 1905(a) of the Social Security Act, and that it must be safe, effective, generally recognized as an accepted method of medical practice or treatment, and cannot be experimental or investigational (which means that most clinical trials cannot be covered).

Requests for MH/IDD/SA services for Medicaid-eligible children under the age of 21 will be reviewed using EPSDT criteria. Requests for NC Innovations Waiver services will be reviewed under EPSDT if the request is both a waiver and an EPSDT service. Most NC Innovations Waiver services are not covered under the Social Security Act (i.e. respite, home modifications and all habilitative services).

Service Frequency Billing Parameters

The Alpha system contains daily, weekly, monthly and annual benefit limits for services that are available to consumers within the Alliance region. The benefit limits in Alpha are designed to help ensure that services are provided within the guidelines and limitations set forth on the Medicaid services and non-Medicaid (IPRS) services Benefit Plans. It should be noted that nothing within the Alpha system is designed to increase or override the service limits listed on our Benefit Plans.

To allow flexibility in the delivery of services, a service with an annual limit in a Benefit Plan might indicate the maximum benefit is 100 units. However, the Alpha benefit grids below may allow the same limit within a month. This does not mean that 1200 units are then available annually. It simply means that if needed the entire benefit could be provided within a month. With prior approval from UM certain benefit limits may be overridden through the authorization process.

Time PeriodNo AuthorizationAuthorization
Daily
Day
Day
WeeklySunday-SaturdaySunday-Saturday
MonthlyCalendar MonthAuth start-same date next month
QuarterlyCalendarCalendar
AnnuallyCalendarAuth start-same date next year
LifetimeLifetimeLifetime


Page last modified: November 21, 2016