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EASTPOINTE
PROVIDER
OPERATIONS
MANUAL
July 21, 2014
Contents
SECTION I: INTRODUCTION AND OVERVIEW .......... 7
Welcome Message from the Eastpointe Managed Care Organization
(MCO) Area Director and CEO ................................................................ 7
Who We Are ............................................................................................. 8
Administrative Operations....................................................................................................... 8
Human Resources and Compliance ......................................................................................... 8
Medical Director...................................................................................................................... 8
Clinical Department................................................................................................................. 8
External Operations Department ............................................................................................. 9
Quality Management (QM) Department ................................................................................. 9
Business Operations .............................................................................................................. 10
Eastpointe Vision, Mission and Guiding Principles ................................ 10
SECTION II: TREATMENT PHILOSOPHY AND
COMMUNITY STANDARDS OF PRACTICE ................. 11
A. Overview ............................................................................................ 11
B. Objectives .......................................................................................... 11
C. About the NC Innovations Waiver .................................................... 12
D. Stakeholder Involvement in Eastpointe System ................................ 12
E. Operational Committees .................................................................... 13
F. Member and Community Relations ................................................... 13
SECTION III: PROVIDER NETWORK ........................ 15
A.
The Eastpointe Provider Network ................................................. 15
B.
Cultural Competency of the Network ............................................ 18
C.
Types of Network Providers .......................................................... 19
1. Critical Access Behavioral Healthcare Agency (CABHA) ............................................... 19
2. Specialty Providers ............................................................................................................ 20
3. Alternative Family Living Providers (AFL) ..................................................................... 20
4. Licensed Practitioners and Professional Practice Groups ................................................. 21
5. Provisionally or Associate Licensed Practitioners ............................................................ 21
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6. Integrated Care Provider.................................................................................................... 22
7. Out of Area Provider ......................................................................................................... 22
8. Out of Network Providers ................................................................................................ 22
9. Non-Enrolled, Non-Contracted Providers ......................................................................... 22
10. .5600 Group Homes......................................................................................................... 23
D.
Location of Services ...................................................................... 23
E.
Quality of Care .............................................................................. 23
F.
Provider Communication ............................................................... 26
G.
Provider Council ............................................................................ 27
H.
Code of Ethics ............................................................................... 29
I.
Changes in Credentialed Status-Independent Practitioners ............ 30
J. Re-credentialing-Independent Practitioners ..................................... 31
K.
Alteration of Practitioner’s Credentialing Status ............................ 32
L. Reconsideration of Credentialing Decisions .................................... 34
M. Actions Against Practitioner Credentialing Reported to External
Bodies .................................................................................................... 34
N.
Performance Reviews ................................................................... 34
O.
Changes in Provider Qualification Status ..................................... 35
P.
Applying for Additional Services ................................................... 35
Q.
Health and Safety Site Reviews .................................................... 36
R.
Eastpointe Implementation Review ............................................... 36
S.
Provider Monitoring ....................................................................... 37
T.
Clinical Home for Members ........................................................... 39
U.
Provider Network Design .............................................................. 40
V.
Contracts ....................................................................................... 40
SECTION IV: CALL CENTER APPOINTMENT
ACCESS STANDARDS (1-800-913-6109) ...................... 43
A.
Eligibility Screening ....................................................................... 43
B.
Accessing Emergent Care ............................................................ 43
C.
Accessing Urgent Services ........................................................... 44
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D.
Accessing Routine Services.......................................................... 45
E.
Process for Initial Authorization .................................................... 46
F.
Discharge ...................................................................................... 46
G.
Follow Up After Discharge ............................................................ 47
SECTION V: AUTHORIZATION, UTILIZATION
REVIEW, CARE MANAGEMENT AND BENEFIT
PACKAGE ...................................................................... 47
A.
Eligibility ........................................................................................ 47
B.
Who is Eligible for the Medicaid Waiver ........................................ 47
C.
Medicaid Waiver Disenrollment..................................................... 49
D.
Eligibility for State Funded Services ............................................. 50
E.
Eligibility for Reimbursement by Eastpointe .................................. 50
F.
Enrollment of Members ................................................................. 51
G. Special Needs Populations Designated in the NC MH/DD/SAS
Health Plan ............................................................................................. 52
H.
I.
Service Array ................................................................................. 54
Hospital Admissions ......................................................................... 54
J. Medicaid Transportation Services .................................................... 54
K.
Registry of Unmet Needs .............................................................. 55
L. Member Registration ........................................................................ 55
M.
Utilization Management Program Overview and Processes ......... 56
SECTION VI: DOCUMENTATION REQUIREMENTS ... 57
A.
NC MH/DD/SAS HEALTH PLAN – 1915(b) WAIVER................... 57
B.
1915(C) NC Innovations HCBS Waiver ........................................ 57
C.
B-3 Alternative Services ................................................................ 57
D.
Resources For Providers .............................................................. 57
E.
Training And Technical Assistance ............................................... 58
SECTION VII: CLAIMS AND REIMBURSEMENT ....... 58
A.
Link to Claims Manual: .................................................................. 58
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SECTION VIII: GRIEVANCES, APPEALS,
RECONSIDERATIONS, INVESTIGATIONS AND
RESOLUTION PROCEDURES ....................................... 58
A.
Role And Responsibilities Of The Provider Monitoring Committee
58
B.
Role And Responsibilities Of The Credentialing Committee......... 59
C.
Grievance And Appeals (Reconsideration) Process Overview ..... 59
D.
Grievances (Complaints)............................................................... 60
E.
Reconsideration (Appeal) Of Eastpointe Actions Taken Against
Providers ................................................................................................ 61
F.
Paybacks Due And Payable Upon Completion Of Reconsideration
63
G.
Reconsideration Of Eastpointe Credentialing Decisions .............. 63
H.
Right To File An Appeal With The State MH/DD/SAS Appeals
Panel For State Funded Services .......................................................... 64
I.
Reconsideration And Appeals Of Decisions Against Members ....... 65
J. Eastpointe Medicaid Member Reconsideration And Appeals Process
67
K.
Eastpointe Non-Medicaid Service (State Funded Services) Appeals
Process .................................................................................................. 72
SECTION IX: CARE COORDINATION AND
DISCHARGE PLANNING REQUIREMENTS ................ 75
A.
Care Coordination (CC) ................................................................ 75
B.
Discharge Planning ....................................................................... 76
SECTION X: PERFORMANCE IMPROVEMENT ......... 77
A.
Introduction ................................................................................... 77
B.
Quality Improvement ..................................................................... 77
C.
Performance Measurement........................................................... 78
D.
Provider Monitoring ....................................................................... 78
E.
Corporate Compliance .................................................................. 81
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F.
Monitoring And Auditing ................................................................ 82
G.
Investigations Of Violations ........................................................... 83
H.
General Medical Records Requirements/Treatment Records
Standards ............................................................................................... 83
I.
Management Information Systems .................................................. 84
SECTION XI: MEMBER RIGHTS AND
EMPOWERMENT ......................................................... 84
A.
Understanding Member Rights ..................................................... 84
B.
Member Rights .............................................................................. 84
C.
Responsibilities of Members ......................................................... 86
D.
Consent for Treatment .................................................................. 86
E.
Restrictive Interventions ................................................................ 87
F.
Protected Health Care Information (PHI) ...................................... 87
G.
Confidentiality ................................................................................ 87
H.
Confidentiality: Information Use Without Prior Consent ................ 88
I.
Client Rights Committee .................................................................. 88
J. Consumer And Family Advisory Committee (CFAC) ....................... 89
K.
Prohibited Restrictions On Providers ............................................ 89
L. Second Opinion ................................................................................ 90
M.
Psychiatric Advance Directives (PAD) .......................................... 90
N.
Client Rights Resources................................................................ 91
SECTION XII: OFFICIAL COMMUNICATION
BULLETINS ................................................................... 92
A.
Eastpointe NETWORK COMMUNICATIONS ............................... 92
B.
Division of MH/DD/SAS................................................................. 92
SECTION XIII: ATTACHMENTS ................................... 92
Attachment A: Glossary Of Terms ......................................................... 92
Attachment B: Utilization Management Plan/Program Overview ......... 109
Purpose and Scope: ...................................................... 109
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Oversight ...................................................................... 110
Medical Director ................................................................................... 110
Chief of Clinical Operations .................................................................. 110
Director of Utilization Management ...................................................... 110
Mental Health/Substance Abuse UM Manager .................................... 111
Intellectual Developmental Disability UM Manager .............................. 111
Manager of UM Support ....................................................................... 111
Covered Services ........................................................... 111
Enrollee Eligibility for Medicaid Services .............................................. 112
Provider Eligibility for Reimbursement by Eastpointe .......................... 112
Utilization Review Decisions ........................................ 118
Appeal of Adverse Actions by the UM Department ...... 125
Delegated UM Functions .............................................. 126
Over-Under Utilization ................................................. 126
Care Coordination Referrals ........................................ 128
UM/ Care Coordination Firewall ........................................................... 128
Utilization Management Team Responsibilities ................................... 128
Attachment C: Provider Manual Revision Information ......................... 129
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SECTION I: INTRODUCTION AND OVERVIEW
Welcome Message from the Eastpointe Managed Care Organization
(MCO) Area Director and CEO
Welcome to the Eastpointe provider network. As a member of the network you join a
select, progressive group of providers who are dedicated to providing quality care for
the members of Eastpointe MCO. As a provider, you represent the network to the
people we serve, and join us in our mission to help people with disabilities,
behavioral health, and special needs improve the quality of their lives.
As a contracted provider in Eastpointe, it is your responsibility to be familiar with and
adhere to the policies and procedures outlined in this manual. Compliance is
necessary to fulfill your contractual obligations in providing services within our
network. The Provider Manual begins with information about Eastpointe, our vision,
mission, and core values. It describes our policies and procedures from the referral
and authorization process to claims submission and problem resolution. We have
also included a glossary of frequently used terms for your reference and copies of
links to all necessary forms. Your adherence to these guidelines will assist Eastpointe
in providing you with timely service authorizations and claims reimbursement.
Providers are encouraged to be involved in the management of the system, including
the creation of strategies to meet performance objectives, reviewing system
performance and developing solutions for systemic problems. I ask you to consider
participation in the ongoing operations of Eastpointe through the Eastpointe Provider
Council, Credentialing Committee, Quality Management Committees, Cultural
Competency Committee and Client Rights Committee.
Eastpointe’s goal is to ensure that people in need receive the appropriate services
for Recovery, Growth, and Quality Care. As our behavioral healthcare system
evolves over the next few years, we will be working in partnership to find solutions
that are timely and responsive to member needs. In partnership with our providers
we want to mutually develop a system where structure, requirements and
expectations are intricately known by our providers, thereby creating a system
where extensive management and intervention by Eastpointe is not required.
I encourage you to use this manual as a resource and tool to assist you with
services provided through the Eastpointe MCO. If you have questions, or need
additional information or assistance, please feel free to contact us at 1-800-9136109 or 1-888-819-5112 for TTY, or visit our Website at www.eastpointe.net
We thank you for your participation in our network, and we look forward to a long
and rewarding partnership as we work together to provide quality treatment to the
individuals we all serve.
Ken Jones
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Who We Are
We are the Eastpointe MCO, an agency of local government responsible for
managing, coordinating, facilitating, and monitoring the provision of state, federal,
and Medicaid funded mental health, intellectual and developmental disabilities and
substance abuse services for members in the Eastpointe catchment area. Residents of
Bladen, Columbus, Duplin, Edgecombe, Greene, Lenoir, Nash, Robeson, Sampson,
Scotland, Wayne and Wilson are eligible members for the Eastpointe MCO.
Eastpointe was established under chapter 122C of the Mental Health, Developmental
Disabilities, and Substance Abuse Act of 1985, and currently meets the statutory
requirements of NC General Statutes 122C Article 4, Part 2. Effective January 1,
2013, Eastpointe MCO began to perform 1915 (b)(c) waiver services. The agency is
overseen by a Board of Directors with membership as defined in 122C.
Eastpointe Departments include:
Administrative Operations includes the Chief Executive Officer (CEO), and the
Chief of Clinical Services, External Operations, Quality Management, and Business
Operations. These officers , in addition to the Director of Human
Resources/Compliance are responsible for the overall management of Eastpointe
MCO and comprise the membership of the agency’s Executive Leadership Team.
Human Resources and Compliance Department provides leadership in the
development, implementation and administration of human resources, policies and
procedures, and programs which support the MCO’s mission. In addition, the Human
Resources Department is responsible for agency compliance activities.
Medical Director is responsible for the overall clinical management of services to
members and the clinical privileging of facilities and Licensed Practitioners serving
Eastpointe members.
Clinical Department is comprised of the following functions:
Access/Call Center is the central point of contact for and on behalf of consumers
and provides screening, triage, and referral of members 24/7/365 including crisis
services.
Utilization Management manages the benefit packages and is responsible for prior
authorization of initial requests as well as on-going services.
MH/SA Care Coordination collaborates with hospitals, crisis units, providers and
members to coordinate care for members who are hospitalized at state hospitals or
other facilities and need a higher level of service coordination, including involuntary
inpatient and outpatient commitments. Consumers with high risk criteria and/or
identified as one of the special healthcare need populations.
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IDD Care Coordination This unit provides care coordination for members
identified as intellectually and/or developmentally delayed (I/DD) who are enrolled in
the Innovation Waiver, individuals on the Registry of Unmet Needs, and IPRS funded
I/DD individuals identified as high risk.
Housing collaborates with other stakeholders to develop and oversee the housing
resources available to members.
Special Population Services assists with the development and oversight of
activities impacting special populations, i.e. traumatic brain injury, deaf services, etc.
External Operations Department is responsible for the following functions:
Network Management develops and oversees the provider network of services for
adults and children with mental health, intellectual /developmental disabilities, and/or
substance abuse issues.
Provider Monitoring performs monitoring of providers to ensure that required
standards of care are followed.
Community Relations collaborates with local stakeholders in the counties that
constitute the Eastpointe MCO to ensure that there is a partnership between
stakeholders and the MCO. They will also ensure that there is coordination of the
System of Care. In addition this unit will have staff dedicated to the role of member
advocacy functions and serve as the liaison to the Consumer Family Advisory
Committee (CFAC).
Program Integrity ensures the compliance, efficiency and accountability of funded
services by detecting and preventing fraud, waste and program abuse.
Communications assists in the review and assessment of documents, presentations
and verbal communications that are targeted to a wide variety of audiences.
Quality Management (QM) Department is responsible for the following
functions:
Quality Management provides oversight of quality assurance and improvement
activities throughout the organization and the provider network.
Training Team facilitates and oversees the training needs of the MCO. The Training
Team includes the Geriatric/Adult Mental Health Specialty Teams (GAST); which
provide consultation, education, training and technical assistance to caregivers and
community facilities serving geriatric adults. Additionally, in collaboration with other
Eastpointe departments, this unit coordinates needed training for the provider
network.
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Medical Records oversees the medical record processes for the MCO, and if
indicated, the storage of provider records.
Grievance and Appeals manages the grievance and appeals processes for the
MCO members and providers. Also services as the department that oversees the
agencies responsiveness to complaints.
Business Operations is responsible for the following functions:
Financial Operations manages the financial resources of the MCO, including the
processing claims and reimbursement.
Information Systems (IS) Team develops and maintains the Eastpointe operating
systems and provides Eastpointe staff as well as provider staff with technical
assistance.
Medicaid Contract Manager is the liaison between the state and the MCO to
ensure compliance with the waiver contract.
Facility Management oversees the physical sites operated by the MCO.
Eastpointe Vision, Mission and Guiding Principles
Vision: Eastpointe is a regional resource for our members, families and
stakeholders, committed to providing leadership and effective management that
promote quality outcomes.
Mission: Eastpointe will work together with individuals, families, providers, and
communities to manage and continually improve our behavioral healthcare system to
ensure accessibility, accountability, and empowerment of people to achieve valued
outcomes.
Eastpointe’s Guiding Principles for Conducting Business
Ethics: We work with integrity
Planning: Members and families are fully involved in all aspects of the
system's redesign and operations.
Customers: We serve members with dignity, respect and sensitivity to their
cultural heritage.
Employees: We give our employees the respect, training and support to be
successful.
Excellence: Our commitment is to continuous quality improvement.
Accountability: We focus on system and member outcomes
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SECTION II: TREATMENT PHILOSOPHY AND
COMMUNITY STANDARDS OF PRACTICE
A. Overview
The North Carolina Mental Health/Intellectual /Developmental Disabilities and
Substance Abuse Services Health Plan and the NC Innovations Waiver are important
building blocks of the foundation of a reengineered system that will more effectively and
efficiently address the needs of members with mental illness, intellectual and/or
developmental disabilities, and substance abuse disabilities.
This system depends on coordination and management of all public resources available to
support this system of care. Federal, State and County funds will be strategically
managed for optimal outcomes for individual members. Significant changes have begun
and will continue to take place in a planned, controlled and sequential manner. Both
external events and improvements in management strategies continue to result in
refinement and improvements to our strategies.
B. Objectives
• Maintain a Clinical Model that is the foundation for all activities. This plan must be
continually and consistently enforced through a variety of activities including Care
Management, Utilization Management, authorization, and clinical protocols,
application of culturally competent recovery principles and practices, Utilization
Review, Care Coordination, and provision of feedback/training to providers.
• Establish a Self-Managed System by developing and training a selectively qualified and
comprehensive network of providers.
• Use funding to encourage the development and provision of services that are based on
clinical evidence, culturally competent and recovery practices, and which have proven
desirable outcomes.
• Involve members and families in ways that ensure their ownership and satisfaction, and
to engender a feeling of shared responsibility.
• Develop a sense of community ownership that comes from communication,
collaboration and commitment to people in the local community, including providers.
• Apply the principles of cultural competence, recovery, and individualized service care
to ensure equitable access to, engagement with, and benefit from services.
• Use data that can be translated into knowledge in order to demonstrate accountability,
efficiency, need, quality, outcomes, awareness of cultural/ethnic variations and to
identify areas for change and improvement.
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C. About the NC Innovations Waiver
The NC Innovations Waiver is a 1915(c) Home and Community Based Services (HCBS)
Waiver. Funds that are typically used to serve a person with intellectual and/or
developmental disabilities in an Intermediate Care Facility (ICF) through this waiver may
be used to support the participant outside of the ICF setting.
The NC Innovations Waiver incorporates self-direction, individual service planning,
individual budgets, participant protections and quality assurance to support the
development of a strong continuum of services that enables individuals to live in
integrated settings. Participants in the waiver and their families are provided the
information and opportunity to make informed decisions about their health care and
services. They are empowered to exercise more control over the decisions they make
regarding services and supports. The NC Innovations Waiver has both Provider Directed
Supports and Individual/Family Directed Supports options.
In Provider Directed Supports, services are delivered in a traditional manner with staff in
the employment of an agency. Participants and their families have the opportunity to
choose their NC Innovations service providers and are included in support planning. The
service provider is fully responsible for the employment of individuals who work with
the participant.
There are two models of Individual/Family Directed Supports. The Agency with Choice
model will be available during the initial implementation of NC Innovations (first three
years). In the Agency with Choice model, the provider agency is the legal employer, but
the participant/legally responsible person is the Managing Employer. The Managing
Employer is responsible for interviewing, training, managing (with oversight by the
agency Qualified Professional), and making recommendations to the provider agency for
hiring and firing. Participants and their families may choose Provider Directed Supports,
Agency with Choice model of Individual/Family Directed Support or a combination of
both options. A Community Guide may be utilized to assist the participant and their
family with any elements of Individual/Family Directed Support.
A second model of Individual/Family Directed Supports, Employer of Record, will be an
option offered to participants and their families after initial implementation. In the
Employer of Record model, the staff are hired, directed and paid by the Innovations
participant/legally responsible persons with the assistance of a Community Guide and a
Financial Supports Agency.
D. Stakeholder Involvement in Eastpointe System
Eastpointe Network has a system of 1915 (b)(c) Waiver implementation work groups and
routine public forums in order to ensure engagement of its members, family members,
advocates, providers, and community agencies. These work groups and forums provide
staff, stakeholders and members with opportunities to discuss problems and concerns,
provide important feedback to Eastpointe Network about its performance, and to assist in
proactive planning. Notice about membership on various committees and workgroups
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and announcements about forums are communicated in a variety of means. These
include, but are not limited to, website postings, list serve announcements, CFAC notices,
Provider Council and Provider Network meeting announcements, media releases, etc
E. Operational Committees
The use of these forums, where Eastpointe, members, family members, providers and the
community come together to exchange ideas, address problems, and plan in a
collaborative planning manner has been a resounding success. For Eastpointe, this has
been a way for us to “keep our feet on the ground” and understand the impact of our
activities. For members of these teams, it has been an opportunity to understand and
assist with requirements and challenges that Eastpointe faces in its role as regional
systems manager. It is expected that these groups will continue to grow in their collective
ability to impact Eastpointe operations and management in a positive manner.
The following is a list of some of the Eastpointe Operational Committees:
• CFAC (Consumer & Family Advisory Committee)
• Provider Council
• Credentialing Committee
• Client Rights
• Cultural Competency
• Quality Management Committee
• I/DD Stakeholders
• I/DD Provider Group
• MH/SA Provider Group (Mental Health / Substance Abuse Provider Group)
F. Member and Community Relations
In terms of members, and families, Eastpointe staff and providers in the network jointly
assist with supporting members involved in the Grievance and Appeals System, assist in
responding to alleged violations of Client Rights and other protections, are involved in
advocacy on behalf of the interests of members and stakeholders (both externally and
within the MCO). This partnership facilitates a clear understanding of the member’s
condition, access to available services, benefits and payments. Eastpointe Community
Relations and Quality Management staff support the Eastpointe Consumer and Family
Advisory Committee (CFAC) and the Client Rights Committee.
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In order to promote and support community integration and communication, Eastpointe’s
Community Relations Department will:
• Participate in advisory groups and collaboratives
• Provide public education on access to services and the functions of the MCO
• Act as the MCO spokespersons to stakeholder groups
• Work with media outlets with oversight of the Communications Director
• Work closely with other health partners to create an effective, efficient service delivery
system
Your responsibility as an Eastpointe Network contracted provider is to:
• Maintain an environment where members and family members are treated with
respect.
• Maintain a formal complaint/grievance process as described in this manual.
• Respond in a timely manner to all inquiries and investigations about member issues or
grievances.
• Refer members who need assistance in making complaints to Eastpointe
• Publicize and support MCO sponsored opportunities for member training
• Facilitate adequate random sampling on state and Eastpointe surveys
• Let Provider and Community Relations staff know about events in your county for
members
• Participate in the education of stakeholders and members on system access, services
supports available, appeals and grievances, Advanced Directives and the provider
network.
• Actively participate in community collaborative efforts to develop prevention,
education and outreach programs.
• Assist in the development of educational materials and brochures on mental
illness, developmental disabilities and substance abuse to educate the community about
the needs of people with disabilities.
• Earnestly participate in initiatives to achieve cultural competence
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• Pursue the acquisition of knowledge relative to cultural competence and the provision
of services in a culturally competent manner and collaborate in Eastpointe’s Utilization
and Care Coordination functions.
Eastpointe’s responsibility to network providers is to:
• Resolve member grievances and appeals impartially and as expeditiously as possible.
• Provide accurate information to members and families about their rights to make
complaints and file appeals.
• Address the stigma and discrimination associated with mental illness,
intellectual/developmental disabilities and/or a substance abuse diagnosis.
• Serve as a resource for the development of peer support.
• Ensure that member interests are represented on management teams, committees and
councils.
• Develop comprehensive prevention, education and outreach programs.
• Lead community collaborative efforts to assess community capacity need and provide
in-service trainings.
• Develop and disseminate educational materials to providers and members relative to
accessing services, member rights and protection, appeals and grievances, advanced
directives, and cultural competency.
• Provide evaluative feedback to providers relative to proficiency in providing culturally
competent services.
• Maintain the Eastpointe website which contains information about the Eastpointe
Network for members, providers, key stakeholders and the general public.
• Be a resource for Evidenced-based Practices and Emerging Best Practices with the
goal of achieving positive outcomes in the community and members’ quality of life and
progress in recovery, and to provide feedback to providers regarding members being
serviced by Eastpointe.
SECTION III: PROVIDER NETWORK
A. The Eastpointe Provider Network
The NC MH/DD/SAS Health Plan under the 1915 (b)(c) section allows for a waiver of
freedom of choice. Under the waiver, Eastpointe is responsible for ensuring that members
15
have freedom of choice of network providers, and accessibility of services. This
provision allows Eastpointe to down-size the network when excess capacity exists and/or
where there are issues related to quality or outcomes. This ensures economic viability of
providers in the Network and promotes effectiveness and efficiency while ensuring that
members have a choice of Providers. The primary goal of Eastpointe is to ensure that the
system can be shaped to better meet the needs of members through member choice and
provider expertise in evidence-based practices.
Eastpointe will assess community needs and provider capacity via an annual Needs
Assessment Study which will be performed during the third quarter of the fiscal year and
reviewed of a quarterly basis. The study will incorporate aspects of the adequacy and
access standards and be used to inform Eastpointe about provider capacity in relation to
the community needs. The annual needs assessment will take into consideration the
population within the Eastpointe catchment area, identified gaps in the service array, and
the number and variety of providers for each service. The annual Needs Assessment will
include input from members, families, network providers and community stakeholders,
gathered through member and community surveys, CFAC, and collaborative meetings,
and community forums. Services/supports will be identified as “needs” through the
Service Gap Analysis. Eastpointe will report the results of the annual needs assessment to
the Eastpointe Board and the Consumer and Family Advisory Committee (CFAC).
On and after January 1, 2013 applications from potential providers will only be accepted
for services that Eastpointe has identified as having a need and has opened up the
network for potential providers. When services are identified as needing additional
providers Eastpointe will first assess the ability of current network providers to expand to
cover the identified service gap. If it is felt that multiple existing network providers are
able to respond to the need a request for proposal or information process may be initiated.
If the service gap is determined to be one for which an existing network provider is not
able to provide the service applications will be accepted from providers outside the
network.
The Provider Network Operations encompasses the following responsibilities:
Provider Relations
• Assist with the development of and managing provider contracts and maintenance and
enrollment of a community of providers which meet the needs of the populations
needing Mental Health, Intellectual/Developmental Disabilities and Substance Abuse
Services and support from the MCO.
• Managing provider contracts and network requirements
• Maintains database of Provider Network by service type and specialty
• Conducts continuous needs assessments to identify gaps in services
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• Assisting with administrative, contractual and technical issues
• Consulting/providing technical assistance as requested or by need determined by the
MCO
• Recruiting providers with demonstrated competencies to meet the service needs of
members and families
• Supporting the community of network providers through the Provider Council, regular
provider meetings, and support of disability-specific focus groups and steering
committees for the implementation of new services
• Liaison with the Division of MH/DD/SAS and DMA regarding provider functions
• Liaison with local agencies and the community at large regarding provider related
issues, concerns and functions
• Disseminating official communication regularly to providers
• Responding to grievances made against providers and conducting investigations as
necessary
Provider Network Operations Training
• Assistance with network training needs
• Coordination of needed trainings
• Coordination of training including federal, state and local requirements, service
authorization and billing procedures, and best-practice modalities
Eastpointe Contracted Provider Responsibilities:
• Provide services for which your agency is contracted and credentialed by Eastpointe
• Provide services only at service sites as outlined in your contract(s)
• Provide quality services through the use of best practices
• Work in collaboration with other providers, members and families
• Be responsive to the cultural and linguistic needs of the members your agency serves
• Obtain authorizations as required for contracted services
• Adhere to all performance guidelines in your contract
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• Work in a solution focused and collaborative manner within the network
• Work with Eastpointe to mediate problem areas through your assigned Provider
Specialist
• Submit clean claims for billable services which are supported by appropriate clinical
documentation
• Comply with insurance requirements as specified in the provider contract
• Comply with no-reject requirements as specified in service definitions, contract and
rules/statutes. In the case of conflict between these requirements comply with the most
restrictive.
• Comply with all licensure requirements as specified in service definitions and contract
requirements
Eastpointe’s Primary Network Responsibilities:
• Identify gaps in network services
• Strategically develop those services through existing providers or by recruiting new
providers for the network that share a mission and vision consistent with that of
Eastpointe
• Respond to requests for applications for network enrollment according to the needs and
gaps analysis
• Support the development and maintenance of best practices or emerging best practices
• Identify a Provider Specialist for each network provider as a resource for technical
assistance
• Keep providers informed through provider meetings, electronic updates and the
provider section on the Eastpointe website at www.eastpointe.net.
• Update provider manual and policies and procedures to reflect changes in requirements
• Identify training needs for providers, and if possible, facilitate or provide the training
• Credential and re-credential providers to insure a qualified network of providers to
meet the member capacity needs in the Eastpointe catchment area.
B. Cultural Competency of the Network
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Cultural and linguistic competency and the delivery of such services should not be seen
as an ‘add on’ to service delivery. It should be integrated in the overall fabric of service
delivery, linked to quality of care and legitimized by the leaders of the system in policy,
practice, procedures, and resources. Eastpointe Network recognizes that becoming
culturally competent is an ongoing process in which we gain knowledge about one
another and use that knowledge to build trust, break down barriers, and improve the
quality of care throughout the network.
We strive to promote cultural awareness and sensitivity among Eastpointe’s staff and
contracted providers to enable us to work effectively with each other in cross-cultural
situations. It is our intention to create an environment that protects and preserves the
dignity of all by acknowledging cultural differences among us without placing values on
those differences.
We encourage our staff and providers to recognize that culture makes us who we are.
