1. society
2. welfare
3. healthcare

PROVIDER MANUAL
1
SECTION I: INTRODUCTION AND OVERVIEW
Cardinal Innovations Healthcare Solutions
PROVIDER MANUAL
Comprehensive Update
January 2014
Table of Contents
SECTION I:
INTRODUCTION AND OVERVIEW .................................................................................................... 5
A.
B.
C.
WELCOME TO CARDINAL INNOVATIONS HEALTHCARE SOLUTIONS ..................................................................................6
CARDINAL INNOVATIONS HEALTHCARE SOLUTIONS – WHO WE ARE ..............................................................................6
THE CARDINAL INNOVATIONS HEALTHCARE SOLUTIONS MODEL ....................................................................................7
1.
Cardinal Innovations Financial Model ........................................................................................................7
2.
Cardinal Innovations: A Self-Managed System ..........................................................................................8
D.
CARDINAL INNOVATIONS PURPOSE, MISSION, VISION AND CORE VALUES .......................................................................8
E.
THE MEDICAID WAIVER: WHAT IS THE 1915 (B)/(C) MEDICAID WAIVER? .....................................................................9
F.
OPPORTUNITIES THAT A 1915(B)(C) WAIVER SYSTEM PRESENTS ...................................................................................9
G.
ABOUT THE NC MH/DD/SAS HEALTH PLAN ..........................................................................................................10
H.
ABOUT THE NC INNOVATIONS WAIVER ..................................................................................................................10
SECTION II:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
GOVERNANCE ....................................................................................................................................................12
OFFICE OF THE CEO............................................................................................................................................12
NETWORK OPERATIONS .......................................................................................................................................12
CLINICAL OPERATIONS .........................................................................................................................................13
ACCESS FUNCTIONS ............................................................................................................................................13
CARE MANAGEMENT FUNCTIONS ..........................................................................................................................14
QUALITY MANAGEMENT ......................................................................................................................................15
FINANCE AND REIMBURSEMENT ............................................................................................................................18
INFORMATION TECHNOLOGY (IT) ..........................................................................................................................19
CARE COORDINATION DEPARTMENT (CCD) ............................................................................................................21
COMMUNITY RELATIONS .....................................................................................................................................23
CONSUMER AFFAIRS ...........................................................................................................................................24
OFFICE OF MEDICAL AFFAIRS ................................................................................................................................26
STAKEHOLDER INVOLVEMENT IN CARDINAL INNOVATIONS SYSTEM MANAGEMENT .........................................................26
COMMUNITY ADVISORY COUNCILS ........................................................................................................................26
OPERATIONAL COMMITTEES .................................................................................................................................27
SECTION III:
A.
B.
C.
D.
E.
F.
G.
H.
I.
2
GOVERNANCE AND ADMINISTRATION .......................................................................................... 12
PROVIDER NETWORK .................................................................................................................... 28
THE CARDINAL INNOVATIONS PROVIDER NETWORK ..................................................................................................28
CULTURAL COMPETENCY OF THE NETWORK .............................................................................................................28
TYPES OF NETWORK PROVIDERS ............................................................................................................................29
LOCATION OF PROVIDERS .....................................................................................................................................33
QUALITY OF CARE...............................................................................................................................................33
PROVIDER COMMUNICATION ................................................................................................................................36
NETWORK COUNCILS: .........................................................................................................................................38
CODE OF ETHICS.................................................................................................................................................38
CHANGES IN STATUS ...........................................................................................................................................38
SECTION I: INTRODUCTION AND OVERVIEW
J.
K.
L.
M.
N.
O.
P.
Q.
R.
S.
T.
U.
R-CREDENTIALING - LICENSED INDEPENDENT PRACTITIONERS (LIPS) ............................................................................39
ALTERATION OF PRACTITIONERS’ CREDENTIALED STATUS ...........................................................................................40
ACTIONS AGAINST PRACTITIONER CREDENTIALING REPORTED TO EXTERNAL BODIES .......................................................41
PERFORMANCE PROFILE REVIEWS..........................................................................................................................41
APPLYING FOR ADDITIONAL SERVICES AND SITES ......................................................................................................42
HEALTH AND SAFETY SITE REVIEWS........................................................................................................................43
CARDINAL INNOVATIONS IMPLEMENTATION REVIEWS ...............................................................................................43
CARDINAL INNOVATIONS NETWORK DEVELOPMENT PLAN ..........................................................................................44
SPECIALTY PROVIDERS .........................................................................................................................................44
LICENSED INDEPENDENT PRACTITIONERS (LIPS) .......................................................................................................44
CLINICAL HOME FOR CONSUMERS .........................................................................................................................44
NETWORK DESIGN ..............................................................................................................................................45
SECTION IV:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
RIGHTS OF CONSUMERS.......................................................................................................................................47
CIVIL RIGHTS .....................................................................................................................................................48
INFORMED CONSENT...........................................................................................................................................50
ADVOCACY FOR CONSUMERS ................................................................................................................................50
PSYCHIATRIC ADVANCE DIRECTIVES (PAD) ..............................................................................................................50
CONFIDENTIALITY ...............................................................................................................................................51
SECOND OPINION ...............................................................................................................................................52
DECISIONS TO DENY, REDUCE, SUSPEND, OR TERMINATE A MEDICAID SERVICE ..............................................................53
RECONSIDERATION REVIEWS ................................................................................................................................53
NON-MEDICAID SERVICE GRIEVANCE PROCESS ........................................................................................................56
GRIEVANCES ......................................................................................................................................................57
CLIENT RIGHTS COMMITTEE (CRC) ........................................................................................................................57
CONSUMER AND FAMILY ADVISORY COMMITTEE (CFAC) ..........................................................................................58
SECTION V:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
CONSUMER RIGHTS AND EMPOWERMENT .............................................................................. 47
BENEFIT PACKAGE ......................................................................................................................... 60
ELIGIBILITY ........................................................................................................................................................60
WHO IS ELIGIBLE FOR THE MEDICAID WAIVERS?.......................................................................................................60
MEDICAID WAIVER DISENROLLMENT .....................................................................................................................61
ELIGIBILITY FOR STATE FUNDED SERVICES ................................................................................................................62
ELIGIBILITY FOR REIMBURSEMENT BY CARDINAL INNOVATIONS ....................................................................................62
ENROLLMENT OF CONSUMERS ..............................................................................................................................63
SPECIAL NEEDS POPULATIONS DESIGNED IN THE NC MH/DD/SAS HEALTH PLAN ..........................................................65
SERVICE ARRAY ..................................................................................................................................................65
HOSPITAL ADMISSIONS ........................................................................................................................................66
MEDICAID TRANSPORTATION SERVICES ..................................................................................................................66
SECTION VI:
CLINICAL DESIGN PLAN ............................................................................................................. 67
SECTION VII:
ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES ..................................................... 68
A.
B.
C.
D.
E.
F.
G.
H.
I.
K.
3
ACCESS UNIT DESCRIPTION ..................................................................................................................................69
ACCESS CALL CENTER PROCESS .............................................................................................................................70
ACCESS TO SERVICES ...........................................................................................................................................70
PROCESS FOR TELEPHONIC PRE-SERVICE-AUTHORIZATION..........................................................................................75
ENROLLMENT ....................................................................................................................................................77
INITIAL ASSESSMENT ...........................................................................................................................................79
INITIAL AUTHORIZATION ......................................................................................................................................79
ADDITIONAL AUTHORIZATION OF SERVICES..............................................................................................................84
DISCHARGE REVIEW ............................................................................................................................................85
UTILIZATION REVIEW ..........................................................................................................................................86
SECTION I: INTRODUCTION AND OVERVIEW
SECTION VIII:
A.
B.
C.
NC MH/DD/SAS HEALTH PLAN-1915 (B) WAIVER ................................................................................................88
NC INNOVATIONS WAIVER-1915 (C) ....................................................................................................................88
B (3) SERVICES ................................................................................................................................................... 88
SECTION IX:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
OFFICIAL COMMUNICATION ................................................................................................... 121
CARDINAL INNOVATIONS WEBSITE.......................................................................................................................121
OFFICIAL COMMUNICATION BULLETINS ................................................................................................................121
SECTION XIV:
4
RECONSIDERATION REVIEW PROCESS FOR PROVIDERS .......................................................... 119
RECONSIDERATION PROCESS...............................................................................................................................119
SECTION XIII:
A.
B.
STANDARDS AND REGULATORY COMPLIANCE ....................................................................... 112
INTRODUCTION ................................................................................................................................................112
QUALITY IMPROVEMENT ....................................................................................................................................112
PERFORMANCE MEASUREMENT ..........................................................................................................................113
PERFORMANCE MONITORING .............................................................................................................................113
CORPORATE COMPLIANCE ..................................................................................................................................116
MONITORING AND AUDITING .............................................................................................................................117
INVESTIGATION OF VIOLATIONS ...........................................................................................................................118
GENERAL MEDICAL RECORDS REQUIREMENTS/TREATMENT RECORDS STANDARDS .......................................................118
MANAGEMENT INFORMATION SYSTEMS ...............................................................................................................118
SECTION XII:
A.
GETTING PAID – FINANCE REQUIREMENTS ................................................................................... 97
ENROLLMENT AND ELIGIBILITY PROCESS..................................................................................................................99
AUTHORIZATIONS REQUIRED FOR PAYMENT ..........................................................................................................100
PAYMENT OF CLAIMS AND CLAIMS INQUIRIES ........................................................................................................101
SERVICE CODES AND RATES - CONTRACT PROVISIONS..............................................................................................104
STANDARD CODES FOR CLAIMS SUBMISSION .........................................................................................................104
DEFINITION OF CLEAN CLAIMS ............................................................................................................................104
COORDINATION OF BENEFITS ..............................................................................................................................104
SLIDING FEE SCHEDULE......................................................................................................................................105
RESPONSE TO CLAIMS .......................................................................................................................................106
FEE-FOR-SERVICE EQUIVALENCY (FFSE) ...............................................................................................................106
CLAIMS INVESTIGATIONS – ABUSE AND FRAUD.......................................................................................................107
REPAYMENT PROCESS/PAYBACKS ........................................................................................................................108
REVIEW AND DETERMINATION PROCESS ...............................................................................................................109
SECTION XI:
A.
B.
C.
D.
E.
F.
G.
H.
I.
RESOURCES FOR PROVIDERS .................................................................................................... 89
TRAINING AND TECHNICAL ASSISTANCE ..................................................................................................................89
ADVOCACY: .......................................................................................................................................................89
ASSOCIATIONS ...................................................................................................................................................89
BEHAVIORAL HEALTHCARE RESOURCES ...................................................................................................................91
CONSUMER AND FAMILY RESOURCES .....................................................................................................................92
CULTURAL COMPETENCE .....................................................................................................................................92
DEVELOPMENTAL DISABILITIES ..............................................................................................................................94
FEDERAL GOVERNMENT.......................................................................................................................................95
GRANTS AND RFPS ............................................................................................................................................95
NORTH CAROLINA STATE LINKS .............................................................................................................................96
OTHER STATE LINKS ............................................................................................................................................96
SECTION X:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
N.
STATE SERVICE DEFINITIONS AND CRITERIA ............................................................................. 88
GLOSSARY OF TERMS ............................................................................................................. 123
SECTION I: INTRODUCTION AND OVERVIEW
SECTION I:
INTRODUCTION AND OVERVIEW
Cardinal Innovations
Quality Driven. Solution Focused. Member Inspired.
A Message from Pam Shipman, the CEO of Cardinal Innovations:
Over the past year, Cardinal Innovations Healthcare Solutions expanded from five to 15
counties, doubling the number of people that we serve, and quadrupling our Provider Network.
We adopted a name that reflects our new identity. Cardinal Innovations Healthcare Solutions
(Cardinal Innovations) comes from consumer stakeholder groups that named the Medicaid
waivers. The Medicaid waivers have been expanded statewide, and the Department of Health
and Human Services has adopted new names. We have retired the PBH name and reclaimed
the original names of the waivers incorporating them into our new name.
Welcome to our new Providers! We need strong Providers that are committed to the principles
of respect, quality, diversity, recovery and self-determination. We look forward to working with
all of you that share our commitment, and that will work with us to make this vision a reality.
Our new Providers are joining a group of Providers that have been with us for the past eight
years. Our efforts have been guided by their advice and supported by their patience.
What you will receive from us is respect, appreciation, engagement, transparency, and trust.
We ask for reciprocity. We offer you our best efforts to support you in your efforts to provide
quality care to those whose care is our responsibility. We will not succeed without you.
We are proud to be a public authority under North Carolina law. Our role is to implement public
policy that organizes and manages the delivery of community and institutional services for
people with mental health, intellectual/developmental disabilities and substance use
conditions. We have many customers and many stakeholders. It is widely recognized that
mental illness, substance use, addictions, and intellectual and developmental disabilities occur
in every family, and that individuals with these conditions and their families need support from
their communities. Our role is both to offer specialized supports and to locate and leverage
generic community services on behalf of people with disabilities. We want to serve people in
the least restrictive settings possible.
With the expansion of health coverage through the Affordable Care Act, the future is bright, but
laden with challenges. We must work together to meet these challenges, and to realize the
possibilities of healthcare reform. We have an unprecedented opportunity to influence the
system of community care in ways that will make it better for the people we serve.
Pamela L. Shipman
CEO
5
SECTION I: INTRODUCTION AND OVERVIEW
A. Welcome to Cardinal Innovations Healthcare Solutions
As a Network Provider for Cardinal Innovations, Local Management Entity/Managed Care
Organization (LME/MCO), you join a progressive group of Providers, dedicated to providing
quality care for North Carolina consumers residing in Alamance, Cabarrus, Caswell,
Chatham, Davidson, Franklin, Granville, Halifax, Orange, Person, Rowan, Stanly, Union,
Vance, and Warren counties. Cardinal Innovations Healthcare Solutions, its contractors and
employees, do not discriminate on the basis of race, color, national origin, sex, religion, age
or disability in the provision of services. Cardinal Innovations welcomes you to join in our
mission to help people with disabilities and special needs improve the quality of their lives.
As a contracted Provider of Cardinal Innovations, it is your responsibility to be familiar with
and adhere to the policies and procedures outlined in this Manual as well as Provider
communication bulletins disseminated exclusively and via the InfoSource Newsletter
publications regarding business updates that occur in the interim of annual Provider Manual
updates. See http://www.cardinalinnovations.org/providers/bulletins.asp (communication
bulletins); http://www.cardinalinnovations.org/providers/InfoSource.asp (InfoSource).
Compliance with such is necessary to fulfill your contractual obligations in providing
services. The Manual begins with the program’s history, mission, vision, and core values,
and describes our policies and procedures from referrals and authorizations to claims
submission and problem resolution. We have also included a glossary of frequently used
terms for your reference and copies of or links to all necessary forms. Your adherence to
these guidelines will assist Cardinal Innovations in providing you with timely service
authorizations and claims reimbursement.
Cardinal Innovations reserves the right to periodically update its organizational structure,
policies and procedures, and other information contained in this manual, and will strive to
notify you of any changes and how they may affect you as far in advance as possible. Please
refer to Communications Bulletins, InfoSource, and periodic updates on our website
(www.cardinalinnovations.org) to ensure you have the most up-to-date information.
We thank you for your participation in our Provider Network, and we look forward to a long
and rewarding relationship as we work together to provide responsive treatment to the
people we both serve.
B. Cardinal Innovations Healthcare Solutions – Who We Are
Cardinal Innovations started as a one-room mental health clinic in the Cabarrus County
Health Department in 1960. We became Piedmont Mental Health, Mental Retardation, and
Substance Abuse Area Program in July 1974 serving Cabarrus, Stanly and Union Counties.
Today, Cardinal Innovations is an LME/MCO (a multi-county area program) serving
Alamance, Cabarrus, Caswell, Chatham, Davidson, Franklin, Granville, Halifax, Orange,
Person, Rowan, Stanly, Union, Vance, and Warren counties with a population of over
6
SECTION I: INTRODUCTION AND OVERVIEW
1,152,458 people spread over 5,832 square miles.
Multi-county Area Programs are political subdivisions of the State of North Carolina
established and operating in accordance with NC General Statute 122C (G.S. 122C-116). The
Secretary of the North Carolina Department of Health and Human Services is charged with
the administration and enforcement of General Statute 122C (G.S.-112.1), which specifies
the legal responsibilities and authority of Area Programs regarding the provision of
community services (G.S. 122C-117). General Statute 122C also specifies the role and
responsibilities of county governments in determining the governance structure and
developing Boards of Directors to manage Area Programs. The State Plan requires Area
Programs to be certified as Local Management Entities through State Approval of the Local
Business Plan (G.S. 122C-115.2). Cardinal Innovations was initially certified by the
Department of Health and Human Services as an LME, effective July 1st, 2003 and remains
certified.
Cardinal Innovations is one of ten LME/MCOs in North Carolina, which are all responsible
for managing a system of care for people with mental health, intellectual/developmental
disability, and substance use/addiction service needs, including operation of a Medicaid
1915 (b) (c) managed care waiver.
C. The Cardinal Innovations Healthcare Solutions Model
One of the major objectives of our model is the alignment of financial incentives with our
values, public policy, best practices and the achievement of positive consumer outcomes.
The core principles upon which our model is based, includes consumer empowerment, best
practice implementation, partnerships with Providers, and extensive community
collaboration with citizens, advocates, and community agencies. Cardinal Innovations is
committed to a strategic partnership with the Department of Health and Human Services,
the Division of MH/DD/SA Services, and the Division of Medical Assistance in the use of
public resources to achieve a state of the art community system of care.
The Cardinal Innovations Model is based on a highly organized clinical design, which is
implemented by a Provider Network that has the competency required to deliver quality
evidence based practices.
1. Cardinal Innovations Financial Model
The financial model uses funds strategically to meet the needs of individuals with
mental health, intellectual/developmental disability and substance use/addiction issues.
The model includes all public resources (e.g., state, county and federal) that are
managed for optimal services and efficiency as a single continuum of care. Our goal is to
move the system away from high-cost and institutional use, to a community-based
7
SECTION I: INTRODUCTION AND OVERVIEW
system that uses best practice approaches to services and supports across all
disabilities.
The Medicaid Managed Care Waiver, named the NC MH/DD/SAS Health Plan (1915 (b)
Medicaid Waiver), http://www.ncdhhs.gov/dma/services/piedmont.htm, and the NC
Innovations
Waiver
(1915(c)
Medicaid
Waiver),
http://www.cardinalinnovations.org/Innovations/index.asp, are especially important in
supporting our goals of redirecting services into more efficient, best practice models of
intervention. Capitation supports the type of creative financial flexibility necessary in a
consumer driven system of care. One of the advantages of the Medicaid Waiver has
been the development of additional Medicaid funded services and supports through
Medicaid
1915(b)
3
authority.
For
more
information,
see
http://www.pbhsolutions.org/consumerfamily/docs/PBH%20Waiver%20Expansion%20F
AQs%2020111219.pdf. The Medicaid (b) 3 services are based on evidence based
practices which support achievement of positive outcomes for people with needs in the
areas of behavioral health and developmental disabilities. These (b)(3) services provide
additional tools needed to reduce reliance on high cost institutional and facility care and
offer a greater range of community services.
2. Cardinal Innovations: A Self-Managed System
A self-managed system relies on educated Providers who understand and operate in
tandem with Cardinal Innovations Clinical Objectives and the Clinical Design Plan. Our
goal is to develop a system where the structure, requirements and expectations are so
well known, that extensive management and intervention by Cardinal Innovations is not
required. This model includes the engagement of our Providers in the management of
the system and relies on their involvement in the development of strategies to meet
quality and performance goals and develop solutions for systemic problems. Provider
participation in the ongoing operations of the Cardinal Innovations system is critical for
the efficient and effective implementation of strategies that will ensure success in
achieving our goals. Our joint purpose is to assure easy access, appropriate, high quality
services for consumers, and the elimination of ineffective and poor outcome services
and practices.
D. Cardinal Innovations Purpose, Mission, Vision and Core Values
Purpose:
To enhance the health and well-being of individuals and their families.
Mission:
We create and manage quality solutions for people who depend on the public system for
care.
8
SECTION I: INTRODUCTION AND OVERVIEW
Vision:
A community where each person is welcomed, respected and valued.
Core Values:
Accountability:
We are responsive, fair and reasonable.
Integrity:
We uphold the highest ethical standards.
Excellence:
We are the best at what we do.
Partnership:
We honor, trust and empower others.
Courage:
We are unwavering in our commitment to the greater good.
E. The Medicaid Waiver: What is the 1915 (b)/(c) Medicaid Waiver?
The 1915 (b)(c) Medicaid Waiver program is a pre-paid health insurance plan (PIHP) funded
by Medicaid. Through the waiver, Medicaid MH/DD/SA services for individuals with
Medicaid originating from Cardinal Innovations’ catchment area are covered by Cardinal
Innovations and services are provided through the Cardinal Innovations Provider Network.
The 1915(b)/(c) Medicaid Waiver program is a combination of two types of waivers: a
1915(b) waiver, generally known as a Managed Care/Freedom of Choice Waiver, and a
1915(c) waiver, generally known as a Home and Community Based Waiver. Through the
1915(b) section of the Social Security Act, States are permitted to submit a request to waive
some Medicaid requirements in order to provide alternatives to the traditional fee for
service system of care. Likewise, through the 1915 (c) section of the Social Security Act,
States are permitted to submit a request to waive some Medicaid requirements in order to
provide alternatives to institutional care. Both waivers are approved under different Federal
Medicaid Regulations and require different reporting and oversight. This type of waiver
system is not intended to limit care or choice but to create an opportunity to work closely
with consumers and Providers on better coordination and management of services,
resulting in better outcomes for consumers and more efficient use of resources.
F. Opportunities that a 1915(b)(c) Waiver System presents
In order to encourage:


9
Coordination - The waiver allows for better coordination of a system of care for
consumers, families and Providers.
Efficient Management of limited public resources - We are able to manage all system
resources so that money can be directed to services most appropriate for identified
consumer needs.
SECTION I: INTRODUCTION AND OVERVIEW

Flexibility in services offered - We have developed a more complete range of services
and supports through Medicaid b (3) authority in order to reduce and redirect reliance
on high cost institutional and hospital care.
G. About the NC MH/DD/SAS Health Plan






This waiver applies to consumers with Medicaid that originates from any of our
counties: Alamance, Cabarrus, Caswell, Chatham, Davidson, Franklin, Granville, Halifax,
Orange, Person, Rowan, Stanly, Union, Vance and Warren.
All Medicaid consumers enrolled in specified eligibility groups (such as Aged, Blind and
Disabled) will automatically be enrolled into this plan for their mental health,
developmental disability, and substance abuse service needs.
The services that are available include current NC State Mental Health Plan Medicaid
services.
Cardinal Innovations has partnered with the state to create additional services, not
covered in the State Plan, called (b) (3) services.
Consumers are able to choose from any Provider in Cardinal Innovations’ Network that
is contracted to provide the service they need.
Information and education will be provided to consumers to help them choose
Providers.
Access to care is made easier through Cardinal Innovations’ Access Center. See
http://www.pbhsolutions.org/consumerfamily/provider.asp
H. About the NC Innovations Waiver
The NC Innovations waiver is a Home and Community Based Waiver 1915 (c). This is a
waiver of institutional care.
This waiver incorporates the essential elements of Self-Direction, Person Centered Planning,
Individual Budgets, Participant Protections and Quality Assurance. The waiver supports the
development of a stronger continuum of services that enable individuals to move to more
integrated settings. People served and their families have the information and opportunity
to make informed decisions about their health care and services, and exercise more control
over decisions regarding services and supports. The NC Innovations Waiver has both a
Provider
Directed
and
Individual/Family
Directed
track.
See
http://www.pbhsolutions.org/consumerfamily/innovations.asp. In the Provider Directed
track, the services are delivered in a traditional manner with consumers and family
members selecting the Providers they believe can best meet their needs. Participants and
their families may choose from two models of Individual/Family Directed services, Employer
of Record or Agency with Choice. In the Employer of Record Model, the staff are hired,
directed and paid by the NC Innovations participant/legally responsible person with the
assistance of a Community Guide and a Financial Supports Agency. In the Agency with
10
SECTION I: INTRODUCTION AND OVERVIEW
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. A consumer or
guardian/family member can choose Provider Directed, Individual /Family directed or a
combination of both options.
11
SECTION II: GOVERNANCE AND ADMINISTRATION
SECTION II:
GOVERNANCE AND ADMINISTRATION
A. Governance
Cardinal Innovations is a political sub-division of the state under G.S. 122C. The Cardinal
Innovations Board is a governance board, and focuses on establishing and monitoring goals
as well as the development of public policy. The CEO reports to the Board, and all other
staff of Cardinal Innovations report to the CEO.
B. Office of the CEO
This unit is responsible for the overall management of Cardinal Innovations. The Executive
Management unit strives to maintain strong working relationships with local and state
partners including local public agencies, Providers, public officials, elected officials,
advocacy organizations as well as state and regional staff. In its scope of responsibilities,
Cardinal Innovations Executive Management includes management of operations,
performance outcomes, and achievement of goals and direction of financial resources to
achieve desired outcomes.
C. Network Operations
Network Operations is responsible for the development and maintenance of the Provider
Network to meet the needs of consumers, ensuring access, choice and best practices in
services. The Network Operations administrative unit is responsible for overall Network
management, monitoring the availability of Providers to meet consumer demand, data
analysis, Provider demographics, enrollment, credentialing, best practices and contract
development.
Your responsibility as a Cardinal Innovations Contracted Provider is:








