= 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 1 Unit = 1 hour 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 Service Names ADATC/Medically Supervised/Detox/Crisis Stabilization Adult Developmental Vocational Program (ADVP) Prospective (Urgent) Prospective (Non-Urgent / Routine) Concurrent (Urgent) Concurrent (Non-Urgent / Routine) or or H0014 H0040 1 Unit = 1 event/day Ambulatory Detox Assertive Community Treatment Team (ACTT) (service auth must go through the end of the month 14 th is the cut-off) (service auth must go through the end of the month 14 th is the cut-off) YA352 YA353 T2029 1 Unit = Invoice Assertive Engagement Assistive Technology Equipment and Supplies H2012:HA 1 Unit = 1 hour Day Treatment (IEP, BIP 504 ) YA382 CAET School to Work H2015:HT H2015 H2015UI YP650 H2011 T2025-U3 T2034 Community Support Team (CST) Community Networking Community Rehabilitation Program (Sheltered Workshop) I/DD Crisis Services / / 2
YP660 Day/Evening Activity I/DD T2021-Individual T2021HQ-Group T2027 YM 580 1 unit= 1 day H2014 H2014:HQ H2014:HM H2014:U1 YP610 Day Supports Day Supports (IPRS) Developmental Therapies Developmental Day Child NCSNAP/SI S or NCSNAP/S or or or T1023 T1023:G T YP690 YP692 YP485 1 Unit = 1 hour YP740 Diagnostic Assessment (pass through event of 1 event per year) Drop-In Center Facility-Based Crisis Program Family Living - Low Intensity * YP750 Family Living - Moderate Intensity T2025U or T2025U1 T2025U2 YP760 YP770 Financial Support Services Group Living Low Intensity (MH) Group Living Moderate Intensity (MH) YP780 Group Living High Intensity or or YP 780 1 Unit= 1 day Group Living-High Intensity (IPRS, SA) 3
YP770 YP 770 1unit =1 day Sandhills Center Care/Utilization Management Group Living Adults Group Moderate (I/DD IPRS only) Group Living-Adults Group Moderate (SA/IPRS only) YP760 YM686 S5165 1 Unit = invoice YM700 T1999 1 Unit = invoice Group Living Adults Group Low (IPRS I/DD only) Guardianship Home Modifications Independent Living Individual Goods and Services T2013 T2013H Q In-Home Skill Building T1015 1 Unit=15 minutes In-Home Intensive Supports YP821(3 WAY) YP820 (Non- Medicaid) YP821(3 WAY) YP820 (Non- Medicaid) H2022 YA 389 H2011 Inpatient Hospital *Psychiatric 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) CC A or or H2033 S5110 S5111 1 Unit = invoice Multi-Systemic Therapy (MST) Natural Supports Education 4
H0010 Sandhills Center Care/Utilization Management Non-Hospital Medical Detox (ned admit) H0020 1 Unit = 1 event/1 day Opioid Treatment H0035 1 Unit = 1 event/1 day Partial Hospitalization YA308 YA309(Group) Peer Support NA YP020 YP021 Personal Assistance or YM050 Personal Care Services or S5125 S9484 (adults) 1 Unit = 1 hour RC911 YA230 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) CON H2017 H2016 T2014 T2020 H2016H1 H0046 Psychosocial Rehabilitation (PSR) Residential Supports I-V Residential Treatment - Level I/Family Type (PA required on first day of service) H2020 Y2362 Y2363 Residential Treatment - Level II / Family (TFC) Residential Treatment - Level II / Group Home 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 1 Unit = 1 hour H2034 YP760 YP710 H0015 1 Unit = 1 event H0013 H0012:HB YP710 YP710 YP720 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 YA254 YA255 YA256 YA257 YA258 YA259 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 - 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 Therapeutic Leave Level I-IV 7 or or or or or or or or or or
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