Culture not only determines how we see the world and each other, but greatly impacts
how we experience physical and mental illness. It also shapes the recovery process,
affects the types of services that are utilized, impacts diagnosis, influences treatment and
the organization and financing of services. We envision that our network includes staff
and providers who recognize that there is variation in behaviors, beliefs and values as
they assess an individual’s wellness/illness and incorporate that awareness in treatment
planning with competence and sensitivity.
Eastpointe has a Cultural Competency Program that involves input from network
providers and members. Eastpointe’s Cultural Competency Committee consists of
membership from the provider network, internal staff and members.
C. Types of Network Providers
1. Critical Access Behavioral Healthcare Agency (CABHA)
A Critical Access Behavioral Health Agency (CABHA) is a provider who delivers a
comprehensive array of mental health and substance abuse services. (CABHAS are not
required to, and typically do not, provide I/DD services). The CABHA’s role is to ensure
that a robust array of critical services is delivered by clinically competent organization
with appropriate medical oversight. A CABHA is required to offer the following core
Services: Comprehensive clinical assessment, medication management, and outpatient
therapy, as well as being endorsed for at least two of the following services in the age and
disability served:
• Intensive In-Home (IIH)
• Community Support Team (CST)
• Substance Abuse Intensive Outpatient Program (SAIOP)
• Substance Abuse Comprehensive Outpatient Treatment (SACOT)
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• Child Residential Level II, III, or IV
• Day Treatment
• Psychosocial Rehabilitation (PSR)
• Assertive Community Treatment Team (ACTT)
• Multi-Systemic Therapy (MST)
• Partial Hospitalization (PH)
• Substance Abuse Medically Monitored Community Residential Treatment
• Substance Abuse Non-Medical Community Residential Treatment
• Outpatient Opioid Treatment
2. Specialty Providers
A Specialty Provider concentrates on a specific disability or service such as vocational,
residential services, child mental health, eating disorders, Autism or Down Syndrome.
Specialty providers fill a critical role in the Eastpointe Network for Priority Populations
and for those members with very specific service and support needs. The Provider
Monitoring Department will review adherence to Best Practice standards for specialty
providers.
3. Alternative Family Living Providers (AFL)
AFLs provide residential care for adults with intellectual/developmental disabilities. Only
AFL providers may provide AFL services. Any agency subcontracting with and AFL
provider must have prior approval. Eastpointe requires the following for AFL services:
• Documentation of training and background checks for both primary staff and back up
staff
• AFL site must be the primary residence of the AFL provider (includes couples or single
person) who receives reimbursement for cost of care
• Any provider that offers services outside the scope of the AFL compensation and/or
requirements must be an employee or an approved subcontractor of the Agency
provider
• If the AFL serves more than one member or a member under 18 years of age, the site
must be licensed by Division of Health Service Regulation
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• Back-up staffing plan must be in place and the back-up staff must be employees of the
provider
• AFL providers must submit to Health and Safety Reviews which are to be completed
by Eastpointe at least annually. Any Certified AFL provider (unlicensed) who does not
continue to meet the Health and Safety standards set by Eastpointe will no longer be
eligible for payment of services.
•
AFL providers are not permitted to provide services to another member while
serving a primary member for AFL services at an unlicensed site
• AFL providers will be required to pay back funds if a member is moved to a new site
and Eastpointe is not notified and the AFL provider bills for the old site
• All AFL providers must have insurance coverage for property, automobile, and liability
as specified in the service contract.
• Personnel files must be maintained on all AFL providers
• All documentation for service provision must meet APSM 45-2, APSM 45-1, HIPAA
and service definition requirements, and be readily available for review upon request
4. Licensed Practitioners and Professional Practice Groups
These providers are Medical Doctors (M.D.), Practicing Psychologists (Ph.D.)
Psychological Associates (Master’s Level Psychologist [LPA]), Licensed Clinical Social
Workers (LCSW), Licensed Marriage and Family Therapists (LMFT), Licensed
Professional Counselors (LPC), Licensed Clinical Addiction Specialists (LCAS),
Advanced Practice Psychiatric Clinical Nurse Specialists, Psychiatric Nurse Practitioners,
and Licensed Physician Assistants who are members of the Provider Network and bill
under their own license. Network Providers must meet Eastpointe Networks criteria for
enrollment, credentialing, and qualifying. Eastpointe verifies that the providers have the
necessary experience and history of giving quality care. Additionally, Eastpointe collects
information about specific expertise of these providers in order to help members make
choices about providers.
5. Provisionally or Associate Licensed Practitioners
These are practitioners who are provisionally or associate licensed in NC and are
employed by a CABHA, Agency, Hospital, or Group Practice that is fully contracted with
Eastpointe to provide Outpatient Treatment. Provisionally or Associate Licensed
Providers providing services to Eastpointe members must submit an application for
credentialing to Eastpointe.
In addition to completing and submitting the application, the Provisionally or Associate
Licensed Practitioner must provide proof of professional clinical supervision as
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evidenced by a current supervision contract including the name and contact information
of the clinical supervisor. The clinical supervisor must provide an attestation stating that
the provisionally licensed practitioner is receiving supervision and that the supervisor has
approved the supervision contract. Upon approval by the Credentialing Committee, the
Provisionally or Associate Licensed Practitioner will be able to provide approved
services to Eastpointe members and submit claims for those services in accordance with
the Eastpointe Provider Contract, the practitioner’s Licensing body, and/or limitations
established by Eastpointe’s Credentialing Committee.
6. Integrated Care Provider
Integrated Care Providers are providers that provide behavioral health services from a
primary care setting. This generally involves a Primary Care Physician employing or
contracting with a Licensed Practitioner to provide outpatient treatment to individuals
being served by the Primary Care Physician. Practice settings could include Federally
Qualified Health Centers (FQHC), Rural Health Centers, County Health Departments,
Hospital Outpatient practices, and general primary care practices.
7. Out of Area Provider
An Out-of-Area provider is a contracted Agency or Licensed Independent Practitioner
that provides specialty services outside the Eastpointe catchment area. Such providers
meet all network requirements and are considered to be full members of the Eastpointe
Network.
8. Out of Network Providers
Eastpointe has an Out of Network Policy and Procedure which is utilized to determine the
need for a client-specific contract with providers outside of the Eastpointe Network.
Some members with Medicaid from the Eastpointe MCO live in other parts of the state.
Eastpointe is committed to ensuring that providers are available to meet their needs and
makes arrangements for member specific contracts. The Eastpointe Medical Director
reviews all member information submitted for out of network members to assist in
determining medical necessity and the need for an member specific contract. Out of
Network providers are not considered to be members of the Eastpointe Network.
9. Non-Enrolled, Non-Contracted Providers
If an Eastpointe member requests services from a provider who does not wish to apply to
become a contracted provider with Eastpointe or is unable to pass the Enrollment process,
the licensed independent practitioner or agency will be required to transition the member
to the Eastpointe contracted provider of their (the member’s) choice by January 1, 2013.
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If the person receives non-emergency services from a non-enrolled, non-contracted
provider, Eastpointe will not pay for the service. Eastpointe will pay for acute behavioral
emergency care for an Eastpointe member by a non-enrolled, non-contracted provider.
When an Eastpointe member enrolled in the NC MH/DD/SA Health Plan resides outside
of the Eastpointe region, Eastpointe will work collaboratively with the member and
providers in that area to ensure that the member has access to needed services.
10. .5600 Group Homes
A facility licensed as a .5600 facility will be a part of the Eastpointe network if they
provide Medicaid funded services and have successfully completed the credentialing
process and remain in good standing with network criteria.
D. Location of Services
Most services will be available within thirty (30) to forty-five (45) miles or 30-45
minutes from an member’s residence. However, some specialty providers may be located
outside of this range including the possibility of a location outside the person’s county of
residence. Eastpointe will annually evaluate the location of providers and types of
services in its Needs Assessment Study, and determine the need for additional providers.
Eastpointe uses GEO Access maps which allow us to determine the location of providers
in relation to where members live within the catchment area, and focus on any areas that
need recruitment.
E. Quality of Care
Eastpointe’s responsibility is to assure the quality of services provided by the Eastpointe
Network of Providers. Eastpointe is accountable to the Division of MH/DD/SA and the
Division of Medical Assistance in the management of both state funded and Medicaid
services. In addition to state requirements, Medicaid waiver quality requirements are
extensive and include:
• Health and safety of members
• Rights protection
• Provider qualifications
• Member satisfaction
• Management of complaints
• Incident investigation and monitoring
• Assessment of outcomes to determine efficacy of care
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• Management of care for Special Needs Populations
• Preventive health care initiatives
• Clinical best practice
Your responsibilities as an Eastpointe Contracted Provider:
• Ensure that members meet medical necessity requirements for all services that you or
your agency provides.
• Provide medically necessary covered services to members according to your contract
and as authorized by Eastpointe.
• Strive to achieve best practice in every area of service.
• Provide culturally competent services and ensure the cultural sensitivity of staff
members. Develop a Cultural Competency Plan and comply with cultural competency
requirements.
• Have a clinical backup system in place to respond to emergencies on weekends and
evenings for members you serve, and serve as a first responder as outlined in the
service definition and your contract.
• Demonstrate member friendly services and attitudes. The Network Provider must have
a system to ensure good communication with members and families.
• Comply with the requirements outlined in this Manual, all policies and procedures
referenced in this manual, any applicable supplements, Eastpointe Communications
Bulletins and in your Provider Contract, including the General Conditions of the
Contract.
• Provide services in accordance with all applicable state and federal laws and
regulations.
• Provide services in accordance with access standards and appointment wait time as
noted in the General Conditions of the Provider Contract.
• Have a no reject policy for members who have been determined to meet medical
necessity for the covered services provided by your agency or by you as a Licensed
Independent Practitioner.
• Work with Eastpointe to ensure a smooth transfer for any members that desire to
change providers, or when you need to discharge an member because you cannot meet
his/her special needs.
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• Document all services provided as per Medicaid Requirements, NC Waiver
requirements and North Carolina State Rules.
• Agree to cooperate and participate with all utilization review/management, quality
management, other reviews, and appeal and grievance procedures.
• Comply with the Credentialing Procedures of Eastpointe that are outlined in the
Enrollment Process to become a Network Provider.
• Comply with Authorization and Utilization Management requirements of Eastpointe.
• Comply with the re-credentialing or re-qualifying procedure of Eastpointe.
• Participate in member satisfaction surveys, provider satisfaction surveys, clinical
studies, incident reporting, and outcomes requirements.
• Transfer all member records to Eastpointe upon termination of the Eastpointe provider
contract or in the event that the provider/agency ceases to operate for any reason.
Eastpointe’s Responsibilities to Network Providers:
• Provide assistance twenty-four (24) hours a day, seven (7) days a week to members,
and potential members including crisis coordination.
• Assist providers in understanding and complying with Eastpointe policies and
procedures, applicable policies and procedures of the Department of Health and Human
Services and federal agencies including the Centers for Medicare and Medicaid, as well
as the requirements of our accreditation agency, Utilization Review Accreditation
Commission (URAC).
• Provide technical assistance related to Eastpointe contract requirements, Eastpointe
Provider Manual requirements, DMA and DMH/DD/SAS requirements of providers,
the development of appropriate clinical services, quality improvement initiatives, or to
assist the provider in locating sources for technical assistance. Eastpointe is not
required to provide technical assistance in areas that would normally be considered
standard operational activities of a provider agency or to providers that have shown by
history not to be able to assimilate previous technical assistance provided.
• Make available to providers upon request, the results of its Needs Assessment Study
which identifies provider under/over capacity as well as priorities for Network
Development. Eastpointe is not required to contract with providers beyond the number
necessary to meet the needs of its members.
• Comply with quality, satisfaction and financial reporting requirements related to our
agreements with the Division of MH/DD/SAS and DMA. Eastpointe understands the
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important role of quality management in protecting members and in promoting quality
of care.
• As part of the continuous quality improvement process, Eastpointe operates a Quality
Management Committee. The Eastpointe Quality Management Department develops a
single Quality Management Plan for the Eastpointe Network with input and feedback
relevant stakeholders. The plan identifies strengths, weaknesses for areas of
improvement and includes a program description, work plan and annual report. The
Quality Management Committee reviews and approves the plan at least annually.
Annually, Eastpointe shall make information available about its quality performance to
providers, practitioners, members and stakeholders on the Eastpointe website. A printed
copy of the information is provided upon direct request to Eastpointe.
F. Provider Communication
Eastpointe is committed to communicating through a variety of means in an effort to keep
the community of network providers well informed of State and Federal changes, new
information, trainings, requests for proposals and opportunities for collaboration.
Eastpointe maintains a provider section of its website that includes specific information
for providers. Additionally, Eastpointe disseminates critical and/or time sensitive
information through official Eastpointe Communication Bulletins and through the use of
Eastpointe Provider Bulletins which are transmitted via the provider list serv. Eastpointe
also maintains information on our website for members including a Provider Search so
that members can search for providers by various factors. Eastpointe incorporates
providers into many aspects of its operations to ensure that management activities are
efficient and effective. Some of these forums include:
• Eastpointe Provider Council
• Client Rights Committee
• Credentialing Committee
• Regular Provider meetings
• Ad hoc work groups
Eastpointe’s intent is to communicate regularly with providers through its website,
forums, listserv updates, Eastpointe Provider Bulletins, Communication Bulletins and
other communications. Training activities offered are intended to support provider efforts
to attain the skills that are important for quality service provision. Training events offered
by Eastpointe and by community agencies are posted on the Eastpointe website.
Eastpointe offers self-registration so that providers can click on a training event and use
the online registration link to register.
Your responsibilities as an Eastpointe Network Provider:
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• Read, understand, and comply with your Eastpointe provider contract.
• Comply with Eastpointe policies and procedures as they relate to your agency and as
communicated through the provider manual and stand-alone policies and procedures.
• Keep updated on current information through the communication offered.
• Provide services according to the most recent state standards and/or waiver service
definitions.
• Attend and participate in Provider Meetings.
• Review the Eastpointe website for updates on a regular basis: www.eastpointe.net
• Regularly review the State and Federal websites for the most up-to-date information on
a regular basis: http://www.ncdhhs.gov/mhddsas/ http://www.ncdhhs.gov/dma/
http://www.cms.gov/
• Keep all relevant staff in your agency informed of new and/or changing information as
it relates to their function within the agency.
• Work in conjunction with the appropriate department at Eastpointe for technical
assistance when needed.
Eastpointe’s responsibilities to the provider:
• Offer provider meetings on a regular basis and post the schedule on the Eastpointe
website.
• Post electronic updates, such as, but not limited to, Communication Bulletins and
Eastpointe Provider Bulletins, on the provider page.
• Send written correspondence via the mail as needed.
• Assign a Provider Network Operations Specialist to each provider to develop a personal
working relationship and act as a contact who can respond to individual provider needs.
• Attend meetings with providers or their board as needed to clarify issues and/or provide
technical assistance.
• Respond to provider inquires and provide feedback in a timely manner.
G. Provider Council
Eastpointe’s Provider Council was established to advise Eastpointe on communication,
policy development, initiatives, projects, and the impact of state and local policy
decisions on the provider network. The Group also assists in the development of plans to
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address concerns from the provider network and Eastpointe. The Provider Council will
receive regular updates regarding on-going projects, special projects and the latest
information on pending changes from state and local organizations.
The Group is one of the key operational committees of Eastpointe and, as such, has
responsibilities to Network Providers in representing their interests and challenges, to
members and family members and to Eastpointe in responding to standards, key
indicators, initiatives and requirements.
Objectives of the Provider Council
• Advise Eastpointe on communication, policy development, initiatives, projects, and the
impact of state and local policy decisions on the provider network.
• Assist in the development of plans to address concerns from the provider network and
Eastpointe.
• Monitor on-going projects, special projects and the latest information on pending
changes from State and local organizations through review of regular updates. The
Council may invite other staff or providers to report to, or update, the Council when
additional information is needed.
• Review and advise Eastpointe regarding the annual plan, goals, and objectives of the
network.
• Review Network Performance against stated goals.
• Review and make recommendations to Eastpointe regarding Performance Indicator
Selection and Performance issues.
• Review reports on referrals made/referrals accepted per service per provider; review
members receiving services per provider; review discharges from providers and
reasons; annual review of trend analysis.
• Recommend new service initiatives that address service gaps.
• Assess and provide for staff education and training needs.
• Assess community and prevention needs.
• Develop strategies to address funding and financial issues.
• Approve the provider satisfaction survey and review results with recommendations.
• Review global as well as individual provider performance issues related to Gold Star
Performance Profiles.
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• Advise Eastpointe staff regarding provider/contractor reconsiderations upon request.
Membership of the Council
The Provider Council membership will consist of currently active, contracted partners in
the Eastpointe Provider Network. Provider membership will represent all three member
demographics (Adult Mental Health, Child Mental Health, Developmental Disabilities,
and Substance Abuse).
Recommendations for membership will be made to the Provider Council by the Provider
Network Department of Eastpointe. Recommendations are based on the demographic
need and the volume of members being served by the provider. Membership lasts for one
year but may be renewed each subsequent year by recommendation of the Council and
Eastpointe.
The membership shall elect a Chair of the Provider Council each year from the provider
representatives and establish bylaws. The Director of Network Operations or their
designee will serve as liaison to the Provider Council. Eastpointe will also provide a
representative that will take minutes and distribute information to the Provider Council.
Agenda
Agenda items may be submitted by any Provider Council member. Agenda items should
be submitted to the Eastpointe designee at least seventy-two hours prior to the scheduled
meeting. Agenda items that require participation from invited Eastpointe employees,
community members, or non-Group providers should be submitted as early as possible to
allow for appropriate requests to be made.
Decisions and Recommendations
The Provider Council will use a consensus-building process for most issues. Based on the
information presented, the Provider Council may choose to study an issue or make
recommendations for consideration by Eastpointe. All recommendations will be
communicated to the appropriate Eastpointe committee by the Provider Council’s staff
liaison. The staff liaison will report findings of each recommendation back to the
Provider Council at the subsequent meeting
Communication
The Council normally meets monthly so please check the website for the next meeting
date and time. Their report is a standing agenda item at the provider meetings and copies
of minutes are available. Current membership, schedule of meetings, and archives of
minutes can be accessed on the Eastpointe Provider website.
H. Code of Ethics
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Eastpointe and Network Providers adhere to the Code of Ethics, which was developed
jointly with the Provider Council and is part of the contractual process. Eastpointe,
Provider Agencies and Licensed Independent Practitioners shall all sign and abide by the
Code of Ethics as a component of the Contractual process.
Ethical violation reporting is made through the Eastpointe Grievance process, and then
sent to the Provider Council through the Provider Relations department if indicated.
Allegations of ethical violations will be reviewed by Council in closed sessions.
I. Changes in Credentialed Status-Independent Practitioners
Eastpointe maintains a comprehensive provider database with the current practice
information submitted by Independent Practitioners and Agencies in support of our
ongoing commitment to our members receiving quality care. Because this data is used for
referral purposes, network participation requires Independent Practitioners to
communicate with the MCO, and the referenced policy and procedures outlines the
process.
• Notify the Provider Network Operations Department in writing within one (1) business
day of any changes in credentialed status, including but not limited to, the scope of their
license, changes in privileged status at other organizations, pending malpractice claims,
etc.
• Notify the Provider Network Operations Department in writing within five (5) business
days of personnel changes or information updates which may include, but is not limited
to, changes in capacity including inability to accept new referrals, addition of capacity
or specialty services, address changes as well as changes in other enrollment
information.
• Independent Practitioners wishing to initiate a Leave of Absence shall notify Provider
Network Operations in writing, no later than sixty (60) days prior to their desired
effective date. Unless the leave is a result of disabling illness, a Licensed Practitioner
shall not request more than six (6) months in an initial Leave of Absence, with the
option for an extension. An extension to the original leave is not to exceed an additional
six (6) months and must be submitted no later than sixty (60) days prior to the
expiration of the original Leave of Absence.
• If an Independent Practitioner was credentialed while employed by another Contracted
Provider and wants to establish their own practice, they must submit an update to their
credentials to the Eastpointe Credentialing Committee and must satisfy all the
requirements and have a fully executed contract prior to delivery of services to any
Eastpointe members. Network capacity needs will be a factor in determining if
expansion of independent practice expansion is warranted.
Address correspondence as follows:
Eastpointe MCO
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Attention: Credentialing Specialist
500 Nash Medical Arts Mall
Rocky Mount, NC 27804
Eastpointe’s responsibilities to Providers are to:
• Update independent practitioner’s credential file and Network database in a timely
manner to reflect the new information.
• Notify independent practitioners in writing if a change of information impacts referral
status.
• Notify you in writing of the decision of the credentialing committee on any requested
Leave of Absence.
J. Re-credentialing-Independent Practitioners
Practitioners in the Eastpointe Provider Network are required to have their credentials rereviewed and verified at a minimum of every thirty-six (36) months from the date of the
last credentialing review for each practitioner.
Your responsibilities as an Eastpointe Contracted Provider are to:
• Complete, sign, and submit your re-credentialing form and disclosure, attestation as to
correctness and completeness, and authorization for release of information and liability,
including questions regarding physical and mental health status and lack of impairment
due to chemical dependency/substance abuse loss or limitation of privileges and /or
disciplinary activity and current malpractice coverage.
• Provide current documentation as requested in the re-credentialing process.
• Submit the completed packet electronically within thirty (30) days of having been
instructed to do so.
As part of the Re-Credentialing process, each practitioner has the right to:
• Review information collected during the re-credentialing process except references and
National Practitioner Data base (NPDB), upon request.
• Be informed of the status of their re-credentialing application, upon request.
• Be notified of information that is significantly different than reported by you and to
have the opportunity to correct erroneous information in writing. Correction of the
erroneous information should be provided by the practitioner within ten (10) business
days of notification regarding any discrepancies in the application packet
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• Be notified about the Credentialing Committee's decision within 30 days of the
Committee’s decision or Medical Director’s approval.
Eastpointe’s Process for Re-credentialing
• Notify providers to submit a re-credentialing packet electronically for each independent
practitioner one hundred twenty (120) days prior to the thirty-six (36) month
appointment period.
• Automatically suspend from the network, any licensed independent practitioner that has
not submitted the completed application packet electronically within the designated
time period.
• Perform a timely review of the returned electronic application packet materials for
completeness and compliance with credentialing standards.
Eastpointe will notify independent practitioners in writing of the Credentialing
Committee’s decisions regarding ongoing network participation via traceable source.
K. Alteration of Practitioner’s Credentialing Status
Eastpointe maintains standards for Licensed Independent Practitioner (LIP or
practitioner) participation that will ensure competent, effective, and quality care for each
member. Eastpointe maintains the rights to sanction, suspend, and/or terminate a
practitioner for activity, actions, and/or non-actions which are contrary to Eastpointe’s
standards of practice or applicable laws.
1) Conditions that may affect a practitioner’s credentialing status include:
• LIP fails to maintain compliance with the credentialing and re-credentialing criteria.
• LIP decides not to execute a Practitioner Contract. LIP’s general area of practice or
specialty, in the opinion of the Credentialing Committee, involves experimental or
unproved modalities of treatment, or therapy not widely accepted in the local medical
community.
• LIP has breached any material term of his/her Provider Contract, including failure to
comply with Medical Management or Quality Improvement requirements.
• LIP has contact with a patient of a sexual or amorous nature, or violation of other
clinician/patient boundaries.
2) Disciplinary actions that can be taken by Eastpointe’s Medical Director, Credentialing
Committee, and/or Eastpointe’s Executive Leadership Team related to credentialing
include:
a.Sanctionscan include, but are not limited to, any one or combination of actions:
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Censure Letter
Suspension of referrals for specified timeframe
Site Visit
Corrective Action Plan
Monetary Penalty
b. Suspension can include, but is not limited to, any one or combination of actions:
Suspension of referrals to individual practitioners
Suspension of referrals to the agency
Site Visit
Corrective Action Plan
Monetary Penalty
c. Termination of credentials may occur for any of the following reasons:
Breach of contract
Refusal to comply with Sanction or Suspension conditions
Failure to get re-credentialed
Failure to maintain license
3) Determination and Notification of actions taken against a practitioner’s credentials:
a.
After respective review, a disciplinary action may be recommended by the
Medical Director, Credentialing Committee, and/or Eastpointe’s Board of
Directors. The Medical Director has the right to suspend a practitioner for up to
fifteen (15) business days pending review by the Credentialing Committee where
potential adverse medical outcome will affect a patient or the general patient
population.
b.
The LIP will be notified by a certified, return-receipt requested letter within 3
business days of invocation of the disciplinary action and the due process afforded
for appealing the action. Written communication will include:
The right to submit additional information
The right to request a hearing up to 30 days after the Disciplinary Action
notification
The right to be represented by an attorney or another person of their
choice
The right to provide written notification of the appeal decision that contains the
specific reasons for the decision
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L. Reconsideration of Credentialing Decisions
Credentialing decisions regarding a practitioner’s entry in to the Eastpointe Network are
final. Reconsideration only applies for adverse actions taken against a practitioner who is
already a contracted provider with Eastpointe.
M. Actions Against Practitioner Credentialing Reported to External
Bodies
All Disciplinary Actions based on professional competency or conduct which would
adversely affect clinical privileges for a period longer than 30 days or would require
voluntary surrender or restriction of clinical privileges, while under, or to avoid,
investigation is required to be reported to the appropriate entity (i.e., State Medical
Board, National Practitioner Data Bank, Federation of State Medical Boards, etc.).
The Eastpointe Medical Director or designee is responsible for notifying all appropriate
entities including State Medical Board, National Practitioner Data Bank, Federation of
State Medical Boards, and the appropriate licensing bodies within fifteen (15) business
days of the Boards final determination.
N. Performance Reviews
All providers/practitioners in the network receive a profile review at least every three (3)
years. The Provider Monitoring Unit will maintain a master schedule of profile review
due dates. Reviews are scheduled and coordinated by the Provider Monitoring Unit. All
profile reviews use standardized score sheets which are made available to
providers/practitioners on the Eastpointe website. Reviews include an exit conference
with the network provider to discuss the outcome of the review. The reviewer(s) will
explain findings and review scores for each area reviewed to include strengths and needs
noted. Any follow up to be completed by the Provider/Practitioner or Eastpointe will be
reviewed during the exit conference.
Copies of profile review results are mailed to the provider within thirty (30) business
days of the review. Documentation will outline areas reviewed; scores achieved, and
required follow up.
Providers/Practitioners are given an opportunity to provide feedback to the Provider
Monitoring unit regarding the profile review process and are provided with a “Profile
Review Feedback Form” at the exit conference. This feedback form should be mailed
directly back to the Director of Provider Monitoring. The Director of Provider
Monitoring will review all feedback for needed improvements in the Eastpointe review
system.
The provider may present any additional information not located during the review
process before or during the exit conference and, if applicable, scores will be altered at
that time. After the review is concluded any additional information located will be
included in the plan of correction and will not be used to change any established scores.
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O. Changes in Provider Qualification Status
In order to link members to appropriate care, Eastpointe is diligent in maintaining a
provider database with the current practice information submitted by our providers.
Providers shall notify the Provider Network Operations Department in writing within one
(1) business day of any changes in their status, including, but not limited to:
• Changes in licensure status
• Changes in privileging status with other accrediting organizations
• Pending citations
• Pending malpractice claims, etc.
Providers shall notify the Provider Network Operations Department in writing within
seven (7) days of personnel changes or information updates. This may include, but is not
limited to:
• Changes in ownership
• Change in management
• Proposed address changes and/or new telephone numbers
• Opening of new locations
• Changes in capacity
• Inability to accept new referrals
• Any proposed acquisitions
• Any proposed mergers
• Any pending investigations for Medicaid fraud
P. Applying for Additional Services
In order for a Network Provider to be considered for Additional Services:
• The Provider must be in "good standing".
• Have a signed contract and all required submissions and/or reports up to date; and
• Eastpointe has established there is sufficient need for the service (s); and
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• Any sanctions, including the submission of a Plan of Correction, follow-up review,
and/or established wait period following satisfactory implementation of a Plan of
Correction, must be completed and verified by Eastpointe’s Provider Network
Operations Department.
Eastpointe will:
• Determine if there is an established need for the service(s).
• Review the performance record of the provider for quality citations, actions that
resulted in suspension of referrals, findings from other oversight agencies, Provider
Performance Profile scores as well as demonstration of quality and best practice.
• Network Providers shall submit a completed Eastpointe Additional Services
Application with all required elements to the Provider Network Operations Director. A
completed Application includes:
o Eastpointe Additional Service Application and all attachments
o Eastpointe Provider Service Request and Qualification Notification Checklist
Once an Additional Service Application is received Eastpointe will:
• Date stamp receipt of the completed Additional Services Application packet.
• Review and render a decision on the completed Application for Additional Services
within forty-five (45) days.
Q. Health and Safety Site Reviews
If a health and safety site visit is required for the new service, Provider Monitoring
Department will schedule the site visit within thirty (30) days of the approval of the
written application.
Any site requested to be added to the contract for the new service will be reviewed on all
applicable areas. During the site visit Eastpointe will evaluate the provider applicant’s
readiness to provide services according to the requirements outlined in state regulations,
the service definition, Eastpointe Practice Guidelines and the Eastpointe contract.
R. Eastpointe Implementation Review
Eastpointe Provider Network Operations Department conducts service implementation
reviews for a service not previously provided at a specific location, after the provider
serves Eastpointe members for 60 days. During this review, a full audit of
implementation will be conducted and any areas previously cited as out of compliance
will be reviewed. If the review findings identify any out of compliance issues, a Plan of
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Correction may be required. Serious out of compliance issues may result in sanctions
other than a Plan of Correction.
Agency Providers/Practitioners should review these carefully and ensure all required
information is submitted with the application. These review sheets also identify items that
will be requested and/or reviewed during the review and on-site visit.