12
to provide services for which your company is qualified/credentialed/enrolled to
provide
to be responsive to the cultural and linguistic needs of the consumers your company
serves
to provide services only at endorsed service sites as outlined in your contract
to obtain authorizations as required for contracted services
to adhere to all performance guidelines in your contract and work to meet the needs of
consumers through best practice approaches to treatment and supports
to work in collaboration with other Providers, consumers and families
to work in a solution focused and collaborative basis within the Cardinal Innovations
Network
to work with Cardinal Innovations to mediate problems and concerns
SECTION II: GOVERNANCE AND ADMINISTRATION

to stay abreast of policy changes and company updates via information disseminated in
communication bulletins and weekly InfoSource Newsletter publications.
Cardinal Innovations’ responsibilities to providers are:










to actively recruit Network Providers that share our mission and vision
to support the development of best practices or emerging best practices
to identify gaps in Network services/capacity and develop a strategy to develop those
services through existing Providers or by recruiting new Providers for the Network
to respond to requests for applications for Network enrollment according to the needs
for additional provider capacity
to update this Provider Manual annually to reflect changes in requirements
to provide periodic updates to this Provider Manual through communications bulletins,
InfoSource, and other methods as appropriate and as items in this manual may change;
to credential and re-credential Providers and re-qualify agencies and facilities
to assign a Network Specialist for each Network Provider as a resource for technical
assistance
to keep Network Providers informed through Provider meetings, disability specific focus
or Provider groups, and coordination of local training, and the Provider page on the
website http://www.cardinalinnovations.org/providers/
to identify training needs of Providers and if possible facilitate or provide the training
D. Clinical Operations
The Clinical Operations Department manages the Cardinal Innovations Access system,
including an Access Call Center, Clinical Support Unit, and a Utilization Management/
Utilization Review Unit. The Clinical Operations Department conducts authorization and
care management functions, performs Utilization Management and Utilization Review
activities, as well as coordinates the crisis response system. The Department defines review
dates, completes concurrent and retrospective reviews, and responds to appeals.
Additionally, the Department researches utilization trends, identifies areas for further study
and review, and develops Clinical Guidelines and written protocols. This unit supports the
Clinical Advisory Committee. The Medical Director oversees all clinical activities performed
in
the
Clinical
Operations
Department.
See
http://www.cardinalinnovations.org/um_access/
and
http://www.cardinalinnovations.org/providers/resources.asp.
E. Access Functions
Cardinal Innovations maintains a telecommunications system with 24 hours per day, 7 days
per week access to an intake worker in the Access Unit, with clinical backup by a licensed
clinician. Access to care for consumers is a critical function of the Clinical Operations
Department. Cardinal Innovations is responsible for timely response to the needs of
consumers and for quick linkages to qualified Providers of the Network through a toll free
13
SECTION II: GOVERNANCE AND ADMINISTRATION
number and secure electronic enrollment system. The Access Unit also provides critical
monitoring and follow-up of referrals to ensure people receive the care they need.
F. Care Management Functions
The Care Management Unit determines whether a consumer meets and continues to meet
medical necessity criteria and target population requirements for the frequency, intensity
and duration of requested services. Our goal is to ensure that consumers receive the right
service; at the right time; at the right level; creating the most effective and efficient
treatment possible. This work is accomplished through consistent and uniform application
of Medical Necessity criteria as well as Cardinal Innovations’ Clinical Criteria as defined in
the Clinical Guidelines. Authorization decisions are made according to each consumer’s
individual clinical needs for the appropriate type of care, service, frequency of services,
intensity of services, in the appropriate clinical setting. UM Care Managers assist the
Provider in managing a consumer’s care needs and identification of appropriate services.
14

Utilization Management (UM):
The primary function is to make authorization decisions by conducting initial,
continuing, discharge and retrospective reviews of services based on Medical
Necessity criteria for the frequency, intensity and duration of the service
request. Utilization Management is the process of evaluating the necessity,
appropriateness, and efficiency of behavioral health care services against
established guidelines and criteria. Utilization Management includes activities
such as ongoing evaluation of timeliness to care, as well as analysis of
utilization patterns to monitor for both under and over utilization, gaps in care
and unnecessary use of restrictive service models.

Utilization Review (UR)
The primary function is to monitor the utilization of services and review service
notes and treatment plans to evaluate and ensure that services are being
provided appropriately in accordance with Treatment Plans, Service
definitions, established benchmarks and clinical guidelines; that services are
consistent with the authorization and approved Person Centered Plan (“PCP”),
Individual Support Plan (“ISP”) or treatment plan; and that the service
continues to meet the needs of the consumer. Utilization review is an audit
process that involves a review of a sample of services that have been provided.
Information from the consumer’s record (assessment information, treatment
plan and progress notes) is evaluated against Medical Necessity Criteria. This is
done concurrently (during re-authorization) and retrospectively (after the
service has been provided). The outcome of this review can indicate services
that were provided that did not meet Medical Necessity, and situations where
the consumer did not receive appropriate services or care that was needed.
Indicators will be identified to select cases for review, such as high utilization of
service, frequent hospital admissions, as well as random sampling. Cardinal
Innovations conducts both focused reviews and routine reviews.
SECTION II: GOVERNANCE AND ADMINISTRATION
 Focused Reviews target specific clinical concerns that are identified as
having the potential to be outside the norm according to utilization data
and use of emergency services. Focused reviews samples may include:
 High-risk consumers - Examples may include, but are not limited to,
consumers who have been hospitalized more than one time in a 30-day
period; consumers with intellectual and developmental disabilities that
are identified as having community safety risks; ; children and youth
that are involved with law enforcement;; or active substance use by a
pregnant female.
 Under-utilization of services – Examples may include, but are not
limited to, consumers who utilize less than 70% of an authorized service
or consumers who have multiple failed appointments.
 Over-utilization of services – Example: consumers who continue to
access crisis services with no engagement in other services.
 Services infrequently utilized – Example: an available practice that is
not being used.
 High-Cost Treatment – Consumers in the top 10% of claims for a
particular service.
 Routine Utilization Review will focus on the efficacy of the clinical
processes in cases as they relate to reaching the goals in the consumer’s
PCP / treatment plan. Cardinal Innovations will also review the
appropriateness and accuracy of the service provision in relation to the
authorizations. All Providers contracted with Cardinal Innovations who are
currently serving Cardinal Innovations consumers are subject to Utilization
Reviews to ensure that clinical standards of care and medical necessity are
being met.
The criteria used in the Utilization Review processes will be based on the most current
approved guidelines and service manuals utilized under the NC MH/DD/SAS Health Plan
and NC Innovations Waivers and processes for NC State services. These documents
include, but are not limited to, the current NC Medicaid State Plan service definitions
with Admission, Continuation, and Discharge criteria; NC Innovations Service
Definitions, IPRS Service definitions, the Cardinal Innovations approved Clinical
Guidelines; the current approved NC MH/DD/SAS service records documentation rules;
the current approved NC DMA Clinical Coverage policy.
G. Quality Management
The Quality Management Department (QM) has oversight for quality assurance and
improvement activities throughout the Cardinal Innovations system. The department
supports a Global Continuous Quality Improvement system that includes all Network
15
SECTION II: GOVERNANCE AND ADMINISTRATION
Providers. QM provides training to the Provider Network on standards, requirements,
quality improvement, indicators and targets, client rights, health and safety and other
critical areas of performance as needed. The department provides monitoring information
to the Client Rights Committee and tracks, evaluates, and investigates incidents. QM also
implements a system of review, monitoring and investigation. The Cardinal Innovations
Provider/Practitioner Performance Profiles (Gold Star Process) are a part of the monitoring
and review activities completed by QM. The review process is based on targeted quality
initiatives for Provider/practitioner performance. The following resource links are provided
for further guidance:
http://www.cardinalinnovations.org/QM/
http://www.pbhsolutions.org/outcomes/
Your responsibility as a Cardinal Innovations Contracted Provider is to:








16
Cooperate fully with any review, investigation, complaint inquiry/follow-up and audit.
Provide to Cardinal Innovations requested records and documentation needed to
resolve issues. All requested information should be provided within the timeframe
specified. The timeframe will vary based on the circumstances.
Maintain systems, procedures and documentation that demonstrates compliance with
all applicable federal, state and local rules, laws and practices, including:
1. Conducting self-monitoring activities for compliance;
2. Developing and implementing, within given timelines, plans of corrections and/or
making paybacks with any area found out of compliance during Cardinal Innovations
monitoring activities.
Maintain internal systems, procedures and documentation that demonstrate
compliance with Cardinal Innovations requirements as outlined in the contract and this
Manual. Conduct self-monitoring activities for compliance and develop/implement plans
of correction for any area of non-compliance identified.
Comply with North Carolina state rules for service records, confidentiality and record
retention..
Ensure all billing submitted for payment is supported by documentation that meets all
requirements.
Conduct
self-monitoring
activities
for
compliance
and
develop/implement plans of correction for any areas of non-compliance identified. Selfinitiate paybacks for services billed in error or without supporting documentation.
Notify Cardinal Innovations of any concerns you have in regards to our actions.
Collaborate with Cardinal Innovations on the development of solutions to issues.
Participate in ongoing training opportunities as applicable. Maintain services at an
optimal level to meet consumer needs by providing services in accordance with Cardinal
Innovations Practice Guidelines.
Develop and implement a system of continuous quality improvement which includes, at
a minimum, the development of systems to self-evaluate services, systems to evaluate
data collected and identify needed areas of improvement, implement strategies to
address areas of improvement and continual evaluation and refinement of processes.
SECTION II: GOVERNANCE AND ADMINISTRATION



Develop/implement systems to assess services to ensure consumers are benefiting from
the services provided.
Submit documentation for all incidents including requested follow-up documentation,
as defined by state rules, to Cardinal Innovations within given timelines. Cooperate fully
with needed follow up from Cardinal Innovations.
Notify Cardinal Innovations immediately of any Type A or Type B
citations/violations/sanctions from the Division of Health Services Regulation.
Cardinal Innovations’ responsibility to Providers is to:










17
Evaluate new applicants for enrollment in the Cardinal Innovations Provider Network
and determine the Provider’s qualifications for enrollment.
Conduct on-site monitoring (if applicable) of Providers to ensure appropriate
implementation of services, consumer health and safety, consumer satisfaction, positive
outcomes for consumers and compliance with provisions of the Provider’s contract.
Conduct routine auditing of Provider documentation in relation to appropriateness and
accuracy of information submitted for authorizations and payment.
Ensure Provider/practitioner compliance with treatment record standards and
confidentiality practices and follow-up on any out of compliances or concerns regarding
these areas.
Implement the Cardinal Innovations Corporate Compliance Plan and activities related to
ensuring Cardinal Innovations staff compliance with rules, laws and regulations. Ongoing
monitoring of systems within Cardinal Innovations and the Network at large to monitor
for fraud and abuse.
Coordination of a system of continuous quality improvement for Cardinal Innovations
and the Network that includes ongoing evaluation and planning in relation to needed
areas of improvement in the service delivery system.
Review, mediate and/or investigate concerns received regarding the quality of services
provided by any Provider. Ensure appropriate corrections are completed if needed.
Review critical incidents that occur within the Network. Ensure that all appropriate
follow up has been completed and that the rights of consumers have been protected.
Monitor data from across the Network and evaluate for trends and patterns.
Ensure publication and availability of the review and monitoring standards for the
Cardinal Innovations Provider/Practitioner Performance Profile (Gold Star Process).
Review any Type A or Type B citations/violations/sanctions a Provider may receive from
the Division of Health Service Regulation and determine the impact of the citations/
violations/sanctions on the consumers served by the Provider. The Cardinal Innovations
Network Operations Cross Functional Team or Credentialing Committee will review the
citations/ violations/sanctions and make determinations regarding the Provider’s
eligibility for continued service delivery for Cardinal Innovations consumers.
SECTION II: GOVERNANCE AND ADMINISTRATION
H. Finance and Reimbursement
The Finance Department manages the financial resources of the LME/MCO. This includes
management of availability of funds, claims processing and payment. The Finance
Department is responsible for ensuring compliance with General Statute 159 (The Local
Government Fiscal Control Act) and other general accounting requirements. The Finance
Department supports Providers through training and through its Claims Specialist
representatives. See http://www.cardinalinnovations.org/finance/.
Your responsibility as a Cardinal Innovations Contracted Provider is to:








Verify consumer insurance coverage at the time of referral; or
o admission; or
o each appointment; and
o on a quarterly basis
Determine the consumer’s ability to pay using the Sliding Fee Schedule for all
designated non-Medicaid services based on your Agency’s contract requirements.
Bill all first and third party payers prior to submitting claims to Cardinal Innovations.
Report all first party required fees and third party payments and denials on the claim
you submit to Cardinal Innovations.
Submit Clean Claims electronically within ninety (90) days of the date of service unless
otherwise stated in your contract.
Identify all billing errors to the Cardinal Innovations Finance Department.
Manage your Accounts Receivable to prevent unnecessary rebilling of services paid.
Submit all documentation which is required for federal, state, or grant reporting
requirements. This includes, but is not limited to, required consumer enrollment
demographics that must be reported to the State of North Carolina by Cardinal
Innovations.
Cardinal Innovations’ responsibility Providers is to:










18
Certify funding for all contracts in accordance with G.S. 159. The Finance Department
will review and approve all financial commitments made by Cardinal Innovations.
Assign and monitor maximum funding for contracts.
Monitor grant funds.
Monitor retroactive Medicaid eligibility and recovery of funds.
Manage claims processing to achieve timely payment for Providers.
Issue payments and Remittance Advices (RA’s) on paid and denied claims.
Assist the Quality Management Unit with review of financial reports, financial
statements, audits and accounting procedures.
Recover funds paid in error or identified as non-compliant based on audit findings.
Audit Providers for Coordination of Benefits (COB).
Pay clean claims within Prompt Pay Guidelines.
SECTION II: GOVERNANCE AND ADMINISTRATION
I. Information Technology (IT)
The Cardinal Innovations information system must support both consumers and Providers.
A secure web based portal called Provider Direct is available for Providers to enroll new
consumers, update current consumer information, submit treatment authorization
requests, upload crisis plans, submit billing, and review status of claims submitted. See
https://www.pbhcare.org/PP/PDirectCI/PD_Login.aspx. This supports all Providers in their
billing and only requires the use of a personal computer and high speed internet
connection. Providers may elect to submit their claims using the HIPAA Standard Electronic
Transaction Sets. This can be accomplished in two ways: first through the web portal in
Provider Direct (PD) or by using a secure FTP with Cardinal Innovations. If a Provider elects
to submit their claims through a clearinghouse, a Cardinal Innovations Provider can enter an
agreement with EMDEON to submit their billing for them. Cardinal Innovations will respond
electronically to all HIPAA EDI transactions.
Cardinal Innovations depends on updated and accurate information on each Network
Provider’s services and capabilities to update our files and provide information to
consumers requesting services.
Below is a summary of the critical functionalities that our Cardinal Innovations (CI)
Information System provides:



19
The CI system has a module called Provider Direct that is a web portal for Providers to
search for consumers, enroll new consumers, update consumer information, submit
treatment authorization requests (TARs), view authorization letters, work with the
registry of unmet needs, and submit billing for processing. The TAR is reviewed and can
be approved or sent back to the Provider for revision through the CI system.
Authorization/Denial letters are sent to the Provider download section in Provider
Direct, where Providers can access them through a secure connection to their
“mailbox”.
All Cardinal Innovations claims must be submitted electronically. Providers can send
standard HIPAA compliant transaction claims, or they can use the Cardinal Innovations
web based billing system and enter their claims directly.
All calls to Cardinal Innovations are answered by a “live” person. When a client or
family member calls our toll free Access Center, the Access Coordinator or Access
Clinician uses the CI system to log the call, gather information on the consumer and
their problems and concerns. The Access staff is able to assess the consumer’s needs
and then offer the consumer/family Provider options based on the consumer’s
preferences and the service needed. Unless the consumer prefers to make their own
arrangements, the Access Coordinator or Clinician will contact the Provider while the
consumer is on the line and assist in scheduling an appointment. A
Screening/Triage/Referral (“STR”) number is given to the Provider so they can pull up
the clinical information in the Provider Direct system. If a Provider does not have access
SECTION II: GOVERNANCE AND ADMINISTRATION
to Provider Direct, Access Staff will send information to the Provider via secure fax.
NOTE: This process may not be able to be followed for Substance Abuse (“SA”) referrals
due to restrictions in release of SA information covered under 42 CFR Part 2
Confidentiality regulations. In cases where referrals are made for Substance Abuse
services, the consumer or caller will be given the contact information for the
appropriate Service Providers or linked to the Provider though a warm transfer.

The CI system manages enrollments, call center, treatment requests, authorizations,
claim submissions and payments for approved services. The CI system also interfaces
with our accounting system. Exchanges between these systems allows for information
on approved claims to be processed for payments to Provider agencies. It then returns
the payment information back to CI to allow the system to generate electronic
remittance advices (RAs) and 835s for Providers who have submitted HIPAA EDI
transactions.
Cardinal Innovations continues to develop the CI system to refine and enhance its
capabilities to support our changing business operations. Refer to your Provider Direct
Manual that is accessible within Provider Direct using the training link for up to date
information on system enhancements to Provider Direct.
Complete and accurate data is critical for Cardinal Innovations reporting to the State.
Cardinal Innovations is dependent upon our Providers to collect and report this data to us.
Your responsibility as a Cardinal Innovations Contracted Provider is to:



Have and maintain high speed Internet connectivity.
Always provide complete and accurate data in all submissions to Cardinal Innovations.
Follow technical support procedures as identified by Cardinal Innovations.
Cardinal Innovations’ responsibility to Providers is to:




20
Maintain the server that provides interface for the functions of Provider Direct
Provide Help Desk technical assistance to support Provider interface
o Helpdesk Hours M-F 8:30am – 5:00pm
o [email protected]
o 704-939-7773
Provide regular training for new Providers on Provider Direct
Maintain updated training manual/materials located in the Training Materials Option
from the Client Gateway of Provider Direct
SECTION II: GOVERNANCE AND ADMINISTRATION
J. Care Coordination Department (CCD)
The Cardinal Innovations Care Coordination Department provides care coordination to
Special Needs Populations as defined in the 1915(b)(c) waivers.. Care Coordinators manage
care 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
and make the best use of resources. This is both a risk management and quality
management function, which has a significant impact on both the management of
resources
and
the
quality
of
care
for
an
individual.
http://www.cardinalinnovations.org/CareCoordination/.
Special Populations are defined as follows:
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 tool that is designed to proactively intervene and ensure optimal care for Special
Needs Populations.
Intellectual/Developmental Disabilities:
Individuals who are functionally eligible for, but not enrolled in, the NC Innovations waiver,
or who are not living in an ICF-MR facility
OR
Individuals with an intellectual or developmental disability diagnosis who are currently, or
have been within the past 30 days, in a facility operated by the Department of Correction
(DOC) or the Department of Juvenile Justice and Delinquency Prevention (DJJDP) for whom
the LME/MCO has received notification of discharge.
Child Mental Health:
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
995.5-995.59
V61.21
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 DJJDP or DOC for whom the LME/MCO has received notification of
discharge.
21
SECTION II: GOVERNANCE AND ADMINISTRATION
Adult Mental Health:
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:
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:
a. Individuals with both a mental illness diagnosis and a substance abuse diagnosis
AND a current LOCUS/CALOCUS of V or higher, OR current ASAM PPC Level of III.5 or
higher
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
Your responsibility as a Cardinal Innovations Contracted Provider for people receiving
Care Coordination is to:




22
Actively participate in a person centered planning process with others serving the
individual to develop a comprehensive Person Centered Plan
Development of treatment and/or habilitative programs that are in accordance with
the Person Centered Plan
Communicate with the Care Coordinators about the needs of individuals that you
support
Notify the Care Coordinator of any changes, incidents, other information of
significance related to the consumer that you serve
SECTION II: GOVERNANCE AND ADMINISTRATION
Cardinal Innovations’ responsibility to Providers is to conduct the following activities
for consumers that are receiving Care Coordination:




Assessment: IDD Care Coordinators will complete or arrange for needed
assessments to identify support needs and to facilitate person centered planning
processes. MH/SA Care Coordinators will complete or arrange for needed clinical
assessments for individuals that have special health care needs in order to identify
any ongoing special conditions that require treatment or monitoring.
Ensuring the Development of a Person Centered Plan: IDD Care Coordinators will
develop the Person Centered Plan for NC Innovations Waiver participants in
collaboration with the individual and his/her support team. For other individuals, the
IDD Care Coordinator will ensure that a Person Centered Plan is developed. MH/SA
Care Coordinators will ensure that a Person Centered Plan is developed by the
Behavioral Health Clinical Home, such as a CCC or ACTT Provider. (Person Centered
Plans should be completed by the designated Provider of an enhanced service.)
Treatment Planning Care Coordination: Both IDD and MH/SA Care Coordinators will
coordinate services for individuals that have been identified as needing assistance to
access the care that they need; activities will involve working across the Cardinal
Innovations Network and with other systems of care, including Primary Care.
Monitoring: IDD Care Coordinators will complete on site visits for NC Innovations
Waiver participants to monitor the health and safety of the individual, to assess the
satisfaction of individuals served, and to monitor implementation of the Person
Centered Plan.
K. Community Relations
The Community Operations Centers are responsible for Community Relations and
collaboration with local organizations, public agencies and community stakeholders. Key
responsibilities include coordination of communication among key stakeholders,
participation and/or facilitation in collaborative efforts, responding to local concerns,
and providing education and materials for consumers, families and the public at large.
See
http://www.cardinalinnovations.org/Providers/coc.asp;
http://www.cardinalinnovations.org/ac/; http://www.cardinalinnovations.org/fc/;
http://www.cardinalinnovations.org/opc/; http://www.cardinalinnovations.org/piedmont/
Your responsibility as a Cardinal Innovations Contracted Provider is to:


23
Actively participate in community collaborative efforts to support prevention,
education and outreach programs.
Participate in the education of community stakeholders on system access and
available services.
SECTION II: GOVERNANCE AND ADMINISTRATION
Cardinal Innovations’ responsibility to Providers is to:




Develop comprehensive prevention, education and outreach programs.
Participate and/or facilitate in Community Collaborative efforts to assess community
capacity, need and gaps in services.
Develop and disseminate educational material to Providers and community
stakeholders relative to accessing services.
The Communications Department will foster effective community relations by
maintaining the www.cardinalinnovations.org website which contains information
about Cardinal Innovations for consumers, Providers, key stakeholders and the
general public.
L. Consumer Affairs
The Cardinal Innovations Office of Consumer Affairs serves as advocates, educators and
liaisons for individuals with mental health, intellectual/developmental disability and
substance use/addiction service needs in the Cardinal Innovations region. See
http://www.pbhsolutions.org/consumerfamily/voice.asp. Each Community Operations
Center has an Office of consumer Affairs. Consumer Affairs can help individuals and
their families:








