= Comprehensive Clinical Assessment Sandhills Center Care/Utilization Management Legend = Service Authorization Request = Individual Support PA=Prior Approval = Person-Centered LOC = Level of Care Form NCSNAP = North Carolina Support Needs Assessment Profile SIS = Supports Intensity Scale Certificate of Need = CON =Treatment/Service IEP=Individualized Education BIP=Behavior Intervention PLEASE NOTE: All Concurrent Urgent requests are to be submitted at least 24 hours prior to the expiration of the previous authorization. All Concurrent Non-Urgent/Routine requests are to be submitted at least 14 days prior to the expiration of the previous authorization. Retrospective requests are only to be conducted for retrospective eligibility dates. Direct Bill Services (not initially requiring a submission) Sandhills Center Review Information 90791 90791:GT 90792 1 Unit = 1 event 90846 90847 90849 90853 90832 90834 90837 Service Names Clinical Evaluation / Intake / Interactive Evaluation Family Therapy (With or Without Member) Group Therapy (Multiple Family or Non-Multiple Family) Individual Therapy (30 minutes/45 minutes/60 minutes) Prospective (Urgent) E/M codes Medication Check 96101 96110 96111 96116 96118 Psychological / Developmental / Neuropsychological Testing Prospective (Non-Urgent / Routine) (prior to (prior to (prior to (prior to (prior to exhausted for adults) (prior to Concurrent (Urgent) Concurrent (Non-Urgent / Routine) 1
Services requiring a submission Sandhills Center Utilization Management (UM) Certification Review Types H2036 YP 620 H0014 H0040 1 Unit = 1 event/day YA352 YA353 T2029 1 Unit = Invoice H2012:HA H2015:HT H2015 H2015UI Service Names ADATC/Medically Supervised/Detox/Crisis Stabilization Adult Developmental Vocational Program (ADVP) Ambulatory Detox Assertive Community Treatment Team (ACTT) Assertive Engagement Assistive Technology Equipment and Supplies Day Treatment Prospective (Urgent) Prospective (Non-Urgent / Routine) Concurrent (Urgent) Concurrent (Non-Urgent / Routine) or (service auth must go through the end of the month 14 th is the cut-off) (IEP BIP 504 plan) or (service auth must go through the end of the month 14 th is the cut-off) YA382 CAET School to Work Community Support Team (CST) Community Networking YP650 H2011 T2025-U3 T2034 Community Rehabilitation Program (Sheltered Workshop) I/DD Crisis Services / NCSNAP / 2
YP660 T2021-Individual T2021HQ-Group T2027 YM 580 1 unit= 1 day H2014 H2014:HQ H2014:HM H2014:U1 YP610 T1023 T1023:GT YP690 YP692 YP485 YP740 YP750 T2025U or T2025U1 T2025U2 YP760 YP770 YP780 YP 780 1 Unit= 1 day YP770 YP 770 1unit =1 day Day/Evening Activity I/DD Day Supports Day Supports (IPRS) Developmental Therapies Developmental Day Child Diagnostic Assessment (pass through event of 1 event per year) Drop-In Center NCSNAP or or or or Facility-Based Crisis Program Family Living - Low Intensity Family Living - Moderate Intensity Financial Support Services Group Living Low Intensity (MH) Group Living Moderate Intensity (MH) Group Living High Intensity Group Living-High Intensity (IPRS, SA) Group Living Adults Group Moderate (I/DD IPRS only) Group Living-Adults Group Moderate (SA/IPRS only) or or 3
YP760 YM686 S5165 1 Unit = invoice YM700 T1999 1 Unit = invoice T2013 T2013HQ T1015 1 Unit=15 minutes YP821(3 WAY) YP820 (Non- Medicaid) YP821(3 WAY) YP820 (Non- Medicaid) H2022 YA 389 H2011 H2033 S5110 S5111 1 Unit = invoice H0010 Group Living Adults Group Low (IPRS I/DD only) Guardianship Home Modifications Independent Living Individual Goods and Services In-Home Skill Building In-Home Intensive Supports Inpatient Hospital Psychiatric LOC Inpatient Hospital Detox Intensive In-Home (IIH) Long-Term Vocational Support Services Mobile Crisis (pass through of 8 hours- PA required prior to 9 th hour of service delivered) Multi-Systemic Therapy (MST) Natural Supports Education Non-Hospital Medical Detox or (ned admit) or 4