S. Provider Monitoring
Types of Provider Reviews may include but not be limited to:
• Reviews to ensure that members receive services and supports from agencies that are in
compliance with state and federal laws and regulations, including service definition
requirements
• Routine Monitoring to ensure compliance of a provider agency in key areas of
performance, and to identify any areas requiring more in-depth or targeted monitoring
• Focused/Targeted Monitoring to determine the extent of non-compliance, to address
issues or concerns identified during routine monitoring or as a result of information
obtained from other sources
• Complaint Reviews in response to complaints or allegations to ensure proper care
coordination and quality of care for members and determine need for a formal
investigation of a provider agency or licensed independent practitioner
• Investigations which are targeted reviews of provider agencies to determine the validity
of allegations. This can include alleged violations of NC Administrative Rules and/or
Service Definition requirements, resulting in determining a Plan of Correction
• Reviews of Level II and III incidents to safeguard the health and safety of the
individuals served, ensure documentation of critical incidents involving members,
identify areas needing correction or improvement, and determine if the provider’s
response to Level II and III incidents adheres to incident response requirements in the
NC Administrative Code
• Post-payment clinical reviews to ensure that delivered services are clinically
appropriate and in accordance with federal and state statutes as well as with relevant
DHHS policies, manuals and communications
• Audits to ensure that services are provided in accordance with state and federal
regulations, that documentation and billing practices demonstrate accuracy and
integrity, that medical necessity has been established, and to monitor quality of the
documentation of services provided
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• Sub-recipient monitoring to ensure that state or federal awards are used for authorized
purposes in compliance with laws, regulations and contracts or grant agreements and
that performance goals are achieved
• Plans of Correction reviews to ensure successful implementation of appropriate
corrective actions related to out-of-compliance findings from monitoring reviews,
audits, or investigations
Review Request for Out of Compliance Issues
If the Provider disagrees with the determination of the MCO that the Provider is Out of
Compliance with the items contained in the Provider Monitoring non-compliance
communication, the Provider shall have the right to ask for a review of the item or items
that it disagrees with to the Director of the Provider Monitoring Department as set forth
below.

Provider requests for review of the original item(s) that they disagree with must
be received in writing via trackable source within ten (10) business days after
receipt of the initial written notice from MCO Staff that the Provider is Out of
Compliance. This request shall be submitted to the Director of Provider
Monitoring/Program Integrity at:
Eastpointe MCO
Attention: Director of Provider Monitoring/Program Integrity
100 S James Street
Goldsboro, NC 27530
The written request should identify the particular item or items that he/she
disagrees with, the Provider’s position, any supporting documentation and the
Provider’s reason for believing that the MCO’s Staff is incorrect and the reason
Provider believes he/she is correct.

The Director of Provider Monitoring/Program Integrity or Clinical designee shall
respond to the Provider in writing via trackable mail within ten (10) business days
of receipt and provide their interpretation and position.

If the Provider disagrees with the decision rendered by the Director of Provider
Monitoring/Program Integrity they may request a second review by submitting a
written request with supporting documents to the Chief of External Operations or
Clinical designee via trackable mail within ten (10) business days of receipt of the
response letter from the Director of Provider Monitoring/Program Integrity. This
request shall be submitted to the Chief of External Operations at:
Eastpointe MCO
Attention: Chief of External Operations
500 Nash Medical Arts Mall
Rocky Mount, NC 27804
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
The Chief of External Operations will respond to the Provider in writing via
trackable mail within ten (10) business days of the receipt of the Providers’
letter. This shall be the MCO’s final decision.

If the Provider fails to submit a request for initial or second review via trackable
mail the determined receipt date of the request will be the date stamp of receipt by
Eastpointe MCO.
T. Clinical Home for Members
The philosophy behind the use of the term “clinical home” is based on the need for each
member to have one provider that is overall responsible for that person’s treatment and
service coordination. This shall include coordination of any support services that the
member may need in addition to formal treatment services.
The provider’s enhanced benefit services listed below assume the clinical home function
for members immediately upon admission to these services:
• Intensive In-Home
• Multi-Systemic Therapy (MST)
• Community Support Team (CST)
• Assertive Community Treatment Team (ACTT)
• Substance Abuse Intensive Outpatient Program (SAIOP)
• Substance Abuse Comprehensive Outpatient Treatment (SACOT)
Outpatient therapists assume clinical home functions in the event that outpatient services
are being delivered and none of the above services are a part of the member’s Individual
Service Plan (ISP)/Person Centered Plan (PCP).
Other clinical home providers may include:
• Day Treatment
• Psychosocial Rehabilitation
• Twenty-four (24) hour residential and treatment providers
The Clinical Home Provider is the cornerstone of the member’s treatment and fulfills key
roles. These include:
• Conduct or ensure completion of the member’s Comprehensive Clinical Assessment.
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• Participate in the development the ISP/PCP and a crisis plan that address the as a whole
person.
• Coordinate service provision for the member, including monitoring of those services.
This includes managing and taking responsibility for a team approach to treatment and
service provision.
• Participate in the revisions to the individual service plan when the member’s needs
indicate a change of service or provider.
• Submit the necessary registration and authorization request paperwork to the MCO
• Emergency Response Services as required by the service being provided
• Enhanced service providers shall respond with a face to face contact if phone contact is
not successful in mitigating the crisis.
• Outpatient therapy providers shall have the ability to respond telephonically, but may
access Mobile Crisis Services for the member if telephone contact cannot mitigate the
crisis.
• Upon discharge from a clinical home provider and no other service provider remains in
place, the clinical home provider will retain emergency response duties for 60 days post
discharge.
U. Provider Network Design
Eastpointe has an array of providers ranging from outpatient therapy to inpatient
hospitalization. Eastpointe is committed to flexible, accessible, family-centered services
which honor the dignity, respect the rights, and maximize the potential of the individual.
Eastpointe is committed to providing choice of providers for members. To that end,
Eastpointe will strive to ensure more than one provider of any given service in all areas.
A possible exception would result if economies of scale based on population would not
support more than one provider.
Additionally, Eastpointe will conduct and regularly update a Service Needs Assessment
by which additional service needs will be identified. Any identified needs in service(s)
will first be addressed by approaching the existing network providers to request provision
of identified service need(s). If the existing provider network cannot provide the needed
service(s), Eastpointe will then look outside its network in an attempt to recruit a provider
to deliver the service(s) within the Eastpointe area.
V. Contracts
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Eastpointe will enter into contracts with Network Providers so that services can be
authorized and paid for. Network Providers are required to have a fully executed
Eastpointe Contract that lists services and approved sites prior to the delivery of services
to an Eastpointe member.
All the Eastpointe Contract Templates have been approved by the Secretary of the
Department of Health and Human Services as required by G.S. 122C 142(a).
Eastpointe will enter into member specific contracts with providers in order to meet the
needs and requirements of members. Providers with client specific contracts are not
considered full members of the Eastpointe provider network, and are not available as
choices for other members.
1. Agency and Hospital Contracts
Agencies and hospitals are required to have a fully executed Eastpointe Contact which
lists credentialed services prior to the delivery of services to an Eastpointe Member.
Agency and hospital responsibilities are to:
• Review the Contract for accuracy and fully execute the Contract and return it to
Eastpointe within thirty (30) days of receipt to assure payment for services.
• Sign and have a fully executed Eastpointe Contract Amendment for any material
changes to the original Contract.
• Submit any required reports or data elements as required in the Contract to remain in
good standing.
• Submit reports as required in attachments and adhere to reporting requirements.
• Understand the obligations and comply with terms of the Contract and all requirements
in the Eastpointe Provider Manual, any referenced P&Ps in the Manual and any other
referenced attachments and/or documents in the Manual as well as the NC Innovations
Operations Manual.
• Notify Eastpointe of any prospective changes in sites; ensure that all Eastpointe
enrollment requirements are met and that any contract amendments are in place prior to
delivery of contracted services.
• Attempt to first resolve any disputes with other network providers or Eastpointe
through direct contact or mediation.
• Notify Eastpointe in advance of any mergers or change in ownership since it may have
implications for contract status with Eastpointe.
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2. Licensed Independent Practitioner (LIP) Contracts
Licensed Independent Practitioners (LIPs) are required to have a fully executed
Eastpointe Contract which lists credentialed services prior to delivery of services to an
Eastpointe member.
The LIP’s responsibility is to:
• Review the Contract for accuracy, fully execute the Contract and return it to Eastpointe
within thirty (30) days of receipt to assure continued payment for services.
• Sign and have a fully executed Eastpointe Contract Amendment for any material
changes to the original contract.
• Submit any required reports or data elements as noted in the Contract to remain in good
standing.
• Understand the obligations and comply with all terms of the Contract and all
requirements in the Eastpointe Provider Manual.
• Notify Eastpointe of any prospective changes in your legal practice name, location of
your practice site(s) or scope of practice and ensure that your contract is amended prior
to delivery of contracted services.
W. Forensic Evaluations
The evaluations are completed by an individual who has completed state-mandated
training and certification as a certified forensic screener. Most forensic evaluations are
completed on site in the jail, but the forensic screener must have the ability to provide
screenings in other sites as needed. These evaluations are requested by the judicial
system, with an expectation of timely response within the timeframes expected by the
court. The forensic screener will be expected to testify in court and must have sufficient
training and experience to provide credible testimony. The contracted forensic screener
must also submit reports to Eastpointe as requested.
The forensic screener must be able to provide a high quality, typed evaluation within
required timeframes and quality parameters. Eastpointe feels strongly that the collection
of collateral information is best practice for forensic evaluations. Every reasonable effort
should be made by the forensic screener to obtain collateral information in preparing their
evaluation report for the court. Evaluations conducted in isolation without obtaining
pertinent collateral information have the risk of producing potentially erroneous or
misleading recommendations. Effective August 1, 2014 forensic screeners should
identify the sources of collateral information in their reports along with any sources of
potential collateral information that the screener was aware of but did not consult or
attempted to obtain information from and was not successful.
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SECTION IV: CALL CENTER APPOINTMENT
ACCESS STANDARDS (1-800-913-6109)
Eastpointe maintains an Call Center 24 hours per day, 7 days per week, and 365 days per
year to serve Eastpointe’s communities (Bladen, Columbus, Duplin, Edgecombe, Greene,
Lenoir, Nash, Robeson, Sampson, Scotland, Wayne and Wilson counties). The Call
Center receives a variety of call types. It is staffed by non-licensed and licensed staff.
Non licensed staff will answer most of the calls and provide information and referral to
internal departments and external agencies.
One of the key functions of the Call Center is to ensure that members, providers and
family members have access to services based on the level of urgency and within
timeframes for Emergent, Urgent and Routine care. Only licensed staff conduct clinical
triage functions. The triage process determines the level of urgency of the member’s
situation and drives the timeframe for obtaining a face to face assessment.
Eastpointe is also responsible for timely response to the needs of members and for quick
linkages to qualified providers. Staff from the Call Center provides meticulous
monitoring and management of referral and follow-up to care in emergent, urgent, and
routine cases.
A. Eligibility Screening
When a call is answered by a non-licensed staff, and the member indicates that he/she
would like to speak with a clinician, schedule an appointment and/or receive a referral for
services the non-licensed staff will gather some demographic information and perform
eligibility screening. During this process, the non-licensed staff is careful to limit
questioning to only those that are necessary to verify that the enrollee may be eligible to
receive Medicaid, third party insurance, or state funds. Once this process is completed a
licensed staff will perform clinical triage. For life threatening emergencies, the safety
and well-being of the enrollee has priority over administrative functions.
B. Accessing Emergent Care
The Access Standard for Emergent Services is to arrange face-to-face emergency care
within two hours after a request for care is initiated by the member. For life threatening
emergencies, care must be provided immediately.
Referral Process
1. Calls that are deemed to be Emergent are immediately “warm transferred” (member
remains on the telephone line without being placed on hold) to a licensed staff.
2. An Emergent situation is described as when an member demonstrates one or more of
the following, including, but not limited to:
 Real and present or potential danger to self or others as indicated by behavior, plan
or ideation.
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3.
4.
5.
6.
7.
 Labile or unstable mood or behavior, and demonstrates significant impairment in
judgement, impulse control, and/or functioning due to psychotic symptoms,
chemical intoxication, or both.
 Immediate and severe medical complications concurrent with, or as a consequence,
of psychiatric and/or substance abuse illness and its treatment.
 Caller indicates, either by request or through assessed need, a need to be seen
immediately.
The licensed staff will determine whether the member presents an immediate danger
to self or others. When a member is in imminent danger to self or others, the licensed
staff will attempt to stabilize the member.
If the member is able to be stabilized, the licensed staff will connect member with
his/her provider, if applicable or a crisis service.
When a member is unable to be stabilized, the licensed staff will, with the assistance
from another staff, contact the appropriate emergency agency to respond. The
licensed staff will remain on the telephone line with member and verify that
emergency service personnel have arrived.
The licensed staff will continue to follow-up with all emergent cases until member
has received the appropriate care.
Call Center staff will collect the remaining enrollment information from the crisis
service provider upon its availability.
Members are informed of the availability and how to access Crisis Services in the
Eastpointe’s area through the advertisement, distribution of brochures to the local
community, welcome letters from Eastpointe, enrollee handbook, community
collaborative meetings, and Eastpointe website.
Provider’s ResponsibilityEastpointe providers are held to the following standard in
regards to Appointment Wait Time for Emergent Referrals: Provider must see all
members in need of emergency services face to face within two hours after the request
for care. Providers must seek assistance from the appropriate emergency agency (i.e. law
enforcement, emergency medical services, etc) when needed.
When calling the Call Center, be as clear as possible in requests for information or
services and/or supports to enable the Call Center staff to help in the most efficient and
effective way possible.
C. Accessing Urgent Services
The Access Standard for Urgent Services to arrange face-to-face emergency care within
forty-eight hours after a request for care is initiated by the member.
Referral Process
1.A member’s level of care may be considered Urgent if, but not limited to the following:
 A member reporting a potential substance-related problem
 A member being discharged from an inpatient mental health or
 substance use facility
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 The member seems at risk for continued deterioration in functioning if not seen
within 48 hours.
2. The non-licensed or licensed staff, whichever presents first will collect the enrollment
information and initiate the screening, triage, and referral process.
3. The Call Center staff will utilize Eastpointe’s electronic scheduling system to offer
choice of provider. To the extent reasonably possible Call Center staff will freedom of
choice to members in selecting a provider from Eastpointe’s network. Call Center staff
will offer at least two providers of choice. Choice is determined by weighting providers
in the following areas:
 Availability of service
 Proximity to member
 Member’s desired attribute in provider or provider speciality.
Information in regards to provider choice will be documented in Eastpointe’s electronic
system.
4. Call Center staff will schedule appointment within forty-eight hours. If there are no
appointments available within the mandated timeframe the enrollee will be referred to a
Walk-in Clinic. When walk-in availability is limited (i.e. during the weekend), a licensed
staff will access whether the enrollee is safe to wait more than forty-eight hours and
initiate procedures for Emergent enrollees, if applicable.
5. The licensed staff will remind the member that Eastpointe’s Call Center is available
24/7/365 days per year and instruct the member to re-contact the Call Center’s telephone
number at any time should their situation escalate.
6. The Call Center staff will continue to follow up with Urgent cases until member has
received the appropriate care.
7. Call Center staff will forward screening, triage, and referral information to Provider.
Provider Responsibility
Eastpointe providers are held to the following standard in regards to Appointment Wait
Time for Urgent Referrals: For scheduled appointments, members are not to wait no
more than one hours; for walk-in appointments no later than two hours.
When calling the Call Center, be as clear as possible in requests for information or
services and/or supports to enable the Call Center staff to help in the most efficient and
effective way possible.
D. Accessing Routine Services
The Access Standard for Routine Services is to arrange face-to-face routine care within
ten business days after a request for care is initiated by the member. The geographic
access standard for services is 30 miles or 30 minutes driving time in urban areas, and 45
miles or 45 minutes driving time in rural areas.
Referral Process
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1.The non-licensed or licensed staff, whichever presents first will collect the enrollment
information and initiate the screening, triage, and referral process.
2.The Call Center staff will utilize Eastpointe’s electronic scheduling system to offer
choice of provider. To the extent reasonably possible Call Center staff will offer freedom
of choice to members in selecting a provider from Eastpointe’s network. Call Center
staff will offer at least two providers of choice. Choice is determined by weighting
providers in the following areas:
 Availability of service
 Proximity to member
 Member’s desired attribute in provider or provider speciality
Information in regards to provider choice will be documented in Eastpointe’s electronic
system.
3.Call Center staff will schedule appointment within ten business days.
4.Call Center staff will remind the member that Eastpointe’s Call Center is available
24/7/365 days per year and instruct the member to re-contact the Call Center’s telephone
number at any time should their situation escalate.
5. The Call Center staff will continue to follow up with Routine cases until member has
received the appropriate care.
6. Call Center staff will forward screening, triage, and referral information to provider.
Provider Responsibility
Eastpointe providers are held to the following standard in regards to Appointment Wait
Time for Routine Referrals; For scheduled appointments, members are not to wait no
more than one hours; for walk-in appointments no later than two hours.
When calling the Call Center, be as clear as possible in requests for information or
services and/or supports to enable the Call Center staff to help in the most efficient and
effective way possible.
E. Process for Initial Authorization
1.Licensed staff have the ability to authorize initial treatment requests and emergency
behavioral health services for, but not limited to, Clinical and Psychiatric Assessments,
Detoxification Services, Facility-Based Crisis Services, and Mobile Crisis Management.
2.After reviewing the request and the member’s condition meets Eastpointe’s established
clinical criteria for the requested service, the licensed staff will authorize the service
based on the authorization guidelines.
3.When the member’s condition does not meet the criteria for the requested service (after
the physician advisor has made such determination, the licensed staff will explore
treatment alternatives with the provider and member.
F. Discharge
Discharge planning begins at the time of the initial assessment and is an integral part of
every member’s treatment plan regardless of the level of care being delivered. The
discharge planning process includes use of the member’s strengths and support systems,
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the provision of treatment in the lease restrictive environment possible, the planned use of
treatment at varying levels of intensity, and the selected use of community services and
support when appropriate to assist the member with functioning in the community.
The Call Center staff my assist with the discharge planning for members in acute levels
of care by: referring the member to Care Coordination and scheduling follow-up
appointments with appropriate providers.
G. Follow Up After Discharge
Call Center staff recognizes the importance of follow up care after a member is
discharged from an acute level of care. Every effort is made to ensure the member is
engaged in treatment. All discharge appointments are followed up on to make sure the
member was seen. This is done in conjunction with the provider.
If an appointment is not kept,Call Center staff:
 Document the reason (i.e. no show, member cancelled, provider cancelled, etc);
follow up measures (i.e. phone contact, home visit, etc); and whether the
appointment was rescheduled.
 Contact the member to discuss barriers and attempt to schedule another
appointment.
 If the member is still not able to engage in treatment, the Call Center staff may refer
to Care Coordination.
SECTION V: AUTHORIZATION, UTILIZATION
REVIEW, CARE MANAGEMENT AND BENEFIT
PACKAGE
(Please see Attachment B for detailed information regarding submission of an
authorization request)
A. Eligibility
The provider must not employ any policy or practice that has the effect of discriminating
against members on the basis of race, color, or national origin.
B. Who is Eligible for the Medicaid Waiver
• Individuals must have Medicaid in a covered eligibility group to be eligible for
inclusion in the waiver: Covered eligibility groups include:
• Individuals covered under Section 1931 of the Social Security Act (TANF/AFDC)
• Optional Categorically and Medically Needy Families and Children not in Medicaid
Deductible status (MAF)
• Blind and Disabled Children and Related Populations (SSI) (MSB)
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• Blind and Disabled Adults and Related Populations (SSI, Medicare)
• Aged and related populations (SSI, Medicare)
• Medicaid for the Aged (MAA)
• Medicaid for Pregnant Women (MPW)
• Medicaid for Infants and Children (MIC)
• Adult Care Home Residents (SAD, SAA)
• Foster Care and Adopted Children
• Participants in Community Alternatives Programs (CAP/DA, NC Innovations, CAP-C,
CAP-I/DD)
• Medicaid recipients living in Intermediate Care Facilities
• Work First Family Assistance (AAF)
• Refugee Assistance (MRF) (RRF)
AND
The individual’s Medicaid County of Origin is in the counties managed by Eastpointe.
Enrollment for individuals meeting the criteria listed above is mandatory and automatic.
Children are eligible beginning the first day of the month following their third birthday
for 1915(b) services, but can be eligible from birth for 1915(c).
Note: 1915(c) NC Innovations HCBS wavier is available for children birth (0) to three
(3) as capacity allows for those deemed eligible.
1915 (c) NC Innovations HCBS Waiver
A person with an intellectual disability and/or a related developmental disability may be
considered for NC Innovations funding if all of the following criteria are met:
• The individual is eligible for Medicaid coverage, based on assets and income of the
applicant whether he/she is a child or an adult.
• The individual meets the requirements for ICF level of care
• The member lives in an ICF or is at high risk for placement in an ICF. High risk for
ICF placement is defined as a reasonable indication that an individual may need such
48
services in the near future (one month or less) but for the availability of Home and
Community Based Services.
• The individual’s health, safety, and well-being can be maintained in the community
with waiver support.
• The individual is in need of NC Innovations waiver services.
• The individual, his/her family, and/or guardian desires participation in the NC
Innovations program rather than institutional services.
• For the purposes of Medicaid eligibility, the person is a resident of, or their Medicaid
originates from, one of the twelve counties in the Eastpointe catchment area. The
counties are Bladen, Columbus, Duplin, Edgecombe, Greene, Lenoir, Nash, Robeson,
Sampson, Scotland, Wayne, and Wilson.
C. Medicaid Waiver Disenrollment
When an member changes county of residence for Medicaid eligibility to a county other
than Eastpointe’s twelve counties, the individual will continue to be enrolled in The NC
MH/DD/SA Health Plan until the disenrollment is processed by the Eligibility
Information System at the state. Disenrollment due to a change of residence is effective at
midnight on the last day of the month.
Members will be automatically removed from enrollment in the NC MH/DD/SA Health
Plan if they are:
• Living in a county other than one of Eastpointe’s covered counties, and Medicaid
changes to the new county
• Deceased
• Incarcerated in a correctional facility for more than thirty (30) days
• No longer qualifies for Medicaid or is enrolled in an eligibility group not included in
the NC MH/DD/SAS Health Plan or NC Innovations 1915(b)(c) waivers
• Admitted to a state psychiatric facility, state drug treatment program, or other state
facility for more than thirty (30) days
• Residing in a facility of any kind deemed to be an Institute of Mental Disease (IMD) in
one of Eastpointe’s covered counties.
• The individual will use one waiver service per month for eligibility to be maintained.
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• All individuals initially selected and deemed eligible as NC Innovations participants
after January 1, 2012, must live independently, with private families, or in living
arrangements with six or fewer persons unrelated to the owner of the facility.
• The member is determined to be eligible for and assigned to the NC Innovations
waiver.
D. Eligibility for State Funded Services
Members who do not have Medicaid may be eligible for state funded services through the
Integrated Payment and Reporting System (IPRS) based on their income and level of
need. No one meeting eligibility requirements will be denied services based on inability
to pay. Eastpointe has a sliding fee schedule that is used to assess a person’s ability to
pay. IPRS funding is not an entitlement. Eastpointe and other MCOs are not required to
fund services beyond the resources that are available to them.
There are also some services, including most residential services for adults, which are not
reimbursed by Medicaid. Therefore, members who receive Medicaid may also receive
state funded services, based on their individual needs and availability of funding.
Eastpointe maintains a Registry of Unmet Needs for I/DD members to track requests for
state funding/non-emergency services that have not been met.
E. Eligibility for Reimbursement by Eastpointe
Members who have their services paid for in whole or in part by Eastpointe must be
enrolled in the Eastpointe system. If you have any questions about an member’s
eligibility, please contact the Call Center at 1-800-913-6109. Individuals who are at
100% ability to pay according to Eastpointe’s sliding fee schedule, or who have insurance
coverage that pays 100% of their services, may not be enrolled into the Eastpointe
system. However, the person may still receive and pay for services from a provider
independent of Eastpointe involvement. Medicaid and IPRS funds should be payment of
last resort. All other funding options need to be exhausted first. Members with a
Medicaid card from one of Eastpointe’s counties are fully enrolled in the Eastpointe
system and are eligible to receive medically necessary Medicaid Basic Benefit Services
or Enhanced Services which have been authorized by Eastpointe.
Members who are not Medicaid eligible are required to provide income verification,
which will be used to determine how much they will be required to pay. Providers are
required to use Eastpointe’s sliding fee schedule to calculate the fee. This schedule is
based on Federal Poverty Guidelines, the member’s family income, and the number of
dependents.
Medicaid regulations prohibit the use of Medicaid funds to pay for services other than
General Hospital Care delivered to inmates of public correctional institutions. Medicaid
funds may not be used to pay for services provided for members in facilities with more
than sixteen (16) beds that are classified as Institutions of Mental Diseases (IMD). IMDs
are considered to be hospitals much like State Facilities because they are more than
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sixteen beds and are not part of a general hospital. Members with private or group
insurance coverage are required to pay the co-pay assigned by their insurance carrier.
Note: Provider contracts specify the funding source available for provider billing.
Providers should know if they have been contracted for Medicaid, IPRS, or both.
If you have questions, please contact your assigned Contract Specialist.
F. Enrollment of Members
It is important for all providers to ensure that member enrollment data is up-to-date based
on the most current Eastpointe Enrollment Procedures and training.
Note: If enrollment data is not complete prior to service provision, authorizations and
claims may be impacted. This could result in denial of authorizations requested
and/or claims submitted for reimbursement.
Service Eligibility - Services are divided into multiple service categories:
Basic Services:
The Basic Benefit package includes those services that will be made available to
Medicaid-entitled individuals and, to the extent resources are available, to non-Medicaid
individuals. These services are intended to provide brief interventions for individuals
with acute needs. The Basic Benefit package is accessed through a simple referral from
Eastpointe to an enrolled Eastpointe provider. Once the referral is made, there are no
prior authorization requirements for these services. Referred individuals can access up to
eight (8) visits for Adults ages 21 and up and sixteen (16) visits for Children and
Adolescents below age 21 from the Basic Benefit package per fiscal year.
Enhanced Services:
The Enhanced Benefit package includes those outpatient services that will be made
available to Medicaid-entitled individuals and depending on available resources, may be
available to non-Medicaid individuals meeting IPRS Target Population criteria. Enhanced
Benefit services are accessed through a individual service planning process. Enhanced
Benefit services are intended to provide a range of services and supports, which are more
appropriate for individuals seeking to recover from more severe forms of mental illness,
substance abuse and intellectual and developmental disabilities with more complex
service and support needs as identified in the person-centered planning process. The
person-centered plan also includes both a proactive and reactive crisis contingency plan.
Enhanced Benefit services include services that are comprehensive, more intensive, and
may be delivered for a longer period of time. An individual may receive services to the
extent that they are identified as necessary through the person-centered planning process
and are not duplicated in the integrated services offered through the Enhanced Benefit
(e.g., Assertive Community Treatment). The goal is to ensure that these Individuals’
services are highly coordinated, reflect best practice, and are connected to the personcentered plan authorized by Eastpointe.
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Target Populations
IPRS Target Population designation is for State funded services. It does not apply to
members who are only receiving Medicaid services. The provider, through review of
Screening, Triage and Referral information (STR), must determine the specific Target
Population for the member according to the Division of MH/DD/SA criteria. Each
Target Population is based on diagnostic and other indicators of the member’s level of
need. If the MH/DD/SAS system does not serve these individuals, there is no other
system that will serve them. The MH/DD/SAS system is the public safety net and
resources will be focused on those most in need.
Web Reference: IPRS link on the NC Division of MH/DD/SAS website.
http://www.ncdhhs.gov/mhddsas/providers/IPRS/Targetpopulations/index.htm
Service Definitions
The regulations of a 1915 (b) waiver require that all NC Medicaid State Plan services be
available under the 1915 (b) waiver. When the NC State Medicaid Plan changes, the
services covered under the NC MH/DD/SAS Health Plan will change as well.
Web Reference: Service Definitions (Scroll down page for Behavioral Health links)
www.ncdhhs.gov/dma/mp/
G. Special Needs Populations Designated in the NC MH/DD/SAS
Health Plan
Special Needs Populations are population cohorts defined by specific diagnostic,
functional, demographic and/or service utilization patterns that are indicators of risk
and need for assessment to determine need for further treatment. The goal of the
Managed Care Waiver is to first identify these individuals and intervene in order to
ensure that they receive both appropriate assessment and medically necessary services.
Care Coordination is a managed care clinical program designed to proactively
intervene and ensure optimal care for Special Needs Populations. Eastpointe Care
Coordinators provide necessary support for individuals meeting the criteria defined
below. The goal is to ensure that members are referred to, and are appropriately
engaged with providers who can meet their needs, both in terms of MH/DD/SA
services as well as Medical care.
Intellectual and/or Developmental Disabilities (I/DD)
Eligible I/DD, special population members are individuals who are functionally eligible
for, but not enrolled in, the NC Innovations waiver, or who are not living in an ICF, OR
individuals with an I/DD diagnosis who are currently, OR have been within the past
thirty (30) days, in a facility operated by the Department of Correction (DOC) OR the
Division of Juvenile Justice (DJJ) for whom Eastpointe has received notification of
discharge.
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Child Mental Health
Eligible child mental health, special population members are children who have a
diagnosis within the diagnostic ranges defined below:
293-297.99 298.8-298.9 300-300.99 302-302.6 302.8-302.9 307-307.99 308.3 309.81
311-312.99 313.81 313.89
AND
Current CALOCUS Level of VI, OR who are currently, or have been within the past
30 days, in a facility (including a Youth Development Center and Youth Detention
Center) operated by the DJJ or DOC for whom the MCO has received notification of
discharge.