Navigate the public behavioral healthcare system
Learn about client rights and responsibilities
Address concerns
Help file grievances
Become self-advocates
Assist with paperwork
Bring suggestions or concerns to Cardinal Innovations management
Find resources within the community
The Office of Consumer Affairs is staffed by openly declared consumers and family
members who work to develop and identify consumer leaders, and encourages
consumer led initiatives. The staff serves as ombudsmen and advocates for individuals,
and assists consumers with appeals and grievances. The office initiates and assists in
activities that promote and support the empowerment of consumers. The Office of
Consumer Affairs participates in consumer education and the development of
educational materials for consumers and families.
Additionally, Consumer Affairs keeps Cardinal Innovations management informed of
innovative activities in the areas of consumer and family member interest. Consumer
Affairs is responsible for conveying LME/MCO and state positions, policies and strategies
to consumers and family members. Consumer Affairs Specialists assist in the
formulation of policy. They respond to concerns and questions from consumers and
24
SECTION II: GOVERNANCE AND ADMINISTRATION
family members. Additionally, they serve as liaisons for Consumer and Family Advisory
Committees and coordinate the Client Rights Committee meetings.
Providers may contact Consumer Affairs if consumers have exhausted the Provider’s
complaint procedure and are not satisfied. A Provider may also contact Consumer
Affairs on behalf of consumers to assist them with advocacy, housing eviction or service
issues with another Provider. Consumer Affairs serves on the Network Council and
brings consumer/family concerns to that body.
The Office of Consumer Affairs also provides education through:






Peer Support Specialist Training
WRAP training
Peer Bridgers Training
PSR/Clubhouse Skills presentations
Participation in consumer conferences
Speakers for local community events and support groups
Consumer Affairs Specialists for Mental Health, Substance Abuse and
Intellectual/Developmental Disabilities are in the local Community Operations
Centers. To contact them, use the numbers listed below::




Alamance-Caswell Region: 336-513-4222
Five County Region: 877-619-3761
OPC Region: 919-913-4000
Piedmont Region: 704-721-7000
Your responsibility as a Cardinal Innovations Contracted Provider is to:





25
Refer consumers who need assistance in making complaints to the Office of
Consumer Affairs at each Community Operations Center, (704) 939-7769 or (704)
721-7018.
o Consumer Affairs Intellectual/Developmental Disabilities Family Advocate
(704) 721-2019
Publicize and support Cardinal Innovations sponsored opportunities for consumer
training.
Facilitate adequate random sampling on state and Cardinal Innovations consumer
satisfaction surveys.
Let Consumer Affairs staff know about events in your county for consumers.
Respond to inquiries from consumer Affairs about consumer issues and concerns.
SECTION II: GOVERNANCE AND ADMINISTRATION
Cardinal Innovations’ responsibility to Providers is to:






Serve as liaison with local and state organizations to promote consumer rights and
integration into the community.
Address the stigma and discrimination associated with mental illness,
intellectual/developmental disabilities and/or a substance abuse diagnosis.
Serve as resource for development of peer support.
Provide information for consumers to make complaints and grievances.
Ensure that consumer interests are always represented on executive management
teams and committees and councils.
Be a resource for Evidenced Best Practices and Emerging Best Practices with the goal
of improving positive outcomes in the self-determination, consumer’s quality of life
and progress towards recovery.
M. Office of Medical Affairs
Cardinal Innovations employs both a Medical Director and Associate Medical Director in
order to ensure the quality of services to consumers, to oversee clinical management
activities and programs including authorization of services, quality oversight, and
utilization management. Other activities include collaboration with Cardinal Innovations
Network Providers, Medical Directors of Provider companies, primary care providers in
the community, and State and community hospitals as well as development of
preventive health projects for Cardinal Innovations consumers. The Medical Director is
responsible for the credentialing of all LIPs enrolled in the Cardinal Innovations Provider
Network and oversight of the Cardinal Innovations Credentialing Committee.
N. Stakeholder Involvement In Cardinal Innovations System Management
Cardinal Innovations has a comprehensive system of operational forums in order to
ensure engagement of our consumers, family members, advocates, Providers, and
community agencies. This system involves a number of operational committees that
bring Cardinal Innovations staff, consumers/family members, Providers and
stakeholders together to address problems and concerns, provide important feedback
to Cardinal Innovations around its performance, and to assist in pro-active planning.
O. Community Advisory Councils
The Community Advisory Councils are active in each of the counties and ensure that the
unique needs and concerns of each county are highly visible to the Cardinal Innovations
LME/MCO. Membership is open to community stakeholders and generally includes the
following:
1. DSS
2. School System
3. Juvenile Justice
26
SECTION II: GOVERNANCE AND ADMINISTRATION
4.
5.
6.
7.
8.
Partnership for Children
Law Enforcement
Advocacy Organizations
Comprehensive Community Provider Representation
Consumer Family Advisory Committee Representation
These forums have served and continue to serve a critical purpose in helping Cardinal
Innovations understand problems, community priorities, and to provide information to
the community about Cardinal Innovations initiatives and activities.
P. Operational Committees
We have relied on Operational Committees where Cardinal Innovations, consumers,
family members, Providers and the community come together to exchange ideas,
address problems and to collaborate on planning. For Cardinal Innovations, this has
been a way for us to “keep our feet on the ground” and understand the impact of our
activities. For the members of these teams, it has been an opportunity to understand
and assist with the requirements and challenges that allows us to continually improve
and strengthen our company. It is expected that these groups will continue to grow in
their collective ability to impact Cardinal Innovations operations and management in a
positive manner. The types of committees vary according to the unique needs of our
local communities.
27
SECTION III: PROVIDER NETWORK
SECTION III:
PROVIDER NETWORK
A. The Cardinal Innovations Provider Network
Cardinal Innovations contracts with a select number of providers in order to promote
efficiency and ensure positive outcomes, while at the same time ensuring that
consumers have a choice of providers. Our primary goal is to ensure choice and to
develop Provider expertise in evidenced based practices in care so that the system can
be shaped to better meet the needs of individuals that we serve.
Cardinal Innovations completes an annual capacity study as well as an annual geo
accessibility study. The purpose of these studies is to evaluate the capacity of the
enrolled Provider Network to meet the needs of the people served, and to measure
geographic access to Provider locations. This information can be accessed via the
provider website at http://www.cardinalinnovations.org/Providers/analysis.asp. The
studies help Cardinal Innovations make decisions on whether to add or limit capacity.
B. Cultural Competency of the Network
The demographics of the Cardinal Innovations region have been changing rapidly and it
is important that we are able to adequately meet the needs of people from all ethnic
groups within our service system.; Cardinal Innovations acknowledges that becoming
Culturally Competent is both a process and a journey, and is committed to incorporating
cultural competency as one of the foundational elements of our system. It must become
an integral part of every facet of care and service. This foundation is essential for us to
reach our goal of helping people achieve their own potential, independence and
recovery.
See http://www.cardinalinnovations.org/Cultural/;
http://www.cardinalinnovations.org/Cultural/plan.asp and
http://www.cardinalinnovations.org/Cultural/Docs/PBH%20CC%20Plan%202011.pdf.
Cardinal Innovations Network Providers have demonstrated extensive leadership and
commitment to this cultural competency initiative. Providers must ensure ongoing
education is provided to their staff regarding cultural competence in an effort to provide
culturally
appropriate
services
to
all
consumers
served.
See
http://www.cardinalinnovations.org/Cultural/docs/ProviderPlancultcompindd1.pdf.
Your responsibility as a Cardinal Innovations Contracted Provider is to:


28
Earnestly participate in initiatives to achieve cultural competence, and
Pursue the acquisition of knowledge relative to cultural competence and the
provision of services in a culturally competent manner.
SECTION III: PROVIDER NETWORK
Cardinal Innovations’ responsibility to Providers is to:



Develop and disseminate educational material to Providers and consumers relative
to cultural competency;
Provide support to Providers in developing culturally appropriate services; and
Maintain the Cultural Competence portion of the Cardinal Innovations website
http://www.cardinalinnovations.org/cultural/ which contains information about
Cardinal Innovations for consumers, providers, key stakeholders and the general
public.
C. Types of Network Providers
1. Comprehensive Community Clinics (CCCs)
Cardinal Innovations has developed this model in order to better meet the needs of
people in the communities we serve. CCCs must provide robust basic assessment,
therapy and medication management services to both children and adults for the
treatment of both substance use and mental health conditions. The CCCs are
established by county and provide a full array of basic services in the county in which
the designation is granted. These clinics are considered the MH/SA safety net. In
counties where the population cannot support a full CCC site, neighboring county CCCs
will be identified to provide services at satellite sites for a limited number of hours per
week, as volume demands.
In addition to providing robust basic services, CCCs are expected to meet the following
clinical standards:










Provide high quality assessments;
Provide outpatient treatment
Offer no less than 24hrs/week of prescriber services;
Primarily utilize on-site prescribers with psychiatric specialty certification
Provide flexible and open-access scheduling;
Provide access to services within 48 hours for urgent needs and 14 days for routine
needs
Meet quality standards for consumer engagement in services and to achieve low
consumer utilization of crisis system resources;
Provide timely 24/7/365 telephonic crisis response to people served
Have Psychiatrist that provides medical leadership at the company level; and,
Demonstrate a willingness to help address system service and access gaps.
Additional expectations include utilization of injectable antipsychotics, clozapine and/or
Suboxone when medically indicated, provision of medication management to
underserved or difficult-to-serve populations, acceptance of consumers on outpatient
commitment, billing of non-Medicaid payers (including Medicare), and
29
SECTION III: PROVIDER NETWORK
effective/efficient interactions with Cardinal Innovations regarding treatment
authorization requests and claims processing.
2. Critical Access Behavioral Healthcare Agency (CABHAs)
A Critical Access Behavioral Health Agency (CABHA) is a state designation of providers
that deliver a comprehensive array of mental health and substance abuse services. The
CABHA’s role 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. It must ensure that consumer care is based upon a comprehensive clinical
assessment and appropriate array of services for the population served.
CABHAs maintain national accreditation and provide three (3) core services (i.e.,
comprehensive clinical assessment, medication management and outpatient therapy)
and at least two (2) additional services in the list below:
 Intensive In-Home (IIH)
 Community Support Team (CST)
 Substance Abuse Intensive Outpatient Program (SAIOP)
 Substance Abuse Comprehensive Outpatient Treatment (SACOT)
 Child Residential Level II, III and 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
3. Provider Businesses:
These are entities that are either incorporated, established as a limited partnership or
limited liability company, or operate under a Certificate of Authority issued by the
Corporation Division of the North Carolina Department of the Secretary of State. Their
source of authority is established through charter, constitution, by-laws, or articles of
incorporation, and they maintain a clients’ rights committee. They provide one or more
clinical/therapeutic/rehabilitative/habilitative
services
to
mentally
ill,
intellectually/developmentally disabled, substance use/addiction, and/or multiple
diagnosis populations groups.
4. Hospital
This is a facility licensed by the North Carolina Division of Health Services Regulation as a
hospital and accredited by the Joint Commission on Accreditation of Health Care
Organizations (JCAHO). Hospitals in the Cardinal Innovations Network may provide
outpatient, inpatient, and/or emergency department-based behavioral health services.
30
SECTION III: PROVIDER NETWORK
5. Specialty Providers
These Providers concentrate on a specific service (such as vocational or residential) or
serve a specific disability area, or both. Specialty Providers fill a critical role in the
Cardinal Innovations Network for Special Needs populations as defined in the Medicaid
waiver. Specialty Providers are important components of the Network because they can
focus their efforts on best practices strategies for a specific population. The majority of
Cardinal Innovations Providers are Specialty Providers. These Providers offer best
practice service options to consumers such as Assertive Community Treatment Team,
Supported Employment, Multi-Systemic Therapy, Mobile Crisis, Intensive In-Home
services and Innovations Waiver Services.
6. Alternative Family Living Providers (AFLs)
AFL services must be provided by Providers incorporated as businesses, and not by
individuals. Cardinal Innovations requires the following for AFL services to be provided:
documentation of training and background checks for both primary staff and back up
staff; the AFL site must be the primary residence of the AFL Provider (includes couples
or single person) who receives reimbursement for cost of care; and any Provider that
offers services within the scope of the AFL compensation and/or requirements must be
an employee of the Provider. If the AFL Provider serves more than one consumer or a
consumer less than 18 years of age, the site must be licensed by Division of Health
Services Regulation. A back-up staffing plan must be in place and the backup staff must
be employees of the Provider. AFL Providers must submit to Health and Safety Reviews,
to be completed by the Quality Management Department based on their performance
profiles. AFL Providers are not permitted to provide services to another consumer while
serving a primary consumer for AFL services at an unlicensed site. AFL Providers will be
required to pay back funds if a consumer is moved to a new site and Cardinal
Innovations is not notified and the AFL Provider bills for the old site. All AFL Providers
must have insurance coverage for property and automobiles. Personnel files must be
maintained on all AFL Providers and all documentation for service provision must meet
APSM 45-2, APSM 45-1, HIPAA and service definition requirements. The service
documentation must be readily available for review upon request.
7. Licensed Independent Practitioners (LIPs) and Professional Practice Groups
These Providers are, among others, Medical Doctors (MD), Practicing Psychologists
(PhD), Psychologist Associates (Master’s Level Psychologist [LPA]), Master’s Level 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 Cardinal Innovations Provider Network
and bill under their own licenses. LIPs must be credentialed by Cardinal Innovations. Our
enrollment process includes background checks, reference checks, license verification
31
SECTION III: PROVIDER NETWORK
and other evaluation criteria to make certain the practitioner meets Cardinal
Innovations and National Committee for Quality Assurance (NCQA) criteria. Additionally,
Cardinal Innovations collects information about LIP’s specific expertise (such as
Women’s issues, Trauma experience, etc.) in order to help consumers make choices
about Providers.
8. Provisionally Licensed Practitioners
These Providers are practitioners who are provisionally licensed in NC and are employed
by a CCC, CABHA, Agency, Hospital, or Group Practice that is fully contracted with
Cardinal Innovations to provide Outpatient Treatment. Under these circumstances a
Provisionally Licensed Practitioner may submit an initial registration form and then a
CAQH application for Cardinal Innovations’ access and processing. He or she must also
provide proof of professional clinical supervision as evidenced by a current supervision
contract that includes 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 Cardinal Innovations Corporate
Credentialing Committee, the Provisionally Licensed Practitioner will be able to provide
Outpatient Treatment to Cardinal Innovations consumers and submit claims for those
services in accordance with the Cardinal Innovations Provider Contract, the
practitioner’s licensing body, and/or limitations established by Cardinal Innovations
Credentialing Committee.
9. Out of Area Providers
These Providers are contracted Agencies or LIPs that provide specialty services not
available within the Cardinal Innovations catchment areas. Such Providers must meet all
Network requirements and are considered to be full members of the Cardinal
Innovations Provider Network.
10. Out of Network Providers
Some consumers with Medicaid originating in the Cardinal Innovations’ catchment live
in other parts of the state. Cardinal Innovations is committed to ensuring that Providers
are available to meet these consumers’ needs and, to that end, frequently makes
arrangements for consumer-specific contracts. Specific procedures are followed to
determine the need for a consumer-specific contract with Providers outside of the
Cardinal Innovations Network to meet these needs. The Cardinal Innovations Medical
Director reviews all consumer information submitted to assist in determining medical
necessity and the need for a client-specific contract. Out of Network Providers are not
considered to be members of the Cardinal Innovations Network.
11. Non-Enrolled, Non-Contracted Providers
If a Cardinal Innovations consumer requests services from a Provider who does not wish
to apply to become a contracted Provider with Cardinal Innovations, the LIP or Provider
32
SECTION III: PROVIDER NETWORK
Company will be required to transition the consumer to a Cardinal Innovations
contracted Provider within 60 days.
If a person receives non-emergency services from a non-enrolled, non-contracted
Provider, Cardinal Innovations will not pay for the service. Cardinal Innovations will pay
for acute behavioral emergency care for a Cardinal Innovations consumer by a nonenrolled, non-contracted Provider.
When a consumer enrolled in the NC MH/DD/SA Health Plan resides outside of the
Cardinal Innovations counties, Cardinal Innovations will work collaboratively with the
consumer and Providers in that area to ensure that the consumer has access to needed
services.
D. Location of Providers
Most services will be available within thirty (30) miles or thirty (30) minutes. However,
some specialty Providers may be located outside the person’s county of residence.
Cardinal Innovations will annually evaluate the location of Providers and types of
services in its Capacity Study, and determine the need for additional Providers. Cardinal
Innovations also maintains geo-maps which allow us to evaluate the location of
Providers in relation to where consumers live.
E. Quality of Care
Our responsibility is to assure the quality of services provided by the Cardinal
Innovations Provider Network. Cardinal Innovations is accountable to the Division of
MH/DD/SAS and the Division of Medical Assistance, in the management of both state
and Medicaid services. In addition to state requirements, Medicaid waiver quality
requirements are extensive and include:
 health and safety of Consumers;
 Consumer rights protection;
 Provider qualifications;
 Consumer satisfaction;
 management of grievances;
 incident investigation and monitoring;
 assessment of outcomes to determine efficacy of care;
 management of care for Special Needs Populations;
 preventive health initiatives; and
 clinical best practice.
Cardinal Innovations has numerous quality, satisfaction and financial reporting
requirements related to our agreements with the Division of MH/DD/SAS and DMA. An
33
SECTION III: PROVIDER NETWORK
Intra-Departmental Monitoring Team evaluates Cardinal Innovations’ performance
annually. An External Quality Review Organization (EQRO) monitors Cardinal
Innovations annually, per Medicaid regulations. Cardinal Innovations understands the
important role of quality management in protecting consumers and in promoting quality
of care.
As part of the continuous quality improvement process, Cardinal Innovations operates
Global Continuous Quality Improvement (GCQI) Committees through the COCs. These
Committees include Cardinal Innovations’ staff, consumers and providers. The purpose
of the Committees is to ensure that we are all working together to achieve system
improvements, and to monitor the overall quality of services. This partnership is critical
for success. The Cardinal Innovations CQI Committee develops a single Quality
Improvement Plan for the Cardinal Innovations Network with input and feedback from
the GCQI Committees and other relevant stakeholders. The plan identifies strengths,
weaknesses, areas of improvement and includes a program description, work plan and
annual report. Annually, Cardinal Innovations makes available information about its CQI
performance to Providers, practitioners, members and stakeholders on the Cardinal
Innovations website. A printed copy of the information is provided upon direct request
to Cardinal Innovations.
Your responsibility as a Cardinal Innovations Contracted Provider is to:










34
Ensure consumers meet medical necessity requirements for all services that you
provide;
Provide medically necessary covered services to consumers per your contract and
authorized by Cardinal Innovations;
Ensure consumers have input into their treatment plan. Providers shall have
consumers and/or their legally responsible person (LRP) sign and date the plan
whenever the plan is developed, reviewed or revised;
Comply with all service definitions and practice guidelines for the services you are
providing;
For residential providers, ensure discharge planning is taking place early in
treatment, with the intention that the consumer continue to improve to require less
restrictive services as time passes;
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;
Provide interpreting services for consumers who may require it;
Have a clinical backup system in place to respond to all crises/emergencies for
consumers receiving services. Part of this clinical function is to develop crisis plans
that are available to clinicians in your office, consumers and their natural supports,
SECTION III: PROVIDER NETWORK











35
and to Cardinal Innovations Access Department. The clinical backup system will
provide information and directions on how to seek assistance in a crisis/emergency
including coverage for posted office hours, weekends, evenings and holidays for all
consumers you serve, or to serve as first responder as outlined in the service
definition of your contract;
Demonstrate consumer-friendly services and attitude. The Network Provider must
have a system to ensure good communication with consumers and families;
Comply with the policies and procedures outlined in this Manual, any applicable
supplements, Cardinal Innovations Communications Bulletins and your Provider
Contract, the General Conditions of the Contract, and applicable state and federal
laws and regulations;
Provide services in accordance with all applicable state and federal laws;
Provide services in accordance with access standards and appointment wait time as
noted in the General Conditions of the Procurement Contract;
Have a no reject policy for Consumers who have been determined to meet medical
necessity for the covered services provided by your Company or as a Licensed
Independent Practitioner;
Provide consumers with 24/7/365 telephonic access to a clinician or qualified
professional in the case of an MH/DD/SA crisis or emergency. This contact may not
be 911. This contact also may not be a hospital or mobile crisis team unless that is
the service being provided under contract with Cardinal Innovations, or unless the
Provider has subcontracted with and pays such Providers directly for emergency
backup services. The backup contact person must:
 have the qualifications, training and capacity to navigate the range of
MH/DD/SA crisis scenarios a consumer may experience;
 advise the consumer and assist in the coordination of care during the crisis;
 be available telephonically and assist in-person if the situation requires;
 have immediate access to crisis plans for consumers who have them.
CABHA and other enhanced service providers must also ensure they fully comply
with additional first responder duties outlined in state policies and service
definitions.
Provide timely notice to Cardinal Innovations and ensure a smooth transfer for any
consumers that desire to change Providers, or when a consumer is discharged
because you cannot meet his/her special needs
Document all services provided per Medicaid Requirements, NC Waiver
Requirements and North Carolina State Rules;
Agree to cooperate and participate with all utilization review/management, quality
management, review, appeal and grievance procedures;
Comply with contractual and/or Credentialing/Endorsement Procedures to maintain
active Provider enrollment status;
Comply with Authorization and Utilization Management requirements of Cardinal
Innovations;
SECTION III: PROVIDER NETWORK



Comply with the Cardinal Innovations re-credentialing or re-qualifying procedures,
which are outlined in the Cardinal Innovations’ Provider Manual or Provider
Communication Bulletins incorporated therein;
Participate in consumer satisfaction surveys, Provider satisfaction surveys, clinical
studies, incident reporting, outcome requirements, and other surveys or
questionnaires related to the capacity of Cardinal Innovations’ provider network
and/or your participation in the Cardinal Innovations’ Provider Network; and
Transfer all consumer records to Cardinal Innovations upon termination of the
Cardinal Innovations provider contract.
Cardinal Innovations’ responsibility to Network Providers is to:




Provide assistance twenty-four (24) hours a day, seven (7) days a week to
consumers, and potential consumers including crisis coordination
Assist Providers in understanding and complying with Cardinal Innovations’ policies
and procedures, the 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 bodies including, but not
limited to, the National Committee for Quality Assurance (NCQA).
Provide technical assistance, when feasible and to the extent practical, related to
Cardinal Innovations contract requirements, Cardinal Innovations Provider Manual
requirements, Department requirements of Providers, the development of
appropriate clinical services, quality improvement initiatives, or to assist the
Provider in locating sources for technical assistance.
Cardinal Innovations will make available to Providers upon request, the results of its
Capacity Study which identifies Provider under/over capacity, as well as priorities for
Network Development. Cardinal Innovations is not required to contract with
Providers beyond the number necessary to meet the needs of its consumers.
F. Provider Communication
Cardinal Innovations is committed to communication through a variety of means in an
effort to keep its Network Providers well informed of the following: State or federal
changes, new information, trainings, requests for proposals and opportunities for
collaboration. To that end, Cardinal Innovations maintains a list of all of its contracted
Providers, updated when new information is received, from which the Cardinal
Innovations Communications Department can generate mass emailing of information. In
addition, Cardinal Innovations maintains a Provider section of our website that includes
specific information for Providers.
See http://www.pbhsolutions.org/providers/.
Cardinal Innovations also disseminates critical and time sensitive information through
official Cardinal Innovations Communication Bulletins which can be retrieved at
http://www.cardinalinnovations.org/providers/bulletins.asp and through the use of
InfoSource,
a
weekly
electronic
newsletter
found
at
36
SECTION III: PROVIDER NETWORK
http://www.pbhsolutions.org/providers/InfoSource.asp
Cardinal Innovations also maintains information on our website for consumers including
a Provider Search function that allows consumers, Providers and stakeholders to search
for Providers by various selections: http://www.cardinalinnovations.org/search/
Cardinal Innovations has also incorporated Providers into management of our
operations in order to ensure that our management activities will be efficient and
effective. Some of these forums include:
 The Cardinal Innovations local and regional Network Councils,
 The Clinical Advisory Committee,
 The COC Global CQI Committees ,
 Ad hoc work groups,
 Regular Provider meetings,
 Planning for training activities, and
It is our intent to communicate regularly with Providers through these forums, email
updates, and other communications. The training activities that we offer are intended to
support Providers’ efforts to attain the skills that are important for quality service
provision.
Your responsibility as a Cardinal Innovations Network Provider is to:





Keep apprised of current information through the communication offered and
provide services as per the most recent State standards or waiver service definitions;
Attend and participate in Provider meetings;
Review the website for updates on a regular basis;
o www.cardinalinnovations.org
Review the State web sites for most up to date information on a regular basis;
o www.dhhs.state.nc.us/mhddsas
o www.dhhs.state.nc.us/dma
o www.cms.gov
Work in conjunction with the appropriate department at your COC or Cardinal
Innovations Corporate Office for technical assistance.
Cardinal Innovations Corporate Office: (704) 939-7700
AC Community Operations Center: (336) 513-4222
(Alamance and Caswell counties)
Five County Community Operations Center: (252) 430-1330
(Franklin, Granville, Halifax, Vance, and Warren counties)
37
SECTION III: PROVIDER NETWORK
OPC Community Operations Center: (919) 913-4000
(Orange, Person, and Chatham counties)
Piedmont Community Operations Center: (704) 721-7000
(Cabarrus, Davidson, Rowan, Stanly, and Union counties)
Cardinal Innovations’ responsibility to Providers is to:






Offer provider meetings on a regular basis and post the schedule on the
www.cardinalinnovations.org web site under the Provider tab;
Post electronic updates on the Provider page;
Post official Network Communications on the Cardinal Innovations web page;
Send written correspondence via the mail as needed;
Assign a Network Specialist to each Provider to develop a personal working
relationship and contact who can respond to individual Provider needs;
Respond to Provider inquiries and provide feedback in a timely manner.
G. Network Councils:
Cardinal Innovations hosts Provider Network Councils with representation who serve as fair
and impartial representatives of all service providers within the Network. Network Councils
facilitate open exchange of ideas, share values, goals and vision, and promote collaboration
and mutual accountability among Providers. The Network Councils strive to achieve best
practices to empower consumers within our community to achieve their personal goals.
H. Code of Ethics
Cardinal Innovations and Network Providers adhere to a Code of Ethics, which was
developed jointly and is a part of the contractual process. Cardinal Innovations, Provider
Agencies and Licensed Independent Practitioners shall all abide by the Code of Ethics as a
component of the Contractual process.
I. Changes in Status
Cardinal Innovations maintains a Provider database with current practice information
submitted by LIPs and Provider Companies to support our ongoing commitment to quality
care. Because this data is used for referral purposes, it is important that Cardinal
Innovations has the most up-to-date information. Providers should submit notice of any
pertinent changes in status within seven days, or sooner, if outlined as such in their
contracts. Such changes include but are not limited to the following: licensure status,
changes in privileged status with other accrediting organizations, pending citations, pending
malpractice claims, changes in ownership, change in management, proposed changes in
facility location, changes in capacity, inability to accept new referrals, proposed mergers or
acquisitions, or pending investigations for Medicaid fraud.
38
SECTION III: PROVIDER NETWORK
If a Provider wishes to acquire, merge with, or otherwise assume the business operations of
another provider, the provider shall notify Cardinal Innovations in advance. The decision
whether or not to add new services/site locations that may have been provided by another
provider to the existing contract is solely at the discretion of Cardinal Innovations.
Additionally, Cardinal Innovations may request periodic updates on information, and
providers should respond to those requests promptly.
Cardinal Innovations’ responsibility to Providers is to:


Update provider credentials file and Network database in a timely manner to reflect the
new information; and
Notify providers in writing if their change of information impacts on their eligibility for
referrals;
J. R-Credentialing - Licensed Independent Practitioners (LIPs)
LIPs in the Cardinal Innovations’ Provider Network are required to have their credentials
reviewed and verified at a minimum of every thirty-six (36) months from the date of the last
credentialing review.
Your responsibility as a Cardinal Innovations Contracted Provider is to:

Respond to communications from Cardinal Innovations regarding the need to update
and reattest to information housed in the Council for Affordable Quality Healthcare
(CAQH) database, updating and attesting to such information no later than ninety (90)
days prior to the LIP’s recredentialing date.
*** As of the date of publication, Cardinal Innovations is transitioning from a
recredentialing process driven solely by internal operations to a process that is driven by
the CAQH database and its participants’ reattestation to the information housed there
on a quarterly basis. Beginning February 1, 2013, registration and the submission of a
completed CAQH application, with all required supporting documentation, will be a
condition of the recredentialing process. The procedure and deadlines for this process
will be detailed for the LIP in a six-month notice letter from Cardinal Innovations, with
similar notices thereafter, in order to avoid the lapse of the LIP’s credentials with
Cardinal Innovations.
As part of the re-credentialing process, each practitioner has the right
1. To review information collected during the recredentialing process (except references
and National Practitioner Data Bank (NPDB) reports), upon request
2. To be informed of the status of their recredentialing application, upon request
39
SECTION III: PROVIDER NETWORK
3. To be notified of information that is significantly different than reported by the LIP and
to be given the opportunity to correct erroneous information in writing. Correction of
the erroneous information should be provided by the practitioner within ten (10)
working days of notification on any discrepancies in the application
4. To be notified about the Credentialing Committee's decision within thirty (30) days of
the decision or the Medical Director’s approval
K. Alteration of Practitioners’ Credentialed Status
Cardinal Innovations maintains standards for LIP participation that will ensure competent,
effective, and quality care. Cardinal Innovations has the right to sanction, suspend, and/or
terminate a practitioner for activity, actions, and/or non-actions which are contrary to
Cardinal Innovations’ standards of practice or governing law.
1. The following conditions can effect a practitioner’s credentialing status:
a. LIP fails to maintain compliance with the credentialing and re-credentialing criteria;
b. LIP decides not to execute a Practitioner Contract;
c. LIPs 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;
d. LIP has breached any material term of his/her Provider Contract, including failure to
comply with Medical Management or Quality Improvement requirements; and
e. Any type of inappropriate relationship with a consumer to include those of a sexual
or amorous nature, or violation of other clinician/consumer boundaries.
2. Disciplinary actions that can be taken by Cardinal Innovations include:
a. Sanctions, which can include, but are not limited to, any one or combination of
actions:
 Censure Letter
 Network Membership Freeze for specified timeframe
 Site Visit
 Corrective Action Plan
 Monetary Penalty
b. Suspension, which can include, but are not limited to, any one or combination of
actions:
 Referral Freeze
 Group Activity Freeze
 Site Visit
 Corrective Action Plan
 Monetary Penalty
40
SECTION III: PROVIDER NETWORK
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
If disciplinary action is taken, Cardinal Innovations will provide written notice with any
applicable due process rights.
L. Actions Against Practitioner Credentialing Reported to External Bodies
1. All disciplinary actions based on professional competency or conduct which would
adversely affect clinical privileges for a period longer than thirty (30) days or would
require voluntary surrender or restriction of clinical privileges, while under, or to avoid,
investigation are required to be reported to the appropriate entity (i.e., State Medical
Board, National Practitioner Data Bank, Federation of State Medical Boards, etc.).
M. Performance Profile Reviews
All Providers/Practitioners in the Network receive a profile review at least every three (3)
years. All profile reviews are scored utilizing standardized score sheets which are made
available to providers/practitioners on the Cardinal Innovations website. All 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 to include strengths and needs noted.
Any follow up to be completed by the Provider/Practitioner or Cardinal Innovations will be
reviewed during the exit conference.
Copies of profile review results are mailed to the Provider following the review.
Documentation will outline areas reviewed, scores achieved and required follow-up.
Providers/Practitioners are given the opportunity to provide feedback to Cardinal
Innovations Quality Management 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 Quality Monitoring Manager. The Quality Monitoring Manager
will review all feedback for needed improvements in the Cardinal Innovations 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.
41
SECTION III: PROVIDER NETWORK
N. Applying for Additional Services and Sites
In order for a Network Provider to be considered for Additional Sites/Services:

The Provider must be in "good standing," which is defined as having a signed contract
and all required submissions and/or reports up to date; and

Cardinal Innovations has established there is sufficient need for the service(s); and

Any Provider with a history of a suspension of referrals, major contract violations,
concerns regarding the quality of services rendered, and/or a State level violation will be
reviewed on a case by case basis.
o If the Provider falls under the criteria listed above, the Provider should contact
their COC Network Specialist to request a decision be rendered prior to the
submission of the Additional Site/ Service Application.
o An Additional Service Application may only be submitted in order to provide
consumer service(s) located within the Cardinal Innovations catchment areas
unless a Cardinal Innovations consumer resides in another county and meets
medical necessity for the specific service(s) requested.
Cardinal Innovations is under no obligation to consider adding additional sites or services to
a contract if it has determined there is not a need for those sites or services.
Cardinal Innovations will:
 Determine if there is an established need for the services; and
 Review the performance record of the Provider for quality citations, actions that
resulted in suspension of referrals, Division of Health Services Regulation findings and
Provider Performance Profile scores, as well as demonstrations of quality and best
practice.
Network Providers shall submit:
 A completed Cardinal Innovations Additional Service or Site Application with all required
elements and supporting documentation to their assigned COC Network Specialist. This
includes the following:
o
Cardinal Innovations Additional Site Application and all required/requested
attachments that identify what services will be rendered at the requested site; and
o
Cardinal Innovations Additional Service Request, and all required/requested
attachments, that identifies from which site(s) the requested service(s) will be
rendered.
See
http://www.cardinalinnovations.org/providers/newproviders/Add_Service_forms.asp
 The Additional Site or Additional Service Application(s), with all required elements and
supporting documentation must be received within sixty (60) days of the date the
42
SECTION III: PROVIDER NETWORK
application is sent to the Provider. If it is not received in this time frame, the Provider
shall have to re-initiate the process.
Cardinal Innovations’ responsibility to Providers is to:
 Direct Providers interested in additional services/sites to the applications on the
http://www.pbhsolutions.org/ website; and
 Document the date the Additional Site or Additional Service Application was accessed by
the Licensed Independent Practitioner or Agency Provider.
o
The complete application packet posted to Cardinal Innovations’ website will
include the following elements:
 Cardinal Innovations Additional Services/Site Cover Letter for Providers
 Cardinal Innovations Additional Services or Site Application
The Additional Service or Site Application is to be submitted to the Provider’s assigned
COC Network Specialist. Any documentation required in support of the application will
be identified by the Network Specialist.

Cardinal Innovations will review and render a decision on the completed Application for
Additional Services or Sites within forty-five (45) days, unless additional time is needed.
O. Health and Safety Site Reviews
If a health and safety site visit is required for the new service, the COC Quality Management
will schedule a site visit.
Any site requested to be added to the contract for the new service will be reviewed on all
applicable areas. During the site visit, Cardinal Innovations will evaluate the Provider
applicant’s readiness to provide services according to the requirements outlined in state
regulations, the service definition, Cardinal Innovations’ Practice Guidelines and the
Cardinal Innovations contract.
P. Cardinal Innovations Implementation Reviews
The Cardinal Innovations Quality Management Department (QM) conducts service
implementation reviews after the Provider serves Cardinal Innovations consumers for
ninety (90) days. During this review, a full audit of implementation will be conducted and
any areas cited as non-compliant will be reviewed. If the review findings identify any noncompliance issues during the follow up visit, a Plan of Correction will be required.
Copies
of
QM
Provider
Review
Tools
are
available
at
http://www.cardinalinnovations.org/QM/. 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 or reviewed during the review and
on-site visit.
43
SECTION III: PROVIDER NETWORK
Q. Cardinal Innovations Network Development Plan
The Network Development Plan is informed by and is a part of Cardinal Innovations’ annual
Capacity Study. The Network Development Plan is used to delineate priorities for
Service/Program Development as identified by the annual Capacity Study.
R. Specialty Providers
Specialty Providers are Providers that specialize in a specific type of service (residential,
vocational, etc.) or in a specific disability area. Most of the Providers in the Cardinal
Innovations Network are Specialty Providers. Cardinal Innovations depends on its Specialty
Providers to engage in best practices and evidence-based practices in the services they
provide. Because these Providers specialize in a type of service or disability, they are well
situated to focus on best practice models of care and services. Clinical Guidelines have been
developed reflecting these best practices and have been approved by the Cardinal
Innovations Clinical Advisory Committee.
S. Licensed Independent Practitioners (LIPs)
LIPs working independently or in small group practices provide important access to
outpatient care for consumers. Often the care that they provide is more specialized than is
available in the CCCs. Licensed practitioners are required to maintain after hours on-call
coverage to respond to their patients who need assistance after hours and to assure
continuity of care.
T. Clinical Home for Consumers
The notion of a Lead Agency for each consumer in need of enhanced services was first
defined in the 2003 PBH Local Business Plan. The State Medicaid Service definitions
implemented in March 2006 included the designation of a Clinical Home for consumers,
which is consistent with the Cardinal Innovations current Lead Agency concept. The role of
the Clinical Home is further reinforced by the development of the Critical Access Behavioral
Health Agency (CABHA) model and the recent design of the Comprehensive Community
Clinics (CCC). CABHAs are designed to provide the core clinical services that are needed to
ensure consumers receive the continuity of services that they need.
Expected Outcomes for CABHAs and CCCs functioning as Clinical Home Providers:




44
Single point of responsibility to plan, link and coordinate clinical and support services for
consumers;
Clinical accountability;
Clearly assigned First Responder responsibility;
Development of Crisis Plan or Advance Directive;
SECTION III: PROVIDER NETWORK



Team approach to planning and monitoring care. Team includes (as appropriate)
psychiatrist, nurse, licensed professional, and peer specialist, as well as staff from other
Provider agencies serving the consumer.
Development of Person Centered Plans that reflect all consumer needs; and
Communication with primary healthcare provider.
U. Network Design
45
SECTION III: PROVIDER NETWORK
Cardinal Innovations must enter into Procurement Contracts with Network Providers before
any
services
can
be
authorized
or
paid.
See
http://www.cardinalinnovations.org/providers/providerenrollment.asp Network Providers
are required to have a fully executed Cardinal Innovations Contract which lists services and
approved sites prior to delivery of services to a Cardinal Innovations consumer. The Cardinal
Innovations Provider Manual, the NC MH/DD/SAS Health Plan Operations Manual and NC
Innovations Operations Manuals are incorporated into the contract by reference.
Your responsibility as a Provider is to:







Review your Contract for accuracy, fully execute the Contract and return to it Cardinal
Innovations within the timeframes indicated to assure continued payment for services;
Sign and have a fully executed Cardinal Innovations Contract Amendment for any
material change 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 all terms of the Contract and all
requirements in the Cardinal Innovations Provider Manual, the NC Innovations
Operations Manual and the NC MH/DD/SAS Health Plan Operations Manual;
Notify Cardinal Innovations of any prospective changes in sites and assure that all
Cardinal Innovations endorsement 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 Cardinal
Innovations through direct contact or mediation;
Notify Cardinal Innovations in advance of any mergers or change in ownership since it
may have implications for your contract status with Cardinal Innovations.
Cardinal Innovations may enter into consumer specific contracts with Providers as it
determines to be necessary.
46
SECTION IV: CONSUMER RIGHTS AND EMPOWERMENT
SECTION IV:
CONSUMER RIGHTS AND EMPOWERMENT
A. Rights of Consumers
Free speech, religious freedom and personal liberty are fundamental American rights.
Personal privacy and confidentiality of personal information are personal rights. When
people receive services/supports in the State’s public system, there are additional rights
too. State rules and state and federal laws spell out these additional rights. Member rights
under a Managed Care Organization include, but are not limited to:
 The right to receive information about Cardinal Innovations, its services, its
Providers/Practitioners, and member rights/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.
 The right to participate with Providers/Practitioners in making decisions about their
health care.
 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. People receiving services may need to decide among relevant treatment
options, 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 voice complaints or appeals about Cardinal Innovations or the care it provides.
 A right to make recommendations regarding Cardinal Innovations’ 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 refuse services.
 The right to request and receive a copy of their medical records 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 wellbeing, the consumer can request that the medical records
be sent to a physician or professional of their choice.
 If they disagree with what is written in their medical records, consumers have the right
to write a statement to be placed in their file. However, the original notes will also stay
in the record until the statute of limitations ends according to the MH/DD/SAS retention
schedule.
 The right to participate in the development of a written person-centered treatment plan
and individualized crisis 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 a second opinion.
 The right to take part in the development and periodic review of their treatment plan
47
SECTION IV: CONSUMER RIGHTS AND EMPOWERMENT


and to consent to treatment goals in it.
The right to treatment in the most normal, age-appropriate and least restrictive
environment possible.
The right to ask questions when they do not understand their care or what they are
expected to do.
Responsibilities
 A responsibility to supply information (to the extent possible) that Cardinal Innovations
and its Providers/Practitioners need in order to provide care.
 A responsibility to follow plans and instructions for care that they have agreed to with
their Providers/Practitioners.
 A responsibility to understand their health problems and participate in developing
mutually agreed-upon treatment goals, to the degree possible.
Cardinal Innovations 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 can request a report of certain disclosures of PHI.
If at any time a member believes that their member rights have been violated, they may
contact the Office of Consumer Affairs at:
 Corporate Office
704-939-7700
 Alamance-Caswell
336-513-4222
 Five County
877-619-3761
 Piedmont
704-721-7000
 OPC
919.913.4000
Any person can report a concern or complaint by calling 1-888-213-9687, or by calling 704939-7700 and asking for Quality Management. The Cardinal Innovations Access Call Center
is also available by calling 1‐800‐939‐5911 24 Hours a Day/7 Days a Week/365 Days a Year.
A more detailed list of member rights & responsibilities can also be found on the Cardinal
Innovations website at www.cardinalinnovations.org under consumer/Family and the
button “What Are My Rights?” See http://www.cardinalinnovations.org/consumerfamily/
B. Civil Rights
Consumers are entitled to all Civil Rights including:
48

To register and vote,

To buy or sell property, own property,

To sign a contract,

To sue others who have wronged them,
SECTION IV: CONSUMER RIGHTS AND EMPOWERMENT

To marry or get a divorce,

To procreate and raise children
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 protection and promotion of recipient rights is a crucial component of the service
delivery system. All consumers are assured rights by law and it is expected that Providers
will respect these rights at all times and provide consumers continual education regarding
their rights as well as support them in exercising their rights to the fullest extent.
North Carolina General Statutes (GS 122C 51-67) and the North Carolina Administrative Code
(APSM 95-2) outline specific requirements for notification of individuals regarding their rights as
well as operational policies and procedures that ensure the protection of rights.
These statutes and regulations also outline the policy and operational requirements for the
use and follow-up of restrictive interventions and protective devices.
It is expected that all Network Providers are knowledgeable of all outlined statutes and
regulations regarding consumer rights and the use of restrictive interventions/protective
devices and that Providers develop operational procedures that ensure compliance. The
Provider is also expected to maintain an ongoing knowledge of changes to the statutes and
regulations and immediately alter operations to meet changes.
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 the minutes of their Client Rights Committee meetings to
Cardinal Innovations on a quarterly basis. Providers should remove any information that is
not in relation to Cardinal Innovations consumers.
Cardinal Innovations maintains a Client Rights Committee that is responsible for the
monitoring and oversight of Provider Client Rights Committee functions. See
http://www.pbhsolutions.org/consumerfamily/oversight.asp.
Additional information for Network Providers working with Cardinal Innovations consumers
is in Section I of this Manual. Client Rights regulations are in NCGS 122-C-51-67 and APSM 952 and APSM 30-1 and NCASC 27G.0504, 10A NCAC 27G.0103 and NC Council Communication
Bulletin #30.
49
SECTION IV: CONSUMER RIGHTS AND EMPOWERMENT
C. Informed Consent
A person receiving services has the right to be informed in advance of the potential risks
and benefits of treatment options, including the right to refuse to take part in research
studies. The person has the right to consent to or refuse any treatment unless:
 It is an emergency situation;
 The person is not a voluntary patient;
 Treatment is ordered by a court of law;
 The person is under eighteen (18) years of age, has not been emancipated, and the
guardian or conservator gives permission.
The Rights noted in this Manual are based on General Statutes 122C Article 3 and the Client
Rights Rules, 10 NCAC 27C, 27D, 27E, 27F (APSM 95-2). Cardinal Innovations reserves the right
to have more restrictive policies and procedures than state and federal rules and regulations.
D. Advocacy for consumers
Cardinal Innovations will not prohibit or otherwise restrict a health care professional acting
within the lawful scope of practice from advising or advocating on behalf of a consumer
who is his or her patient. Cardinal Innovations will not:
1. Restrict a Provider from advocating for medical care or treatment options.
2. Restrict a Provider from providing information the consumer needs in order to decide
among all relevant treatment options.
3. Restrict a Provider from providing information about the risks, benefits, and
consequences of treatment or non-treatment options to the consumer.
4. Restrict a Provider from providing information to the consumer 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.
5. Take punitive action against a Provider that supports a consumer’s appeal of a Medicaid
action. (438.410)
A Provider may file an appeal on behalf of a consumer with the consumer’s written
consent. (438.402)
E. Psychiatric Advance Directives (PAD)
In 1997, North Carolina developed a way for consumers who received mental health
services to plan ahead for treatment they might want to receive if they experienced a crisis
50
SECTION IV: CONSUMER RIGHTS AND EMPOWERMENT
and were unable to communicate for themselves or make voluntary decisions of their own
free will. A statutory form 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 consumers to write down treatment preferences or instructions if
they experience a crisis in the future and cannot make their own mental health treatment
decisions. The 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, ECT, or admission to a hospital, restraints, and whom to notify in case of
hospitalization. The PAD may include instructions about paying rent or feeding pets while
the consumer is in the hospital. The consumer could also put in an advance instruction
“please call my doctor or clinician and follow his/her instructions.” That way if they are in an
emergency room and unable to speak for themselves or confused, these instructions can be
used as a means to help them at vital moments.
If you are assisting a consumer 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
permission, and other instructions.
Consumers can choose someone they trust (like a family member) to make treatment
decisions for them if they cannot make the decisions themselves by designating a Health
Care Power of Attorney.
The Psychiatric Advanced Directive and Health Care Power of Attorney legal forms were
designed by Duke University. They are available electronically at
http://pad.duhs.duke.edu
Or
Cardinal Innovations Office of Consumer Affairs, 704-939-7769
F. Confidentiality
The Network Provider shall ensure that all individuals providing services hereunder will
maintain the confidentiality of any and all consumer information received in the course of
providing services hereunder and will not discuss, transmit, or narrate in any form any
consumer information of a personal nature, medical or otherwise, except as authorized in
writing by the consumer or his legally responsible person or except as otherwise permitted
by applicable federal and state confidentiality laws and regulations including N.C.G.S. 122C,
Article 3, which addresses confidentiality of all confidential information acquired in
attending or treating a consumer, and 42 CFR, Subchapter A, Part 2, which addresses
confidentiality of records of drug and alcohol abuse patients.
51
SECTION IV: CONSUMER RIGHTS AND EMPOWERMENT
Information can be used without consent to help in treatment, for health care operations,
for emergency care, and given to law enforcement officers to comply with a court order or
subpoena.
A disclosure to next of kin can be made when a consumer is admitted or discharged from a
facility, but only if the person has not objected.
A minor has the right to agree to certain treatments without the consent of his/her parent
or guardian.
If the consumer disagrees with what a physician, treating Provider, clinician, or case
manager has written in their records, the consumer 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 up to
twenty-five (25) years.
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.
Since there is no guarantee of adequate firewalls for electronic mail, Cardinal Innovations
staff and contractors cannot transmit e-mail with consumers about their personal or health
matters. Consumer related information should be communicated by paper mail, face to
face, by telephone, or over a secure electronic connection such as Provider Direct.
Confidentiality Rules (ASPM 45-1) were adopted in accordance with General Statute 150B-14C.
Confidentiality and Privacy Practices are also based on the federal HIPAA regulations that went
into effect April 14, 2003.
G. Second Opinion
A Medicaid consumer has the right to a second opinion if the person does not agree with
the diagnosis, treatment, or the medication prescribed. The Cardinal Innovations Clinical
Operations Department can arrange for a second opinion. Consumers are informed of the
right to a second opinion in the Cardinal Innovations Consumer & Family Handbook, which
is sent to them when the individual is enrolled. The role of the Network Provider is to be
aware that this is a right of all Medicaid consumers and refer the consumer to the Clinical
Operations Department at Cardinal Innovations if a second opinion is requested.
52
SECTION IV: CONSUMER RIGHTS AND EMPOWERMENT
H. Decisions to Deny, Reduce, Suspend, or Terminate a Medicaid Service
It is important that Providers understand the following rights so they may discuss the
consumer’s case with them, if asked. If a consumer wishes to appeal, the Provider may file
the appeal on the consumer’s behalf, with written consent.
If the treating
physician/practitioner/Provider would like to discuss the case with the Cardinal Innovations
UM care manager or the physician/psychologist, please call 704-939-7700.
Cardinal Innovation will make every effort to provide information on adverse decisions and
the appeals process to members in a culturally and linguistically appropriate manner.
Interpreting services are available 24 hours a day through the Access line at 1-800-5395911.
There are times when an Enrollee’s request for services may be denied, and there are times
when a current service authorization may be changed (i.e. terminated, reduced or
suspended) by Cardinal Innovations Utilization Management. All adverse decisions are
made by a psychiatrist or doctoral level psychologist after careful review of all information
submitted.
NOTE: Cardinal Innovations is prohibited from implementing UM procedures that provide
incentives for the individual or entity conducting utilization reviews to deny (reduce,
terminate or suspend), limit or discontinue medically necessary services to any enrollee.
UM decision‐making is based only on appropriateness of care and service, and the existence
of coverage. Cardinal Innovations does not reward practitioners or other individuals for
issuing denials of coverage or services. There are no financial incentives for UM decision‐
makers that would encourage decisions resulting in under-utilization.