H0020 1 Unit = 1 event/1 day H0035 1 Unit = 1 event/1 day Opioid Treatment Partial Hospitalization YA308 YA309(Group) Peer Support NA YP020 YP021 Personal Assistance or YM050 S5125 S9484 (adults) RC911 YA230 H2017 H2016 T2014 T2020 H2016H1 H0046 H2020 Y2362 Y2363 Personal Care Services Personal Care Services Professional Treatment Services in Facility Based Crisis Program (7 day pass through, PA required prior to day 8) Psychiatric Residential Treatment Facility (PRTF) Psychosocial Rehabilitation (PSR) Residential Supports I-V Residential Treatment - Level I/Family Type Residential Treatment - Level II / Family (TFC) Residential Treatment - Level II / Group Home or CON 5
Y2348 H0019:A H0019:B Y2349-Level III GH (5+ beds) Y2360-Level IV GH (4 beds or less) Y2361-Level IV GH (5+ beds) H0019:C H0019:D H0019:CTL H0019:DTL S5150 Individual S5150HQ Group T1005TD (RN) T1005TE (LPN) S5150US (Facility) YP010-Hourly YP730-Daily YP010-Hourly YP730-Daily YP790 T2025 T2025HO Residential Treatment Level III (4 beds or less) Residential Treatment Level III-IV Placement must be transition from PRTF/inpatient setting; MST or IIH within last 6 months and severe/functional impairment consists CFT reviewed alternatives Residential Treatment Level IV Respite Respite-Crisis Respite-ned (I/DD only) Social Detox Specialized Consultative Services - Psych Eval for requests exceeding a 120 days - Psych Eval for requests exceeding a 120 days 6
H2035 H2034 YP760 YP710 H0015 1 Unit = 1 event H0013 H0012:HB YP710 YP710 YP720 YM725 YM811-I YM812-II YM813-III YM814-IV YM815-V YM816-VI YP630 Individual YA 390 Individual YP640 Group H2025-Individual H2025HQ-Group I Unit=15 minutes YM 120 1 unit = 15 minutes Substance Abuse Comprehensive Outpatient Treatment (SACOT) (pass through 60 days of service avail. 1x/cal. year) Substance Abuse Halfway House Substance Abuse Intensive Outpatient (SAIOP) (pass through for 30 days of service available 1x/ calendar year) Substance Abuse Medically Monitored Community Residential Substance Abuse Non-Medically Monitored Community Residential Supervised Living Low Intensity (IPRS MH) Supervised Living Low Intensity (IPRS I/DD) Supervised Living Moderate Intensity Supervised Living High Intensity Supervised Living - MR/MI I-VI Residents (I/DD only) Supported Employment (IPRS)(MH/SA) Supported Employment (IPRS)(I/DD) Supported Employment Management Services(TMS) (IPRS/Adult MH) Pass through for 5 hours for 30 days or or or or or or or or or or or or 7
YA254 YA256 YA258 YA255 YA257 YA259 Sandhills Center Care/Utilization Management Therapeutic Leave Level I-IV T2039 1 Unit = invoice Vehicle Modifications/Adaptations THE FOLLOWING ARE B-3 SERVICES THAT ALSO REQUIRE THE IDENTIFIED DOCUMENTATION T2041 U4 1 Unit = 1 month H0018 U4 1 Unit = 24 hours T1019 U4 H2023U4-Individual H2023HQU4-Group I Unit = 15 minutes H2026U4-Individual H2026HQU4-Group I Unit = 15 minutes H2023U4HE H2026U4HE H0038U4 H0038HQU4 H0045U4-Individual H0045U4-Group H0045U4-Individual H0045U4-Group Community Guide Crisis Respite Individual Support Initial Supported Employment I/DD Maintenance Supported Employment I/DD Initial Supported Employment MH/SA Maintenance Supported Employment MH/SA Peer Support Respite I/DD Respite MH/SA or or or or 8