Adult Mental Health
Eligible adult mental health, special population members are adults who have a diagnosis
within the diagnostic ranges of:
295-295.99 296-296.99 298.9 309.81
AND
Current LOCUS Level of VI
Substance Dependent
Eligible substance abuse, special population members are individuals with a substance
dependence diagnosis,
AND
Current ASAM PPC Level of III.7 or II.2-D or higher.
Opioid Dependent:
Individuals with an opioid dependence diagnosis
AND
Who have reported to have used drugs by injection within the past 30 days
Co-occurring Diagnoses
Eligible special population members with co-occurring diagnosis are:
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a. Individuals with both a mental illness diagnosis and a substance abuse
diagnosis and is a current LOCUS/CALOCUS of V or higher, or Current ASAM PPC
Level of III.5 or higher
OR
b. Individuals with both a mental illness diagnosis and an intellectual or
developmental disability diagnosis and current LOCUS/CALOCUS of IV or higher
c. Individuals with both an intellectual or developmental disability diagnosis and a
substance abuse diagnosis and Current ASAM PPC Level of III.3 or higher.
H. Service Array
For a listing of services, please refer to the most current version of the service arrays by
benefit level and disability. For Mental Health, Substance Abuse and
Intellectual/Developmental Disabilities, further detail can be found in the North Carolina
Mental Health/Developmental Disabilities/Substance Abuse Services Health Plan
Operations Manual. For the NC Innovations Waiver, further detail can be found in the
NC Innovations Technical Manual.
I. Hospital Admissions
DMA is responsible for payment of inpatient hospital services provided to members who
are inpatient prior to the effective date of their enrollment in the Medicaid waiver
operated by Eastpointe and until the member is discharged from the hospital. For
members hospitalized on or after the effective date of enrollment in the waiver operated
by Eastpointe, Eastpointe will provide authorization for all covered services, including
inpatient and related inpatient services, according to Medical Necessity requirements.
Eastpointe shall provide authorization for all inpatient hospital services to members who
are hospitalized on the effective date of disenrollment (whether voluntary or involuntary)
until such member is discharged from the hospital.
J. Medicaid Transportation Services
Transportation services are among the greatest needs identified to assist members in
accessing care. It is Eastpointe’s goal to assist members in accessing generic public
transportation. Providers are requested to assist in meeting this need whenever possible.
The Department of Social Services in each county has access to Medicaid approved
transportation. Transportation is for medical appointments or getting prescriptions at the
drug store. Riders have to call two (2) to four (4) days ahead to arrange a ride. There is no
fee for members who are enrolled in Medicaid. For those who are not enrolled in
Medicaid, transportation depends on available space, and there may be a fee.
Those members needing transportation should call the County DSS from where the
members Medicaid originates.
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K. Registry of Unmet Needs
The purpose of this procedure is to ensure a standardized practice of initiating,
monitoring and managing a Registry of Unmet Needs for I/DD services that reach
capacity as a result of limitations of non-Medicaid funding sources.
Process
A Registry of Unmet Needs for I/DD services may be necessary when the demand for
services exceeds available IPRS funding or when Service Capacity is reached as
evidenced by no available provider for the service needed. (This applies to non-Medicaid
funds only)
• Standardized monitoring reports are available from Eastpointe’s Finance Department
indicating level of funding available for services daily.
• Reports are monitored by Quality Management and by the Clinical Services
Departments.
• Should funding levels reach a predetermined percentage of obligated/ projected
expenditures, the Executive Leadership Team will be notified and make a
determination whether to begin a waitlist process.
• The Clinical Operations Department will maintain a Registry of Unmet Needs for all
services meeting the service capacity or funding limitation criteria listed above.
If a Medicaid funded service is needed by a Medicaid recipient, and there is no capacity
within the network to provide this service or an alternative agreeable to the member, the
service will be sought from an out of network provider.
L. Member Registration
Please refer to the most current versions of the member registration documentations on
our website.
Registration Process
Follow these general steps for registration of a new member via the Access/Call Center:
• A resident of a county in the Eastpointe catchment area calls the Access/Call Center at
1-800-913-6109 for a referral to services.
• Access/Call Center clinicians determine if the call is routine, urgent or emergent.
(Reference: Access to Services section of this manual)
• If the call is routine, Access/Call Center staff checks to see if the resident is in the
Eastpointe Data System.
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• If the resident is not in the system, the Access/Call Center staff completes the initial
STR and screens the member for eligibility for services.
• Member is referred for an assessment and the Screening, Triage, Referral form (STR) is
forwarded to the receiving provider via secure web portal or via secure fax.
• Provider submits the completed information to Eastpointe via ProviderConnect.
Process for Providers with an Electronic Link to Eastpointe
The purpose of this process is to outline the ways in which providers with the ability to
electronically submit confidential documents securely to Eastpointe handles catchment
area residents who present to their agency by phone or in person (“No Wrong Door
Policy”).
1.Walk-In Members at a Provider Site
The provider assesses for a life threatening situation:
• If a life-threatening situation is present, proceed with emergency response as clinically
indicated.
• If not life threatening, the provider determines if the individual is active with Eastpointe
by:
o Checking the status of the member in the Eastpointe system or by contacting the
call center.
o If the member is in the Eastpointe system and has been previously seen by the
provider, the provider conducts an assessment and requests services as per
Eastpointe Care Management/Utilization Management Procedures.
o If the individual is not in the Eastpointe system, provider staff collects information
on the most current Eastpointe STR, and submits it via the following link:
https://fd10.formdesk.com/eastpointe/standardizedstrform?test=true
2.Call-In Members
The provider schedules an assessment appointment. Information is collected on the most
current Eastpointe STR Forms. This information is transmitted to Eastpointe through
ProviderConnect.
M. Utilization Management Program Overview and Processes
Attachment B of this document details the purpose, scope, responsibilities of parties and
processes for requesting service authorization and appealing authorization decisions.
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SECTION VI: DOCUMENTATION REQUIREMENTS
A. NC MH/DD/SAS HEALTH PLAN – 1915(b) WAIVER
The NC MH/DD/SAS Health Plan services follow the NC State Medicaid Plan Service
Array for Behavioral Healthcare. Visit the DHHS website for the most current version of
the Service Definitions and Admission, Continuation, and Discharge Criteria. Web
Reference: www.dhhs.gov (APSM1026)
B. 1915(C) NC Innovations HCBS Waiver
Services defined in the 1915(c) NC Innovations Home and Community Based Services
waiver replace CAP-I/DD services outlined in Clinical Coverage Policy #8M. An
member must be assigned to NC Innovations in order to receive these services. Please
refer to the most current version of the Service Definitions.
• Eastpointe Innovations Operations Manual
• DMA - http://www.ncdhhs.gov/dma/mp/
• Eastpointe – www.eastpointe.net
C. B-3 Alternative Services
B-3 services are Medicaid services that are funded through a separate capitation payment.
Reference: Section of this manual includes instructions on Access, Member Registration
and Authorization of Services.
D. Resources For Providers
Contracted providers must keep informed of rule changes at the federal, state and local
levels, attend training to maintain clinical skills and licensure, be knowledgeable
regarding evidence-based or emerging best practices, and be current on coding and
reimbursement requirements. Eastpointe Network provides a number of resources to
assist providers in meeting these requirements. We communicate information regarding
workshops, trainings, and conferences and offer trainings and technical assistance as
needed. The Provider Network Operations Department maintains the Eastpointe provider
training calendar that lists all trainings offered by internal departments (as well as some
external trainings).
Web Reference: www.eastpointe.net
Resources listed below can assist and link providers to additional resources, but are not
designed to be a comprehensive list.
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E. Training And Technical Assistance
Eastpointe provides timely and reasonable training and technical assistance to providers
on a regular basis in the areas of state mandates and initiatives, or as a result of
monitoring activities related to services for which the provider has a contract with
Eastpointe.
Requests for training and technical assistance from individual providers will be fulfilled
as time permits. You may contact the Provider Network Operations Department at 1-888977-2160 to discuss training needs with your provider specialist. You may also email us
your request at [email protected].
Training
A list of training events for providers and other stakeholders is available on the
Eastpointe website at the following link: www.eastpointe.net
http://www.protectionandadvocacy.com/
National Mental Health Association (NMHA): www.nmha.org
North Carolina Council of Community Programs: www.nc-council.org
North Carolina Substance Abuse Professional Certification Board: www.ncsapcb.org
United States Psychiatric Rehabilitation Association: www.uspra.org
SECTION VII: CLAIMS AND REIMBURSEMENT
A. Link to Claims Manual:
http://www.eastpointe.net/aboutus/MedicaidWaiver/docs/CLAIMS%20BILLING%20M
ANUAL%2012%206%2012.pdf
SECTION VIII: GRIEVANCES, APPEALS,
RECONSIDERATIONS, INVESTIGATIONS AND
RESOLUTION PROCEDURES
A. Role And Responsibilities Of The Provider Monitoring
Committee
Designated Eastpointe staff and committees will review documentation and
recommendations provided by the Provider Monitoring Department regarding provider
audits and investigations. Upon a review of documentation and recommendations to
determine possible sanctions and other agency actions. Possible sanctions or other
actions could be, but not limited to:
• Provider disenrollment
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• Sanctions and penalties
• Lifting of a freeze on referrals or sanction
• The need for additional provider technical assistance or training
• A corrective action plan
• Suspension of referrals
• Transfer of Eastpointe funded clients to another provider
• Additional audits
• Interest charges on paybacks
• De-credentialing of individual practitioners within the agency
• Loss of enrollment
Eastpointe shall notify in writing the providers of any sanctions levied.
B. Role And Responsibilities Of The Credentialing Committee
The Eastpointe Credentialing Committee (CC) is tasked with assuring that licensed
independent practitioners meet standards for entrance into the Eastpointe. The CC is
comprised of providers enrolled in the Eastpointe network as well as licensed staff
employed by Eastpointe who represent various licensing guilds and disability groups.
The CC reviews licensure, sanctions, criminal background checks, and other relevant
documents to determine if the applicant meets Eastpointe standards. If the applicant
meets those standards, then the applicant is privileged to enter the Eastpointe network
once a contract is executed.
The CC may limit, suspend, or revoke the applicant’s privileges to practice in the
Eastpointe network on the basis of an action or non-action that violates Eastpointe’s
standards of practice. In such cases, the applicant is informed of reconsideration rights
upon notification of the adverse action, which follow a standardized protocol.
The Eastpointe Medical Director is responsible for reporting adverse actions taken
regarding an applicant’s credentialed status to the requisite licensing board.
C. Grievance And Appeals (Reconsideration) Process Overview
Eastpointe has an internal system of Grievance and Appeals. Our policy and procedures
assure that providers, members and member’s representatives have access to Due
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Process. The Eastpointe Grievance and Appeals Process allows for filing a grievance,
filing an Appeal and access to the State Fair Hearing/Appeal system.
D. Grievances (Complaints)
A grievance is a statement of dissatisfaction by or on behalf of a member of publicly
funded services about any matter other than an Appeal of an action taken by Eastpointe.
Examples of a grievance may include but are not limited to grievances about:
• Quality of care
• Failure of the provider or Eastpointe Network to follow Client Rights Rules
• Failure of providers to provide services in the member’s Individualized Service Plan
(ISP)/Person Centered Plan (PCP), including emergency services noted in the Crisis
Plan
• Interpersonal issues such as being treated rudely
• Complaints by members about services
• A provider may not violate or obstruct the rights of an member to make a complaint
and will not take or allow staff to take any punitive action whatsoever against an
member who exercises this right.
The provider must have a grievance policy and procedure to address any concerns of the
member and/or the member’s family related to the services provided. Providers will post
the procedure to file a grievance in the member waiting area. Instruction about the
provider’s grievance (Complaint) process must be provided in writing to all members and
families of members upon admission, and upon request. The provider’s written materials
on grievances must advise members and their families that they may contact Eastpointe
about any concerns or grievances.
The provider must keep documentation on all grievances received including date
received, points of grievance, and resolution information. Upon request, Eastpointe has
the right to review provider documentation on grievances. Any unresolved concerns or
grievances must be referred to Eastpointe Director of Grievance and Appeals. The
Eastpointe Member Complaint line and the toll free telephone number for Disability
Rights of North Carolina’s (877-235-4210) must be published, posted and made available
to the member and the member’s family.
Eastpointe may also receive grievances directly about a provider’s operations, services or
staff. Once a grievance is documented, it is assessed by the Grievance and Appeal
Coordinator. Based on the nature of the grievance(s), Eastpointe may choose to follow-up
with an informal inquiry, formal investigation or other action in order to determine the
validity of the grievance.
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Investigations may be announced or unannounced. It is very important that the provider
cooperate fully with all investigative requests.
Refusal by any provider to comply with any grievance follow-up or any other
investigation is a breach of contract.
It is important to understand that this is a serious responsibility that is invested in
Eastpointe and their Provider Network, and we take all grievances very seriously. The
Eastpointe grievance policy and actions are closely monitored by the Division of Medical
Assistance and by Eastpointe’s Quality Improvement Team. Eastpointe maintains a data
base where all grievances and resolutions are recorded.
Additionally, Eastpointe Network maintains documentation on all follow-up activities
and findings from any grievance and any investigation undertaken. A written summary of
the findings of a formal investigation will be made available to the provider. If problems
are identified, the provider may be required to complete a plan of correction and/or be
subject to other sanctions.
E. Reconsideration (Appeal) Of Eastpointe Actions Taken Against
Providers
Definitions of Terms Related to Reconsideration:
• Administrative Reconsideration: The term used for internal MCO appeals following
actions taken against providers.
• Abuse: Provider practices that are inconsistent with sound fiscal, business, or medical
practices, and result in an unnecessary cost to the Medicaid program, or in
reimbursement for services that are not medically necessary or that fail to meet
professionally recognized standards for health care. It also includes beneficiary
practices that result in unnecessary cost to the Medicaid program. Reference:
Guidelines for Addressing Fraud and Abuse in Medicaid Managed Care, October 2000
• Administrative Action: An event in which Eastpointe applies sanctions such as the
requirement for Plan of Correction, Enrollment Withdrawal, payback or referral freeze.
Administrative action is the result of findings from audits, quality of services
evaluations, investigations or report by outside investigative authorities. Administrative
action also includes a denial (in whole or in part) of a provider’s request to employ a
family member to serve a member.
• Fraud: A deception or misrepresentation made by a person with the knowledge that the
deception could result in some unauthorized benefit to himself or some other person.
Fraud includes any act that constitutes fraud under applicable Federal or State law.
Reference: Guidelines for Addressing Fraud and Abuse in Medicaid Managed
Care, October 2000
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• Reconsideration Committee: The Reconsideration Committee and Chair are appointed
by Eastpointe’s CEO. With the consent of the CEO, the Chair may request that ad-hoc
members be assigned when specific expertise is required. The Committee has authority
to make final determinations or a recommendation to the CEO on provider Requests for
Reconsideration of Eastpointe actions.
• Reconsideration Review: A review of an action based on the provider’s
Reconsideration Request and any additional materials presented by the provider.
This process includes a review of the decisions of the department staff involved in the
initial administrative action. The Reconsideration Committee or the CEO makes the
determination as to whether the provider’s request is approved or denied by Eastpointe.
Reconsideration Process
The Reconsideration process is a part of the Grievance and Appeals System managed by
the Grievance and Appeals Department. Reconsideration of decisions of the Eastpointe
Credentialing Committee is specifically noted in this section.
Provider Request for Reconsideration
1. When a provider receives a notice of an administrative action, the provider has twenty
one (21) calendar days to request reconsideration of the administrative action. All
Requests for Reconsideration must be in writing and must be specifically directed to
the Director of Grievance and Appeals Department. Requests for Reconsideration
should only be sent return receipt requested. The provider must provide any
additional written documentation to be considered during the Reconsideration Process
at the time the Request for Reconsideration is filed.
2. All Requests for Reconsideration will be recorded.
3. The Grievance and Appeals staff will send a response to the provider indicating the
date of receipt; such notice will be sent by registered mail, return receipt requested.
4. The Grievance and Appeals staff will notify the Director of the department of which
initiated the action resulting in the reconsideration request by providing a written
notification of receipt of the Request for Reconsideration, if the reconsideration
request is due to an action initiated by that Department.
5. Reimbursement will continue during the local Reconsideration Process unless the
provider is cited for:
• Gross negligence
• Suspected of committing fraud or abuse
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• Eastpointe believes continued reimbursement is likely to increase any payback
amount due.
The provider may be required to submit documentation of services provided in order to
continue to receive reimbursement during the Reconsideration process. This
determination will be made by the Eastpointe Finance Office.
Reconsideration by Eastpointe
1. The Reconsideration Committee will make a decision (the “final Eastpointe
decision”) regarding all Requests for Reconsideration within sixty (60) business days
of the receipt of the Request for Reconsideration.
2. In the event that the Reconsideration Committee decides in favor of the initial
Eastpointe administrative action, Eastpointe’s CEO will review the Request. This
decision must be made within the same sixty (60) business days allowed for the entire
reconsideration.
3. The Chair of the Reconsideration Committee will send notice of the final Eastpointe
decision to the Provider within seven (7) days of the decision, registered mail, return
receipt requested. The return receipt will be maintained with the Reconsideration
documents. The final Eastpointe decision will be mailed within the same sixty (60)
business days, registered mail.
4. Notice of the final Eastpointe decision of the Reconsideration Committee will be
communicated to applicable Departments.
F. Paybacks Due And Payable Upon Completion Of
Reconsideration
All paybacks are due and payable by the Provider upon completion of the
Reconsideration. All payments to the Provider shall cease unless and until the required
payback is paid in full. Paybacks shall be paid by withholding reimbursement payments
due to the Provider or by direct repayment to Eastpointe, as specified in an approved
payment plan. Approval of a payback payment plan shall be made by the Chief Finance
Officer in writing. All payments due to the Provider shall continue to be withheld until
either the payback is paid in full or a payback payment plan is approved in writing.
G. Reconsideration Of Eastpointe Credentialing Decisions
The Grievance and Appeals staff will forward requests for reconsideration of
Credentialing Committee decisions to the Medical Director for review. In the event the
Medical Director was involved in the first decision then the Medical Director
reconsideration request will be reviewed by the CEO or designated ad hoc committee in
order to assure compliance with CFR 42 § 438.406 “Handling of grievances and
appeals”.
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All other Sections and conditions of this Policy and Procedure apply to Credentialing
Reconsideration and continued Appeals.
H. Right To File An Appeal With The State MH/DD/SAS Appeals
Panel For State Funded Services
In accordance with General Statute 122C-151.4, if not satisfied with the final Eastpointe
decision involving State funded services, the Provider may file an appeal of the final
Eastpointe decision with the State Mental Health/Developmental Disabilities/Substance
Abuse (MH/DD/SA) Appeals Panel as outlined below at the following address:
N.C. Division of MH/DD/SAS, Division Affairs
3018 Mail Service Center
Raleigh, NC 27699-3001
General Statute 122C – 151.4 subsections c (1), (2), (3) provides members, contractors
and former contractors the right to file appeals to the State MH/DD/SA Appeals Panel
after they have exhausted the Reconsideration process at Eastpointe.
• A contractor or former contractor who claims that an area authority or county program
is not acting, or has not acted, within applicable State law or rules in imposing a
particular requirement on the contractor on fulfillment of the contract
• A contractor or former contractor who claims that a requirement of the contract
substantially compromises the ability of the contractor to fulfill the contract
• A contractor or former contractor who claims that an area authority or county program
has acted arbitrarily and capriciously in reducing funding for the type of services
provided or formerly provided by the contractor or former contractor.
Process
A provider wishing to appeal the final Eastpointe decision can file an appeal with the
State MH/DD/SA Appeals Panel as follows:
1. The Provider shall file written notice of appeal with the Director of the Division of
MH/DD/SAS at the address provided above within fifteen (15) days of the date of
the final Eastpointe decision. Reference: 10A N.C.A.C. 27G.0810(a). File (or filing)
means personal delivery, delivery by certified mail, or delivery by overnight express
mail to the current Director of the N.C. Division of MH/DD/SAS. A document is
deemed filed as of the date of delivery to the Director. Failure to timely file or to file
in conformity with the rules shall be considered an improper filing and denied.
Reference: 10A N.C.A.C. 27G.0810(b).
2. The Division Director will appoint an impartial Panel (the Panel) to complete an
administrative review and make an administrative review decision on the appeal.
Reference: 10A N.C.A.C. 27G.0810(e)-(l).
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a. The administrative review decision is appealable by either the provider or
Eastpointe upon written request for an informal hearing made to the Chairman of the
Panel within fifteen (15) business days of the date of the administrative review
decision. Reference: 10A N.C.A.C. 27G.0810(m).
b. If no appeal is made with fifteen (15) business days of the date of the
administrative review decision, the administrative review decision shall be considered
final. Reference: 10A N.C.A.C. 27G.0810(n).
3. The administrative code at 10A N.C.A.C. 27G.0811 provides the process and
procedures for an informal hearing. The Panel will render a hearing decision, which
may be appealed pursuant to N.C. Gen. Stat. § 122C-151.4(f), as set forth below.
4. The final Eastpointe decision, including the requirement for a payback, is not stayed
by an appeal to the Panel. N.C. Gen. Stat. § 122C-151.4(d),
Right to File a Contested Case under Chapter 150B Appeal
In accordance with N.C. Gen. Stat. § 122C-151.4(f), a provider that is dissatisfied with
the Panel's hearing decision may file a contested case under Chapter 150B of the North
Carolina General Statutes. Notwithstanding G.S. 150B-2(1a), Eastpointe as an area
authority is considered an agency for purposes of the limited appeal authorized by this
section. The Secretary shall make a final decision in the contested case.
I. Reconsideration And Appeals Of Decisions Against Members
All members are entitled to Due Process when they do not agree with an “Action” taken
by Eastpointe regarding an authorization. An action is defined as follows:
• The Denial of or limited authorization of a requested service;
• The reduction, suspension or termination of a previously authorized service;
• The denial, in whole or in part, of payment for a service;
• The failure to provide services in a timely manner; or
• The failure of Eastpointe Network to act within time frames.
Definitions:
• Appeal: The request for review of any action taken by the MCO. Reconsideration is the
first step in the MCO process of appeals and applies to the step where the action is
reconsidered internally by Eastpointe.
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• Grievance: Statement of dissatisfaction about any matter involving Eastpointe
Network. The term grievance cannot be used inter-changeably with the term Appeal.
Summary of the Appeals Process from NC Division of Medical Assistance
Within a managed care waiver environment Medicaid recipients have very clear appeals
and due process rights that are protected by state and federal law. If a Managed Care
Organization (MCO) denies, reduces, suspends, or terminates a service the service
recipient must be notified and has the right to appeal. Only the service level or type can
be appealed; the duration of a service authorization, or how long a service can be
received, is not something that can be appealed.
At least ten (10) days before the service reduction, suspension, or termination the MCO
is required to provide detailed information about the appeals process in a written notice
so that the recipient may file in a timely manner. Below is a summary of that process.
Level 1: Reconsideration
If the recipient files an appeal within thirty (30) days of the service change they have the
right to request reconsideration. Reconsideration must be completed within forty-five
(45) days from the date the reconsideration request was received. The service recipient
can review any information used as part of the reconsideration process and may also
submit additional information that supports the level of service being requested.
Reconsideration is a record review conducted by the MCO and must be conducted by a
licensed professional who did not have any role in the original decision to reduce, deny,
suspend, or terminate the service that is being appealed. The recipient may examine
his/her medical records during the appeal process. Discussions can occur during
reconsideration between the individual and the MCO reviewer, and agreements can be
reached on the types and amount of services and supports to provide to the service
recipient.
Reconsideration is a process that occurs only in waiver sites. Recipients must utilize the
reconsideration process before being able to use the State Fair Hearing process. A
recipient can appeal the Reconsideration decision and may submit an appeal to the North
Carolina Office of Administrative Hearings (OAH). Information on this process is
included in notification of the Reconsideration decision.
Level II: Mediation
The appeal of a Reconsideration decision must be filed with thirty (30) days of that
decision to the North Carolina Office of Administrative Hearings (OAH). After filing, the
individual is offered the opportunity to accept Mediation. If Mediation is accepted, it
must be completed within twenty-five (25) days of the request. A mediator from the
Mediation Network of North Carolina is assigned to the case. The recipient may choose
to have Mediation by telephone or at the mediator’s office. The recipient may bring
information to support the need for services based on medical necessity.
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If Mediation is declined or is unsuccessful, the appeal proceeds to a hearing at the Office
of Administrative Hearings (OAH). This level of appeal is currently available through the
state Fair Hearings process.
Level III: Office of Administrative Hearings
If the recipient is not satisfied with the Mediation process, they may proceed to the OAH
hearing. After the hearing an administrative law judge will make a recommendation
regarding the case. This level of appeal is currently available through the state Fair
Hearings process.
Continuation of Benefits
The MCO must continue the service during the reconsideration process and during the
State Fair Hearing if all of the following are met:
• The Reconsideration is requested within thirty (30) days
• The Reconsideration involves the termination, suspension, or reduction of a currently
authorized service
• The service was ordered by an authorized provider
• The current service authorization has not expired
• The member requests a continuation of the service
Service must continue until:
• The recipient withdraws from the Reconsideration process
• Ten (10) days after the reconsideration decision is made, unless the recipient requests a
State Fair Hearing within those 10 days
• A State Fair Hearing decision is made against the recipient
• The service authorization expires
Note: If the final appeal decision is against the recipient, the recipient is responsible for
the cost of the services provided during the reconsideration and/or State Fair Hearing
processes.
J. Eastpointe Medicaid Member Reconsideration And Appeals
Process
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Eastpointe’s process is based on the above NC Division of Medical Assistance Process.
This process outlines Due Process rights of members during the Level 1 Reconsideration
process at Eastpointe, and their rights to additional steps, Level 2 – 4, in the State Appeal
Process.
The Community Relations and Grievance and Appeal staff at Eastpointe are available to
assist members, families and community partners with questions, concerns, complaints
and appeals. A representative from the Grievance and Appeal and/or Community
Relations Department will explain the Reconsideration and Appeal process, and assist in
the filing of an appeal, if assistance is requested by the member or the legally responsible
person.
Eastpointe has information regarding the appeals (and grievances) process available for
members:
• On the Eastpointe website
• In brochures distributed in the twelve-county area, or upon request.
Providers should be aware that all member confidentiality and privacy requirements
apply to complaints.
Level 1: Eastpointe Network’s Reconsideration Process
The member or guardian must request reconsideration within thirty (30) days from the
date on the Notice of Decision. The member, guardian, or service provider must complete
a written Reconsideration/Appeal Request form. The Grievance and Appeal and
Community Relations Department will provide support and assistance to any member in
making a request.
The completed Reconsideration form may be returned to Eastpointe by any of the
following methods:
• By fax, to the attention of “Director of Grievance and Appeals” at 1-(910) 298-7176
• By mailing, or by bringing the form in person to the:
Eastpointe
Director of Grievance and Appeals
500 Nash Medical Arts Mall
Rocky Mount, NC 27804
• The member may call and make a verbal request for Reconsideration but must followup with a written request unless the Expedited Appeal process applies.
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Members, guardians and/or anyone chosen by the member may represent them. Members
or guardians have the right to review any information that was utilized as part of the
Reconsideration process. They may also submit any additional information or request that
their provider submit any additional information that they feel supports the level of
service(s) being requested. Providers must submit additional information in a timely
fashion in order for a thorough reconsideration to be completed.
The following exception does not apply to the denial of an initial service request:
• Decisions involving a reduction, termination or suspension of services
Continuation of Existing Services during Reconsideration
In order to continue with existing services during the Reconsideration and Appeal
Process, the member or guardian must request Reconsideration within ten (10) days of
the date of the Notification letter.
• Services will then continue until the end of the original authorization period as long as
the member remains Medicaid eligible. This right to receive services applies even if the
member changes providers.
• Service will be provided at the same level the member was receiving the day before the
decision or the level requested by member’s provider, whichever is less.
• Services that continue must be based on member’s current condition, and must be
provided in accordance with all applicable state and federal statutes, rules and
regulations. (See note on Member or guardian responsibility for payment if decision is
upheld at final appeal).
As noted, this exception does not apply to the denial of an initial service request.
The Eastpointe Reconsideration Review is a local, impartial review of the decision to
deny, reduce, suspend, or terminate requested Medicaid services. The Reconsideration
Decision is reviewed by a health care professional who has the appropriate clinical
expertise in treating Members condition or disorder. This health care professional has not
been previously involved in the initial authorization decision.
It can take up to forty-five (45) days from the date the Request for Reconsideration is
received for a decision to be made. The Eastpointe Reconsideration/Appeal process must
be completed before member or guardian can request an Appeal using the State Fair
Hearing system.
Providers should understand that there are two reconsideration timeframes based upon
the needs of the member. While the Eastpointe staff will resolve each request as
expeditiously as possible, there is a Standard Appeal and an Expedited Appeal Process.
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 A Standard or Routine Request for Reconsideration/Appeal must be made within 30
days of the date of the written “Notice of Decision.” The process allows Eastpointe a
maximum of forty-five (45) days to complete the routine reconsideration process.
 An Expedited Request for Reconsideration is a special case used to address situations
where, “following the standard timeframes could seriously jeopardize the member’s
life, health, or ability to attain, maintain, or regain maximum function.” Eastpointe
reviews each expedited request to determine if the evidence supports the need for
expedited handling. If it is determined not to meet the requirements for expedited
handling the request will revert to Standard Request time frames.
Eastpointe must resolve each expedited request and provide notice, as expeditiously as
the Member’s health condition requires, within State-established timeframes not to
exceed three (3) business days after Eastpointe receives the Request for
Reconsideration.