Denial: A denial could occur if the criteria are not met to support a new authorization
request for a service. If a service is denied, once the authorization runs out, the
individual is not entitled to receive the services in dispute during the appeal period.

Reduction, Suspension, or Termination: Services an Enrollee is currently receiving may
be reduced, suspended or terminated based on different factors including not following
clinical guidelines or not continuing to meet medical necessity for the frequency,
amount, or duration of a service. Enrollee/Guardian will receive a letter by certified mail
at least ten (10) days before the change occurs explaining how to request a
Reconsideration Review. If Enrollee/Guardian requests a Reconsideration Review by the
deadline stated in the letter, the services may be able to continue through the end of
the original authorization. The Notice of Decision letter sent to Enrollee/Guardian will
explain how this “Continuation of Benefits” may be able to occur.
I. Reconsideration Reviews
Under the NC MH/DD/SAS Health Plan (1915(b) waiver) and the NC Innovations Waiver
(1915(c) waiver), a consumer who does not agree with Cardinal Innovations’ decision to
53
SECTION IV: CONSUMER RIGHTS AND EMPOWERMENT
deny, reduce, suspend, or terminate Medicaid services, are entitled to a Reconsideration
Review through the Cardinal Innovations Reconsideration Review process.
To request a Reconsideration Review, Enrollee/Guardian must complete and return the
Reconsideration request form by fax, mail, verbally over the phone, or by bringing the form
to Cardinal Innovations in person. Enrollee/Guardian has thirty (30) days from the date of
notification to request a Reconsideration Review. During a Reconsideration Review,
Enrollee/Guardian and/or anyone they choose may represent them. Enrollee/Guardian has
the right to review any information that was utilized as part of the Reconsideration process.
They may also submit any additional information they feel supports the level of service(s)
being requested.

Exception: An enrollee may be able to have his or her services continue during the
appeal process. This process is called “Continuation of Benefits,” and it does not apply if
Cardinal Innovations’ decision is a denial of an initial request. In order to continue with
existing services during the appeal process, the Enrollee/Guardian must request a
Reconsideration Review within ten (10) days of the date of the Notification letter and
indicate that he or she wants his or her services to continue. The services may then be
able continue until the end of the original authorization period as long as the Enrollee
remains Medicaid eligible. The Notice of Decision letter sent to Enrollee/Guardian will
explain how this “Continuation of Benefits” may be able to occur. This right to receive
services applies even if the Enrollee changes Providers. The services may be provided at
the same level the Enrollee was receiving the day before the decision or the level
requested by Enrollee’s Provider, whichever is less. The services that continue must be
based on Enrollee’s current condition and must be provided in accordance with all
applicable state and federal statutes and rules and regulations.
If the final resolution of the Appeal is not decided in the Enrollee/Guardian’s favor, (that
is, Cardinal Innovations’ action was upheld), Cardinal Innovations may recover the cost
of the services furnished to the Enrollee/Guardian while the Appeal is pending.
**This does not apply for the denial of an initial service request.**
A Cardinal Innovations Reconsideration Review is an impartial review of Cardinal
Innovations’ decision to reduce, suspend, terminate or deny Medicaid services. The
Reconsideration Review Decision is determined by a health care professional who has
appropriate clinical expertise in treating Enrollee’s condition or disorder and was not
previously involved in Cardinal Innovations’ initial decision. If a decision to deny, reduce,
suspend, or terminate services is made, Cardinal Innovations will provide written notice,
and the process to appeal will be explained. In the event any of the processes explained in
the notice differ from those in this manual, the consumer should follow the steps in the
notice.
54
SECTION IV: CONSUMER RIGHTS AND EMPOWERMENT
a. Steps to file a Reconsideration Review Request
To request a Cardinal Innovations Reconsideration Review the Enrollee/Guardian or
the Provider (in making the request on the Enrollee/Guardian’s behalf or supporting
the Enrollee/ Guardian’s request with written consent) must complete and return
the Cardinal Innovations Reconsideration Review Request Form by one of the
following methods:



Fax (704-939-7911);
Mail or in person (Cardinal Innovations Medicaid Appeals Coordinator at
4855 Milestone Avenue, Kannapolis, NC 28081 ); or
Verbally by Phone (1-800-939-5911)
Upon completion of the Reconsideration Review decision, if the Enrollee/Guardian
disagrees with the decision, the Enrollee/Guardian can then Appeal the decision to
the Office of Administrative Hearing by filing a Request for a State fair hearing.
b. Expedited Reconsideration Review Process
An Expedited Reconsideration Review may be requested by the Enrollee/Guardian
or the Provider (in making the request on the Enrollee/Guardian's behalf or
supporting the Enrollee/Guardian's request), if it is indicated that taking the time for
a standard Review could seriously jeopardize the Enrollee’s life or health or ability to
attain, maintain, or regain maximum function. 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 seventytwo (72) hours and the enrollee will be notified of the decision. If there is not
sufficient evidence to require an expedited request, the Enrollee/Guardian will be
notified of the reason and the process will follow the normal reconsideration
timelines.
If the Enrollee/Guardian disagrees with the Reconsideration Review decision, the
Enrollee/Guardian may submit the form enclosed with the Reconsideration Review
decision to request a State fair hearing.
2. State Fair Hearing Process
If the Reconsideration Reviewer does not overturn Cardinal Innovations’ decision, the
Enrollee may file a request for a State fair hearing as the next step of the appeal.
Enrollee/Guardian must file their appeal with the North Carolina Office of
Administrative Hearings, Department of Health and Human Services and Cardinal
Innovations within thirty (30) days from the date of the Reconsideration Review decision
to the addresses listed on the form.
55
SECTION IV: CONSUMER RIGHTS AND EMPOWERMENT
a. Mediation
Once the appeal form is processed, a mediator will contact the Enrollee/Guardian to
offer an opportunity to mediate the disputed issues in an effort to informally resolve the
pending Appeal. Mediation will generally be completed within twenty-five (25) days of
the request.
If the issues are resolved at mediation, the case will be dismissed. If Enrollee/Guardian
does not accept the offer of mediation or the case is unable to be resolved at mediation,
the case will proceed to a hearing and will be heard by an Administrative Law Judge with
the Office of Administrative Hearings.
b. Hearings
This state level hearing is conducted by an Administrative Law Judge (ALJ) at the Office
of Administrative Hearings (OAH). The Enrollee/Guardian may represent themselves in
this process, ask a relative, friend or spokesperson to speak for them, or may hire an
attorney to represent them during the appeal process. After both sides have an
opportunity to present evidence, the ALJ will make a decision.
Consumer responsibility for services furnished while the Appeal is pending:
If the appeal is involving a reduction, termination, or suspension of services, and the
enrollee elected Continuation of Benefits during the appeal, and the final resolution of
the Appeal is not decided in the Enrollee/Guardian’s favor, Cardinal Innovations may
recover the cost of the services furnished to the Enrollee/Guardian while the Appeal is
pending.
Requesting UM Criteria for Service Authorization
The medical policies and criteria for Medicaid services authorized by Cardinal
Innovations can be found at http://www.ncdhhs.gov/dma/waiver/ in The NC
MH/DD/SAS Health Plan and NC Innovations Waiver. If a person does not have internet
access or wishes to receive a written copy of these documents, a request may be made
by calling 1-800-939-5911 to receive a copy by mail.
J. Non-Medicaid Service Grievance Process
If Cardinal Innovations’ denies, reduces, suspends, or terminates a non-Medicaid services,
the Enrollee/Guardian affected will be notified in writing. If an Enrollee/Guardian disagrees
with Cardinal Innovations’ decision he/she may file a grievance within ten (10) calendar
days from the decision date. If the 10th day falls on a weekend or holiday, the deadline is the
next business day. The grievance may be filed by phone, e-mail, fax, or in person.
56
SECTION IV: CONSUMER RIGHTS AND EMPOWERMENT
K. Grievances
The Provider must have a Grievance process to address any concerns of the consumer and
the consumer’s family related to the services provided. The Provider must keep
documentation on all grievances received including date received, points of grievances, and
resolution information. Any unresolved concerns or grievances should be immediately
referred to Cardinal Innovations. The Provider’s Grievance Process must be provided to all
consumers and families of consumers upon admission and upon request. The Provider must
advise consumers and families that they may contact Cardinal Innovations directly about
any concerns or grievances.
Cardinal Innovations Anonymous Concern Line 1-888-213-9687, available for both English
and Spanish-speaking callers, must be published and made available to the consumer and
family members, as well as 1-800-662-7660 for the North Carolina Bar Association Lawyer
Referral Service or 1-800-662-7407 for the Pro Bono Project of the North Carolina Bar
Association.
Cardinal Innovations may also receive grievances directly about a Provider’s services or
staff. Based on the nature of the grievances, Cardinal Innovations may choose to investigate
the grievance in order to determine its validity. Investigations may be announced or
unannounced. It is very important that the Provider cooperate fully with all investigative
requests. Refusal to comply with any grievance follow-up or investigation is a breach of
contract. It is important to understand that this is a serious responsibility that is invested in
Cardinal Innovations, and that we must take all grievances very seriously until we are able
to resolve them. Cardinal Innovations management of grievances is carefully monitored by
the NC Department of Health and Human Services. Cardinal Innovations maintains a data
base where all grievances and resolutions are recorded.
Cardinal Innovations maintains documentation on all follow-up and findings of any
grievance investigation and a written summary will be provided to the Provider. If problems
are identified, the Provider may be required to complete a plan of correction.
See http://www.pbhsolutions.org/consumerfamily/grievance.asp;
http://www.pbhsolutions.org/consumerfamily/appeal.asp
L. Client Rights Committee (CRC)
The CRC has a responsibility to oversee Cardinal Innovations’ compliance with federal and
state rules regarding consumer rights, confidentiality, and grievances. The Cardinal
Innovations CRC is made up of consumers and family members and expert advisors who
meet at least quarterly.

57
The CRC reviews and monitors trends in the use of restrictive interventions, abuse,
SECTION IV: CONSUMER RIGHTS AND EMPOWERMENT
neglect and exploitation, deaths and medications errors.

The CRC also makes reports to Cardinal Innovations and DMA/DMH.

The CRC reviews grievances regarding services as an advisor to the Area Director/CEO.

Consumers or Family Members of consumers that wish to apply to serve on the CRC
may call the Office of Consumer Affairs or Quality Management at 704-939-7700.

See http://www.pbhsolutions.org/consumerfamily/oversight.asp.
Client Rights regulations are in NCGS 122-C-51-67 and APSM 95-2 and APSM 30-1 and NCASC
27G.0504, 10A NCAC 27G.0103 and DMH Communication Bulletin #30.
M. Consumer and Family Advisory Committee (CFAC)
The Consumer/Family Advisory Committee (CFAC) membership consists of consumers and
family members of consumers who receive Mental Health, Intellectual/Developmental
Disability and Substance Use/Addiction services. The Consumer Family Advisory Committees
(CFAC) are self-governing committees that serve as advisors to the Community Operations
Centers, Cardinal Innovations administration and Cardinal Innovations Board of Directors.
See
http://www.cardinalinnovations.org/consumerfamily/cfac.asp;
http://www.cardinalinnovations.org/cfac/.
The purpose of the CFAC is to ensure that consumers are involved in both oversight,
planning and operational committees of Cardinal Innovations. This is accomplished through:

CFAC representation on Cardinal Innovations Operational Committees is as follows:
o Network Council
o Global Continuous Quality Improvement Committee
o Regional Housing Continuum of Care
o County Advisory Councils
o System of Care
o Clinical Advisory Committee
o Cultural Competence Advisory Committee
Cardinal Innovations has enjoyed a strong and mutually supportive relationship with CFAC.
This ongoing interaction has resulted in important involvement from consumers and family
members across the Cardinal Innovations LME/MCO.
58
SECTION IV: CONSUMER RIGHTS AND EMPOWERMENT
Any consumer, Provider, or family member can bring issues of concern to the CFAC’s
attention by e-mailing [email protected] or calling the Director of Consumer
Affairs at 704-939-7700.
CFAC members serve for a maximum of two (2) consecutive three (3) year terms. If
Providers know of individuals that would like to serve on this committee, please advise
them to call the Office of Consumer Affairs.
59
SECTION V: BENEFIT PACKAGE
SECTION V:
BENEFIT PACKAGE
A. Eligibility
The Provider must not employ any policy or practice that has the effect of discriminating
against consumers on the basis of race, color, or national origin.
B. Who is eligible for the Medicaid Waivers?
1. The NC MH/DD/SAS Health Plan (1915(b) waiver):
The following criteria must be met for an individual to be eligible for services in the
waiver:
a. Individuals must have Medicaid in a covered eligibility group. Covered eligibility
groups include:
1. Individuals covered under Section 1931 of the Social Security Act (TANF/AFDC)
2. Optional Categorically and Medically Needy Families and Children not in
Medicaid Deductible status (MAF)
3. Blind and Disabled Children and Related Populations (SSI) (MSB)
4. Blind and Disabled Adults and Related Populations (SSI, Medicare)
5. Aged and related populations (SSI, Medicare)
6. Medicaid for the Aged (MAA)
7. Medicaid for Pregnant Women (MPW)
8. Medicaid for Infants and Children (MIC)
9. Adult Care Home Residents (SAD, SAA)
10. Foster Care Children and Adoption
11. Participants in Community Alternatives Programs (CAP/DA, NC Innovations,
CAP-C, CAP-MR/DD)
12. Medicaid recipients living in ICF-MR Facilities
13. Work First Family Assistance (AAF)
14. Refugee Assistance (MRF)(RRF)
b. The individuals Medicaid County of Residence is:
1. Alamance
2. Cabarrus
3. Caswell
4. Chatham
5. Davidson
6. Franklin
7. Granville
8. Halifax
9. Orange
10. Person
11. Rowan
12. Stanly
60
SECTION V: BENEFIT PACKAGE
13. Union
14. Vance
15. Warren
Enrollment in the waiver 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 the 1915(c) waiver.
See
http://www.cardinalinnovations.org/consumerfamily/healthplan.asp;
http://www.cardinalinnovations.org/consumerfamily/innovations.asp;
http://www.ncdhhs.gov/dma/services/piedmont.htm.
The NC Innovations Waiver (1915 (c) waiver):
A person with mental retardation (intellectual disability) and/or a related
developmental disability may be considered for NC Innovations funding if all of the
following criteria are met.
a. The individual is eligible for Medicaid coverage, based on assets and income of the
applicant whether he/she is a child or an adult.
b. The individual meets the requirements for ICF-IID level of care. Refer to the Cardinal
Innovations’ NC Innovations Operations Manual for the ICF-IID Criteria.
c. Lives in an ICF-IID facility or is at high risk for placement in an ICF-IID facility. High
risk for ICF-IID institutional placement is defined as a reasonable indication that
individual may need such services in the near future (one month or less) but for the
availability of Home and Community Based Services.
d. The individual’s health, safety, and well-being can be maintained in the community
with waiver support.
e. The individual requires NC Innovations waiver services.
f. The individual, his/her family, or guardian desires participation in the NC Innovations
waiver program rather than institutional services.
g. The person’s Medicaid originates from of one of the 15 counties within the Cardinal
Innovations region Alamance, Cabarrus, Caswell, Chatham, Davidson, Franklin,
Granville, Halifax, Orange, Person, Rowan, Stanly, Union, Vance, and Warren
counties.
h. The individual will use one waiver service per month for eligibility to be maintained.
i. NC Innovations participants must live in a private home or in a residential facility
with six or fewer persons unrelated to the owner of the facility.
j. Qualifies for the NC Innovations Waiver and has been assigned a waiver “slot”.
C. Medicaid Waiver Disenrollment
When a consumer changes county of residence for Medicaid eligibility to a county other
than Alamance, Cabarrus, Caswell, Chatham, Davidson, Franklin, Granville, Halifax, Orange,
Person, Rowan, Stanly, Union, Vance and Warren, the individual will continue to be
61
SECTION V: BENEFIT PACKAGE
managed in the NC MH/DD/SAS Health Plan through Cardinal Innovations until the change
is processed by the Eligibility Information System at the State. Transfers due to a change of
residence are effective at midnight on the last day of the month. A consumer may be
automatically disenrolled from the NC MH/DD/SAS Health Plan if:
1. The individual is deceased
2. The individual is admitted to a correctional facility for more than thirty (30) days
3. The individual 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.
4. The Individual is admitted to a State Facility with more than sixteen (16) beds.
D. Eligibility for State Funded Services
Consumers who live in one of the fifteen counties that Cardinal Innovations covers that do
not have Medicaid may be eligible for state funded services based on their income and level
of need. The Cardinal Innovations sliding fee schedule is designed to assess a person’s
ability to pay. State Funded Services are dependent upon the resources available.
E. Eligibility for Reimbursement by Cardinal Innovations
Consumers who have their services paid for in whole or in part by Cardinal Innovations must
be enrolled in the Cardinal Innovations system. If you have any questions about a
consumer’s eligibility, please call the Access Center 1-800-939-5911. Individuals who are at
100% ability to pay according to Cardinal Innovations’ sliding fee schedule or who have
insurance coverage that pays 100% of their services, must not be enrolled into the Cardinal
Innovations system. However, the person may still receive and pay for services from a
Provider independent of Cardinal Innovations’ involvement. Medicaid and State Funds
should be payment of last resort. All other funding options need to be exhausted first.
Consumers with a Medicaid card from any of the Cardinal Innovations counties are fully
enrolled in the Cardinal Innovations system and are eligible to receive Basic Benefit
Services, Basic Augmented, or Enhanced Services which have been authorized by Cardinal
Innovations.
Consumers 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 Cardinal Innovations’ sliding fee schedule to calculate the fee. This schedule is based on
Federal Poverty Guidelines, consumer’s family income, and the number of dependents. See
http://www.cardinalinnovations.org/finance/billing.asp
Medicaid regulations prohibit the use of Medicaid funds to pay for services other than
General Hospital Care delivered to inmates of public correctional institutions, and Medicaid
62
SECTION V: BENEFIT PACKAGE
funds may not be used to pay for services provided for consumers in facilities with more
than 16 beds that are classified as Institutions of Mental Diseases (IMD).
Consumers 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. You
should consult your contract to determine which funding source(s) you are contracted for.
If you have questions, please contact your assigned Network Specialist.
F. Enrollment of Consumers
It is important for all Providers to ensure consumer enrollment data is up-to-date based on
the most current Cardinal Innovations Enrollment Procedures and training. These
documents can be found in the NC MH/DD/SAS Health Plan Operations Manual and/or
under the consumer Enrollment section of the Cardinal Innovations website at
www.cardinalinnovations.org.
See http://www.cardinalinnovations.org/enrollee/
If enrollment data is not complete prior to service provision, authorizations and claims may
be affected. This could result in denial of authorizations requested and/or claims submitted
for reimbursement. (See Section X Finance for additional information.)
1. Service Eligibility:
Services are divided into multiple service categories:
a. Basic Services:
The Basic Benefit package includes those services that are made available to
individuals with Medicaid and, to the extent resources are available, to nonMedicaid funded 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 Cardinal Innovations to an enrolled Cardinal
Innovations Provider or by directly contacting a Provider enrolled in the Cardinal
Innovations Network. There are no prior authorization requirements for certain
amounts of these services. Medicaid consumers referred for Basic Benefit Services
can access up to twenty-four (24) visits for Adults and for Children from the Basic
Benefit package. State Funded consumers referred for Basic Benefit Services can
access up to eight (8) visits for Adults and twelve (12) visits for Children from the
Basic Benefit package.
63
SECTION V: BENEFIT PACKAGE
Once an authorization has been requested and approved, the Provider must bill
against that authorization until the end date. This means during the period
authorized, the Provider is limited to the number of visits on the authorization. This
service is now a “managed” service, even if there are unmanaged sessions available.
It is recommended only to request authorization when unmanaged sessions have
been used. Also, unmanaged visits may not be used for an individual who is
receiving Enhanced Services that include therapy as a component, such as PRTF,
Residential III, Day Treatment, IIHS, MST, CST, and SAIOP. If there is a need for
outpatient therapy, beyond what is provided in the Enhanced Service, the
individual’s plan must provide justification for these services and an authorization is
required.
b. Basic Augmented Services:
The Basic Augmented Benefit package includes those services that will be made
available to individuals with Medicaid and, to the extent resources are available, to
non-Medicaid funded individuals meeting Target Population criteria. A consumer
requiring this level of benefit is in need of more than the twenty-four (24)
unmanaged visits for adult and child Medicaid consumers or eight (8) unmanaged
visits for State Funded Adults and twelve (12) unmanaged visits for State Funded
Children under the Basic Benefit in order to maintain or improve his/her level of
functioning. An Authorization for the services available in this level will need to be
requested through Cardinal Innovations Clinical Operations Department.
Authorization is based on the consumer’s need and medical necessity criteria for the
service requested.
c. Enhanced Services:
The Enhanced Benefit package includes those services that will be made available to
individuals with Medicaid and, to the extent resources are available, to nonMedicaid funded individuals meeting 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 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 person-centered
64
SECTION V: BENEFIT PACKAGE
plan authorized by Cardinal Innovations.
Enhanced services require prior
authorization from Cardinal Innovations. Cardinal Innovations is not obligated to
pay for services provided where prior authorization was not obtained.
2. Target Populations:
Target Population designation is for State-funded services. It does not apply to
consumers who are only receiving Medicaid services. The Provider, through review of
screening, triage and referral information, must determine the specific Target
Population for the consumer according to the Division of MH/DD/SA Criteria. Each
Target Population is based on diagnostic and other indicators of the consumer’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 its
resources will be focused on those most in need.
Please see the most current version of the Target Population Criteria:
 Go to the IPRS Website link on the NC Division of MH/DD/SAS homepage:
http://www.ncdhhs.gov/mhddsas/Providers/IPRS/index.htm
G. Special Needs Populations designed 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 tool that is designed to proactively intervene and ensure optimal care for Special
Needs Populations.
The Care Coordination function is provided through the Care Coordination Units in each of
the Community Operations Centers. Cardinal Innovations Care Coordinators carry out this
function in order to provide necessary support for consumers meeting the criteria defined
below. The goal is to ensure that consumers are referred to and appropriately engaged with
Providers that can meet their needs, both in terms of MH/IDD/SA services as well as
Medical care.
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 services covered under the NC MH/DD/SAS Health Plan,
more information can be provided in the DMA Clinical Coverage Policies for behavioral
65
SECTION V: BENEFIT PACKAGE
health, located at http://www.ncdhhs.gov/dma/mp/. For the NC Innovations Waiver,
further detail can be found in the NC Innovations Technical Manual, located at:
http://www.cardinalinnovations.org/pubdocs/upload/documents/NC%20Innovations%20Te
chnical%20Manual%20and%20Cover%20Letter%20June%202012.pdf
I. Hospital Admissions
DMA is responsible for payment of inpatient hospital services provided to consumers who
are inpatient prior to the effective date of their enrollment in the Medicaid waiver operated
by Cardinal Innovations and until the consumer is discharged from the hospital. For
consumers hospitalized on or after the effective date of enrollment in the waiver operated
by Cardinal Innovations, Cardinal Innovations will provide authorization for all covered
services, including inpatient and related inpatient services, according to Medical Necessity
requirements. Cardinal Innovations shall provide authorization for all inpatient hospital
services to consumers who are hospitalized on the effective date of disenrollment (whether
voluntary or involuntary) until such consumer is discharged from the hospital.
J. Medicaid Transportation Services
Transportation services are among the greatest needs identified to assist consumers in
accessing care. It is Cardinal Innovations’ goal to assist consumers 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 request three (3) to five (5) business days ahead to arrange a ride.
There is no fee for consumers who are enrolled in Medicaid. For those who are not enrolled
in Medicaid, transportation depends on available space, and there is a fee.
For information on available transportation in your county please contact the local DSS
http://www.ncdhhs.gov/dss/local/
There are no special publically funded medical transportation services in the evening and on
weekends.
66
SECTION VI: CLINICAL DESIGN PLAN
SECTION VI:
CLINICAL DESIGN PLAN
The NC MH/DD/SAS Health Plan and the NC Innovations Waiver are important building blocks
of the foundation of a re-engineered system that will more effectively and efficiently address
the needs of consumers with mental health, intellectual/developmental disabilities, and
substance use/addiction disorders. 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 consumers. 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.
Cardinal Innovations’ Goals:
1. To 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, authorization, clinical protocols, application of culturally
competent recovery principles and practices, utilization review, Care Coordination,
Case Management, and provision of feedback/training to Providers.
2. To develop a Self-Managed System by developing and training a selectively
qualified and comprehensive Provider Network.
3. To 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.
4. To involve consumers and families in ways that ensures their ownership and
satisfaction, and which engenders a feeling of shared responsibility.
5. To develop a sense of community ownership that comes from communication,
collaboration and a commitment to people of the local communities, including
Providers.
6. To apply the principles of cultural competence, recovery, and person-centered
care to ensure equitable access to, engagement with, and benefit from services.
7. To use data that can be translated into knowledge in order to demonstrate
accountability, efficiency, need, quality, outcomes, awareness of cultural and
ethnic variations and to identify areas for change and improvement.
67
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES
This section contains the following information:
A. Access Unit Description
1. Access Coordinators
2. Access Clinicians
B. Access (Call Center) Process
C. Access to Services
1. Routine Service
2. Urgent Service
3. Emergent Service
D. Process for Telephonic Pre-Service-Authorization:
1. Process
2. Discharge
3. Follow up after discharge
E. Enrollment
1. Process for Enrollment
2. For Providers with an electronic link to Cardinal Innovations
F. Cardinal Innovations Liaisons
G. Initial Assessment
H. Initial Authorization
1. Process for Prior Authorization of Services
2. Initial Authorization of Basic Augmented and Enhance Transitional Services
3. Initial Authorization of Enhanced Services
I. Additional Authorization of Services
1. Additional Authorization of Basic Augmented Services
2. Additional Authorization of Enhanced Services
J. Discharge Review
K. Utilization review