The Standard Medicaid Reconsideration Review
To make a standard Appeal/Reconsideration request the member or guardian must
complete and return the Eastpointe Reconsideration Request Form. The provider may
make the request on the member or guardian’s behalf or support the member or guardians
request with signed, written consent from the member or guardian.
Responding to member requests for Reconsideration is the responsibility of the Appeal
and Grievance Department. The Reconsideration Form may be returned to Eastpointe by
several methods:
• By fax to attention of “Director of Grievance and Appeals” at 1 (910) 298-7176
• By mailing or by bringing the form in person to the:
Eastpointe
Director of Grievance and Appeals
500 Nash Medical Arts Mall
Rocky Mount, NC 27804
• The member may call and make a verbal request for Reconsideration, but must followup with a written request unless the Expedited Appeal process applies. The call should
be made to the Grievance and Appeals Department. For the Standard Request, the
member or provider acting on behalf of the member must follow-up this call with a
written request.
The Appeal will be resolved as expeditiously as possible and may not exceed the State
established timeframes of forty five (45) days from the receipt of the Appeal. The
member and the provider will receive written notice of the disposition.
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Upon completion of the Reconsideration decision, if the member or guardian disagrees
with the Eastpointe decision, the member or guardian can then appeal the decision to the
Office of Administrative Hearing by filing a Request for Hearing.
Expedited Medicaid Reconsideration Review
An Expedited Reconsideration Review may be requested by the member or guardian or
made on behalf of the member by the provider, if it is indicated that taking the time for a
Standard Review could “seriously jeopardize the member’s life or health or ability to
attain, maintain, or regain maximum function.” The member may request an expedited
request without the additional written follow-up required under the standard appeal.
If an Expedited Request is received, it is reviewed to determine if there is sufficient
evidence to support the need for this type of request. If so, a Reconsideration Review will
be completed within seventy-two (72) business hours and the member will be notified of
the decision. If the provider does not submit sufficient evidence to require an expedited
request, the member or guardian will be notified of the reason and the process will follow
the Standard Reconsideration timelines. If the member disagrees with the
Reconsideration decision, the member or guardian may submit the form enclosed with
the Reconsideration decision to start the State Appeals Process.
State Fair Hearings System: (Levels 2– 4)
Once the reconsideration process of Eastpointe is exhausted, members who continue to
disagree with the Eastpointe Network decision have the right to appeal the decision using
the State Fair Hearings system.
The member or guardian must file their appeal with the NC Office of Administrative
Hearings and with the Appeals Coordinator of the Eastpointe within thirty (30) days
from the date of the Reconsideration decision. The Appeal must be sent to the addresses
listed on the appeal form mailed with the Eastpointe Reconsideration decision.
Level 2: Mediation
Once the Appeal is processed, OAH or The Mediation Network of North Carolina will
contact the member or guardian to offer an opportunity to mediate the disputed issues in
an effort to informally resolve the pending Appeal. It must be completed within twentyfive (25) days of the request.
If the issues are resolved at mediation, the Appeal will be dismissed and services will be
provided pursuant to the Mediation Agreement. If member or guardian does not accept
the offer of mediation or the results of mediation, the case will proceed to a hearing and
will be heard by an Administrative Law Judge with the Office of Administrative
Hearings.
Level 3: Office of Administrative Hearings
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The next step is a state level hearing conducted by an Administrative Law Judge working
for the Office of Administrative Hearings (OAH). The hearing is scheduled to occur by
telephone unless member or guardian requests to attend in person. The member or
guardian will receive notice of the date, time and location of the hearing. The hearing will
be scheduled at the member or guardian’s convenience in a location close to the member
or guardian.
The member or guardian may represent him/herself at this hearing. They may also ask a
relative, a friend or a spokesperson to speak for them, or they may hire an attorney to
represent them during the Appeal Process. The costs associated with any attorney are the
responsibility of the member or guardian.
The member or guardian has a right to receive a copy of all documents relevant to the
appeal. An Administrative Law Judge will make a recommendation regarding the
member or guardian’s case.
If member or guardian or Eastpointe disagrees with this decision, they may then ask for a
judicial review in Superior Court. Only documents presented in the Administrative
Hearing can be used in the judicial review.
Member Responsibility for Services Furnished while the Appeal is Pending
If the final resolution of the Appeal is not decided in the member or guardian’s favor,
Eastpointe Network may recover the cost of the services furnished to the member or
guardian while the appeal is pending.
K. Eastpointe Non-Medicaid Service (State Funded Services)
Appeals Process
This does not apply to Medicaid funded services.
There are two appeal timeframes based upon the needs of the member. While the
Eastpointe staff will resolve each appeal as expeditiously as possible there is a Standard
Appeal and an Expedited Appeal Process.
A Standard (or routine) Request for reconsideration/appeal allows Eastpointe a maximum
of forty-five (45) days to complete the routine reconsideration process.
An Expedited Request for Reconsideration is simply a special case designed to address
situations where “following the standard timeframes could seriously jeopardize the
members life, health, or ability to attain, maintain, or regain maximum function.”
Eastpointe must resolve each Expedited Request and provide notice, as expeditiously as
the member’s health condition requires, within State-established timeframes not to
exceed three (3) business days after Eastpointe Network receives the Request for
Reconsideration.
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An Appeal concerning a clinical decision regarding non-Medicaid services may be filed
by a member or legally responsible person. A notification letter will be sent to the
member explaining the reason for the decision to deny a request for services; or the
reason to reduce, suspend or terminate an existing authorization. The notice will explain
any available options or considerations while the Appeal is under review.
The letter shall be dated and mailed no later than the next day following the decision.
A copy of the Eastpointe Non-Medicaid Service Complaint Form will be mailed with
the letter. The provider will be notified separately.
Responding to member requests for Reconsideration is the responsibility of the and
Grievance and Appeals Department at 1-800-513-4002.
The Reconsideration form may be returned to Eastpointe Network by several methods:
• By fax to attention of “Director of Grievance and Appeals” at 1(910) 298-7176;
• By mailing or by bringing the form in person to the;
Eastpointe
Director of Grievance and Appeals
500 Nash Medical Arts Mall
Rocky Mount, NC 27804
• The member may call and make a verbal Request for Reconsideration but must followup with a written request unless the Expedited Appeal process applies. The call should
be made to the Grievance and Appeals Department at 1 (910) 513-4002. For the
Standard Request the member or provider acting on behalf of the member must followup this call with a written request.
Standard Non-Medicaid Appeal Process
The Complaint Form or other written appeal must be received in writing by the Appeal
Coordinator of the Grievance and Appeal Department, or designee, within fifteen (15)
working days of the date on the notification letter.
A Clinical Review of the request is handled as follows:
• A qualified reviewer who has not been involved in the initial authorization decision
reviews the request. The reviewer may request additional information from providers or
the member, and their provider may submit additional information at this time.
• The reviewer’s clinical credentials shall be at least comparable to those of the person
who rendered the initial decision. The reviewer will complete a clinical review of the
appeal in consultation with the Medical Director. The Medical Director may convene a
Review Committee to assist in the decision at his/her discretion. The Medical Director
shall uphold or overturn the original decision.
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• The Appeals Coordinator will notify the member in writing in a letter dated and mailed
within seven (7) working days from receipt of the appeal request. A copy of the NonMedicaid Appeal Form for requesting a Division of MH/DD/SAS hearing will be
included with this notice. The provider will be notified separately.
Expedited Non-Medicaid Complaint Process
Any time during the Complaint process, the member or guardian may request an
Expedited Complaint process if it is indicated that taking the time to “follow the standard
resolution could seriously jeopardize the member's life or health or ability to attain,
maintain, or regain maximum function”.
When an Expedited Request is received, it is reviewed to determine if there is sufficient
evidence to support the need for this type of request. If the request for an Expedited
Appeal is upheld, Eastpointe Network will review the Complaint and provide the member
or guardian with a disposition of the Clinical Review of the Complaint within two (2)
days after Eastpointe Network receives the Complaint.
This timeframe may be extended by up to fourteen (14) days if:
• The member requests the extension, or
• Eastpointe shows (to the satisfaction of the Department of Health and Human Services,
upon its request) that additional information is needed, and how the delay is in the
member's interest.
If Eastpointe denies a request for expedited resolution of an appeal, Eastpointe will make
reasonable efforts to give the member or guardian prompt oral notice of the denial, and
follow up within two (2) days with a written notice and will transfer the Complaint to the
timeframe for standard resolution in accordance with the procedures listed above.
Receiving Services during the Non-Medicaid Appeal Process
During a non-Medicaid Appeal Eastpointe has the option of authorizing other NonMedicaid Services that are appropriate. Services may be authorized for the duration of the
Complaint process at the discretion of Eastpointe. Other community resources may also
be referred to the member for support.
Denial of a New Service
When an member or guardian files a complaint for the denial of a new service, Eastpointe
is under no obligation to provide the requested service during the Complaint process.
Non-Medicaid Appeal Request to the Department of Health and Human Services
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If the member or guardian disagrees with the decision of the Eastpointe Network, the
member may submit an Appeal Form entitled “Non-Medicaid Appeal Request Form” to
the Division of Mental Health, Developmental Disabilities, and Substance Abuse
Services (DMH/DD/SAS). A verbal appeal will not be accepted.
The DMH/DD/SAS hearing office must receive the member’s appeal within ten (10) days
from the date on the Eastpointe Network Clinical Review Letter. If the eleventh (11th)
day falls on a weekend or holiday, the deadline is the next business day.
The Non-Medicaid Appeal Request is reviewed by a panel of individuals designated by
the Division of Mental Health, Developmental Disabilities, and Substance Abuse
Services. The panel will issue their findings and decisions within sixty (60) days of
receipt of the Appeal Request Form to the member or guardian and to the CEO of
Eastpointe.
Within ten (10) days of the receipt of the panel’s findings and decisions, the CEO of
Eastpointe will issue a final decision based on those recommendations. This decision is
final and there are no further appeal rights as set forth in N.C.G.S. 143B-147(a)(9). NonMedicaid services are not an entitlement.
SECTION IX: CARE COORDINATION AND
DISCHARGE PLANNING REQUIREMENTS
A. Care Coordination (CC)
The Care Coordination department provides Care Coordination to individuals enrolled
in NC Innovations, individuals enrolled in the (b)(3) Service Array, and to individuals
meeting specific criteria defined as special needs populations within child and adult
Mental Health and Substance Abuse (MH/SA) disability groups. Care Coordination is
focused on the individual as part of a population and in relationship to the overall system.
Care Coordinators address the needs of members across the continuum of care,
throughout various care settings, and work in conjunction with the person, providers, and
others to improve outcomes for the individual while maximizing efficient use of
resources. This is both a risk management and quality management function with
significant impact on both resource management and individual quality of care.
Responsibilities of Providers Working with Members Receiving Care Coordination:
• Active participation with the individual, their families, community resources, and other
providers in development of a comprehensive Person Centered Plan or Individualized
Service Plan.
• Development of methodologies for treatment, support, and/or habilitation programs that
are in accordance with the Person Centered Plan or Individualized Service Plan.
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• Communicate with the Eastpointe Care Coordinator about the needs of individuals
receiving support from your agency.
• Notify the Care Coordinator of any changes, incidents or other information of
significance related to the individual supported.
Responsibilities of Care Coordinators:
Assessment: I/DD Care Coordinators will arrange for needed assessments to identify
support needs and to facilitate individualized service planning processes. MH/SA Care
Coordinators will arrange for needed clinical assessments for individuals with special
health care needs to help identify any ongoing special conditions that require treatment or
monitoring. The Person Centered Plan will be written by the Care Coordinator.
Ensure the Development of a Individualized Service Plan: I/DD Care Coordinators will
develop the Individualized Service Plan (ISP) in collaboration with the individual and
his/her support team. MH/SA Care Coordinators will ensure that a Individualized service
Plan is developed by the Behavioral Health Clinical Home.
Treatment Planning Care Coordination: Both I/DD and MH/SA Care Coordinators will
link individuals to services deemed medically necessary through consultation with the
member’s provider(s) (including primary medical care) regarding the type, level,
duration, and frequency of services in the I/DD and/or special populations treatment plan.
Monitoring: I/DD Care Coordinators will complete on-site visits to monitor the health
and safety of the individual as indicated by the Waiver Amendment, to assess the
satisfaction of individuals served, and to monitor implementation of the Individualized
Service Plan. MH/SA Care Coordinators will maintain lists of special population cases,
prioritize their severity of clinical need, and triage efficacy of special population planning
and implementation. MH/SA Care Coordinators would then further monitor in a
hierarchy of involvement ranging from periodic case file review, phone consultation,
provider site visits and in some cases longer-term treatment team participation.
B. Discharge Planning
Discharge planning begins at the time of the initial assessment and is an integral part of
every member’s treatment plan regardless of the level of care being delivered. The
discharge planning process includes use of the member’s strengths and support systems,
the provision of treatment in the least restrictive environment possible, the planned use of
treatment at varying levels of intensity, and the selected use of community services and
support when appropriate to assist the member with functioning in the community.
Follow-Up after Discharge
Care Coordination staff recognizes the importance of follow up care after an member is
discharged from an acute level of care. Every effort is made to ensure the member is
engaged in treatment. All discharge appointments are followed up to make sure the
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member has been seen and linked to services. This is done by contacting the provider to
verify that the appointment was kept.
SECTION X: PERFORMANCE IMPROVEMENT
A. Introduction
Eastpointe is committed to working in collaboration with providers to achieve the highest
standards of quality in service delivery.
B. Quality Improvement
Eastpointe maintains a strong commitment to continual improvement of its services and
those services/supports provided directly to members. A focus on quality requires basic
principles, which include:
• Commitment to the involvement of the members in all areas and levels of the service
system in regards to analysis, planning, implementing changes, and assessing quality
and outcomes.
• Commitment to strengthen systems and processes – By viewing the system as a
collection of interdependent processes, we can understand how problems occur and can
strengthen the system as a whole.
• Encouraging participation and teamwork – Every member of the system can help assure
quality if included in processes and are empowered to solve problems and recommend
improvements.
• Decisions are based on reliable information – By collecting and analyzing
accurate, timely and objective data, we can diagnose and solve system problems and
measure progress.
• Improvement in communication and coordination – Different members of the system
can work together to improve quality, if they share information freely and coordinate
their activities.
Eastpointe maintains an established quality structure that ensures the participation of all
persons and agencies involved in the service system. Committees and their function
include:
• Quality Management (QMC) Committee
• Provider Advisory Council
• Client Rights Committee
• Consumer Family Advisory Committee (CFAC)
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• Cultural Competency Advisory Committee
• Executive Leadership Team (ELT)
• Clinical Advisory Committee
• Credentialing/Privileging Committee
• Interdepartmental Disabilities Teams
The continual self-assessment of services and operations and the development and
implementation of plans to improve outcomes to members is a value and expectation that
Eastpointe extends to its providers. Providers are required to be in compliance with all
Quality Assurance and Improvement standards outlined in North Carolina Administrative
Code as well as in the Eastpointe Contract. These items include:
• The establishment of a formal continuous Quality Management Committee to evaluate
services, plan for improvements and assess progress made towards goals.
• The assessment of need as well as the determination of areas for improvement should
be based on accurate, timely, and valid data. The provider’s improvement system, as
well as systems used to assess services, plans for improvement and their effectiveness
will be evaluated by Eastpointe at the provider’s qualifying review.
C. Performance Measurement
Data collection and verification: Eastpointe is required to measure outlined performance
indicators in the following domains: Access and Availability, Quality and
Appropriateness of Service, Use of Service, Effectiveness of Service and Satisfaction in
order to assure compliance with DMH & DMA contract requirements.
Performance Improvement: Eastpointe will complete Quality Performance Improvement
Projects (QIPs/PIP’s) as indicated in DMH & DMA contracts and URAC Standards.
These Performance Improvement Projects may require provider participation.
Provider Performance Profile: Eastpointe’s Quality Management Committee will monitor
a performance review system which targets specific quality initiatives for provider
performance. Based on these quality initiatives, providers are ranked by their
performance into categories: Gold Star, Exceptional, Preferred and Routine.
D. Provider Monitoring
An important part of Eastpointe’s role as a MCO is to monitor the performance of
providers in its network. Eastpointe maintains the following systems to assist in
monitoring the health and safety of members, rights protections, and quality of care:
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Monitoring of Incidents
An incident is an event at a facility or in a service/support that is likely to lead to adverse
effects upon an member. Incidents are classified into several categories according to the
severity of the incident. Providers are required to develop and maintain a system to
collect documentation on any incident that occurs in relation to an member. This includes
all state reporting regulations (NCAC 27G.0103(b)(32) in relation to the documentation
and reporting of critical incidents. In addition, providers must submit all Level II and
Level III incident reports to Eastpointe and a summary of all Level I incidents must be
submitted per the Division of MH/DD/SAS policy and procedure manual.
As part of its quality management process, it is important for the provider to implement
procedures that ensure the review, investigation, and follow up for each incident that
occurs through its own internal Quality Management process. This includes:
• A review of all incidents on an ongoing basis to monitor for trends and patterns
• Strategies aimed at the reduction/elimination of trends/patterns
• Documentation of the efforts toward improvement as well as an evaluation of ongoing
progress
• Mandatory reporting requirements are followed
• Enter Level II and III incidents into the state’s Incident Response Improvement System
(IRIS)
There are specific state laws governing the reporting of abuse, neglect or exploitation of
members. It is important that the provider’s procedures include all of these requirements
and comply with all submission timeframes as indicated in General Statute,
administrative rule and the contract agreement with Eastpointe. If there is a conflict
between regulatory and/or contractual terms the most restrictive condition will apply. If a
report alleges the involvement of a provider’s staff in an incident of abuse, neglect or
exploitation, the provider must ensure that members are protected from involvement with
that staff person until the allegation is proved or disproved. The agency must take action
to correct the situation if the report of abuse, neglect or exploitation is substantiated.
Eastpointe Incident Review Process
Eastpointe is required, under the North Carolina Administrative Code, to monitor certain
types of incidents that occur with providers in its network, as well as, providers who
while not in Eastpointe’s network, operate services in one of Eastpointe’s twelve
counties. Regulations regarding the classification of incidents (Level I, II, or III), as well
as requirements related to the submission of incident reports to home and host MCO’s
and state agencies, can be located in the North Carolina Administrative Code. Eastpointe
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is required to monitor the state IRIS system. For more information regarding these
classifications, please see the following websites:
http://www.ncdhhs.gov/mhddsas/Whatisnew/index.htm
http://www.ncdhhs.gov/mhddsas/statspublications/index.htm
https://iris.dhhs.state.nc.us/
The Eastpointe Provider Monitoring Department shall review all incidents when received
by Eastpointe for completeness, appropriateness of interventions, achievement of short
and long term follow up both for the individual member, as well as the provider’s service
system. If questions/concerns are noted when reviewing the incident report the Provider
Monitoring staff will work with the provider to resolve these. If concerns are raised
related to member’s care, services, or the provider’s response to an incident, the Provider
Monitoring Department may request an onsite review of the provider. If at all possible
the review will be coordinated with the provider and, if deficiencies are found, the
designated Provider Network Specialist will work with the provider on the
implementation of a plan of correction. The cumulative incident reporting data will be
periodically reviewed by the Quality Management Department and they will ensure
transmission of any annual and/or quarterly reports to the North Carolina Department of
Health and Human Services and their applicable Divisions.
Monitoring to Ensure Quality of Care
The Eastpointe Provider Monitoring Department is charged with conducting compliance
reviews and audits of medical records, administrative files, physical environment, and
other areas of service including cultural competency reviews. Quality Management is the
department at Eastpointe that reviews data from critical incidents, death reports, and
restrictive interventions as an important role in assuring the protection of rights and the
health and safety of members.
The Provider Monitoring Departments review incidents reported and determine
whether any follow up is needed. The Provider Monitoring Department may conduct
investigations of incidents reported directly by providers on Incident Reports, as well
as reports provided by members, families and the community. Eastpointe Quality
Management Department will analysis the data submitted and the outcome of the
review and submit a quarterly report to the State which reflects the incidents that have
been reported and Eastpointe’s monitoring activities related to these incidents.
Grievances
Eastpointe may receive grievances from providers, stakeholders, members, families, legal
guardians, or anonymous sources regarding Eastpointe’s Provider Network, and/or a
specific provider’s services or staff. Based on the nature of the grievance, Eastpointe’s
Grievance and Appeals Department may choose to investigate the grievance in order to
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determine its validity. Investigations may be announced or unannounced. It is very
important that the provider cooperate fully with all investigative requests. It is important
to understand that this is a serious responsibility that is invested in Eastpointe, and that
we must take all grievances very seriously until we are able to resolve them. Eastpointe
management of grievances is carefully monitored by DMA and Eastpointe maintains a
database where all grievances and resolutions are recorded. Depending on the nature
and/or scope of the investigation the Grievance and Appeals Department may partner
with other Eastpointe Departments in the course of their review.
Eastpointe’s Grievance and Appeals Department maintains documentation on all
follow up and findings of any grievance investigation and a written summary of
findings that is provided to the provider. If problems are identified, the provider
involved may be required to complete a plan of correction.
Member Satisfaction Surveys and Mystery Shopping Program:
Eastpointe values the satisfaction of members/family members/stakeholders with service
provided in the Eastpointe. Eastpointe has various ways member satisfaction is measured.
These include annual surveys and “mystery shopping”. The goal of these initiatives
would be to gather feedback on how various Eastpointe departments perform during
random and anonymous monitoring. This system will be used to pinpoint the need for
additional training of staff. Eastpointe will utilize these tools to monitor provider
customer service.
E. Corporate Compliance
Providers are advised that Eastpointe expects all its employees to practice honesty,
directness and integrity in dealings with one another, business partners, the public, the
business community, internal and external stakeholders, “customers”, suppliers, elected
officials, and government authorities.
Primary Areas Covered by Corporate Compliance
Corporate Compliance deals with the prohibition, recognition, reporting and investigation
of suspected fraud, abuse, misappropriation, and other similar irregularities.
The term fraud includes misappropriation and other irregularities including dishonest or
fraudulent acts, embezzlement, forgery or alteration of negotiable instruments such as
checks and drafts, misappropriation of an agency’s, employee, customer, partner or
supplier assets, conversion to personal use of cash, securities, supplies or any other
agency assets, unauthorized handling or reporting of agency transactions, and
falsification of an agency’s records, claims or financial statements for personal or other
reasons.
The above list is not all-inclusive but intended to be representative of situations involving
fraud. Fraud may be perpetrated not only by an agency’s employees, but also by agents
and other outside parties. All such situations require specific action.
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Within any agency, management bears the primary responsibility for detection of fraud.
Finance management in particular is accountable to monitor any potentially fraudulent
situations.
Corporate Compliance Plan:
Agency providers that receive in total more than $300,000 in Federal funds must develop
a formal Corporate Compliance Plan that includes procedures designed to guard against
fraud and abuse. The plan should include:
• An internal audit process to verify that services billed were provided by appropriately
credentialed staff and appropriately documented.
• Process to ensure that staff performing services under the Eastpointe contract has not
been excluded from participation in Federal Health Care Programs under either Section
1128 or 1128A of the Social Security Act. The agency consults with the Health and
Human Services Office of the Inspector General’s list of Excluded Individuals, the
Medicare Exclusion Databases (MED), and the Excluded Parties Listing System
(EPLS).
• Written policies, procedures and standards of conduct that articulate the agency’s
commitment to comply with all applicable State and Federal standards for the
protection against fraud and abuse.
• Designation of a Compliance Officer and Compliance Committee.
• A training program for the Compliance Officer and agency employees.
• Systems for reporting suspected fraud and abuse by employees and members and
protections for those reporting.
• Provisions for internal monitoring and auditing.
• Procedure for response to detected offenses
• Procedure for the development of corrective action plans
• Procedures to report to monitoring, law enforcement and other outside agencies as
indicated, including Eastpointe.
Note: All providers must monitor for the potential for fraud and abuse and take
immediate action to address reports or suspicion.
F. Monitoring And Auditing
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Eastpointe has taken reasonable steps to monitor and audit corporate compliance,
including the establishment of monitoring and auditing systems that are reasonably
designed to detect conduct in violation of our employees and agents of our agency.
Eastpointe has established a reporting system to support efforts to identify noncompliance issues. Providers may access this reporting system’s toll free number at 1800-913-6109. Reporters may make reports anonymously or leave their name. Reports
may also be made by calling at 1-800-913-6109 and asking for the Corporate Compliance
Officer or the Area Director.
It is a violation of Eastpointe policy to intimidate or impose any form of retribution on an
employee, agent, or provider that utilizes our reporting system in good faith to report
suspected violations (except that appropriate action may be taken against such employee,
agent, or provider if such is implicated as one of the wrongdoers).
G. Investigations Of Violations
If Eastpointe receives information regarding an alleged corporate compliance violation,
an investigation will occur to evaluate such information as to gravity and credibility.
Eastpointe may also disclose the results of investigations to regulatory and/or law
enforcement agencies depending on the nature of the allegation.
H. General Medical Records Requirements/Treatment Records
Standards
Each provider must follow the Records Management and Documentation Manual for
Providers of Publicly-Funded MH/DD/SA Services, CAP-MR/I/DD Services, and Local
Management Entities (APSM 45-2) (see manual website below) for record and
documentation requirements.
• Each provider must follow APSM – 45-1 Confidentiality Rules.
• Each provider must follow the APSM – 10-3 Records Retention and Disposition
Manual. (See website below.) Reference: Further information can be found at the
following website:
www.ncdhhs.gov/mhddsas/statspublications/manuals/index.htm#manuals
Clinical Coverage Policies
• NC MH/DD/SAS Health Plan and Innovations Waivers
• Each provider must comply with HIPAA Privacy Regulations. HIPAA resource
websites:
http://www.dhhs.state.nc.us/mhddsas/manuals/index.htm
http://www.hhs.gov/ocr/hipaa/
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I. Management Information Systems
• Each provider must have Internet Capacity and compatibility with Eastpointe operating,
data and software systems.
• Each provider must comply with HIPAA Security Regulations.
• Please go to the CMS web site as a further resource: http://www.cms.hhs.gov
SECTION XI: MEMBER RIGHTS AND
EMPOWERMENT
A. Understanding Member Rights
Under the Bill of Rights of the Constitution of the United States all citizens have certain
rights such as freedom of speech, freedom of religious choice, freedom of association and
many other fundamental American rights. In addition to these constitutional rights,
members maintain their civil rights. Unless a person has been declared incompetent by a
court of law, they have the same basic civil rights as other citizens. Civil Rights include
the right to marry and divorce, to sue others in court, to have and raise children, to sign
contracts, and the right to sell, buy and own property. Persons determined to be
incompetent and that are assigned a court appointed guardian retain all legal and civil
rights except those rights that are granted to the guardian by the court.
The Behavioral Health system is empowered by law to make determinations such as
involuntary commitment, guardianship determinations and rules in 24-hour facilities that
restrict the rights of individuals. In part to assure that member rights are respected, the
state of North Carolina and the Federal government have enacted several laws and rules
to protect members. Specific member rights are found in State or Federal law, State and
Federal Regulation or State Rules governing mental health, substance abuse, and
developmental disabilities services.
The protection of the rights of members is crucial to the successful operation of providers
doing business in the Eastpointe network. All members are assured rights by law and
regulation. Providers in the Eastpointe Network will respect these rights at all times.
Providers are required to offer and provide members education on their rights and
responsibilities whenever needed. Where needed, providers will offer their members
assistance in exercising those rights to the fullest extent. When this is not possible,
providers will refer the individual to Community Relations department advocates for
assistance.
B. Member Rights
Members of mental health, substance abuse and developmental disability services have
the following rights:
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• The right to receive information about Eastpointe, services available,
providers/practitioners and the rights and responsibilities presented in a manner
appropriate to their ability to understand.
• The right to be treated with respect and recognition of their dignity and right to privacy.
• A right to voice complaints or appeals about providers or any other aspect of Eastpointe
operations, including grievances about the providers in the Network and the care an
member receives.
• The right to participate with providers/practitioners in making decisions about their
health care.
• The right to treatment in the most normal, age-appropriate and least restrictive
environment possible.
• The right to ask questions to help them understand their care or what they are expected
to do.
• A right to a candid discussion with service providers/practitioners on appropriate or
medically necessary treatment options for their condition, regardless of cost or benefit
coverage. They may need to decide among relevant treatment options, the risks,
benefits, and consequences, including their right to refuse treatment and to express their
preferences about future treatment decisions regardless of benefit coverage limitation.
• A right to make recommendations regarding Eastpointe’s member rights and
responsibilities policy
• The right to be free from any form of restraint or seclusion used as a means of coercion,
discipline, convenience, or retaliation.
• The right to request and receive a copy of his or her medical record subject to
therapeutic privilege set forth in NC G.S. 122C-53(c) and to request that the medical
record be amended or corrected in accordance with 45 C.F.R. Part 164 and the
provisions of NC G.S. 122C-53(c). If the doctor or therapist determines that this would
be detrimental to their physical or mental well-being, they can request that the
information be sent to a physician or professional of their choice.
• Right to participate in the development of a written person-centered treatment plan that
builds on individual needs, strengths, and preferences. Their treatment plan must be
implemented within thirty (30) days of their starting service.
• The right to take part in the development and periodic review of their treatment plan
and to consent to treatment goals in it.
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• The right of freedom of speech and freedom of religious expression
• The right to equal employment and educational opportunity.
If at any time an member needs information on their rights or believes that their rights
have been violated, they may contact the offices of Eastpointe.
Responding to member and family questions or complaints is the responsibility of the
Eastpointe Grievance and Appeals Department. Office hours for this department are
Monday-Friday, 8:00 AM to 5:00 PM. A member or family can communicate a
complaint by calling the Eastpointe Access Call Center at 1-800-913-6109 twenty-four
(24) hours a day/7 days a week/365 days a year. The Access Call Center may take
complaint information and refer the complaint to be managed by the Grievance and
Appeal Department the next business day.
Providers are required to make a copy of Client Rights material available to each member
at admission and to have this information publicly available in their offices for member
review.
C. Responsibilities of Members
Member Rights information available from Eastpointe also outlines the corresponding
responsibilities of members receiving services. Additional responsibilities may be
required in 24-hour facilities. Some of these responsibilities are as follows:
• A responsibility to supply information (to the extent possible) that Eastpointe and its
practitioners and providers need in order to provide quality care.
• A responsibility to follow plans and instructions for care that they have agreed to with
their provider or practitioner.
• A responsibility to develop understanding of their health problems and participate in
developing mutually agreed-upon treatment goals, to the degree possible.
• Follow the rules posted in day, evening or 24-hours service programs.
D. Consent for Treatment
Members have a right to consent to treatment support in advance. Any individual
requesting and receiving services from an Eastpointe provider must be informed in
advance of the potential risks and benefits of treatment support options. Members have
the right to be informed of and refuse to take part in research studies.
Members maintain their right to consent to, or refuse, any treatment support unless:
• Treatment is provided in an emergency situation;
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• The member is not a voluntary patient, treatment is ordered by a court of law;
• The member is under eighteen (18) years of age, has not been emancipated, and the
guardian or conservator gives permission. Exceptions may apply related to substance
abuse treatment for minors.
E. Restrictive Interventions
North Carolina statutes and regulations outline specific policy and procedural
requirements for the use and reporting of restrictive interventions and other types of
protective devices. All Eastpointe providers and their staff are expected to be
knowledgeable about and adhere to all statutes and regulations regarding member rights
and the use of restrictive interventions/protective devices. Providers are required to
develop operational procedures that ensure compliance. Providers are responsible to
remain up to date in their policies and daily practices as changes to statues and
regulations affecting the rights of members may occur over time.
F. Protected Health Care Information (PHI)
Eastpointe uses and discloses member protected health information (PHI) appropriately
in order to protect member privacy. Members can request restrictions on use and
disclosure of PHI. Members have the right to receive a report of disclosures that have
been made of PHI. Privacy Practices used by providers must be based on the federal
Health Insurance Portability and Accountability Act (HIPAA) as amended and other
confidentiality regulations noted in the following section.
G. Confidentiality
Each Eastpointe provider shall ensure that all staff providing services to members of
Eastpointe maintains confidentiality of members, as well as information related to their
treatment. Providers will not discuss, transmit, or communicate in any form member
information of a personal nature, medical or otherwise, except as authorized in writing by
the member or his legally responsible person; or as otherwise permitted by applicable
federal and state confidentiality laws and regulations.
The Confidentiality of all member information acquired in treating an Member is
addressed in 10A NCAC 122C. The Confidentiality of records of drug and alcohol abuse
patients has additional protections established under Federal Regulations 42 CFR,
Subchapter A. Confidentiality Rules (ASPM 45-1) were based upon General Statute
150B-14C. Confidentiality and Privacy Practices are also based on the federal Health
Insurance Portability and Accountability Act (HIPAA).
If a person applies for a permit to carry a concealed weapon in North Carolina, the person
must give consent for the details of mental health and substance abuse treatment and
hospitalizations to be released to law enforcement.
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H. Confidentiality: Information Use Without Prior Consent
Information can be used without consent to help in treatment, for health care operations,
for emergency care, and to law enforcement officers to comply with a court order or
subpoena depending on the criteria in State and Federal requirements
A disclosure to next of kin can be made when an member is admitted or discharged from
a facility, if the person has not objected to this disclosure.
A minor has the right to agree to the following treatment(s) without the consent of his/her
parent or guardian:
1.Treatment for venereal diseases
2.Treatment for pregnancy
3.Treatment for the abuse of controlled substances or alcohol
4.Treatment for emotional disturbance
If members disagree with what a physician, treating provider, or clinician, has written in
their record, the member can write a statement from their point of view to go in the
record, but the original notes will also stay in the record for eleven (11) years for adults
and twelve (12) years for children after the age of eighteen (18).
Given the various degrees of risk associated with the use of electronic mail to send or
exchange PHI, this practice is discouraged. Providers that need to use regular e-mail
services to communicate with Eastpointe Network must assure all individual identifying
information is expunged prior to sending. The use of first and last initials and Eastpointe
Record Number is permitted. Eastpointe staff and contractors cannot communicate via email with members about their personal or health matters. Member related information
should be communicated by paper mail, face to face, by telephone, or over a secure
encrypted e-mail system (ZixMail).
I. Client Rights Committee
Each network provider agency is expected to maintain a Client Rights Committee
consistent with regulations outlined in North Carolina General Statue and Administrative
Code. Providers are required to submit documentation of their Client Rights Committee
activities to Eastpointe on a quarterly basis. Providers may provide services to members
of other Managed Care Organizations. Therefore, Client Rights Committee or other
QA/QI reports should not include identifying information that does not relate directly to
an Eastpointe member.
The Eastpointe Board of Directors maintains a Client Rights Committee (CRC) that is
responsible for the monitoring and oversight of the Provider Client Rights Committee
functions. The CRC receives and reviews Critical Incident cumulative reports and data on
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grievance and appeals submitted from other Eastpointe departments or committees.
While specific member identity and information is redacted from Client Rights
Committee material the committee willreview reports on the use of restrictive
interventions, Critical Incidents, rights violations and incidents of abuse, neglect and
exploitation across the Eastpointe Network to assist with trend identification.
J. Consumer And Family Advisory Committee (CFAC)
The CFAC of Eastpointe is an advisory committee to the Board of Directors, and as such,
they play a key role in operations. CFAC consists of representatives of the members and
families receiving services in our Network. As representatives they speak not only on
behalf of their individual family members but for a specific disability population, as well
as their home county. CFAC members are volunteers and as such commit hundreds of
hours to work toward improving the quality of services across Eastpointe.
CFAC monitors Client Rights issues in general, maintains active participation through
membership on the Client Rights Committee, and serves on the many workgroups
associated with the Medicaid Waivers. CFAC members are critical in helping the
Network identify the needs of members, identify barriers to accessing services and
working to bring about resolutions to issues that satisfy the needs of members and their
families. CFAC members are an informed, available and valued voice for our members.
The Eastpointe Network CFAC holds its public meetings at least six times per year. Any
member, provider, or family member of an member can bring issues of concern to the
attention of CFAC by attending meetings, by calling the CFAC Liaison in the
Community Relations Department.
K. Prohibited Restrictions On Providers
Eastpointe will not prohibit or otherwise restrict a health care professional acting within
the lawful scope of practice from advising or advocating on behalf of an member who is
his or her patient. Eastpointe will not:
• Restrict a provider from advocating for the member’s medical care or treatment
options.
• Restrict a provider from providing information the member needs in order to decide
among all relevant treatment options.
• Restrict a provider from providing information about the risks, benefits, and
consequences of treatment or non-treatment options to the member.
• Restrict a provider from providing information to the member about his/her right to
participate in decisions regarding his or her healthcare, including the right to refuse
treatment, and to express preferences about future treatment decisions.
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L. Second Opinion
Medicaid members have the right to a second opinion if they do not agree with the
diagnosis, treatment, or the medication prescribed by an Eastpointe provider. Eastpointe
will pay for a second opinion arranged through the Eastpointe Clinical Operations
Department. Provider staff should be aware of this right and refer the member to the
Clinical Operations Department at Eastpointe when a second opinion is requested.
Members are informed of their right to a second opinion in the Eastpointe Member
Handbook sent to them when they are initially enrolled in the Medicaid Program.
M. Psychiatric Advance Directives (PAD)
In 1997 North Carolina developed a way for members of mental health treatment to plan
ahead for mental health treatment they might want to receive if they experience a crisis
and are unable to communicate for themselves or make voluntary decisions of their own
free will.
A statutory reference for advance instruction for mental health treatment is provided by §
122C-77 of the North Carolina General Statutes. An Advance Directive for Mental
Health Treatment allows members to write down treatment preferences or instructions if
they had a crisis in the future and could not make their own mental health treatment
decisions. PAD is not designed for people who may be experiencing mental health
problems associated with aging, such as Alzheimer’s disease or dementia. To address
these issues, a general health care power of attorney is used.
A Psychiatric Advance Directives document can include a person’s wishes about
medications, treatment modalities, admission to a hospital, restraints, and whom to notify
in case of hospitalization. PAD may include instructions about paying rent or feeding pets
while the member is in the hospital. The member could also put in an advance instruction
in place such as please call my doctor or clinician and follow his/her instructions.
With this directive in place, if they are in an emergency room and unable to speak for
themselves or confused, these instructions can be used as a means to secure help from
experienced caregivers who are familiar with them during critical moments.
The member must sign the Advance Directive for mental health treatment in the presence
of two (2) qualified witnesses. The signatures must be acknowledged before a notary
public. The witnesses may not be the attending physician, the mental health treatment
provider, an employee of the physician or mental health treatment provider, the owner or
employee of a health care facility in which the member is a resident, or a person related
to the member or the member’s spouse. The document becomes effective upon its proper
execution and remains valid unless revoked.
If you are assisting an member in completing a Psychiatric Advance Directive, plan on
several meetings to thoroughly think about crisis symptoms, medications, facility
preferences, emergency contacts, and preferences for staff interactions, visitation
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permission, and other instructions. Involvement by the member with persons included in
the PAD and notification of those named is encouraged.
Upon being presented with a Psychiatric Advance Directive, the physician or other
provider must make it a part of the person’s medical record. The attending physician or
other mental health treatment provider must act in accordance with the statements
expressed in the Advance Directive when the person is determined to be incapable, unless
compliance is not consistent with G. S. 122C-74(g), i.e. generally accepted practice
standards of treatment to benefit the member, availability of the treatments or hospital
requested, treatment in case of an emergency endangering life or health, or when the
member is involuntarily committed to a twenty-four (24) hour facility and undergoing
treatment as provided by law. If the doctor is unwilling to comply with part or all of the
Advance Directive, he or she must notify the member and record the reason for
noncompliance in the patient’s medical record.
Members can choose someone they trust (like a family member) to make treatment
decisions for them if they cannot make the decisions themselves. This surrogate decision
maker has Health Care Power of Attorney and functions as an Agent to carry out
instructions of the PAD. If the member does not have a PAD, the health care agent must
make mental health decisions consistent with what the agent, in good faith, believes to be
the wishes of the principal. The health care agent must be competent, at least eighteen
(18) years of age, and not providing health care to the member for remuneration. The
agent is not subject to criminal prosecution, civil liability, or professional disciplinary
action for any action taken in good faith pursuant to an advance instruction.
Under the Health Care Power of Attorney a person may appoint a person as their health
care agent to make treatment decisions. The powers granted by this document are broad
and sweeping and cannot be made by a doctor or a treatment provider under North
Carolina law.
The Psychiatric Advanced Directive and Health Care Power of Attorney legal forms were
designed by Duke University: Reference http://pad.duhs.duke.edu
N. Client Rights Resources
Eastpointe providers can access additional Client Rights information by using the
Division of Mental Health, Substance Abuse and Developmental Disabilities Services
Website to obtain the following resources:
• Area Program Service Manual (APSM) 95-2, Clients Rights Rules in Community
Mental Health, Substance Abuse and Developmental Disabilities
• APSM 30-1, Rules for Mental Health/ Substance Abuse/Developmental Disabilities
Facilities and Services
• ASPM 45-1, Confidentiality Rules
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• APSM 45-2, Records Management and Documentation Manual
• North Carolina General Statues (NCGS) 122C Article 3; 10A North Carolina
Administrative Code (NCAC) 27G.0504, 10A NCAC 27G.0103
• NCGS 143B-147(a) and NCAC 10A-27I.0600-.0609
Web Reference: DHHS Website - Client Rights
Note: Eastpointe reserves the right to adopt more restrictive policies and procedures
than state and federal rules and regulations.
SECTION XII: OFFICIAL COMMUNICATION
BULLETINS
A. Eastpointe NETWORK COMMUNICATIONS
All official Communication Bulletins are posted on Eastpointe’s website and sent out to
list serv participants.
B. Division of MH/DD/SAS
Implementation Updates:
http://www.ncdhhs.gov/mhddsas/servicedefinitions/servdefupdates/index.htm.
Division of MH/DD/SAS Communication Bulletins:
http://ncdhhs.gov/mhddsas/announce/index.html
Division of MH/DD/SAS Announcements: http://www.ncdhhs.gov/mhddsas/whatsnetcomprehensive.htm
SECTION XIII: ATTACHMENTS
Attachment A: Glossary Of Terms
Ability-to-Pay Determination: The amount an member is obligated to pay for services.
The ability to pay is calculated based on the member’s income, and number of
dependents. The Federal Government Poverty Guidelines are used to determine the
member’s payment amount. http://www.cms.hhs.gov/medicaid/eligibiity/default.asp
Abuse and Waste: Incidents or practices that is inconsistent with sound fiscal, business,
or medical practices that could result in an unnecessary cost to Eastpointe, the State or
Federal government, or another organization. It could also result in reimbursement for
services that are not medically necessary or that fail to meet professionally recognized
standards for health care. It also includes recipient practices that result in unnecessary
cost to the Medicaid program. (42 CFR 455.2)
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Access Center: Access management is a critical function of the Local Management Entity
and Managed Care Organization. The MCO is responsible for timely response to the
needs of members and for quick linkages to qualified providers in the network. To ensure
the simplicity of the system requested by our members and stakeholders, the MCO will
maintain a toll free call system to receive all inquiries. This will include information,
access to care, emergency, and network provider assistance. The call center phone system
will rely on information systems management software to assist in tracking and
responding to calls.
Action: An action is defined as an event by which Eastpointe responds to findings from a
provider audit, review, investigation or report by outside investigative authorities. The
action includes but is not limited to: paybacks, plan of correction as a result of an audit,
and sanctions.
Adjudicate: A determination to pay or reject a claim.
Administrative Review: A review of documentation to determine whether Eastpointe
procedures were followed, and if any additional information provided warrants a change
in a previous determination.
Agency: An Area Facility as defined by 122C-3. An Agency may deliver a number of
services and submit bills/claims under a tax ID number.
ANSI: American National Standards Institute
Advanced Directive: A communication given by a competent adult which gives
directions or appoints another individual to make decisions concerning an member’s care,
custody or medical treatment in the event that the member is unable to participate in
medical treatment decisions.
Appeal: A request for review of an action, as “action” is defined in this glossary
Appellant: An individual filing an appeal.
Assessment: A procedure for determining the nature and extent of need for which the
individual is seeking services
Authorized Service: Medically necessary services pre-approved by the MCO.
Basic Augmented Services: The Basic Augmented Benefit package includes those
services that will be made available to Medicaid – entitled individuals and, to the extent
the resources are available, to non - Medicaid individuals meeting Priority population
criteria. An member requiring this level of benefit is in need of more than the
automatically authorized visits in order to maintain or improve his/her level of
functioning. An authorization for the services available in this level will need to be
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requested through the MCO’s Utilization Management Unit. Authorization is based on
the member’s need and medical necessity criteria for the services requested.
Basic Benefit Plan: The Basic Benefit package includes those services that will be made
available to Medicaid-entitled individuals and, to the extent resources are available, to
non- Medicaid individuals according to local business plans. These services are intended
to provide brief interventions for individuals with acute needs. The Basic Benefit package
is accessed through a simple referral from the MCO, through its screening, triage and
referral system. Once the referral is made, there are no prior authorization requirements
for these services. Referred individuals can access up to eight (8) visits for adults ages
twenty-one (21) and up and twelve (12) visits for children and adolescents below age
twenty-one (21) from the Basic Benefit package from any provider enrolled in the
MCO’s provider network.
Benchmark: A standard by which something can be measured, judged, or compared.
Best Practices: Recommended practices, including Evidenced Based Practices that
consist of those clinical and administrative practices that have been proved to consistently
produce specific, intended results, as well as, Emerging Practices for which there is
preliminary evidence of effectiveness of treatment.
Billing Audit: An audit, conducted by Eastpointe, to assess the presence of appropriate
documentation to support claims submitted for payment by Eastpointe.
Business Associate: A person or organization that performs a function or activity on
behalf of a covered entity but is not part of the covered entity’s work force. A business
associate can also be a covered entity in its own right. See the HIPAA definition as it
appears in 45 CFR 160.103.
CALOCUS: Child and Adolescent Level of Care Utilization System – A standardized
tool that measures level of care needs for children and adolescents. Note: LOCUS is used
to assess adults.
Care Coordination Department (CCD): A division of Eastpointe that provides outreach
and Treatment Planning Case Management functions for special, high-impact population
of members.
Care Management: Care Management is non-face-to face monitoring of an individual
members care and services, including follow-up activities, as well as, assistance to
members in accessing care on non-plan services, including referrals to providers and
other community agencies.
Catchment Area: Geographic Service Area with a defined grouping of county or counties.
Eastpointe’s catchment area includes twelve counties and they are Wayne, Duplin,
Sampson, Lenoir, Edgecombe, Greene, Nash, Wilson, Bladen, Columbus, Robeson, and
Scotland.
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Clean Claim: A Clean Claim is a claim that can be processed without obtaining additional
information from the provider of the services or a third party. It does not include a claim
under review for medical necessity, or a claim from a provider that is under investigation
by a governmental agency for fraud or abuse.
Claim: A request for reimbursement under a benefit plan for services.
Client: As defined in the General Statutes 122C).
CMS: Centers for Medicare and Medicaid Services
Consumer and Family Advisory Committee (CFAC): CFAC is a formalized group of
members and family members appointed in accordance with the requirements of NCGS
122-C-170. The purpose of CFAC is to ensure meaningful participation by members and
families in shaping the development and delivery of public mental health, developmental
disabilities, and substance abuse services in the twelve county region serviced by
Eastpointe .
Concurrent Review: A review conducted by the MCO during a course of treatment to
determine whether services meet Medical Necessity and quality standards and whether
services should continue as prescribed or should be terminated, changed or altered.
Consumer/Member: A person that needs services for treatment of a mental health,
intellectual and/or developmental disability, or substance use/addiction condition.
Contractor: An entity providing services to the MCO described in either the Procurement
Contract for Provision of Services to Clients with Disabilities or the Consultant Contract
for the Provision of Services.
Covered Services: The service which the MCO agrees to provide, or arranges to provide
to members.
Credentialing: The review process to approve a licensed independent practitioner who
has applied to participate in the MCO network of providers.
Crisis Intervention: Unscheduled assessment and treatment for the purpose of resolving
an urgent/emergent situation requiring immediate attention.
Crisis Plan: An individualized, written plan developed in conjunction with the member
and treatment team. The Plan contains clear directives information to assist in deescalating a crisis, for member supports, as well as crisis response clinicians or others
involved. Crisis plans are developed for members at-risk for inpatient treatment,
incarceration, or out-of-home placement.
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Critical Access Behavioral Healthcare Agency (CABHA) Providers: A Critical Access
Behavioral Health Agency (CABHA) is a provider who delivers a comprehensive array
of mental health and substance abuse services. This does not include
intellectual/developmental disability services, although some CABHAs may provide
I/DD services. The role of a CABHA is to ensure that critical services are delivered by a
clinically competent organization with appropriate medical oversight and the ability to
deliver a robust array of services. CABHAs ensure member care is based upon a
comprehensive clinical assessment and appropriate array of services for the population
served. A CABHA is required to offer the following Core Services: Comprehensive
Clinical Assessment, Medication Management and Outpatient Therapy.
Cultural Competency: The understanding of the social, linguistic, ethnic, and behavioral
characteristics of a community or population and the ability to translate systematically
that knowledge into practices in the delivery of behavioral health services. Such
understanding may be reflected, for example, in the ability to: identify and value
differences; acknowledge the interactive dynamics of cultural differences; continuously
expand cultural knowledge and resources with regard to populations served; collaborate
with the community regarding service provisions and delivery; and commit to crosscultural training of staff and develop policies to provide relevant, effective programs for
the diversity of people served.
Days: Except as otherwise noted, refers to calendar days. Working day or business day
means day on which the MCO is officially open to conduct its affairs.
Description of Consumer Clinical Issues (DCCE) – A statement of need for services.
Developmental Disabilities (I/DD): Characterized by the following:
• Impairment of general intellectual functioning and adaptive behavior that occurs before
age twenty-two (22) which:
• Limits one (1) or more major life functions
• IQ of sixty-nine (69) or below
• Impairment has continued since its origination or can be expected to continue
indefinitely.
Denial of Service: A determination made by the MCO in response to a network
provider’s request for approval to provide in-plan services of a specific duration and
scope which:
• Disapproves the request completely; or
• Approves provision of the requested service(s), but for a lesser scope or duration than
requested by the provider; (an approval of a requested services which includes a
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requirement for a concurrent review by the MCO during the authorized period does not
constitute a denial); or
• Disapproves provision of the requested service(s), but approves provision of an
alternative service(s)
Dispute Resolution Process: Eastpointe process to address verbal concerns, grievances,
and/or disputes by providers in a consistent manner.
DMA: The State of North Carolina, Division of Medical Assistance
DMH/DD/SAS: The State of North Carolina, Division of Mental Health, Developmental
Disabilities and Substance Abuse Services
Eligibility: The determination that an individual meets the requirements to receive
services as defined by the payor.
Emergency Medical Condition: A medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) such that a prudent layperson,
who possesses an average knowledge of health and medicine, could reasonably expect
the absence of immediate medical attention to result in:
• Placing the health of the individual (or with respect to a pregnant woman, the health of
the woman or her unborn child) in serious jeopardy
• Serious impairment to bodily functions, or
• Serious dysfunction of any bodily organ or part
Emergency Services: Covered inpatient and outpatient emergency services are:
• Furnished by a provider that is qualified to furnish such services; and,
• Needed to evaluate or stabilize an emergency medical condition as defined above.
Emergent Need Mental Health: A life threatening condition in which a person is suicidal,
homicidal, actively psychotic, displaying disorganized thinking, or reporting
hallucinations and delusions that may result in self harm or harm to others, and/or
vegetative signs and is unable to care for self.
Emergent Need Substance Abuse: A life threatening condition in which the person is by
virtue of their use of alcohol or other drugs, suicidal, homicidal, actively psychotic,
displaying disorganized thinking or reporting hallucinations and delusions which may
result in self-harm or harm to others, and/or is unable to adequately care for self without
supervision due to the effects of chronic substance abuse or dependence.
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Endorsement: The review process to approve an Agency that has applied to be a provider
of state or Medicaid funded services in Eastpointe’s Provider Network. Eastpointe’s
Provider Network Operations Department is responsible for endorsements.
Enhanced Benefit Plan: Includes those services, which will be made available to
Medicaid- entitled individuals and non-Medicaid individuals meeting priority population
criteria. Enhanced Benefit services are accessed through a person-centered-planning
process. Enhanced Benefit services are intended to provide a range of services and
supports, which are more appropriate for individuals seeking to recover from more severe
forms of mental illness and substance abuse and with more complex service and support
needs as identified in the individualized service planning process.
Enrolled Provider: A provider that has submitted an enrollment application with
Eastpointe, who may or may not have a fully executed contract in place.
Enrollment: Action taken by the Division of Medical Assistance (DMA) to add a
Medicaid recipient’s name to the monthly Enrollment report.
Enrollment Period: The time span during which a recipient in enrolled with the MCO as a
Medicaid waiver eligible recipient.
EPSDT: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) are the federal
law that says Medicaid must provide all necessary health care services to Medicaid
eligible children. Even if the service is not covered under the NC Medicaid State Plan, it
can be covered for recipients under 21 years of age if the service is listed at 1905 (a) of
the Social Security Act and if all EPSDT criteria are met.
Facility: As defined in 122-C subsection 14, “Facility” means any person at one location
whose primary purpose is to provide services for the care, treatment, habilitation, or
rehabilitation of the mentally ill, the developmentally disabled, or substance abusers, and
includes:
• An area facility, which is a facility that is operated by or under contract with the area
authority or county program. For the purposes of this subparagraph, a contract is a
contract, memorandum of understanding, or other written agreement whereby the
facility agrees to provide services to one or more clients of the area authority or county
program. Area facilities may also be licensable facilities in accordance with Article 2 of
this Chapter. A State facility is not an area facility;
• A Licensable facility is a facility that provides services for one or more minors or for
two or more adults. When the services offered are provided to individuals who are
mentally ill or developmentally disabled, these services shall be day services offered to
the same individual for a period of three hours or more during a 24-hour period, or
residential services provided for 24 consecutive hours or more. When the services
offered are provided to individuals who are substance abusers, these services shall
include all outpatient services, day services offered to the same individual for a period
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of three hours or more during a 24-hour period, or residential services provided for 24
consecutive hours or more. Facilities for individuals who are substance abusers include
chemical dependency facilities;
• A private facility is a facility that is either a licensable facility or a special unit of a
general hospital or a part of either in which the specific service provided is not covered
under the terms of a contract with an area authority;
• The psychiatric service of the University of North Carolina Hospitals at Chapel Hill;
• A residential facility, which is a 24-hour facility that is not a hospital, including a group
home;
• A State facility, which is a facility that is operated by the Secretary;
• A 24-hour facility, which is a facility that provides a structured living environment and
services for a period of 24 consecutive hours or more and includes hospitals that are
facilities under this Chapter; and
• A Veterans Administration facility or part thereof that provides services for the care,
treatment, habilitation, or rehabilitation of the mentally ill, the developmentally
disabled, or substance abusers.
Fee-For-Service: A payment methodology that associates a unit of service with a specific
reimbursement amount.
Fidelity: Adheres to the guidelines as specified in the evidenced based best practice.
Financial Audit: Audit generally performed by a CPA in accordance with Generally
Accepted Accounting Principles to obtain reasonable assurance about whether the general
purpose financial statements are free of material misstatement. An audit includes
examining, on a test basis evidence supporting the amounts and disclosures in the
financial statements. Audits also include assessing the accounting principles used and
significant estimates made by management, as well as evaluating the overall general
purpose financial statement presentation.
Fiscal Audit: Audit performed by the Financial Department of the MCO which includes a
review of the contractor’s evaluation of an member’s income, member’s determined
ability to pay, third party insurance verification, first and third party billing, receipts and
denials. A review of Coordination of Benefits (COB) information will also be conducted
to verify support of claimed amounts submitted to MCO.
Fiscal Agent: An agency that processes and audits provider claims for payment and
performs certain other related functions as an agent of DMA and DMH
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Fraud: The misrepresentation or concealment of a material fact made by a person that
could result in some unauthorized benefit to self, some other person, or organization. It
includes any act that constitutes fraud under applicable Federal or State law. (42 CFR
455.2)
GAF: Global Assessment of Functioning.
Grievance: An expression of dissatisfaction about any matter other than an action, as
action is defined in this section. The term is also used to refer to the overall system that
includes grievances and appeals handled at the MCO level and access to the State fair
hearing process. (Possible subjects for grievances include, but are not limited to, the
quality of care or services provided, aspects of interpersonal relationships such as
rudeness of a provider or employee, and failure to respect the member’s rights).
Grievance Procedure: The written procedure pursuant to which members may express
dissatisfaction with the provision of services by the MCO and the methods for resolution
of member’s grievance by the MCO
HIPAA: Acronym for the Health Insurance Portability and Accountability Act of 1996.
Incident: An unusual occurrence as defined in APSM 30-1. Incidents are reported as
Level I, II, or III as defined in APSM 30-1.
Initial Authorization (also called Pre-Authorization): The initial or first approval by
Eastpointe’s Utilization Management Department of a medically necessary service(s) at a
given level of care prior to services being rendered.
Individualized Service Planning: A process for planning and supporting the individual
receiving services that builds upon the individual's capacity to engage in activities that
promote community life and that honor the individual's preferences, choices and abilities.
The individualized service planning process involves families, friends and professionals
as the individual desires or requires. The resulting treatment document is the
Individualized Service Plan (ISP).
JCAHO (Joint Commission on Accreditation of Healthcare Organizations): The national
accrediting organization that evaluates and certifies hospitals and other healthcare
organizations as meeting certain administrative and operational standards.
Least Restrictive Environment: The least intensive/restrictive setting of care sufficient to
effectively treat an member.
Licensed Independent Practitioner: Medical Doctors (M.D.), Practicing Psychologists
(Ph.D.) Psychologist Associates (Master’ Level Psychologist [LPA]), Master’ Level
Social Workers (LCSW), Licensed Marriage and Family Therapists (LMFT), Licensed
Professional Counselors (LPC), Licensed Clinical Addictions Specialists (LCAS),
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Advanced Practice Psychiatric Clinical Nurse Specialists, Psychiatric Nurse Practitioners,
and Licensed Physician Assistants who are eligible to bill under their own license .
MCO: (Managed Care Organization) a local political subdivision of the state of North
Carolina as established under General Statute 122C. Under the 1915 b/c waiver, the
MCO will become a Managed Care Organization, or MCO
MCO Authorization: Same as Initial Authorization above.
MCO Authorization Request Form: The most currently approved Treatment
Authorization Request form used to request initial or continuing services. The
abbreviation for this form is the TAR.
LOCUS: Level of Care Utilization System – A standardized tool for measuring the level
of care needs for adult members. Note: CALOCUS is used with children and adolescents.
Managed Benefit: Services that require authorization from Utilization Management.
Managed Care: This term is used in the United States to describe a variety of techniques
intended to reduce the cost of providing health benefits and improve the quality of care
("managed care techniques") for organizations that use those techniques or provide them
as services to other organizations ("managed care organization" or "MCO"), or to
describe systems of financing and delivering health care to members organized around
managed care techniques and concepts ("managed care delivery systems").