NOTE: The General Processes listed below apply to both the NC MH/DD/SAS Health
Plan 1915(b), NC Innovations (Home & Community Based) Waiver 1915(c) and the b(3)
Alternative Service Definitions
For more specific Technical information on Service and eligibility criteria, please refer to the
appropriate Waiver Technical Manuals available on the Cardinal Innovations website at
www.cardinalinnovations.org:
 NC MH/DD/SAS Health Plan, see
http://www.cardinalinnovations.org/Cardinal/index.asp
 The NC Innovations Waiver, see
http://www.cardinalinnovations.org/innovations/
 b(3) Alternative Service Definitions, see
http://www.cardinalinnovations.org/Cardinal/consumers.asp
68
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES

Access, see
http://www.pbhsolutions.org/umaccess/
A. Access Unit Description
Access management is a critical function of Cardinal Innovations. Cardinal Innovations is
responsible for timely response to the needs of consumers and for quick linkages to
qualified Providers of the Network. To ensure the simplicity of the system requested by our
consumers and stakeholders, Cardinal Innovations will maintain toll-free numbers for each
region. These numbers ring into the Cardinal Innovations Access Call Center. They are
answered 24 hours a day, 7 days a week, 365 days a year for telephonic assessments and
crisis intervention for people seeking assistance with mental health,
intellectual/developmental disability and substance use/addiction issues. The Access Unit
also provides our communities with information and referral for MH, SA, and DD services
within our catchment area. This area includes the following counties: Alamance, Cabarrus,
Caswell, Chatham, Davidson, Franklin, Granville, Halifax, Orange, Person, Rowan, Stanly,
Union, Vance and Warren.
Cardinal Innovations’ Access Unit can be reached toll-free at 1‐800‐939‐5911.
If for any reason, a caller cannot get through using these numbers, they can call the main
number at the Cardinal Innovations Corporate Headquarters (704-939-7700) and ask to be
transferred to the Access Call Center.
The Access Unit is staffed by:
 Access Coordinators
 Access Clinicians
1. Access Coordinators:
Bachelor level or non-licensed Qualified Professionals. Access Coordinators answer the
telephone calls coming in to the Access Call Center; they collect demographic
information, verify insurance eligibility, and complete a brief intake screening to
determine the appropriate type and level of services needed. The Access Coordinator
can also provide information about community resources, assist with placements to
inpatient facilities, when appropriate, and follow up to assure consumers discharged
from inpatient facilities are engaging in the next level of care.
2. Access Clinicians:
Access Clinicians are Master’s Prepared Qualified Professionals who work in the same
capacity as the Access Coordinators. However, additional responsibilities include
emergency services and crisis intervention calls. The Access Clinicians will follow all
requests for emergency services until it is established that contact with a Provider has
been made. Access Clinicians are available to take over calls with consumers that are in
distress.
69
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES
B. Access Call Center Process
Cardinal Innovations’ Responsibility:
1. Access Line calls are answered within 30 seconds by Access Staff. During times of heavy
call volume, excess calls may be routed to internal overflow staff. The Contract Agency
for Call Center back-up coverage will be used as a last resort for overflow calls.
2. Access Staff will screen the urgency of the call and, if appropriate, refer to the Access
Clinician, collect important demographic information such as name, address, and
telephone number to identify the member (person requesting services or information)
and his/her current location in case the call becomes emergent.
3. Provide interpreter services to callers, if needed.
4. Based on the member’s response to the greeting and prompting questions from the
Access Staff, the call will address the following issues.
a. Providing Information about Community (Non-treatment) Resources
b. Enrollment of an individual
c. Address eligibility questions
d. Provide referral for Routine Assessment
e. Manage and provide referrals for Urgent Calls
f. Manage and provide referrals for Emergent Calls
g. Complete Authorizations for Inpatient Placement
h. Document grievances and route the information to the appropriate unit for attention
i. Assist Providers
j. Transfer calls to appropriate department for specialized questions
k. Provide general information of Mental Health, Substance Abuse, and Developmental
Disabilities.
Provider’s Responsibility:

To be as clear as possible in requests for information or services to enable our
Access Center to help you in the most efficient and effective way possible.
C. Access to Services
1. Routine Service:
This process pertains to referrals for Routine Services. The Access Standard for Routine
Services is to arrange for services within fourteen (14) calendar days of contact at the
Access Line. The geographic access standard for services is thirty (30) miles or thirty (30)
minutes driving time in urban areas, and forty-five (45) miles or forty-five (45) minutes
70
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES
driving time in rural areas. The purpose of this procedure is to delineate the ways in
which referrals for Routine Services will be handled by Access Call Center staff. It is the
responsibility of all Access Call Center staff to ensure that Routine Referrals are handled
in the appropriate way.
a) Routine Referral Process:
1.
The Access Call Center staff will collect demographic information on the caller
and the consumer and search for the consumer in the CI System.
2.
If the consumer is not located in the eligibility file, the Access Call Center staff
will advise the consumer of this, and proceed with collection of enrollment data
on the most current Cardinal Innovations Enrollment Form.
3.
The Access Call Center staff will evaluate the consumer’s clinical need as follows:
 Complete the State mandated Screening, Triage, and Referral tool and
document the information obtained following the current CI System;
 Retrieve and review the consumer’s historical information, if available;
 Use the information provided, determine the type of clinical services
indicated.
4.
The Access Call Center staff will offer the consumer a choice of three Providers
(when available) and document in the CI System the Providers offered and the
Provider selected.
 Choice is provided by weighting Providers in the following areas:
a) Availability of service
b) Proximity to consumer
c) consumer’s desired attribute in Provider or Provider specialty
5. The Access Call Center staff will call the chosen Provider for immediate
scheduling with the consumer on the line. If an appointment is not available
within availability guidelines, the consumer may choose another Provider.
 The Access Call Center staff will provide the Provider with a brief overview of
the consumer’s need for service as well as indicating the service to be
provided.
 The Access Call Center staff will either remain on the line with the Provider
and consumer to obtain the date of the initial appointment or request that
the Provider call back to provide this information. This is to ensure
appointments are being set within the State required time frame for the
determined level of care and is documented in the computer system.
 In the event that the consumer chooses to contact the selected Agency on
his/her own, Access Call Center staff will indicate this in their documentation.
Appointment date will be obtained by claim information.
71
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES


Access Call Center staff will give the Provider the STR number so the Provider
can access the screening information in Provider Direct. If Provider does not
have access to Provider Direct, Access Call Center staff will send information
to the Provider via secure fax.
Note: This process cannot be followed for SA referrals due to restrictions in
release of SA information covered under 42 CFR confidentiality regulations.
In cases where referrals are made for Substance Abuse services, the
consumer or caller will be given the contact information for the appropriate
service providers.
Note: Cardinal Innovations Network Providers are held to the following standard
regarding Appointment Wait Time for Routine Referrals: Scheduled - one hour;
Walk-in - within two hours.
2. Urgent Service:
The purpose of this process is to outline the steps that Cardinal Innovations’ Access Call
Center staff will take to ensure appropriate care for consumers with Urgent care needs.
This procedure explains the way in which referrals for Urgent Services will be handled
from the Cardinal Innovations Access Line. The Access Standard for Urgent Care is to
arrange for services within 48 hours of contacting the Access Line. 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. Emergency calls that are immediately
transferred to an Access Clinician. Urgent calls can be completed and referred by Access
Coordinators but if/when the call becomes crisis/emergent status, then it is typically
warm-transferred to an Access Clinician.
a. Urgent Referral Process:
1. A consumer’s clinical need may be considered Urgent under the following
circumstances (including, but not limited to):
 A consumer reporting a potential substance-related problem;
 A consumer being discharged from an inpatient mental health or substance
abuse facility;
 The consumer seems at risk for continued deterioration in functioning if not
seen within forty-eight (48) hours;
2. The Access Staff will collect the enrollment data and proceed with a State
screening form to identify treatment needs.
3. After completing the screening, the Access staff will offer the consumer a choice
of three Providers (when available) and document in the CI System the Providers
offered and the Provider selected.
72
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES
4. The Access Staff will call the chosen Provider and schedule an appointment,
which must be available within 48 hours. If this does not occur an explanation
will be documented.
5. If there are no scheduled appointments available within the mandated
timeframe the consumer will be referred to walk-in with the Advanced Access
Provider (available Monday – Friday, 8am to 8pm).
6. The Access Clinician will remind the consumer that the Cardinal Innovations
Access Call Center is available twenty-four (24) hours a day and instruct the
consumer to re-contact the Access Call Center by telephone at any time should
the situation escalate and require immediate attention.
7. Cardinal Innovations’ Access Staff will continue to follow-up with any Urgent
contact until it is ascertained that the consumer has been able to receive the
care that is most appropriate to meet the consumer’s clinical needs.
Note:
 Cardinal Innovations Network Providers are held to the following standard
regarding Appointment Wait Time for Urgent Cases: Scheduled Appointment:
one hour; Walk-in: within two hours.
 Urgent callers (not Medicaid/IPRS) are typically referred to walk-in centers,
with cross-referencing known insurances that providers offer, if known. These
callers are also encouraged to follow up with either the provider or their
insurance company to make sure insurances cover those services.
 If consumer requires emergent care, the consumer will be referred to a
Provider regardless of funding status (Medicaid, Medicare, Insurance, etc.).
3. Emergent Service:
The purpose of this process is to delineate the steps required to ensure that referrals for
emergency care are handled and documented in an appropriate manner. This process
describes the way in which referrals for Emergency Services are handled within Cardinal
Innovations’ Access Unit. The access standard for Emergency Services is two (2) hours
(or immediately, for life-threatening emergencies.) The geographic access standard for
services is thirty (30) miles or thirty (30) minutes driving time.
NOTE: In potentially life-threatening situations, the safety and well-being of the
consumer has priority over administrative requirements. Eligibility verification will be
deferred until the caller receives appropriate care.
73
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES
a. Emergent Referral Process:
1. Any calls that are deemed to be Emergent are immediately transferred to an
Access Clinician via a “warm” transfer (consumer remains on the line without
being put on hold). Access Call Center staff will exit the call once transfer has been
verified.
2. An Emergent situation is indicated if the consumer 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.
 Labile or unstable and demonstrates significant impairment in judgment,
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 or substance abuse illness and its treatment.
 Caller indicates (either by request or through assessed need) a need to be
seen immediately.
 The Access Clinician will determine through clinical screening whether the
consumer represents an immediate danger to self or others. If consumer is
an imminent danger to self or others, the Access Clinician will implement
crisis intervention procedures as an attempt to stabilize the consumer.
 The Access Clinician will attempt to determine any available supports for the
caller and when possible speak to them directly for assistance
If the consumer is able to be stabilized:
1. The Access Clinician will initiate a call to the Mobile Crisis Management Agency
to follow up with the consumer.
If the consumer is unable to be stabilized:
1. The Access Clinician will, with assistance from other staff when needed, contact
the appropriate emergency agency (i.e. law enforcement, emergency medical
services, etc.) to respond and attempt to keep the caller on the phone until they
arrive. The Access Coordinator will collect the remaining enrollment data from
the crisis worker when it becomes available.
2. Cardinal Innovations’ Access Clinicians will continue to follow-up with any
emergency contact until it is ascertained that the consumer has been able to
receive the care that is most appropriate to meet the consumer’s clinical needs.
74
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES
Note:
1. Consumers will be informed of the availability and types of Emergency Services
through advertising and development and distribution of brochures on
Emergency Services in the local community. Also, consumers receive a member
handbook as they begin services. This member handbook will contain
information on the ways in which members can access emergency services. In
addition, it is the responsibility of Access Call Center staff to inform consumers of
the availability and type of the nearest emergency services as they are assisting
the consumer in an emergency.
2. Cardinal Innovations Network Providers are held to the following standard
regarding Appointment Walk-In Time for Emergencies: Provider will see all
Emergencies within two hours, or immediately if the situation is life
threatening.
D. Process for Telephonic Pre-Service-Authorization
1. Process:
Access Clinicians will conduct telephonic reviews for Pre-Service authorization of the
following services due to the acute nature of the need:
 Acute Psychiatric Inpatient

All Detoxification Services

Facility-based Crisis Services (Pre-authorizations are not needed for the first 7
days. After 7 days, re-authorizations are submitted, with a maximum of 30 days
within a year’s period).

Emergency Respite Services

Mobile Crisis Management Services
Upon Cardinal Innovations Access Clinicians reviewing and approving TARS in the CI
systems, a “UM Note” is then entered in the “Provider Notes” section of the TAR, in
which each Access Clinician sends a TAR Report at the end of their shift to UM Inpatient
Staff and management, and eligibility/enrollment staff with a list of TARs completed,
along with hospital name, consumer name, number of days authorized, and other
information as needed.
a. When the Provider calls Cardinal Innovations with a Pre-Service authorization
request, the call is answered by the Access Call Center staff. The Access staff will
confirm eligibility and enrollment of the consumer. If the consumer is not enrolled,
the Access Staff will assist the Provider in enrolling the consumer (See - Eligibility
and Enrollment above) If there is a question about the consumer’s eligibility, even if
75
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES
eligibility is not confirmed at the time of the call, the Pre-Service-authorization
review will be conducted and a decision made, with a disclaimer given that eligibility
must be confirmed in order for payment to occur.
b. If the consumer’s situation meets Cardinal Innovations’ established clinical criteria
for the requested service, the Access Clinician will complete the following steps:
1. Authorize the service based on the Authorization Guidelines. The Access Clinician
will verbally notify the caller of the authorization, and generate an authorization
number, by completing a Treatment Authorization Request (TAR).
c. If the consumer’s condition does not meet the criteria for the requested service, the
Access Clinician will explore treatment alternatives with the Provider and consumer.
2. Discharge:
Discharge planning begins at the time of the initial assessment and is an integral part of
every consumer’s treatment plan regardless of the level of care being delivered.
The discharge planning process includes use of the consumer’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 consumer with
functioning in the community.
Care Coordinators assist with the discharge planning for consumers in acute levels of
care. Among the functions:
 Identify consumers who have multiple admissions to acute care facilities and make
recommendations, when appropriate, that enhanced services start prior to
consumer discharge.
 Make follow-up appointments with appropriate community Providers with-in 48
hours of discharge, when available.
3. Follow up after Discharge:
Cardinal Innovations recognizes the importance of follow up care after a consumer is
discharged from an acute level of care. Every effort is made to ensure the consumer is
engaged in treatment. All discharge appointments are followed up by the Follow-Up
Specialist or by an assigned Care Coordinator to make sure the consumer was seen. This
is done by contacting the Provider to verify that the appointment was kept. This, along
with the next appointment date, is monitored in the CI system.
76
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES
If an appointment is not kept, the Follow-Up Specialist:
a. Document the reason (i.e. No Show, consumer canceled, Provider canceled, etc.)
and whether the appointment was rescheduled.
b. Attempts to contact the consumer to discuss barriers and schedule another
appointment.
c. If the consumer is still not able to engage in treatment, the Follow-up Specialist will
make a referral to the Care Coordination Department to contact the consumer faceto-face to attempt engagement in services.
E. Enrollment
Please refer to the most current version of Cardinal Innovations’ Enrollment documentation
on the Provider Direct Website:
 Current Enrollment Request Form
 Online Enrollment Request Instructions and definition
The process is different for consumers receiving only Medicaid funded services than for
consumers that receive State funded services.
The following is the general processes for enrollment of a new consumer. Please ensure all
information is accurate and complete when enrolling a member into the Cardinal
Innovations system.
1. Process for Enrollment:
a. A Resident of Cardinal Innovations’ catchment area calls the 1-800-939-5911 Call
Center Number for a referral to services.
b. Access Coordinator determines if a request for service is routine, urgent or
emergent. (See Access to Services above)
c. If a request is routine, Access Coordinator checks if Resident of Cardinal Innovations’
catchment area is enrolled via current CI System client search.
d. If a Resident of Cardinal Innovations’ catchment area is not enrolled, the Access
Coordinator completes the initial enrollment data in the CI System
e. Consumer is referred for an assessment and the enrollment data is forwarded to the
receiving Provider via secure web portal (Provider Direct) or via confidential fax.
77
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES
f. Provider conducts an assessment and completes the “Additional Enrollment Data”
on the enrollment form. Provider collects documentation of Medicaid enrollment or
ability to pay information.
g. Provider submits the completed enrollment to Cardinal Innovations via Provider
Direct or confidential fax.
h. Enrollment is reviewed for completeness and accuracy by the Eligibility and
Enrollment Specialist and entered into the CI System.
2. For Providers with an electronic link to Cardinal Innovations:
The purpose of this process is to outline the ways in which Providers with the ability to
electronically submit confidential documents securely to Cardinal Innovations will
handle enrollment of Cardinal Innovations catchment area residents who present to
their Agency by phone or in person.
a. Process for handling enrollment electronically:
1. Walk-In consumers at a Provider site.




The Provider assesses for life threatening situation.
a. If life threatening situation is present proceed with emergency response
as clinically indicated.
1. If not life threatening, the Provider determines if person is enrolled
with Cardinal Innovations.
a. By checking the enrollment status in Provider Direct
b. By calling the Access Center and inquiring about the consumer’s
enrollment status.
If consumer is enrolled and has been previously seen by the Provider, the
Provider will conduct an assessment and request services as per Cardinal
Innovations Utilization Management Procedures. The Provider should also
ensure the accuracy of the consumer’s information and complete a Clinical
Update if needed.
If consumer is not enrolled, Provider will collect enrollment information on
the most current Cardinal Innovations Enrollment Form and send
electronically through Provider Direct.
Cardinal Innovations Eligibility / Enrollment Specialist will check enrollment
for completeness and accuracy and verify insurance eligibility.
2. Call-In Consumers

78
The Provider will schedule an assessment appointment. Enrollment
information will be collected on the most current Cardinal Innovations
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES
Enrollment Form and transmitted to Cardinal Innovations through Provider
Direct.