Managed Care Organization: An organization that combines the functions of health
insurance, delivery of care, and administration.
Material Change: A material change in any written instrument is one which changes its
legal meaning and effect.
Medicaid Member Registration: Information used to register Medicaid members with
Eastpointe while in unmanaged basic benefit services, or while accessing hospital beds,
and for the release of information regarding eligibility for services.
Medicaid Identification (MID) Card: The Medical Assistance Eligibility Certification
card issued by DMA to Medicaid recipients.
Medicaid for Infants and Children (MIC): A program for medical assistance for children
under the age of nineteen (19) whose countable income falls under a specific percentage
of the Federal Poverty Limit and who are not already eligible for Medicaid in another
category.
Medicaid for Pregnant Women (MPW): A program for medical assistance for pregnant
women whose income falls under a specified percentage of the Federal Poverty Limit and
who are not already eligible in another category.
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Medical Assistance (Medicaid) Program: DMA's program to provide medical assistance
to eligible citizens of the State of North Carolina, established pursuant to Chapter 58,
Articles 67 and 68 of the North Carolina General Statutes and Title XIX of the Social
Security Act, 42 U.S.C. 1396 et. se.
Medical Record: A single complete record, maintained by the provider of services, which
documents pertinent facts, history, findings and observations about a person’s course of
treatment/habilitation. The medical record provides a chronological record of care and
services which the individual has received and is an essential element in contributing to a
high standard of care.
Medically Necessary Services: A range of procedures or interventions that is appropriate
and necessary for the diagnosis, treatment, or support in response to an assessment of an
member’s condition or need. Medically necessary means services and supplies that are:
• Provided for the diagnosis, secondary or tertiary prevention, amelioration, intervention,
rehabilitation, or care and treatment of a mental health, developmental disability or
substance abuse condition, and
• Necessary for and appropriate to the conditions, symptoms, intervention, diagnosis, or
treatment of a mental health, developmental disability or substance abuse condition,
and
• Within generally accepted standards of medical practice, and
• Not primarily for the convenience of an member, and
• Performed in the least costly setting and manner appropriate to treat the Member’s
mental health, developmental disability or substance abuse condition.
Mediation: The process of bringing individuals or agencies in conflict together with a
neutral third person who assists them in reaching a mutually agreeable solution.
Memorandum of Agreement (MOA): A client specific agreement between an out of
network provider and the MCO that covers reimbursed services for that particular client.
The provider is not eligible for any further referrals.
MIS: Management Information System.
Natural Resource Linking: Processes that maximize the use of family and community
support systems to optimize functioning.
NC Innovations: A 1915(c) Home and Community Based Waiver for individuals with
Intellectual and/or Developmental Disabilities. This is a waiver of institutional level of
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care; Funds that could be used to serve a person in an Intermediate Care Facility may be
used to serve people in the community.
NC MH/DD/SAS Health Plan: A 1915(B) Medicaid Managed Care Waiver for Mental
Health and Substance Abuse allowing for a waiver of freedom of choice of providers so
that the MCO can determine the size and scope of the provider network. This also allows
for use of Medicaid funds for alternative services.
NCQA: National Council of Quality Assurance is an independent, 501(c)(3) non-profit
organization whose mission is to improve health care quality through accreditation and a
rigorous on-site review of key clinical and administrative processes; through the Health
Plan Employer Data and Information Set (HEIDAS®)- a tool used to measure
performance in key areas; and through a comprehensive member satisfaction survey.
Network Provider: A provider of behavioral health services that meets the MCO's criteria
for enrollment, credentialing and/or accreditation requirements, and is under written
agreement to provide services.
No Reject: Providers must have a no reject policy. Providers must agree to accept all
referrals meeting criteria for service provided; provider capacity to meet individual
referral needs will be negotiated between the MCO and the provider.
Non-paneled staff: Staff who provide services that are approved for billing by the
member’s third party insurer or Medicare.
Out-of Area Provider: A contracted Agency or Licensed Independent Practitioner, who
provides services to an member of the MCO outside of the twelve county catchment area
as per the MCO Policy and Procedure.
Out-of-Plan Services: Health care services, which the Plan is not required to provide
under the terms of this Contract. The services are Medicaid covered services reimbursed
on a fee-for-service basis.
Out-of-Network Provider: A practice or agency who has been approved as an out-of
network provider under the Eastpointe Out-of-Network Policy and Procedure and has
developed a Memorandum of Agreement with Eastpointe. The Memorandum of
Agreement is client specific and the out of network provider is not offered as a choice to
Eastpointe members.
Outlier: An event that falls outside a particular range (e.g., average length of stay is
significantly greater than the norm), or deviates markedly from other members of the
group in which it occurs.
Penetration Rate: The degree to which a defined population is served.
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Person Centered Planning: A process for planning and supporting the individual
receiving services that builds upon the individual's capacity to engage in activities that
promote community life and that honor the individual's preferences, choices and abilities.
The process involves families, friends and professionals as the individual desires or
requires. The resulting treatment document is the Person Centered Plan (PCP).
PIP: Performance Improvement Project for Medicaid funded services
Pre-Authorization (also called Initial Authorization): The initial or first approval by
Eastpointe’s Utilization Department of a medically necessary service(s) at a given level
of care prior to service delivery.
Primary Clinician: A professional assigned after the initial intake that is ultimately
responsible for implementation/coordination of the Individualized Service Plan.
Primary Diagnosis: The most important or significant condition of an individual at any
time during the course of treatment in terms of its implications for the individual’s health,
medical care and need for services.
Prior Authorization: The act of authorizing specific services before they are rendered.
Priority Populations: People with the most severe type of mental illness, severe emotional
disturbances, as well as, substance abuse disorders with complicating life circumstances
conditions, and /or situations which impact the person’s capacity to function, often
resulting in high risk behaviors.
Prompt payment guidelines: State mandated timelines that MCO’s must follow when
adjudicating and paying claims.
Protected Health Information (PHI): Under the U.S. Health Insurance Portability and
Accountability Act (HIPAA), any information about health status, and provision of
healthcare, or payment for healthcare that can be linked to a specific individual.
Provider: Any person or entity providing services.
Provider Council: The Provider Council, which represents providers in the Eastpointe
catchment area, consists of providers that are currently contracted partners in the
Eastpointe network. The purpose of this Council is to advise Eastpointe on
communication, policy development, initiatives, projects and the impact of state and local
policy decisions on the provider network.
Provider Network: The agencies, professional groups, or professionals under contract to
the MCO that meet MCO standards and that provide authorized, covered services to
eligible and enrolled persons.
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Provisional Status: Status of provider agency following the occurrence of a significant
event which requires state level reporting and increased monitoring of the contract status
of the provider by the MCO.
QHP: Qualified Health Plan.
Re-qualification: Process to assess network providers for continued participation as a
contracted provider.
Qualified Professional: Any individual with appropriate training or experience as
specified by the North Carolina General Statues or by rule of the North Carolina
Commission on Mental Health, Developmental Disabilities, and Substance Abuse
Services in the field of mental health or intellectual/developmental disabilities, or
substance abuse treatments or habilitation, including physicians, psychologists,
psychological associates, educators, social workers, registered nurses, certified fee-based
practicing pastoral counselors, and certified counselors (NC General Statute 122C-3).
QIP: Quality Improvement Plan for URAC
RARF: Regional Assessment and Referral Form used for referral to state inpatient
facilities.
Recipient: A member who is receiving services.
Reconsideration review: A review of a previous finding or decision by the Quality
Management Department based on the provider’s Reconsideration Request and any
additional materials presented by the provider.
Re-Credentialing: The review process to determine if a provider continues to meet the
criteria for inclusion as a network provider.
Routine Need - Mental Health: A condition in which the person describes signs and
symptoms which are resulting in impairment and functioning of life tasks; impact the
person’s ability to participate in daily living; and/or have markedly decreased the
person’s quality of life.
Routine Need – Substance Abuse: A condition in which the person describes signs and
symptoms consequent to substance use resulting in a level of impairment which can
likely be diagnosed as a substance use disorder according to the current version of the
Diagnostic and Statistical Manual.
SED (Children with Severe Emotional Disturbances): Describes members who:
• Are age seventeen (17) or under;
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• Have mental, behavioral, or emotional disturbance severe enough to substantially
interfere with or limit the minor's role or function in family, school, or community
activities;
• Score less than sixty (60) on the Global Assessment Scale (GAF).
Service Location: Any location at which an member may obtain any covered service
from a Network provider.
SMI (Persons with Severe Mental Illness): Describes members who:
• Are age eighteen (18) or older;
• Have substantial disorder of thought or mood that significantly impairs judgment,
behavior, capacity to recognize reality, or the ability to cope with the ordinary demands
of life;
• Score less than or equal to fifty (50) on the Global Assessment Scale (GAF) OR
• Have had One (1) or more psychiatric hospitalizations or crisis home admissions in the
last year.
SNAP: Scale used for level of care for I/DD. This scale will be replaced by the Support
Intensity Scale.
Special Needs Population: Population cohorts defined by diagnostic, demographic and
behavioral characteristics that are identified in a Managed Care Waiver. The managed
care organization responsible for waiver operations must identify and ensure that these
individuals receive appropriate assessment and services.
Spend Down: Medicaid term used to indicate the dollar amount of charges a Medicaid
member must incur before Medicaid coverage begins during a specified period of time.
SPMI (Persons with Severe and Persistent Mental Illness): Describes members who:
• Are age eighteen (18) or older;
• Have a substantial disorder of thought or mood that significantly impairs judgment,
behavior, capacity to recognize reality, or the ability to cope with the ordinary demands
of life;
• Score less than or equal to thirty (30) on the Global Assessment Scale (GAF) AND
• Have had three (3) or more psychiatric hospitalizations or crisis home admissions in the
last year.
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• Includes all persons diagnosed with: *Bipolar Disorders 296.00-296.96 *Schizophrenia
295.20-295.90 *Major Depressive Disorders 296.20-296.36
Support Plan: A component of the Individual Service Plan that addresses the treatment
needs, natural resources, and community resources needed for the member to achieve
personal goals and to live in the least restrictive setting possible.
TAR: Treatment Authorization Request form
Third-Party Billing: Services billed to an insurance company, Medicare or another
agency.
Treatment Planning Case Management: A managed care function that ensures that
members meeting Special Needs Population criteria receive needed assessments and
assistance in accessing services. Eastpointe Care Coordinators carry out this function
working with providers if the member is already engaged with providers, or assists in
connecting and engaging the member with providers that will provide the necessary
services to meet his/her needs. Activities may include:
• Referral for assessment of the eligible individual to determine service needs
• Development of a specific care plan
• Referral and related activities to help the individual obtain needed services
• Monitoring and follow-up
Unmanaged Benefit: Services that do not require authorization from Utilization
Management (UM).
Urgent Need Mental Health: A condition in which a person is not actively suicidal or
homicidal; denies having a plan; means or intent for suicide or homicide but expresses
feelings of hopelessness, helplessness or rage; has potential to become actively suicidal
or homicidal without immediate intervention; a condition which could rapidly deteriorate
without immediate intervention; and/or without diversion and intervention will progress
to the need for emergent services and care.
Urgent Need Substance Abuse: A condition in which the person is not imminently at risk
of harm to self or others or unable to adequately care for self, but by virtue of their
substance use is in need of prompt assistance to avoid further deterioration in the person’s
condition which could require emergency assistance.
Utilization Review: A formal review of the appropriateness and medical necessity of
behavioral health services to determine if the service is appropriate, if the goals are being
achieved, or if changes need to be made in the Individual Service Plan or services and
supports provided.
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Utilization Management Authorization: The process of evaluating the medical necessity,
appropriateness and efficiency of behavioral healthcare services against established
guidelines and criteria and to ensure that the client receives necessary, appropriate, highquality care in a cost-effective manner.
Utilization Review Manager: MCO qualified professional who reviews an member's
clinical data to determine the clinical necessity of care and authorizes services associated
with the plan of care.
Waste and Abuse: Incidents or practices that are inconsistent with sound fiscal, business
or medical practices that could result in unnecessary costs to Eastpointe, the State of
Federal government, or another organization. Waste could also result in reimbursement
for services that are not medically necessary, or services that fail to meet professionally
recognized standards for health care. It also includes recipient practices that result in
unnecessary costs to the Medicaid program. (42 CFR 455.2)
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Attachment B: Utilization Management Plan/Program Overview
Purpose and Scope:
Eastpointe’s Utilization Management (UM) Process is one of the necessary key functions
in managing Eastpointe’s Prepaid In-patient Health Plan (PIHP) resources. Eastpointe
maintains a comprehensive and effective UM Plan/ Program to review proposed care in
order to evaluate the medical necessity, efficacy, frequency, duration and setting of the
services based on a set of clinical decision support tools, level of care criteria and clinical
outcomes. Eastpointe reviews the medical necessity and appropriateness of care in a fair,
impartial and consistent manner. The goal of the UM plan is to ensure enrollee’s
opportunity for recovery through access to the most effective and least restrictive
medically necessary behavioral health services.
The purpose of the UM Plan/Program Overview is to provide direction to Eastpointe care
management staff and providers regarding requests for authorization of covered
behavioral health services and of the denial, reduction, termination or suspension of
services.
The UM plan also provides a framework for monitoring over and under-utilization of
services by identifying outliers, and evaluating trends in service delivery.
The UM department has sufficient qualified staff members to review and authorize
behavioral health services. Eastpointe maintains through employment and/or contract
sufficient qualified physicians to perform second level reviews which could result in an
adverse decision for the enrollee.
The elements of the UM program are addressed, monitored and improved through
Eastpointe’s:
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policies and procedures,
clinical documentation audits,
key performance measures,
committee meeting minutes,
annual review/modification of UM plan,
UM staff job descriptions,
training and supervision of UM staff through documentation audits
departmental/individual performance benchmarks,
individual and departmental performance improvement plans and
quality improvement plans if indicated.
Responsibilities as an Eastpointe Contracted Provider
• Submit Treatment Authorization Requests (TAR) with the proper clinical information
to allow UM Care Managers to review for medical necessity; and
• Submit Continuing Treatment Authorization Requests with sufficient clinical/ supports
justification on a timely basis to allow for Utilization Management activities and
authorization 10 days prior to initiating services.
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• Submit Emergency/Expedited Authorizations when necessary, ensuring they are only
used when needed to provide for client health, safety, and well-being. (See Section for
authorization instructions)
Eastpointe’s Responsibility to Providers
Provide accurate and timely response to Treatment Authorization Requests and ensure
that enrollees receive services for which they are eligible, and which are clinically
appropriate in the right time and the right place.
Oversight
Medical Director
The Medical Director is ultimately responsible for oversight of all clinical services
including the Utilization Management Plan to ensure that the plan is comprehensive and
effective. The Medical Director is involved in key aspects of the UM program including
but not limited to chairing the Clinical Advisory Committee which approves Eastpointe’s
clinical decision support tools, staff training, development/review/dissemination and
training of staff and providers on clinical practice guidelines, identification of barriers to
admission, discharge and dispositions, and oversight of clinical decision-making.
Chief of Clinical Operations
The Chief of Clinical Operations provides leadership to the Call Center, UM, MH/SA
Care Coordination, IDD Care Coordination and Housing. Eastpointe’s Clinical
Departments operate under the leadership of the Chief of Clinical Operations who reports
directly to the Chief Executive Officer with a dotted reporting relationship to the Medical
Director. The Chief of Clinical Operations directly supervises the Director of the UM
Department. The Chief of Clinical Operations promotes collaboration and consistency of
UM processes, identifies, reports and analyzes key performance indicators, monitors
over- and under-utilization, works closely with the Chief of Business Operations to
analyze and review key reports and participates in cross departmental teams to
implement, review and collaborate to improve internal efficiencies and promote effective
use of Eastpointe’s resources.
Director of Utilization Management
The UM Department operates under the leadership of the UM Director who reports to the
Chief of Clinical Operations. The UM Director provides direct supervision to the
MH/SA UM Manager and to the IDD UM manager, ensures new staff have effective and
sufficient training and supervision, promotes collaboration and consistency in UM
processes, monitors the performance of the department and of individual staff within the
department against established benchmarks and assists in the establishment of benchmark
performance measures for the department and staff. The UM Director performs regular
audits of clinical UM decisions, performs documentation audits, ensures consistency of
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decisions through performance of inter-rater (rater-to –standard) reliability of UM
clinicians with the Medical Director serving as the standard rater. The UM Director
implements departmental performance improvement plans and participates in the
development and implementation of quality improvement plans if necessary.
Mental Health/Substance Abuse UM Manager
The MH/SA UM Manager is supervised by the UM Director and provides day to day
supervision to the licensed clinicians who perform first level reviews of requests for
mental health and substance abuse services. The UM Manager ensures that the staff are
in compliance with
Eastpointe’s policies and procedures, state and federal regulations and contractual
requirements for the UM department.
Intellectual Developmental Disability UM Manager
The IDD Manager is supervised by the UM Director and provides day to day supervision
to the qualified professional screeners and the licensed clinicians who determine ICF-MR
level of care and approve individual service plans for IDD Innovations enrollees,
individuals on the Registry of Un-Met Needs and IDD state funded services. The IDD
UM Manager ensures that the staff are in compliance with Eastpointe’s policies and
procedures, state and federal regulations and contractual requirements for the UM
department.
Manager of UM Support
The Manager of UM Support is supervised by the UM Director. This Unit reviews
authorization requests for validity and confirms eligibility for Medicaid and State funded
services, assigns cases to UM screeners or care managers, posts approval letters to the
electronic system for providers, mails adverse letters and ensures adverse decision letters
are sent by trackable mail within required timeframes, manages the timelines and
processes for reconsiderations and peer reviews, uploads adverse decision documents into
the adverse decision database, coordinates Mediation for Medicaid appeals and ensures
OAH receives any requested documents for Medicaid appeal hearings.
Covered Services
Eastpointe, through arrangements with our provider network provides the following
services:
• All Medicaid MH/SA/IDD services described in clinical coverage policies 8A through
8J located on DMA website at: http://www.ncdhhs.gov/dma/mp/index.htm
• Medicaid covered MH/SA/IDD emergency room services, including all professional
charges
• All Medicaid covered services provided by psychiatrists
• 1915c waiver services as defined in the Innovations waiver at:
http://www.ncdhhs.gov/mhddsas/providers/1915bcWaiver/index.htm
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• Section 1915 b3 waiver services as defined in the 1915 b MH/DD/SA waiver at:
http://www.ncdhhs.gov/mhddsas/providers/1915bcWaiver/index.htm
• All services covered under Eastpointe’s State Funded Benefit Plan at:
• http://www.eastpointe.net/providers/iprs/docs/IPRS%20Updated%20%20Benefit%20P
ackage-Eastpointe%20%207-31-%2012.pdf
ENROLLMENT/ ELIGABILITY
Enrollee Eligibility for Medicaid Services
Providers may request the appropriate medically necessary services for enrollees who
meet the eligibility criteria under the 1915 b/c Waiver. The eligibility criteria for
enrollees can be found at the following locations:
1. http://www.ncdhhs.gov/dma/lme/MHWaiver.htm
2. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Eligibility/Eligibility.html
Enrollee Eligibility for State Funded Services
Enrollees who do not have insurance may be eligible for state funded services through the
Integrated Payment and Reporting System (IPRS) based on their income and level of
need. No one meeting eligibility requirements will be denied services based on inability
to pay. Eastpointe’s providers have a sliding fee schedules used to assess a person’s
ability to pay. IPRS funding is not an entitlement. Eastpointe and other MCOs are not
required to fund services beyond the resources that are available to them.
Eastpointe maintains a Registry of Unmet Needs for I/DD enrollees to track requests for
state funded/non-emergency services that have not been met.
Target Populations
IPRS Target Population designation is for State funded services. It does not apply to
enrollees who are only receiving Medicaid services. The provider, through review of
Screening, Triage and Referral information (STR), must determine the specific Target
Population for the enrollee according to the Division of MH/DD/SA criteria. Each Target
Population is based on diagnostic and other indicators of the enrollee’s level of need. If
the MH/DD/SAS system does not serve these individuals, there is no other system that
will serve them. The MH/DD/SAS system is the public safety net and resources will be
focused on those most in need.
Web Reference: IPRS link on the NC Division of MH/DD/SAS website:
http://www.ncdhhs.gov/mhddsas/providers/IPRS/index.htm
Provider Eligibility for Reimbursement by Eastpointe
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Enrollees who have their services paid for in whole or in part by Eastpointe must be
enrolled in the Eastpointe system. If you have any questions about an enrollee’s
eligibility, please contact the Call Center at 1-800-913-6109. Individuals who are at
100% ability to pay according to Eastpointe’s sliding fee schedule, or who have insurance
coverage that pays 100% of their services, may not be enrolled into the Eastpointe
system. Medicaid and IPRS funds should be payment of last resort. All other funding
options need to be exhausted first. Enrollees with a Medicaid card from one of
Eastpointe’s counties are fully enrolled in the Eastpointe system and are eligible to
receive medically necessary Medicaid Basic Benefit Services or Enhanced Services
which have been authorized by Eastpointe.
Enrollees who are not Medicaid eligible are required to provide income verification,
which will be used to determine how much they will be required to pay. Providers are
required to use Eastpointe’s sliding fee schedule to calculate the fee. This schedule is
based on Federal Poverty Guidelines, the enrollee’s family income, and the number of
dependents.
Medicaid regulations prohibit the use of Medicaid funds to pay for services other than
General Hospital Care delivered to inmates of public correctional institutions. Medicaid
funds may not be used to pay for services provided for enrollees in facilities with more
than sixteen (16) beds that are classified as Institutions of Mental Diseases (IMD). IMDs
are considered to be hospitals much like State Facilities because they are more than
sixteen beds and are not part of a general hospital. Enrollees with private or group
insurance coverage are required to pay the co-pay assigned by their insurance carrier.
Note: Provider contracts specify the funding source available for provider billing.
Providers should know if they have been contracted for Medicaid, IPRS, or both.
If you have questions, please contact your assigned Contract Specialist.
ENROLLMENT
IPRS
Individuals must be enrolled in the IPRS Benefit Plan through completion of the Member
Enrollment/LCAD. Non-Members who are screened are eligible to receive clinical and
psychiatric assessments but must be enrolled within 48 hours to be eligible for treatment
under the IPRS Benefit Plan. All individuals receiving IPRS (state funded for the indigent)
services from Eastpointe must have been screened through the screening, triage, and referral
process, been evaluated for services, and ultimately admitted into services with a provider
from within the Eastpointe provider network.
For additional information, training, processes, and forms for IPRS:
http://www.eastpointe.net/providers/iprs/iprs.aspx
MEDICAID
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Providers will have the capabilities through Provider Connect to enter and enroll individuals
for services prior to being able to completing a treatment authorization request.
Training materials regarding enrollment are located on Eastpointe’s website at
www.eastpointe.net under provider community meeting/training.
REQUESTING SERVICES
Eastpointe utilizes the Provider Connect electronic database system for treatment
authorization requests for all levels of service. Requests for services can be submitted
twenty hours a day through Provider Connect.
The following functions are available within the Provider Connect system on the main
menu:
• Look up client – this allows you to search for a enrollee that has been assigned to you
in the system.
• Change password – this allows you to change your password. If you feel that there may
be a security threat you should always change your password.
• Billing – this option will allow you to bill for all the services you have entered through
Provider Connect.
• Note: only 1 person in your agency needs to be responsible for using this option.
• News – this option takes you back to the news page.
• Reports – this option will allow you to pull reports based on your enrollees
authorization history.
• Add New Client/Client Search – this option will allow you to look to see if a enrollee is
assigned to your agency. If the enrollee is not assigned you can create the admission for
that consumer so that you can access him/her.
• Logout/Exit – logs you out of the system when you are done.
A manual regarding Provider Connect can be found on the Eastpointe Website under
Provider Community and Manuals. The website address for the manual is
http://www.eastpointe.net/providers/manuals/LME%20ProviderConnect%20Manual.pdf .
Additional Resources and trainings for Provider Connect can be found on the Eastpointe
website (www.eastpointe.net) under Provider Community and Trainings.
The Provider Connect website
Website Address: https://carelink.carenetasp.com/EastpointePC
Authorization Process
Prior to seeking authorization a consumer must be enrolled as a member into the Eastpointe
Network via the LME Consumer Admission/Discharge form (LCAD) for IPRS funded
services and Provider Connect for Medicaid eligible services. Eastpointe is responsible for
the authorization of state funded services and Medicaid Eligible services. Eastpointe does not
approve care retrospectively utilizing state funding. All services require prior approval. It is
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recommended for continued stay requests that requests are submitted at least ten days prior to
the expiration of the current authorization.
Treatment Authorization Request (TAR) Documentation
The service provider initiates the authorization/re-authorization process by
completing and submitting the required Treatment Authorization Request form
through the Provider Connect electronic system. Providers are encouraged to submit
supporting documentation that demonstrates medical necessity.
Treatment Authorization Request
The Eastpointe Treatment Authorization Request (TAR) captures demographic
and clinical information. When this form is properly completed, Utilization
Management staff can use the information documented on this form along with
other supporting documentation to make a medical necessity determination.
To remain consistent with Division of Medical Assistance (DMA) guidelines, the
Clinical Operations Department is only able to make formal decisions (approval,
denial, or extensions when appropriate) when a complete request is received.
For an authorization request to be considered “complete” it must contain the
following elements:
• Recipient Name
• Medicaid ID
• Date of Birth
• Provider contact information and signatures
• Date of request
• Service(s) requested
• Service Order
• Completed check boxes for the following:
oSignature Page
oService Order Page
• Yes/No check boxes related to medical necessity, direct contact with the
individual, and review of the individual’s Clinical Assessments
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• Person Centered Plan (PCP), Individual Service Plan (ISP), or other approved
treatment plan
• Clinical information to support the service(s) requested. This should include
information that supports the eligibility for service(s) requested.
• Some of the above elements will be contained in the corresponding Treatment
Authorization Request (TAR). A TAR constitutes a service request and starts the
timeline for review. A Person Centered Plan (PCP ) alone does not initiate a
request for service, as it does not meet the criteria identified above since it does
not indicate the service provider and requested services dates, as this
information is submitted via the TAR.
• If a TAR is received that requires a corresponding PCP, ISP, or other approved
treatment plan, and none is submitted or there is not enough clinical
information to support the request, this request will be administratively denied
as an incomplete request and provider notified.
If the form is not completed in full, including all clinical information required, a
delay in the approval of a service request or a denial of the TAR may occur.
Utilization Management staff may attempt to gather the information through
contact with the provider, but this may take several days to resolve in some
cases. Providers are monitored for accuracy and completeness in submitting
TARs, and may be identified for additional training as needed.
Any provider can request specific technical assistance on TAR submission by
contacting the Eastpointe Customer Service/Provider Assistance line at 1-800513-4002.
The following information can be found on Eastpointe’s website
(www.eastpointe.net) under Provider Community forms and meeting/trainings:
• Treatment Authorization Request Form (TAR)
• TAR Instructions
Receipt of UM Request
Authorization requests are received via the electronic managed care system.
Authorization requests are defined as routine or urgent. Eastpointe defines urgent care
as the type of care needed when a clinical situation exists where there is potential for
the situation to become a life-threatening emergency in the absence of treatment.
Therefore, requests for the following levels of care are deemed to be “urgent”
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requests: inpatient, crisis bed, and detoxification treatment. Eastpointe defines nonurgent care as ambulatory care that is routine. However, if a physician with
knowledge of the consumer's condition believes that failure to treat the request as
"urgent" would jeopardize the health of the consumer, Eastpointe defers to the
physician.
Eastpointe accepts and takes into account relevant information from any reasonably
reliable source, such as treating providers, other providers on the treatment team,
consumers or their family members, when making utilization management
determinations. [HUM 26 (a)]
Authorization requests received via the electronic managed care system are date and
time stamped by the system in reportable fields that are used to calculate turn-around
times (TAT) for decision-making.
Service Type Requests
Basic Services:
The Basic Benefit package includes those services that will be made available to
Medicaid-entitled individuals and, to the extent resources are available, to nonMedicaid individuals. These services are intended to provide brief interventions
for individuals with acute needs. The Basic Benefit package is accessed through a
simple referral from Eastpointe to an enrolled Eastpointe provider. Once the
referral is made, there are no prior authorization requirements for these services.
Referred individuals with Medicaid can access up to eight (8) visits for Adults
ages 21 and up and sixteen (16) visits for Children and Adolescents below age 21
from the Basic Benefit package per calendar year per DMA Clinical Policy 8C. If
and when the Eastpointe MCO decides to allow unmanaged outpatient visits it
will be through the Provider Connect system.
Enhanced Services:
The Enhanced Benefit package includes those services that will be made
available to Medicaid-entitled individuals and depending on available resources,
may be available to non-Medicaid individuals meeting IPRS Target Population
criteria. Enhanced Benefit services are accessed through a person-centered
planning process. Enhanced Benefit services are intended to provide a range of
services and supports, which are more appropriate for individuals seeking to
recover from more severe forms of mental illness, substance abuse and
intellectual and developmental disabilities with more complex service and
support needs as identified in the person-centered planning process. The
person-centered plan also includes both a proactive and reactive crisis
contingency plan. Enhanced Benefit services include services that are
comprehensive, more intensive, and may be delivered for a longer period of
time. An individual may receive services to the extent that they are identified as
necessary through the person-centered planning process and are not duplicated
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in the integrated services offered through the Enhanced Benefit (e.g., Assertive
Community Treatment).An individual may receive services that are reviewed by
the UM department and determined to be medically necessary.
The regulations of a 1915 (b) waiver require that all NC Medicaid State Plan
services be available under the 1915 (b) waiver. When the NC State Medicaid
Plan changes, the services covered under the NC MH/DD/SAS Health Plan will
change as well.
Web Reference: Service Definitions (Scroll down page for Behavioral Health links)
www.ncdhhs.gov/dma/mp/
Utilization Review Decisions
Eastpointe uses established medical necessity criteria, clinical decision support tools and
level of care tools that serve as the basis for consistent and clinically appropriate service
authorization decisions for all levels of mental health, substance abuse and
intellectual/developmental disability services. The UM department consistently adheres
to adopted clinical practice guidelines. The UM department promotes clinically sound,
efficient utilization of available resources. These criteria are also available to any
interested party, including enrollees, family members and advocates through Eastpointe’s
website at http://www.eastpointe.net/providers/MedicaidUR/mur.aspx or in hardcopy
upon request.
Authorization decisions take into account both administrative and clinical factors;
 Determination that the individual for who the service is request is an Eastpointe
Medicaid enrollee of is eligible for state funded services
 Determination that the service requested is a covered service
 Determination of special regulatory requirements such as EPSDT
 Determination that the requested service is medically necessary ad defined by
Eastpointe’s definition of medical necessity, clinical decision support tools, level
of care tools
Authorization of services are based on the submission of the Treatment Authorization
Request and a thorough review of complete and current clinical information submitted
with the request, including level of care. If the documentation is incomplete, Eastpointe
UM staff may contact the provider for the missing clinical information.
All covered MH/SA/I-DD services are authorized in sufficient amount, duration and
scope to achieve the identified treatment objectives and are made in compliance with
regulatory, contractually required timelines and documentation standards and
Eastpointe’s policies and procedures.
First level licensed clinicians can approve a service as medically necessary but cannot
take an adverse action. Second level peer reviewers who are Ph.D. or MD are the only
professionals who can render an adverse action. Eastpointe does not arbitrarily deny or
reduce the amount, duration or scope because of a particular diagnosis, type of illness or
condition of the enrollee. All authorization decisions are based on the appropriateness of
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service on an individualized basis. Eastpointe does not offer incentives of any kind for
individuals or entities to limit, discontinue, or deny medically necessary services to any
enrollee.
Eastpointe UM operates under Medical necessity defined as those procedures, products,
and services that are provided to Medicaid recipients that are necessary and appropriate
for the prevention, diagnosis, palliative, curative, or restorative treatment of a mental
health or substance abuse condition when the procedure, product, or services are:
• Consistent with N.C. DHHS-defined standards, Medicaid clinical coverage criteria, and
national or evidence-based standards verified by independent clinical experts at the time
the procedures, products, or services are provided.
• Individualized, specific, and consistent with symptoms or confirmed diagnosis of the
illness or injury under treatment, and not in excess of the recipient’s needs.
• Able to be safely furnished, and no equally effective and more conservative or less
costly treatment is available statewide (this should be linked with network development
in the catchment area).
• Furnished in a manner not primarily intended for the convenience of the recipient, the
recipient’s caretaker, or the provider.
• Not for experimental, investigational, unproven or solely cosmetic purposes.
• Furnished by or under the supervision of a practitioner licensed (as relevant) under state
law in the specialty for which they are providing service and in accordance with federal
and state laws and regulations, the Medicaid State Plan, the North Carolina
Administrative Code, Medicaid clinical coverage policies, and other applicable federal
and state directives.
• Sufficient in amount, duration and scope to reasonably achieve their purpose.
• Reasonably related to the diagnosis for which they are prescribed regarding type,
intensity, duration of service and setting of treatment.
Utilization Review Criteria
I.
Listed below are the primary clinical decision support tools, which include
the following:
a. DMA-Clinical Coverage Policy 8A, Enhanced Mental Health and Substance
Abuse Services (http://www.ncdhhs.gov/dma/mp/mpindex.htm).
b. DMA-Clinical Coverage Policy 8B, Inpatient Behavioral Health Services –
(http://www.ncdhhs.gov/dma/mp/mpindex.htm).
c. DMA-Clinical Coverage Policy 8D-1 and 8D-2, Psychiatric Residential
Treatment Services (http://www.ncdhhs.gov/dma/mp/mpindex.htm).
d. DMA-Clinical Coverage Policy 8D-2, Therapeutic Foster
Care(http://www.ncdhhs.gov/dma/mp/mpindex.htm).
e. DMA-Clinical Coverage Policy 8C, Outpatient Behavioral Health Services
(http://www.ncdhhs.gov/dma/mp/mpindex.htm).
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f. DMA-Clinical Coverage Policy 8E, Intermediate Care Facilities for Individuals
with Mental Retardation(http://www.ncdhhs.gov/dma/mp/mpindex.htm).
g. DMA-Clinical Coverage Policy 8I, Psychological Services in Health Departments
and School-Based Centers Sponsored by Health Departments to the Under 21
Population
(http://www.ncdhhs.gov/dma/mp/8i.pdf)
h. DMA-Clinical Coverage Policy 8L, Mental Health/Substance Abuse Targeted
Case Management (http://www.ncdhhs.gov/dma/mp/mpindex.htm).
i. DMA-Clinical Coverage Policy 8M, Community Alternatives Program for
Persons with Mental Retardation and Developmental Disabilities (CAP-MR/DD)
http://www.ncdhhs.gov/dma/mp/8M.pdf
j. DMA-Clinical Coverage Policy 8N, Intellectual and Developmental Disabilities
Targeted Case Management (http://www.ncdhhs.gov/dma/mp/8N.pdf)
k. The Division of Mental Health Service Definitions, including:
a. Service Definitions-2003
http://www.ncdhhs.gov/mhddsas/providers/servicedefs/archive/DMHDDS
A%20Service%20Definitions%20Manual%20%20Revisions%2015%20January%20..pdf
b. Developmental Therapy- Implementation #5 with a memo dated 2-222006
http://www.ncdhhs.gov/mhddsas/implementationupdates/Archive/2006/up
date005/dmadmh2-23-06update5.pdf
j. Early Periodic Screening, Diagnosis, and Treatment Requirements
(Social Security Act 42 U.S.C. 1396d(r) {1905(r)}
http://www.ncdhhs.gov/dma/epsdt/
II.
Eastpointe shall utilize clinical care criteria related to best practices based on
current treatment protocols and national standards (e.g., SAMHSA, American
Psychiatric Association, etc.) for all major diagnoses and treatment modalities.
III. Level of Care
A. American Society of Addictive Medicine (ASAM) Patient Placement Criteria
B. Level of Care Utilization System (LOCUS)
C. Child and Adolescent Level of Care Utilization System (CALOCUS)
D. Intermediate Care Facilities for Individuals with Mental Retardation (ICF/MR)
The Clinical Coverage Policies have embedded in them, the clinical (or medical
necessity) criteria for each specific service and/or level of care. These criteria are based
on current valid clinical principles and processes and are developed with the involvement
from appropriate actively participating providers with current relevant clinical
knowledge.
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The regulations of a 1915 (b) waiver require that all NC Medicaid State Plan services be
available under the 1915 (b) waiver. When the NC State Medicaid Plan changes, the
services covered under the NC MH/DD/SAS Health Plan will change as well.
Web Reference: Service Definitions (Scroll down page for Behavioral Health links)
www.ncdhhs.gov/dma/mp/
AUTHORIZATION
Requesting treatment/service authorization is the responsibility of the provider.
The process required to obtain initial authorization of services is outlined below.
Prior-authorization of services is the responsibility of Eastpointe’s UM
Department
Note: For a full listing of all State Medicaid Plan Service Definitions and Criteria,
follow the link www.dhhs.nc.gov
Unable to Process-No Appeal Rights
There are two conditions that meet the criteria for returning a Treatment Authorization
Request to the provider with no action taken.
1. Services that are currently authorized to Another Provider
Eastpointe shall not authorize a service for a recipient during any active authorization
period for this same service with another service provider.
Eastpointe must receive the completed Discharge from Treatment Form from the service
provider with the active authorization.
2. Duplicate Requests
If it is determined that the Treatment Authorization Request is a duplicate of a request
already received and:
• If no action has been taken on the initial request, return the duplicate request and
indicate that no action was taken because the request was a duplicate and that action on
the original request will be forthcoming.
• If the request has been reviewed and approved, return the duplicate request to the
provider and indicate that no action was taken because the request was a duplicate.
• If the request has been reviewed, adverse action taken, and the recipient’s appeal rights
have not expired, review the request to see if additional information is contained in the
request that would change the adverse decision.
If there is no change in the adverse action, return the duplicate request to the
service provider indicating that the initial decision stays; no appeal rights should be
granted.
Prior Authorization
Prior-authorization is required for all Eastpointe covered services, with the following
exceptions:
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• Initial eight (8) adult and initial sixteen (16) children outpatient services per year that
are covered under the Medicaid Basic Benefit Package.
• Emergency/Crisis services for Behavioral Healthcare.
• Codes specifically agreed upon by Eastpointe and provider to be listed as “No
Authorization Required” under a contract. Please see your contract for applicability.
• Exceptions in accordance with the Clinical Coverage Policy 8A Revised Date: August
1, 2011 for the following services:
1. SAIOP: Recipients may be seen for the initial 30 days of treatment without a
prior authorization. Services provided after this initial 30 day “pass-through”
period require authorization from the Medicaid approved vendor. This passthrough is available only once per calendar year. Reauthorization shall not
exceed 60 days. Under exceptional circumstances, one additional
reauthorization up to 2 weeks can be approved. This service is billed with a
minimum of 3 hours per day as an event.
2. SACOT: Recipients receiving Substance Abuse Comprehensive Outpatient
Treatment (SACOT) services may be seen for the initial 60 days of treatment
without a prior authorization. Services provided after this initial 60 day
“pass-through” period require authorization from the Medicaid approved
vendor. This pass through is available only once per calendar year.
Reauthorization shall not exceed 60 days. All utilization review activity shall
be documented in the Provider’s Service Plan.
Types of Utilization Reviews
The TAR and information from the provider is submitted with the Treatment Plan
(Person Centered Plan or Individualized Service Plan). This information is evaluated
against Medical Necessity criteria. If information from these sources does not support the
service supports request, other information will be requested from the provider. This may
include assessments, treatment notes, and plan updates. This process is done initially,
concurrently and retrospectively.
A. Initial Reviews
Initial reviews are completed for requests of service where, typically, the recipient is new
to the service being requested or the request is submitted after a break in service from the
last date of authorized service.
Note: If a request for authorization of services for a recipient is submitted by a new
service provider, it is considered to be an initial request.
Initial Authorization
Enhanced level services are authorized through the review of the TAR and
documentation to support the medical necessity of the request as submitted by the
Clinical Home Provider. Services are identified through the Person Centered/Treatment
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planning process in a coordinated effort between the clinical home provider, the enrollee,
enrollee’s family, providers, and other involved professionals or supports when indicated.
1. Provider to complete the TAR within the Provider Connect system
2. The information required to establish the need for medical necessity and service
continuation criteria must be included.
3. UM clinical staff member reviews the request for medical necessity and then follows the
approval/denial process.
4. Certification and non-certification letters will be posted within the Provider Connect
System.
B. Continued Stay Reviews for Authorization of Service
1. In order for services to continue beyond the initial authorization time frame, a TAR is
completed for each continued stay service request through the Provider Connect system.
2. The information required to establish the need for continued medical necessity and
service continuation criteria must be included.
3. UM clinical staff member reviews the request for medical necessity and then follows the
approval/denial process.
4. Certification and non-certification letters will be posted within the Provider Connect
System.
Continued Stay reviews are required when:
• The service provider requests authorization for care beyond the dates of service initially
authorized.
• The service provider requests a revision to the units of service initially authorized. The
purpose of a concurrent review is to determine if the authorized service continues to be
appropriate at the current level. Eastpointe must assure that the least restrictive and most
cost-effective service option that appropriately addresses the need, for which the original
service was authorized, is being utilized. Requests for continued stay requests must be
submitted to Eastpointe prior to the end of the current authorization period. If a continued
stay request is submitted AFTER the end of the previous authorization period, it will be
handled as an initial request.
Note: If a request for authorization of services for a recipient is submitted by a new
service provider, it is considered to be an initial request.
C. Retrospective Reviews Medicaid Eligibility
Retrospective reviews may be performed if the recipient did not have Medicaid at the
time the service was provided but obtains Medicaid eligibility with an effective date that
encompasses the dates that the service was provided. Eastpointe must verify with DMA
the date that the eligibility was entered into the Recipient Eligibility file to assure the
authenticity of the provider request.
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The records must be submitted with the Service Request Form and the authorization
documentation specific to the service being requested. Any authorization information
from a different vendor or LME/MCO that may have been applicable during the period of
services to be reviewed should be included with the request.
D. EPSDT Reviews
EPSDT reviews are defined as reviews for treatment authorization requests for recipients
under the age of twenty-one (21) when the service(s) requested exceed unit or visit
limitations or age exclusions as delineated in the service definitions or clinical coverage
policies for the service. As documented in the EPSDT requirements (42 U.S.C. 1396d(r)
{1905(r)} of the Social Security Act), requests for services beyond the established
limitations or exclusions must be considered if they are medically necessary to correct or
ameliorate the condition.
Treatment authorization requests must be reviewed under Early Periodic Screening,
Diagnosis and Treatment (EPSDT) requirements if adverse action is to be taken on a
request because the request exceeds policy limitations. If all EPSDT criteria are met, the
service request should be approved even if policy limitations are exceeded. For further
information see the guidelines published in the EPSDT Policy Instruction Update on
DMA’s website at http://www.ncdhhs.gov/dma/epsdt.
E. Requests for Non-Covered Services
Requests for mental health or substance abuse treatment services for recipients under the
age of twenty-one (21) that are not covered by Medicaid must also be reviewed and
recommendations must be sent to DMA’s Assistant Director for Clinical Policy and
Programs Section for a final decision. Eastpointe must notify the service provider in
writing that the request was referred to DMA for disposition.
F. Insufficient Clinical Information (appeal rights)
If a Medicaid case is missing any of the required information (per contract) or a Statefunded request is missing necessary information to make a medical necessity
determination, the UM staff may contact the requesting provider to request the needed
clinical information as soon as possible. The UM Staff may inform the provider of the
specific information needed to process the request and allows the provider time to
provide the missing information but must render an action in accordance with turnaround
time requirements for initial action-making.
Consistency and Timeliness of UM Actions
Eastpointe’s policies and procedures ensure UM criteria and are consistently applied by
UM staff across levels of care. Periodic inter-rater reliability studies are conducted and
reviewed as part of Eastpointe’s continuous quality improvement philosophy.
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Eastpointe’s contractual requirements and policy and procedure require adherence to time
frames for UM decisions. The UM Director monitors the timeliness of UM actions
through tracking of turn-around time for both routine and expedited service authorization
requests. The UM Director takes immediate action if turn-around timeframes are not met.
Review timelines accommodate the clinical urgency of the request. All UM decisions
and related notifications accommodate clinical urgency and comply with the timeframes
established by contractual requirements and Eastpointe’s policies and procedures.
Service authorization decisions are communicated to Eastpointe’s enrollees and providers
in compliance with Eastpointe’s policies and procedures, contractual requirements
regarding timelines and notice content.
Standard service authorization decisions are made and communicated to enrollees and/or
providers within 14 calendar days following the receipt of valid requests. Eastpointe
may extend Medicaid requests under certain conditions but must justify the extension to
DMA.
An expedited process is used when Eastpointe determines that the standard authorization
timeline could seriously jeopardize the enrollee’s health and safety or the ability to attain,
maintain or regain maximum functioning. Expedited requests are processed within 72
hours.
The table below indicates the timeliness standards based on line of business: [HUM 30 (a)]
Eastpointe Timeliness Standards for UM Action-Making
Type of Non-Urgent
Medicaid
State-Funded
Request
Action
Standard- Initial;
Continued Stay
Retrospective
Type of Urgent
Request
Expedited- Initial;
Continued Stay
Post stabilization
Retrospective
13 calendar
days
30 calendar
days
Notification
1 calendar day
from action
No additional time
Action
Notification
13 calendar
days
N/A
Medicaid
1 calendar day
from action
N/A
State-Funded
24 hours
No additional time
24 hours
No additional time
1 hour
N/A
No additional time
N/A
N/A
N/A
Appeal of Adverse Actions by the UM Department
Eastpointe notifies the enrollee and requesting provider of any adverse decision. The
enrollee is notified in writing and the provider is notified via the electronic authorization
system. The adverse notification is written in English and the recipient’s primary
language as indicated on the Global Eligibility File.
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Notification of adverse actions by Eastpointe’s UM Department are in compliance with
Medicaid contract required content and timelines, Eastpointe’s policies and procedures
for state funded appeals, and URAC accreditation standards.
Eastpointe follows the required timelines for standard and expedited appeals. An
expedited appeal process will be followed when it is determined that taking the time for a
standard appeal could seriously jeopardize the Enrollee’s life or health or ability to attain,
maintain, or regain maximum function.
Eastpointe actively participates in Mediations and considers Mediation to be an
opportunity to hear additional information and seeks to resolve the appeal at this level as
appropriate. Eastpointe participates in any hearing at the Office of Administrative
Hearings (OAH) and provides all documents related to the adverse decision to the
Attorney General’s office. Eastpointe is receptive to resolving the appeal at any point in
time during the pending appeal.
Delegated UM Functions
Eastpointe is accountable for any UM functions or responsibilities it delegates to any
subcontractor. Eastpointe has written a delegation agreement that specifies the activities
and reporting responsibilities delegated to the subcontractor. Eastpointe can revoke or
impose other sanctions if the subcontractor’s performance is not adequate and does not
meet Eastpointe’s standards or contractual, regulatory standards and timelines.
Eastpointe provides to the delegate all policies, procedures, protocols, guidelines and
contractual/regulatory requirements necessary to ensure compliance. Eastpointe
conducts an annual delegation oversight evaluation to review policies and procedures
related to the sub-contracted function unless the delegated agency is URAC accredited.
Over-Under Utilization
Eastpointe will analyze and trend utilization data to identify normal and special cause
variations that impacts patterns of utilization. Eastpointe will establish criteria ranges for
utilization of services and will examine utilization patterns outside the established criteria
ranges at an individual, provider, and at the aggregate system level.
Key measures would be penetration rates by age, ethnicity and geographic area, inpatient
recidivism, inpatient admissions, and bed days per 1,000 consumers by age group,
disability group (MH, SA, I-DD) and geography, emergency department visits per 1,000
consumers by age group, disability group and geography, and outpatient utilization. Data
is analyzed for under and over utilization and identification of problem areas.
Over Utilization of Services
Over utilization of crisis services may indicate ineffective or inadequate service
availability. Identification of providers who have significantly more enrollees who are
over utilizing crisis services compared to similar providers may indicate inadequate care
planning or crisis management.
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Over utilization of residential care as defined by length of stay may indicate inadequate
or ineffective community based services.
Over-under-utilization at an individual enrollee level would be discussed in clinical case
reviews to identify barriers to access, barriers to discharge from high levels of care, gaps
in service continuum, etc. This process may uncover barriers to appropriate service
utilization not reflected in aggregate data. Case reviews may involve an in-depth review
of medical records. Another potential measure of over utilization is prescription patterns,
specifically enrollees having been prescribed four or more psychotropic medications at
any one time during the last six months.
One example of over-utilization of services includes, but are not limited to:
• Enrollees over-accessing crisis care due to ineffective or non-existent crisis plan,
persistent technique, or service without positive outcome
Under-utilization of Services
At the provider level a pattern of under-utilization of services authorized as medical
necessity may indicate inadequate service delivery, difficulty engaging individuals in
treatment and could trigger a focused monitoring including a review of medical records.
Examples of under-utilization of services may include, but are not limited to, enrollees
who utilize less than their authorized service or enrollees who have multiple failed
appointments, or providers not adequately or effectively engaging the enrollee in
authorized and needed enhanced services.
Infrequently Utilized Services
These are services needed by enrollees that are not offered by most providers, and are not
frequently used. This includes specialty evaluations such as psychological evaluations,
sex offender specific evaluations, and specialty medical evaluations, to name a few. On
occasion, there is under-utilization due to the absence of availability for specialty
treatment care, such as eating disorders and sexual behavior problems. In addition, many
times enrollees need assistance from the MCO in accessing specialty educational testing,
vocational evaluation, or other services not provided by Critical Access Behavioral
Health Agencies (CABHA).
POST PAYMENT REVIEWS
Focused post payment reviews are implemented based on the results of Monitoring
Reports that identify outliers as compared to expected/established service levels or
through specific cases identified in the course of work.
Focused samples may include:
• High-impact enrollees - Examples may include, but are not limited to, enrollees who
have been hospitalized more than one time in a 30-day period,
intellectually/developmentally disabled enrollees as identified in the Risk/Support
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Needs Assessment, children and youth with multiple-agency involvement, or active
substance use by a pregnant female.
• Under-utilization of services – Examples may include, but are not limited to, enrollees
who utilize less than 70% of an authorized service or enrollees who have multiple
failed appointments.
• Over-utilization of services – Example: Enrollees who continue to access crisis services
with no engagement in other services.
• Services infrequently utilized – Example: An available specialty best practice that is not
being used in cases where this type of care is indicated.
• High-Cost Treatment – Involves enrollees in the top 10-20% of claims for a particular
service.
Care Coordination Referrals
Utilization Management will refer high risk enrollees to care coordination and will refer
enrollees for whom an inpatient authorization has been requested. Enrollees who meet
the criteria for special healthcare needs will also be referred to care coordination.
Enrollees with significant co-morbid behavioral and medical issues will also be referred
to care coordination to support and encourage integrated collaborative care.
UM/ Care Coordination Firewall
UM does not discuss authorization requests with Care Coordination except to request
additional information per policies and procedures regarding insufficient information to
determine medical necessity or to inform them of missing required elements. The
department does not collaborate with the care coordination department in determining
medical necessity of services requested.
Utilization Management Team Responsibilities
The UM team determines whether an enrollee’s clinical need meets and continues to
meet medical necessity criteria requirements for the frequency, intensity and duration of
requested services. Our goal is to ensure that enrollees receive the right service, at the
right time, at the right level, thus creating the most effective and efficient treatment
possible. UM team works with providers to manage care. This is accomplished through
consistent and uniform application of authorization protocols. Each enrollee’s needs are
evaluated to determine the medical necessity for the service requested.
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Attachment C: Provider Manual Revision Information
Date
8/5/13
8/5/13
8/5/13
8/5/13
8/5//13
8/5/13
8/5/13
Section Revised
Change To
VIII (E) Provider
Request for
Reconsideration #4
(pg.61)
The Grievance and Appeals staff will notify the
Director of the department of which initiated the
action resulting in the reconsideration request by
providing a written notification of receipt of the
request Reconsideration, if the reconsideration
request is due to an action initiated by that
Department.
VIII (E)
The Reconsideration Committee will make a
Reconsideration by
decision (the “final Eastpointe decision”)
Eastpointe (#1) (pg.61) regarding all Requests for Reconsideration within
sixty (60) business days of the receipt of the
Request for Reconsideration.
VIII (E)
In the event that the Reconsideration Committee
Reconsideration by
decides in favor of the initial Eastpointe
Eastpointe (#2) (pg.62) administrative action, Eastpointe’s CEO will review
the Request. This decision must be made within
the same sixty (60) business days allowed for the
entire reconsideration.
VIII (E)
The final Eastpointe decision to the Provider will
Reconsideration by
be mailed within the same sixty (60) business
Eastpointe (#3) (pg.62) days, registered mail.
VIII (H) Right To File A Entire section deleted to comply with
Petition For
Communication Bulletin 55
Administrative
Reconsideration
Review With The
Division Of Medical
Assistance For
Medicaid Funded
Services pg 63)
VIII (K) Continuation of (See note on Member or guardian responsibility
Existing Services
for payment if decision is upheld at final appeal).
during
Reconsideration (3rd
bullet) (pg 69)
VIII (K) The Standard
Medicaid
Reconsideration
Review (Last
Upon completion of the Reconsideration decision,
if the member or guardian disagrees with the
Eastpointe decision, the member or guardian can
then appeal the decision to the Office of
129
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8/5/13
8/5/13
8/5/13
8/5/13
paragraph) (pg 70)
Administrative Hearing by filing a Request for
Hearing.
VIII (K) Eastpointe
Medicaid Member
Reconsideration and
Appeals Process: Level
1 Eastpointe
Network’s
Reconsideration
Process (3rd paragraph
(pg.68)
VIII (K) Eastpointe
Medicaid Member
Reconsideration and
Appeals Process:
Continuation of
Existing Services
during
Reconsideration (pg.
69)
VIII (K) Eastpointe
Medicaid Member
Reconsideration and
Appeals Process: The
Standard Medicaid
Reconsideration
Review (5th
paragraph)(pg.70)
VIII (K) Eastpointe
Medicaid Member
Reconsideration and
Appeals Process: The
Standard Medicaid
Reconsideration
Review (7th paragraph)
(pg.70)
VIII (K) Eastpointe
Medicaid Member
Reconsideration and
Appeals Process: State
Fair Hearing System:
(Levels 2-4)(1st
By fax, to the attention of “Director of Grievance
and Appeals” at 1(910)298-7176
Remove the word Network after Eastpointe.
There are five(5) of them in this section
The member may call and make a verbal request
for Reconsideration, but must follow-up with a
written request unless the Expedited Appeal
process applies. The call should be made to the
Grievance and Appeals Department. For the
Standard Request, the member or provider acting
on behalf of the member must follow-up this call
with a written request.
Remove the word Network after Eastpointe
Remove the word Network after Eastpointe. There
are (2) in this paragraph.
130
8/5/13
paragraph)(pg.71)
VIII (K) Eastpointe
Medicaid Member
Reconsideration and
Appeals Process: State
Fair Hearing System:
(Levels 2-4)(2nd
paragraph)(pg.71)
8/5/13
VIII (K) Eastpointe
Medicaid Member
Reconsideration and
Appeals Process: State
Fair Hearing System:
(Levels 2-4)(2nd
paragraph)(pg.71)
8/5/13
VIII (K) Eastpointe
Medicaid Member
Reconsideration and
Appeals Process: State
Fair Hearing System:
(Levels 2-4)(Level 3
Section)(pg.72)
The member or guardian must file their appeal
with the NC Office of Administrative Hearings
(OAH), the Department of Health and Human
Services and with the Appeals Coordinator of
Eastpointe within thirty (30) days from the date of
the Reconsideration decision. The Appeal must be
sent to the addresses listed on the appeal form
mailed with the Eastpointe Reconsideration
decision.
(Removed the Department of Health and Human
Services) The member or guardian must file their
appeal with the NC Office of Administrative
Hearings and with the Appeals Coordinator of the
Eastpointe within thirty (30) days from the date
of the Reconsideration decision. The Appeal must
be sent to the addresses listed on the appeal form
mailed with the Eastpointe Reconsideration
decision.
(Removed DMA as a final agency Decision maker
and the need for OAH to send the decision to
DMA) The member or guardian has a right to
receive a copy of all documents relevant to the
appeal. An Administrative Law Judge will make a
recommendation regarding the member or
guardian’s case.
If member or guardian or Eastpointe disagrees with
this decision, they may then ask for a judicial
review in Superior Court. Only documents
presented in the Administrative Hearing can be
used in the judicial review.
8/5/13
8/5/13
VIII (K) Eastpointe
Medicaid Member
Reconsideration and
Appeals Process: State
Fair Hearing System:
(Levels 2-4)(Level 4
Section)(pg.72)
VIII (K) Eastpointe
Medicaid Member
Reconsideration and
Omitted
(Removed DHHS) If the final resolution of the
Appeal is not decided in the member or guardian’s
favor, Eastpointe Network may recover the cost of
131
8/5/13
8/5/13
8/5/13
8/5/13
9/09/13
9/20/13
Appeals Process: State
Fair Hearing System:
Member
Responsibility for
Services Furnished
while the Appeal is
Pending
(pg.72)
VIII (L) Eastpointe
Non-Medicaid Service
(State Funded
Services) Appeals
Process (3rd and 6th
sentence)(pg.73)
VIII (L) Eastpointe
Non-Medicaid Service
(State Funded
Services) Appeals
Process (7th
paragraph)(pg.73)
VIII (L) Eastpointe
Non-Medicaid Service
(State Funded
Services) Appeals
Process (9th
paragraph)(pg.73)
VIII (L) Eastpointe
Non-Medicaid Service
(State Funded
Services) Appeals
Process (11th
paragraph)(pg.73)
the services furnished to the member or guardian
while the appeal is pending.
Remove word Network
Responding to member requests for
Reconsideration is the responsibility of the
Grievance and Appeals Department at 1(800)5134002.
By fax to attention of “Director of Grievance and
Appeals” at 1(910) 298-7176.
The member may call and make a verbal Request
for Reconsideration but must follow-up with a
written request unless the Expedited Appeal
process applies. The call should be made to the
Grievance and Appeals Department at 1(800)5134002. For the Standard Request the member or
provider acting on behalf of the member must
follow-up this call with a written request.
VIII (E)Reconsideration Date of submission of reconsideration request and
(Appeal) Of Eastpointe supporting documentation changed from seven to
Actions Taken Against twenty-one calendar days.
Providers (pg.61)
SECTION V (F)
Changed the number of unmanaged visits for
AUTHORIZATION,
children from the word(number) twelve(12) to the
word(number) sixteen(16).
UTILIZATION REVIEW,
CARE MANAGEMENT
AND BENEFIT PACKAGE
132
(pg.50)
9/20/13
Attachment B-Service
Type Section (pg.115)
11/12/13
Review Request of out
of compliance issues
(pg37)
7/9/14
Forensic Evaluations
Information added with 8-1-14 effective date
7/21/14
Forensic Evaluations
Typographical Errors Corrected
Changed the number of unmanaged visits for
children from the word twelve to the word
sixteen.
Added procedure
133