Cardinal Innovations Enrollment and Eligibility Specialist will check the
enrollment data for completeness and accuracy and verify insurance
eligibility.
F. Initial Assessment
Providers should complete an initial assessment addressing the elements required in the
current Service Records Manual (APSM 45-2).
1. Treatment Authorization Request Forms:
Cardinal Innovations has formulated a Treatment Authorization Request form (TAR) that
captures demographic and clinical information. When this form is completed
thoroughly, the Utilization Management Staff will be able to use this form to make the
clinical determination required for the consumer’s needs. If the form is not completed
fully, including all clinical information required, a delay in the approval of a service
request or a denial of the TAR may occur. Cardinal Innovations normally will respond to
all TARs within 14 days, but may extend the timeframe by up to an additional 14 days if
additional information is needed. The Utilization Management Staff will attempt to
garner the information through contact with the Provider, but this can take several days
to resolve in some cases. Providers will be monitored for TAR completeness and will be
identified for additional training as needed.
An instruction manual is available for review by logging into Provider Direct and
selecting
the
Training
Materials
link
from
the
Client
Gateway
(www.cardinalinnovations.org). Any Provider can request specific technical assistance
on TAR submission by contacting the Cardinal Innovations Utilization Management Unit
at 1-800-939-5911.
Please refer to the most current version of the forms and instructions:
 Treatment Authorization Request Form (TAR)
 TAR Instructions
G. Initial Authorization
NOTE: Cardinal Innovations is prohibited from implementing Utilization Management
procedures that provide incentives for the individual or entity conducting utilization reviews to
deny (reduce, terminate, or suspend), limit, or discontinue medically necessary services to any
enrollee. Utilization Management decision making is based only on appropriateness of care and
service and the existence of coverage. Cardinal Innovations does not specifically reward
79
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES
practitioners or other individuals for issuing denials of coverage or services. Financial incentives
for Utilization Management decision makers do not encourage decisions that result in underutilization.
The purpose of this process is to identify the steps required in performing priorauthorization of services. Prior-authorization of services is the responsibility of Cardinal
Innovations’ Utilization Management Unit. Requesting the Authorization is the
responsibility of the Provider.
NOTE: For a full listing of all State Medicaid Plan Service Definitions and Criteria, follow the
link www.dhhs.state.nc.us; http://www.ncdhhs.gov/dma/medicaid/index.htm.
1. Process for Prior Authorization of Services:
Prior-authorization is required for all Cardinal Innovations covered services, with the
following exceptions:
a. Initial 24 outpatient services (assessment, individual, family, and group therapy) for
Medicaid and the Initial 8 for Adult and 12 for Children for Non-Medicaid
b. Psychiatric Services
c. Emergency/Crisis services for Behavioral Healthcare.
d. Codes specifically agreed upon by Cardinal Innovations and Provider to be listed as
“No Authorization Required” under a contract. Please see your contract for
applicability.
The Cardinal Innovations Utilization Management (UM) Unit is only able to make
decisions (approval, denial, or extensions when appropriate) when a complete request
is received. For a request to be considered “complete” it must contain the following
elements:
 Recipient/consumer Name
 Medicaid ID
 Date of Birth
 Provider contact information and signatures
 Date of request
 Service(s) requested
 Service Order
 Completed Check boxes (Signature Page/Service Order Yes or No Check Boxes
related to medical necessity, direct contact with the individual, and review of the
individual’s Clinical Assessment)
 Individualized Service Plan/Person Centered Plan (ISP/PCP if applicable)
If all of these elements are not contained, Cardinal Innovations will return the request as
being unable to process.
80
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES
Some of these elements will be contained in the corresponding Treatment Authorization
Request (TAR). A TAR constitutes a service request and starts the timeline for review. A
Individualized Service Plan/Person Centered Plan (ISP/PCP ) alone does not initiate a
request for service, as it does not meet the criteria identified above because it is does
not indicate the service provider and requested services dates (since this information is
submitted via the TAR). Cardinal Innovations still recommends specific Provider names
not be listed in ISP’s/PCP’s in the event a transfer would ever need to occur. This
information would be identified on the TAR.
If a TAR is received and requests a service or frequency that is different from the PCP,
the Cardinal Innovations UM Unit will administratively deny the TAR as an incomplete
request and notify Provider.
If a TAR is received that requires a corresponding PCP/ISP and one is not submitted, this
will be administratively denied as an incomplete request and the Provider will be
notified.
2. Initial Authorization of Basic Augmented and Enhanced Transitional Services:
a. Prior-authorization for all Basic Augmented services may be requested through
submission of the Treatment Authorization Request (TAR) form. (An expedited
prior-authorization can be requested telephonically for any service, if immediate
access is clinically indicated.)
i. Please refer to the most current version of Cardinal Innovations’ TAR and TAR
Instructions (available on-line by logging into Provider Direct and selecting the
Training
Materials
link
from
the
Client
Gateway
at
www.cardinalinnovations.org).
b. Process for Telephonic Prior-Authorization.
Access Clinicians will conduct telephonic reviews for prior-authorization of the
following services due to the acute nature of the need:
i. Acute Psychiatric Inpatient
ii. All Detoxification Services
iii. Facility-based Crisis Services
iv. Emergency Respite Services
v. Mobile Crisis Management Services
The Cardinal Innovations Access Clinicians will conduct telephonic reviews for priorauthorization of “acute services” or services for which access is urgent or emergent.
Except for instances of life threatening emergency situations, a prior-authorization
review is conducted between the Provider or facility’s utilization review staff and a
Cardinal Innovations Access Clinician to determine the appropriateness of care and
to certify the initial treatment plan. The clinical information provided in the review
81
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES
must have been obtained from a face-to-face assessment of the eligible consumer
conducted within 24 hours prior to the call.
a. When the Provider calls Cardinal Innovations with a prior-authorization request,
the call is answered in the Access Call Center. The Access Coordinator will
confirm eligibility and enrollment of the consumer. If the consumer is not
enrolled, the Access Coordinator will assist the Provider in enrolling the
consumer. (See - Eligibility and Enrollment above.) If there is a question about
the consumer’s eligibility, even if eligibility is not confirmed at the time of the
call, the prior-authorization review will be conducted and a decision made, with
a disclaimer given that eligibility must be confirmed in order for payment to
occur.
b. The Access Coordinator will transfer the call to the appropriate Access Clinician
based on the diagnostic type or disability that will be the focus of treatment (i.e.
Mental Health, Intellectual/Developmental Disabilities or Substance
Use/Addiction).
c. When a request for prior-authorization for the above services is received, the
Access Clinician will access any existing clinical case information in Cardinal
Innovations’ CI system.
d. If the consumer’s situation meets Cardinal Innovations’ established clinical
criteria for the requested service, the Access Clinician will complete the following
steps:
i. Authorize the service based on the Authorization Guidelines. The Access
Clinician will verbally notify the caller of the authorization, and generate an
authorization letter in Cardinal Innovations’ computer system which can be
viewed by the Provider by logging into Provider Direct and clicking on the
Print Authorizations link.
ii. Discuss the details of making contact with the designated Access Clinician for
the first concurrent review. Give the Provider the name and telephone
number of the designated Access Clinician, and obtain the name and number
of the Provider who will be available for the first concurrent review.
iii. Document the clinical information and date of next review in the Cardinal
Innovations CI system.
e. If the consumer’s condition does not meet the criteria for the requested service,
the Access Clinician will explore treatment alternatives with the Provider and
consumer.
i. If agreement is reached regarding treatment at a different level of care or
with a different service, the Access Clinician will document the treatment
plan agreed upon, and complete the authorization and notification
procedures for that level of care or service.
82
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES
ii. If the Provider continues to request authorization for services which do not
appear to meet Cardinal Innovations’ applicable clinical criteria and
guidelines, the Access Clinician will advise the Provider that a review will be
necessary and that arrangements will be made by the Access Clinician.
iii. All determinations and related actions will be recorded in the Cardinal
Innovations CI System.
iv. Any denial of service will follow the Medicaid Appeals process for Medicaid
services and/or the local Cardinal Innovations Grievance procedure for NonMedicaid services.
3. Initial Authorization of Enhanced Services:
NOTE: Authorization of Enhanced Services: Enhanced level services will be authorized through the
review of the TAR and approved Person Centered Plan as submitted by the Clinical Home Provider.
Services will be identified through the Person Centered planning process in a coordinated effort
between the Clinical Home Provider, the consumer, consumer’s family and Providers.
a. Authorization of Enhanced Services:
i.
Enhanced level services needing immediate authorization should be submitted
to the Utilization Management Unit on the Treatment Authorization Request
(TAR) form. An Initial Individualized Service Plan (ISP)/Person Centered Plan
(PCP should be submitted to cover any services requested, which will be
utilized to develop the full ISP/PCP.
ii. The Clinical Home Provider completes the ISP/PCP with input from consumer,
consumer’s family, and Providers.
a. The services are listed with any limitations noted.
b. The Provider for each service is listed on the TAR.
iii. PCP and TAR are submitted to Utilization Management (UM) for review.
iv. All UM actions are documented in the Cardinal Innovations (CI) Computer
System.
v. If the ISP/PCP and TAR are missing information or contain incorrect
information, UM may extend the timeframe to respond to the TAR and request
the additional information and/or that the provider correct any incorrect
information.
vi. UM Staff will document the reason for not approving the PCP and TAR.
vii. The Clinical Home Provider will update as needed and re-submit for approval.
viii. All versions of the document will be maintained in the CI System.
ix. A TAR is required to request initial authorization of services. An initial
Authorization Letter is automatically generated by the CI computer system and
available Provider Direct informing the Provider of the initial service approval.
x. The letter will also indicate the date span of the authorization and the need for
a re-authorization request to be generated by the Provider using the electronic
version of the Treatment Authorization Request (TAR) form found by logging
into Provider Direct.
83
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES
H. Additional Authorization of Services
1. Additional Authorization of Basic Augmented Services
a. The next review date is indicated by the end date on the authorization letter. It is
the Provider or facility's responsibility to submit a request for further service
authorization to Cardinal Innovations’ UM Unit prior to the expiration of the current
authorization, and to conduct a clinical review.
b. The request for additional services must be made no earlier than thirty (30) days and
no later than fifteen (15) days before the current service authorization expires. In
acute situations, it is recommended that, when possible, the clinical review should
be conducted at least twenty-four (24) hours prior to the expiration of the current
authorization. UM Care Managers refer to the Authorization Guidelines to
determine when reviews should be conducted for each level of care.
c. If the Provider indicates that the consumer requires additional care at that level, the
UM Care Manager will conduct a clinical review by requesting information (i.e., an
updated ISP/PCP and a new TAR). When it is received, the UM Care Manager will
review the information.
i. Based on a review of the information provided, the UM Care Manager will make
a decision to authorize or deny the request.
ii. If the request is denied, the consumer and provider will be notified and appeal
rights will be provided.
e. All determinations and related actions will be recorded in the Cardinal Innovations CI
System.
2. Additional Authorization of Enhanced Services:

If the Person Centered Plan has changed or has been updated, the ISP/PCP and TAR
approval process must be completed before an authorization of services can occur.

If the Person Centered Plan has not been updated, the additional authorization of
services will be the responsibility of the Provider.
a. At the time of need for an additional authorization, the Provider shall complete a
TAR online and submit it electronically to Utilization Management via Provider
Direct.
i. The information required establishing the need for continued medical necessity
and service continuation criteria must be included.
ii. The CI System TAR Entry screen will have list of the service(s).
84
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES
b. Treatment Authorization Request (TAR) should validate against the PCP and the UM
Criteria.
c. A UM Care Manager will review the request for medical necessity and then follow
the approval / denial process.
I. Discharge Review
Discharge planning begins at the time of the initial assessment and is an integral part of
every consumer’s treatment plan regardless of the level of care being delivered.
The discharge planning process includes use of the consumer’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 consumer with functioning in the
community.
Involvement of family members and other identified supports, including members of the
medical community, require the consumer’s written consent. The purpose of this process is
to identify the steps to be taken by the Utilization Management Care Manager in assisting
with Discharge Planning Efforts.
Process of Discharge Planning:
1. The Utilization Management Care Manager reviews the status of the discharge plan at
each review to assure that:
 A discharge plan exists;
 The plan is realistic, comprehensive, timely and concrete;
 Transition from one level of care to another is coordinated;
 The discharge plan incorporates actions to assure continuity of existing therapeutic
relationships; and
 The consumer understands the status of the discharge plan;
2. When the discharge plan is lacking in any respect, the Utilization Management Care
Manager addresses the relevant issues with the Provider.
3. The Utilization Management Care Manager assists with the development of discharge
plans for consumers in all levels of care. Among the functions:
 Identify consumers who are remaining hospitalized, or at any other level of care,
who do not meet criteria for that level of care and help develop a plan to get the
right service at the right level.
 Monitor consumers to assure that they receive clinically indicated services.
 Whenever a consumer is discharged from detoxification, inpatient psychiatric or
partial hospitalization care, the discharge plan should include a follow-up
85
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES

appointment within five (5) working days. Cardinal Innovations will work with the
discharging facility to ensure that an appointment is made and monitor whether the
consumer kept the appointment.
The Utilization Management Care Manager will coordinate with the consumer’s
Clinical Home to ensure there are appropriate services in place following discharge.
If the consumer does not have a Clinical Home, and the consumer meets Special
Needs Population criteria, the UM Care Manager will refer to the Care Coordination
Department for follow-up by a Care Coordinator.
K. Utilization Review
The primary function is to monitor the utilization of services and review utilization data to
evaluate and ensure that services are being provided appropriately within established
benchmarks and clinical guidelines; that services are consistent with the authorization and
approved PCP / Treatment Plan; and that established penetration goals are maintained.
Utilization review is an audit process that involves a review of a sample of services that have
been provided. Information from the consumer’s record (assessment information,
treatment plan and progress notes) is evaluated against Medical Necessity Criteria. This is
done concurrently (during re-authorization) and retrospectively (after the service has been
provided). The outcome of this review can indicate areas where Provider training is needed,
services that were provided that did not meet Medical Necessity, and situations where the
consumer did not receive appropriate services or care that was needed. Indicators will be
identified to select cases for review, such as high utilization of service, frequent hospital
admissions, etc. as well as random sampling of other events. Cardinal Innovations utilizes
both Focused Utilization Review and a sampling process across Network Providers in its
Utilization Review methodologies. Other reviews may be performed as Cardinal
Innovations deems appropriate.
1. Focused Review will be based on the results of Monitoring Reports that identify outliers
as compared to expected / established service levels or through specific cases identified
in the Cardinal Innovations clinical staffing process to be found outside the norm.
Focused samples may include:
 High-risk consumers - Examples may include, but are not limited to, consumers who
have been hospitalized more than one time in a 30-day period; developmentally
disabled consumers as identified in the Risk/Support 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,
consumers who utilize less than 70% of an authorized service or consumers who
have multiple failed appointments.
 Over-utilization of services – Example: consumers who continue to access crisis
services with no engagement in other services.
 Services infrequently utilized – Example: an available practice that is not being used.
86
SECTION VII: ACCESS, ENROLLMENT AND AUTHORIZATION OF SERVICES

High-Cost Treatment – consumers in the top 10% of claims for a particular service.
2. Routine Utilization Review will focus on the efficacy of the clinical processes in cases as
they relate to reaching the goals in the consumer’s ISP/PCP / treatment plan. Cardinal
Innovations will also review the appropriateness and accuracy of the service provision in
relation to the authorizations. All Providers contracted with Cardinal Innovations who
are currently serving Cardinal Innovations consumers are subject to Utilization Reviews
to ensure that clinical standards of care and medical necessity are being met. A routine
utilization review (UR) will be inclusive of, but not limited to: evaluations of services
across the delivery spectrum; evaluations of consumers by diagnostic category or
complexity level; evaluations of Providers by capacity, service delivery, best-practice
guidelines and evaluations of utilization trends.
3. The criteria used in the Utilization Review processes will be based on the most current
approved guidelines and service manuals utilized under the NC MH/DD/SAS Health Plan
and NC Innovations Waiver and processes for NC State services. These documents
include, but are not limited to, the current NC State Plan service definitions with
Admission, Continuation, and Discharge criteria; the Cardinal Innovations approved
Clinical Guidelines; the current approved NC MH/DD/SAS service rules; and the current
approved NC DMA Clinical Coverage policy.
Cardinal Innovations may perform other reviews as it deems appropriate.
87
SECTION VIII: STATE SERVICE DEFINITIONS AND CRITERIA
SECTION VIII: STATE SERVICE DEFINITIONS AND CRITERIA
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. Please follow the link for the most current version of the Service
Definitions and Admission, Continuation, and Discharge Criteria:

Service Definitions Manual:
http://www.ncdhhs.gov/mhddsas/statspublications/Manuals/index.htm

Clinical Coverage Policies: http://www.ncdhhs.gov/dma/mp/index.htm
B. NC Innovations Waiver-1915 (c)
The NC Innovations Waiver is a 1915 (c) Home and Community Based Waiver. A consumer
must be a member of the NC Innovations Waiver in order to receive these services. Please
refer to the most current version of the Service Definitions on the:

NC Innovations Technical Guide:

http://www.cardinalinnovations.org/Providers/manuals.asp
DMA website: http://www.ncdhhs.gov/dma/mp/index.htm
Cardinal Innovations website: www.cardinalinnovations.org

C. b (3) Services
These are Medicaid services that are funded through a separate capitation payment.
Definitions can be accessed on the Cardinal Innovations website at
www.cardinalinnovations.org; http://www.cardinalinnovations.org/Cardinal/providers.asp.
See Section VII for instructions on Access, Enrollment and Authorization of Services.
88
SECTION IX: RESOURCES FOR PROVIDERS
SECTION IX:
RESOURCES FOR PROVIDERS
Contracted Providers must keep abreast of rule changes at the State level, attend workshops
and trainings to maintain clinical skills and/or licensure, be knowledgeable on evidenced based
or emerging practices, and be current on coding and reimbursement. Cardinal Innovations will
provide a number of resources to assist Providers in meeting this requirement. We will
communicate information regarding workshops through a variety of mediums and will offer
trainings or technical assistance as needed. The Network Operations department will
coordinate the Cardinal Innovations Calendar that lists all trainings offered by internal
departments and post it on www.cardinalinnovations.org. The following resources are provided
as assistance and linkage and are not designed to be a comprehensive list for Providers.
A. Training and Technical Assistance
Cardinal Innovations
http://www.cardinalinnovations.org
Click on Current Cardinal Innovations Provider’s link – Cardinal Innovations Provider Training
OR
Click this link for training calendar for all external training offered by QM
http://www.cardinalinnovations.org/calendars/?CalendarID=8
OR
Click this link to request Provider Direct Training. Trainings are offered live
on-line once a quarter and also on demand. (NOTE: Live-online classes
will be cancelled if we have less than five registered attendees.)
http://www.cardinalinnovations.org/providers/PDTraining/
B. Advocacy:
National Alliance on Mental Illness (NAMI)
www.nami.org
C. Associations
American Academy of Child and Adolescent Psychiatry
www.aacap.org
American Academy of Psychoanalysis and Dynamic Psychiatry
www.aapsa.org
89
SECTION IX: RESOURCES FOR PROVIDERS
Association of Ambulatory Behavioral Healthcare
www.aabh.org
American Association for Geriatric Psychiatry
www.aagponline.org
American Association of Marriage and Family Therapy
www.aamft.org
American Association of Pastoral Counselors
www.aapc.org
American Psychiatric Association
www.psych.org
American Psychological Association
www.apa.org
American Psychological Society
www.psychologicalscience.org
Autism Society of America
www.autism-society.org
National Association of Protection and Advocacy Systems (NAPAS)
www.protectionandadvocacy.com
National Association of Psychiatric Health Systems
www.naphs.org
National Association of Social Workers
www.socialworkers.org
National Association of State Mental Health Program Directors (NASMHDPD)
www.nasmhpd.org
National Mental Health Association (NMHA)
www.nmha.org
North Carolina Council of Community Programs
www.nc-council.org
90
SECTION IX: RESOURCES FOR PROVIDERS
North Carolina Substance Abuse Professional Practice Board
http://www.ncsappb.org/
United States Psychiatric Rehabilitation Association
www.uspra.org
D. Behavioral Healthcare Resources
Behavioral Healthcare Institute
http://www.behavioralhealthcareinstitute.com/
Boston University Center for Psychiatric Rehabilitation
www.bu.edu/sarpsych
Council for Affordable Quality Healthcare (CAQH)
www.caqh.org
CARF
www.carf.org
International Center for Clubhouse Development
www.iccd.org
Latino Behavioral Healthcare Institute
www.lbhi.org
Manisses Communication
www.manisses.com
National Center for Child Traumatic Stress (NCCTS)
www.NCTSNet.org
National Committee for Quality Assurance (NCQA)
www.ncqa.org
North Carolina Foundation for Alcohol and Drug Studies
www.ncfads.org
Open Minds
www.openminds.com/
Research and Training Center for Children’s Mental Health
http://rtckids.fmhi.usf.edu/
91
SECTION IX: RESOURCES FOR PROVIDERS
TeenScreen
www.teenscreen.org
E. Consumer And Family Resources
Association for Person in Supported Employment (APSE)
www.apse.org
Children and Adults with Attention-Deficit/Hyperactivity Disorder
www.chadd.org
CHADD on –line library
http://www.chadd.org/Content/CHADD/Support/CHADDExchange/StartCHADDExchange.ht
m
Federation of Families for Children’s Mental Health
www.ffcmh.org
NMHA-Consumer Supporter Technical Assistance Center
www.ncstac.org/
National Empowerment Center
www.power2u.org
National Mental Health Consumers’ Self –Help Clearinghouse
http://www.mhselfhelp.org/
F. Cultural Competence
Cardinal Innovations Cultural Competence Page:
http://www.cardinalinnovations.org/Cultural/
92

Annie E. Casey Foundation
www.aecf.org

Association of Gay and Lesbian Psychiatrists
www.aglp.org

Association for Lesbian, Gay, Bisexual & Transgender Issues in Counseling
www.algbtic.org/

Diversity Inc.
http://www.diversityinc.com/
SECTION IX: RESOURCES FOR PROVIDERS
93

Indian Country (The nation’s leading American Indian news source)
www.indiancountry.org

Latino Behavioral Health Institute
www.lbhi.org

Medline Plus has health information in over 40 different languages
www.medlineplus.gov

National Asian American Pacific Islander Mental Health Association
www.naapimha.org

National Congress of American Indians
www.ncai.org/

National Latino Behavioral Health Association
www.nlbha.org

National NAMI
www.nami.org
Has NAMI en Español, as well as the NAMI Multicultural Center Resources webpage.

National Organization of People of Color Against Suicide
www.nopcas.org/

Native Web (resources for indigenous cultures around the world)
www.nativeweb.org

NCLR – National Council of La RAZA (the largest Latino civil rights and advocacy
organization in the U.S.)
www.nclr.org

Pan American Health Organization
www.paho.org

The Association of Black Psychologists
www.abpsi.org/

The Black Mental Health Alliance
www.blackmentalhealth.com

The Office of Ethnic Minority Affairs of the American Psychological Association has a
webpage
www.apa.org/pi/oema/homepage.html
SECTION IX: RESOURCES FOR PROVIDERS

World Federation for Mental Health (making mental health a global priority)
www.wfmh.com/

World Health Organization - this website can be accessed in Arabic, Chinese, English,
French, Russian, and Spanish
www.who.int/en/
G. Developmental Disabilities
Autism Speaks Family Services
www.autismspeaks.org
Center for Study on Autism
www.autism.org or www.GlobalAutismCollaboration.com
Centers for Medicare and Medicaid
www.cms.gov
Council for Exceptional Children (CEC)
www.cec.sped.org
Exceptional Children’s Assistance Center
www.ecac-parentcenter.org
Family Support Network of North Carolina
www.fsnnc.org
NC Division of Health and Human Services
www.dhhs.state.nc.us
Spectrum resources of NC
www.spectrumresourcesofnc.net
The Arc of the United States
www.thearc.org
The Arc of NC
www.arcnc.org
The Autism Society of NC
www.autismsociety-nc.org
94
SECTION IX: RESOURCES FOR PROVIDERS
The Beach Center/Family Training
www.beachcenter.org
The National Inclusion Project
www.inclusionproject.org
H. Federal Government
US Department of Health and Human Services – Substance Abuse and Mental Health
Services Administration
www.samhsa.gov/
Centers for Medicare and Medicaid
www.cms.hhs.gov
Medicare
www.medicare.gov
National Council on Disability
www.ncd.gov
Knowledge Exchange Network
www.mentalhealth.org
National Institute on Alcohol Abuse and Alcoholism
http://www.niaaa.nih.gov/
National Institute on Drug Abuse
www.nida.nih.gov
United State Department of Housing and Urban Development
www.hud.gov
White House Office of National Drug Control Policy
www.whitehousedrugpolicy.org
I. Grants And RFPs
American Psychiatric Foundation
www.psychfoundation.org
Foundation Center Philanthropy News Digest- RFP Bulletin
http://fdncenter.org/pnd/index.jhtml
95
SECTION IX: RESOURCES FOR PROVIDERS
J. North Carolina State Links
North Carolina Department of Health and Human Services
www.dhhs.state.nc.us
North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse
Services
www.dhhs.state.nc.us/mhddsas
North Carolina Coalition to End Homelessness
www.ncceh.org
North Carolina Division of Medical Assistance
www.dhhs.state.nc.us/dma/
North Carolina Housing Coalition
www.nchousing.org
North Carolina Housing Finance Agency
www.nchfa.com
K. Other State Links
New York State Office of Mental Health
www.omh.state.ny.us
South Carolina Department of Mental Health
http://www.state.sc.us/dmh/
Tennessee Department of Mental Health and Substance Abuse Services
http://www.state.tn.us/mental/
Virginia Department of Behavioral Health and Developmental Services
http://www.dbhds.virginia.gov/
96
SECTION X: GETTING PAID-FINANCE REQUIREMENTS
SECTION X:
GETTING PAID – FINANCE REQUIREMENTS
A. Enrollment and Eligibility Process
1. Eligibility Determination
2. Key Data to Capture During Enrollment
3. Effective Date of Enrollment
4. Member ID
B. Authorizations Required for Payment
1. System Edits
2. Authorization Number and Effective Dates
3. Service Categories or Specific Services
4. Units of Service
5. Exceptions to Authorization Rule
C. Payment of Claims and Claims Inquiries
1. Timeframes for Submission of Claims
2. Process for Submission of Replacement and Voided Claims
3. Provider Direct Claims Submission
4. 837 Claims Submission
a. Formats
b. Multiple Occurrences of Same Service in a Day
c. Authorization
d. National Provider Identifier (NPI)
e. Verification and Notification
5. Providers Who Submit Paper Claims
D. Service Codes and Rates – Contract Provisions
1. Publishing of Rates
E. Standard Codes for Claims Submission
1. Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System
(HCPCS)/Revenue Codes: CPT/HCPCS/Revenue Codes
2. Diagnosis Codes
3. Place of Service Codes
F. Definition of Clean Claims
G. Coordination of Benefits
1. Eligibility Determination Process by Provider
2. Obligation to Collect
3. Reporting of Third-Party Payments
97
SECTION X: GETTING PAID-FINANCE REQUIREMENTS
H. Sliding Fee Schedules
1. Eligibility for Benefit Determination
2. Process to Establish the Sliding Fee
3. Process to Modify
I. Response to Claims
1. Remittance Advice
2. Electronic Remittance Advice (835) – for 837 Providers
3. Management of Accounts Receivable – Provider Responsibility
J. Fee-For-Service Equivalency (FFSE)
1. Contract Agreement
2. Review of FFSE Process
3. Reconciliation
K. Claims Investigations – Abuse and Fraud
1. Trends of Abuse and Potential Fraud
2. Audit Process
3. Role of Finance Department
4. Voluntary Repayment of Claims
5. Reporting to State and Federal Authorities
L. Repayment Process/Paybacks
M. Review and Determination Process
1. Authorization Issues
2. Claim Denial
3. Review and Determination Request
4. Cardinal Innovations Network Provider Review And Determination (R&D) Request Form
98
SECTION X: GETTING PAID-FINANCE REQUIREMENTS
A. Enrollment and Eligibility Process
1. Eligibility Determination:
Consumers who have their services paid for in whole or in part by Cardinal Innovations must
be enrolled in the Cardinal Innovations system. If you have any questions about a consumer’s
eligibility, please call the Access Call Center. Assistance can be found on the Provider Direct
website using the current version of Cardinal Innovations’ Enrollment documentation.
Individuals who have 100% ability to pay according to Cardinal Innovations’ sliding fee
schedule or who have insurance coverage that pays 100% of their services must not be
enrolled in the Cardinal Innovations system. However, the person may still receive and pay for
services from a Provider independent of Cardinal Innovations’ involvement.
It is the responsibility of each Provider to make a complete and thorough investigation of a
consumer’s ability to pay prior to requesting to enroll that person in the Cardinal Innovations
system. This would require that the Provider determine:





If the consumer has Medicaid or whether the consumer may be eligible for Medicaid.
If the consumer has Medicare or any other third party insurance coverage.
If there is any other payor involved – worker’s compensation, EAP program, court ordered
services paid for by the court, etc.
If the consumer meets Cardinal Innovations criteria for use of local or state funds to pay for
services. The criteria will be the lack of Medicaid or other third party insurance, as well as
the inability of the individual or family to pay for a portion of healthcare services based on
Cardinal Innovations’ published Sliding Fee Schedule. Cardinal Innovations publishes a
Sliding Fee Schedule that Providers must use to determine non-Medicaid consumer’s
ability to pay for services and Medicaid consumers’ ability to pay for non-Medicaid billable
services. See http://www.cardinalinnovations.org/finance/forms.asp.
If the consumer has already been enrolled in the Cardinal Innovations system.
If the consumer has Medicaid and has already been enrolled in the Cardinal Innovations
system, they are financially eligible for Medicaid reimbursable services from Cardinal
Innovations. If they are not yet enrolled, then the Provider must provide the information
necessary to enroll the consumer. Consumer enrollment can be performed electronically
through the Provider Direct System or by contacting the Access Center at 1-800-939-5911.
Assistance can be found on the Provider Direct website using the current version of Cardinal
Innovations’ Enrollment documentation. Providers should assist consumers that may be
eligible for Medicaid funding to apply for Medicaid through the county Department of Social
Services.
Consumer Confidentiality:
Consumers who request enrollment in the Cardinal Innovations system should be asked to sign
a Privacy Notice making them aware of their rights and the use of their Protected Health
Information (PHI) to obtain payment for their services.
99
SECTION X: GETTING PAID-FINANCE REQUIREMENTS
2. Key Data to Capture During Enrollment:
All Providers are required to ensure consumer enrollment data is up-to-date based on the
most current Cardinal Innovations Enrollment Procedures and training. These documents can
be found in the NC MH/DD/SAS Health Plan Operations Manual at
http://www.ncdhhs.gov/mhddsas/statspublications/manuals/.
Training documentation can be accessed by logging into Provider Direct and clicking on the
Training Materials link. See https://www.pbhcare.org/PP/PDirectCI/PDLogin.aspx.
If enrollment data is not complete prior to service provision, authorizations and claims will be
affected, including authorization and claims denials. Consumers’ Medicaid information must
be provided to the Access Center when requesting an enrollment. If the consumer has any
other third-party insurance, including Medicare, this information must also be included in the
enrollment request. Consumers whose services are paid in part by third-party insurance can be
enrolled if Cardinal Innovations is to be a secondary payor.
3. Effective Date of Enrollment:
Enrollment into the Cardinal Innovations system must be done prior to providing services
except in emergency situations. It is the Provider’s responsibility to complete the eligibility
determination process, including verification of previous enrollment in the Cardinal
Innovations system and to complete the enrollment process prior to providing services. Crisis
services provided in emergency situations are the exception to this rule. In these cases, the
Provider must enroll the consumer within seven (7) days of the first date of service and
indicate the date of enrollment as the date that the emergency services were provided.
Services billed with service dates prior to an enrollment date will be denied.
4. Member ID:
The Member ID Number identifies the specific consumer receiving the service and is assigned
by the Cardinal Innovations information system. The consumer must be enrolled in the
Cardinal Innovations system in order for a claim to be accepted. In order for the Provider to
obtain this number, the consumer must have been successfully enrolled into the Cardinal
Innovations information system. All claims submitted with incorrect Member ID numbers, or
for consumers whose enrollments are no longer active, will be denied.
B. Authorizations Required for Payment
1. System Edits:
Cardinal Innovations’ information system is specifically designed to identify authorization data
prior to approving claims. The information system contains edits that are verified, so Providers
must be very attentive to authorized units to ensure maximum reimbursement.
2. Authorization Number and Effective Dates:
Each authorization has a unique number, a start date and an end date. Only services with
dates of service within these specific time frames will be approved. Dates and/or units outside
these parameters will be denied.
100
SECTION X: GETTING PAID-FINANCE REQUIREMENTS
3. Service Categories or Specific Services:
Each authorization indicates specific categories of services or in some cases very specific
services that have been authorized. Each service is validated against the authorization to
ensure that the service matches the authorization. Services outside of these parameters will
be denied.
4. Units of Service:
Each authorization indicates the maximum number of authorized service units. As each claim is
processed, the system validates units claimed against the units of service authorized. The
system will deny any claims that exceed the limits. Providers must establish internal
procedures to monitor units of service against authorizations to avoid claim denials due to
exceeding units of service.
5. Exceptions to Authorization Rule:
Certain services are approved without an authorization. These services are limited in scope
and are limited in total number to a consumer, not to a Provider. Once the annual limit has
been reached for a consumer, then all services without an authorization, regardless of the
Provider of the service, will be denied. Providers must be constantly aware of this issue in
order to avoid denied claims.
C. Payment of Claims and Claims Inquiries
Providers must submit claims through Provider Direct or an 837 file unless their contract
specifically states an alternative method. Providers are encouraged to produce routine billings
on a weekly or bi-monthly schedule.
1. Timeframes for Submission of Claims:
All claims must be submitted within ninety (90) calendar days of the date of service to ensure
payment, unless otherwise specified in the Provider’s contract. Claims submitted outside of
the allowable billing days will be denied.
2. Process for Submission of Replacement and Voided Claims:
Submission of Replacement Claims
Providers may submit replacement claims for originally paid claims within (90) ninety calendar
days from the service date. Replacement claims submitted past (90) ninety calendar days from
the service date will be denied for exceeding billing days and cannot be resubmitted.
Instructions for claims submitted through Provider Direct
 In Box 22 on the CMS1500, key 10 and the original Cardinal Innovations claim number
found on the Remittance Advice (RA) where the claim was paid as the reference
number.
 In Box 4 on the UB04, use 7 as the 4th digit which indicates “replacement of prior claim.”
Reference the original Cardinal Innovations claim number in Box 64A (Document
Control Number).
101
SECTION X: GETTING PAID-FINANCE REQUIREMENTS
Instructions for claims submitted via an 837 transaction set
 In Loop 2300 – Claim segment/5th element (CLM05-03), 7 (code for resubmission)
should be submitted along with a REF segment with “F8” as reference code identifier
and the claim number found on the RA as the reference number. See example below:
CLM*01319300001*500***11::7*Y*A*Y*Y***02******N~REF*F8*111111~
Once the replacement claim has been received, the original claim will deny and the
replacement claim will be processed according to all Cardinal Innovations Billing Guidelines.
Submission of Voided Claims
Providers may submit voided claims for originally paid claims. Billing days for a void claim is
ninety (90) calendar days from the service date.
Instructions for claims submitted through Provider Direct
 In Box 22 on the CMS1500, key 12 and the original Cardinal Innovations claim number
found on the RA where the claim was paid as the reference number.
 In Box 4 on the UB04, use 8 as the 4th digit which indicates “reversal of prior claim.”
Reference the original Cardinal Innovations claim number in Box 64A (Document
Control Number).
Instructions for claims submitted via an 837 transaction set
 In Loop 2300 – Claim segment/5th element (CLM05-03), 8 (code for reversal) should be
submitted along with a REF segment with “F8” as reference code identifier & the claim
number found on the RA as the reference number. See example below:
CLM*01319300001*500***11::8*Y*A*Y*Y***02******N~REF*F8*111111
Voided claims will be reverted and the original claim payment will be recouped.
1. Provider Direct Claims Submission:
Providers are contractually required to submit billing electronically. Provider Direct is a webbased system available to Cardinal Innovations Providers upon completion of a Trading Partner
Agreement (TPA). Billing through the Provider Direct System is Direct Data Entry (DDE) where
an electronic CMS1500 or UB04 form is accessed and billing information is entered and
submitted to Cardinal Innovations for reimbursement. The Provider Direct Manual (a user
manual for Provider Direct claim submissions) gives very specific instructions on information
needed to complete a claim form.
See: TPA http://www.cardinalinnovations.org/tpa/
Provider Direct Manual (available after logging-in) https://www.pbhcare.org/PP/PDirectCI/PD_Login.aspx
2. 837 Claims Submission:
Detailed instructions are provided in the Companion Guide, a user manual for electronic 837
submissions). See http://www.cardinalinnovations.org/finance/billing.asp. The Companion
Guide gives specific instructions regarding information required to submit claims electronically
to Cardinal Innovations. The entire testing and approval process is outlined in this document.
102
SECTION X: GETTING PAID-FINANCE REQUIREMENTS
The HIPAA compliant ANSI transactions are standardized; however each payor has the ability
to exercise certain options and to insist on use of specific loops or segments. The purpose of
the Companion Guide is to clarify those choices and requirements so that Providers can submit
accurate HIPAA transactions. Cardinal Innovations will accept only HIPAA-compliant
transactions, as required by law. Cardinal Innovations provides the following HIPAA transaction
files back to Providers: 999 (an acknowledgment receipt), 824 (a line by line
acceptance/rejection response) and 835 (an electronic version of the remittance advice).
Other general guidelines to consider include the following:
a. Formats:
NC Innovations Services, Out-patient Therapy, Residential (state-funded) and other daily
and periodic services must be submitted using the ANSI 837P (Professional) format or the
electronic CMS 1500 form if billing through the Provider Direct System. Inpatient,
Therapeutic Leave, Residential Services (Medicaid funded), Out-patient Revenue Codes and
ICF Services must be submitted using the ANSI 837I (Institutional) format or the electronic
UB04 form if billing through the Provider Direct System.
b. Multiple Occurrences of Same Service in a Day:
When a specific service is rendered multiple times in a single day at the same location, the
services must be billed using multiple bundled units rather than as separate line items.
Doing so will prevent a duplicate billing denial.
c. Authorization:
As described in the authorization section of this Manual, authorizations are for specific
consumers, Providers, types of services, date ranges, and for a set number of units.
Providers are responsible for maintaining internal controls within their information
systems to avoid a denial due to not being consistent with the authorization.
d. National Provider Identifier (NPI):
Providers are required to obtain an NPI number to submit billing. The NPI number and
taxonomy code are required for claims to be accepted and processed. Failure to comply
with these guidelines will result in denied billing.
e. Verification and Notification:
Cardinal Innovations provides the following responses to ensure that electronic 837 billing
is accepted into the Cardinal Innovations system for processing and payment:
o 999 X12 File-this file acknowledges receipt of the 837 billing file.
o 824 X12 File-this file provides feedback regarding whether line items in the 837 file
have been accepted or rejected. If the line item has been rejected a detailed
explanation will be provided.
These files are available in the File Download option of the Provider Direct system. It is the
Provider’s responsibility to review these responses to verify billing has been accepted into
the Cardinal Innovations system for processing so reimbursement is not interrupted due to
file formatting issues.
103
SECTION X: GETTING PAID-FINANCE REQUIREMENTS
Providers are able to perform claim inquiries within Provider Direct. The Provider Direct
Manual can be accessed via the Training Materials Link located on the Client Gateway of
Provider Direct.
See https://care.pbhsolutions.net/PP/PDirectCI/PDLogin.aspx
Inquiries regarding the status of claims should be directed to the Cardinal Innovations Finance Claims
Specialist Staff. Contact information can be accessed via the Cardinal Innovations website
www.cardinalinnovations.org, under the Financial Information for Providers.
D. Service Codes and Rates - Contract Provisions
1. Publishing of Rates:
Provider contracts include a listing of services that they are eligible to provide. All Providers
are reimbursed at the Cardinal Innovations published rates unless otherwise stated in their
contracts. Providers must only use the service codes in their contract or reimbursement will be
denied as non-contracted services. Providers can submit claims for more than the published
rates, but only the published or contracted rate will be paid. If a Provider submits a service
claim for less than the published rate, the lower rate will be paid. It is the Provider’s
responsibility to monitor the publishing of rates and to make necessary changes to their billing
systems. See http://www.cardinalinnovations.org/finance/rates.asp.
E. Standard Codes for Claims Submission
1. CPT/HCPCS/Revenue Codes:
Refer to Cardinal Innovations Finance website: http://www.cardinalinnovations.org/finance
2. Diagnosis Codes:
Use diagnosis codes from the ICD9 Code Manual.
3. Place of Service Codes:
Refer to Cardinal Innovations Finance website: http://www.cardinalinnovations.org/finance/
F. Definition of Clean Claims
A clean claim is defined as a claim that can process without manual intervention, has all of the
required data elements, is submitted in the correct format and meets the terms of the contract
between Cardinal Innovations and the Provider.
G. Coordination of Benefits
Cardinal Innovations is the payer of last resort. Providers are required to collect all first- and thirdparty funds prior to submitting claims to Cardinal Innovations for reimbursement. First-party
payers are the consumers or their guarantors. Services paid for with Local or State funds are
subject to the Sliding Fee Schedule. Third-party payers are any other funding sources that can be
billed to pay for the services provided to the consumer. This can include workers’ compensation,
disability insurance or other health insurance coverage.
104
SECTION X: GETTING PAID-FINANCE REQUIREMENTS
All claims must identify the amounts collected from both first and third parties and only request
payment for any remaining amount.
1. Eligibility Determination Process By Provider:
Providers should conduct a comprehensive eligibility determination process whenever a client
enters the delivery system. Periodically (no less than quarterly), the Provider should update its
eligibility information to determine if there are any first- or third-party liabilities for this
consumer. It is the Provider’s responsibility to monitor this information and to adjust billing
accordingly. First- or third-party insurances should be added to the consumer’s record by
completing a Client Update in the Provider Direct System.
2. Obligation to Collect:
Providers must make good faith efforts to collect all first- and third-party funds prior to billing
Cardinal Innovations. First-party charges must be shown on the claim whether they were
collected or not. The Cardinal Innovations CI System has the ability to validate third-party
payers and can deny or adjust the claim.
3. Reporting of Third Party Payments:
Providers are required to record on the claim either the payment or denial information from a
third-party payer. Copies of the ERA or EOB from the insurance company should be retained by
the Provider if they submit electronic billing. If paper claims are submitted to Cardinal
Innovations, the Provider is required to submit copies of the ERA or EOB with the claim form to
Cardinal Innovations. Providers must bill any third-party insurance coverage. This includes
workers’ compensation, Medicare, EAP programs, etc. Providers must wait a reasonable
amount of time in order to obtain a response from the insurance company. However, it is
important that Providers not exceed the ninety (90) day rule before submitting claims. If an
insurance company pays after a claim has been submitted to Cardinal Innovations, the
Provider must notify Cardinal Innovations and reimburse Cardinal Innovations.
H. Sliding Fee Schedule
1. Eligibility for Benefit Determination:
All consumers must be evaluated at the time of enrollment on their ability to pay. This
determination should be updated at least quarterly to ensure compliance with the Sliding Fee
Schedule. See http://www.cardinalinnovations.org/finance/billing.asp.
2. Process to Establish the Sliding Fee:
Each consumer enrolled in the Cardinal Innovations CI System must complete the financial
eligibility process to establish any third-party coverage and to establish the ability to pay for
services. The combination of a consumer’s adjusted gross monthly income and the number of
dependents determines the payment amount based on the Sliding Fee Schedule established by
Cardinal Innovations.
Medicaid consumers are not subject to Sliding Fee Schedules for services paid for by Medicaid.
If a consumer does not qualify for the Sliding Fee Schedule they should pay 100% of the
services being provided. In this case, the consumer should not be enrolled in the Cardinal
105
SECTION X: GETTING PAID-FINANCE REQUIREMENTS
Innovations CI System and claims should not be submitted to Cardinal Innovations for
reimbursement.
3. Process to Modify:
If there are known changes to the consumer’s income or family status, the Provider should
update their records and adjust the payment amount based on the Sliding Fee Schedule.
Consumers who become Medicaid-eligible are not subject to Sliding Fee Schedules for
Medicaid-covered services and payments should be adjusted immediately when this is
determined.
At least on a quarterly basis—every ninety (90) days—the consumer’s ability to pay should be
verified and adjusted by completing a Client Update in the Provider Direct system as
necessary. The Sliding Fee Schedules are managed by Providers and first-party liability must be
reported on claims. This compliance issue will be audited.
I. Response to Claims
1. Remittance Advice:
The Remittance Advice is Cardinal Innovations’ method of communicating back to the Provider
community exactly how each and every claim has been adjudicated. Cardinal Innovations
provides the Remittance Advice in the form of Adobe Acrobat (*.pdf) files. The Remittance
Advice can be accessed via the Provider’s outbound folder in Provider Direct.
2. Electronic Remittance Advice (835) – for 837 Providers:
HIPAA regulations require payers to supply Providers with an electronic Remittance Advice
known as the 835. The 835 reports electronically the claims status and payment information.
This file is used by the Provider’s information system staff or vendor to automatically post
payments and adjustment activity to their consumer accounts. This allows process Providers
the ability to manage and monitor their accounts receivables.
3. Management of Accounts Receivable – Provider Responsibility:
Providers are responsible for the management of their consumer accounts receivable.
Cardinal Innovations produces Remittance Advices based on the current check write schedule.
Cardinal Innovations produces a weekly claims status report, which is an Excel document of
cumulative processed claims for the current fiscal year. Providers may select, sort and manage
their billings, payments and denials. This file can be accessed through the Providers’ outbound
folder in Provider Direct.
J. Fee-For-Service Equivalency (FFSE)
1. Contract Agreement:
All Providers have a contract that defines the terms of payment. On a selected basis some of
the smaller agencies will have grant-funded or “Fee-For-Service Equivalency” contracts. These
contracts allow Providers to be paid a pre-established amount of funding with the expectation
that they will provide a determined amount of services for these funds. Cardinal Innovations
has developed a process to receive claims against these contracts in order to monitor the
services being provided, but not pay these claims on a Fee-For-Service basis. The information
106
SECTION X: GETTING PAID-FINANCE REQUIREMENTS
system approves the claims, but then adjusts the amount so that the claim is zero paid on the
Remittance Advice. This is known as Fee-For-Service Equivalency (FFSE). This approach cannot
be used to pay Medicaid claims. Only State and Local funds can be paid using this
methodology.
2. Review of FFSE Process:
Once these contracts are active, the Provider will submit claims to Cardinal Innovations in the
same fashion as all other claims. If the claims are Medicaid claims, they will be paid following
the standard Fee-For-Service methodology. However, if the contract for State or Local funds is
set up as a FFSE, then the claims will be adjudicated as usual except the allowed amount on
the claim will be adjusted (via a contractual allowance) to zero. The Provider will receive a
weekly Claims Status Report showing all adjudicated claims which can be accessed via the
Provider’s outbound folder in Provider Direct. The FFSE claims will show as being fully
adjudicated, but with a zero dollar amount paid. Payments will be made on a monthly basis as
determined in the contract.
3. Reconciliation:
It is important that Providers post these “paid claims” against their client accounts receivable
system. Even though these FFSE claims are zero dollars, they are considered paid in full and
will be counted against their FFSE contract obligations.
K. Claims Investigations – Abuse and Fraud
1. Trends of Abuse and Potential Fraud:
One of the primary responsibilities of Cardinal Innovations is to monitor the Provider Network
for fraud and abuse. Both the Medicaid and State contracts hold Cardinal Innovations
responsible for monitoring and conducting periodic audits to ensure compliance with all
Federal and State laws and in particular the Medicare/Medicaid fraud and abuse laws.
Specifically, Cardinal Innovations must validate the presence of material information to
support billing of services consistent with Medicaid and State regulations. Cardinal Innovations
will systematically monitor paid claims data to look for trends or patterns of abuse.
2. Audit Process:
Cardinal Innovations has the responsibility to ensure that funds are being used for the
appropriate level and intensity of services, as well as in compliance with Federal, State, and
general accounting rules.
The Cardinal Innovations Quality Management Department (QM) is responsible for billing
audits for all contract Providers. The Finance Department is primarily responsible for collecting
any paybacks that result from a QM or Financial Audit. The Finance Department will
collaborate with the QM audit team, the Network Manager and the Provider in the collection
of any determined paybacks.
3. Role of Finance Department:
The Finance Department will assist the QM Unit with the review of financial reports, financial
statements and accounting procedures.
107
SECTION X: GETTING PAID-FINANCE REQUIREMENTS
4. Voluntary Repayment of Claims:
It is the Provider’s responsibility to notify Cardinal Innovations in writing of any claims billed in
error that require repayment. Providers are required to complete a Claims Adjustment
Request Form. This form, as well as instructions on how to use the form, is posted on the
Cardinal
Innovations
Finance
website
at
http://www.cardinalinnovations.org/finance/forms.asp. Cardinal Innovations will make
adjustments in the system and those adjustments will appear on the next Remittance Advice.
5. Reporting to State and Federal Authorities:
For each case of a credible allegation of fraud involving a Provider, Cardinal Innovations is
obligated to provide a report to DMA.
L. Repayment Process/Paybacks
If Cardinal Innovations, through any manner, determines that a provider has been paid for a
service or a portion of a service that Cardinal Innovations determines, in its sole discretion, should
not have been paid, based on but not limited to, audits, fraud, abuse, waste, acts or omissions,
clinical models, medical necessity, or policies or procedures, waivers, Cardinal Innovations shall
notify the provider of the service or portion of service that should not have been paid along with
the amount improperly paid by Cardinal Innovations. The provider shall contact their Claims
Specialist within seven (7) calendar days from the date the provider receives the payback
notification to establish a mutually agreed upon payback payment agreement. If the provider fails
to contact their Claims Specialist with this seven (7) day period, Cardinal Innovations shall
automatically withhold payment to the provider from current pending and/or future submitted
claims. If no current pending and/or future claims exist for the provider, Cardinal Innovations shall
automatically invoice the provider for the full payback payment amount. The payback payment
agreement will specify, if applicable, the time period within which the payback must be paid and
the method of payment. Payment methods may include, but are not limited to, one or a
combination of the following: provider’s check, recoupment of current claims, and/or
recoupment of future claims, until the payback payment amount is in paid-in-full.
If the provider fails to comply with the payback payment agreement, all current pending and/or
future submitted provider claims shall be withheld for payment by Cardinal Innovations and be
applied to the payback payment amount until the payback payment amount is paid in full.
Notwithstanding this recovery method, Cardinal Innovations reserves the right to, at any time,
invoice provider for any or the entire unpaid payback payment amount if the provider fails to
comply with the payback payment agreement. If the payback payment amount exceeds
outstanding provider claims, Cardinal Innovations may invoice the provider for the remaining
payback payment amount owed to Cardinal Innovations. The provider shall have thirty (30)
calendar days from the invoice date to pay the remaining payback payment amount . If the
provider fails to repay funds within thirty (30) calendar days, Cardinal Innovations reserves the
right to take any and all action to collect the outstanding balance from the provider.
If advance payments have been made for services not provided as of the notification date of
termination, Cardinal Innovations will invoice the provider for the amount due to be repaid to
Cardinal Innovations. The provider shall submit payment within thirty (30) calendar days of the
invoice date.
108
SECTION X: GETTING PAID-FINANCE REQUIREMENTS
M. Termination Audits
Upon the notification date of termination of a provider’s contract, Cardinal Innovations reserves
the right, at its sole discretion, to withhold any future payments to the provider until Cardinal
Innovations completes a contract termination audit to ensure that all contractual and other fiscal
requirements have been fulfilled. The provider shall return all original client records to Cardinal
Innovations in accordance with Article II, number 23 of the General Conditions. Cardinal
Innovations’ termination audit may include a review of, but not be limited to, billing records, fiscal
records, and any other documentation Cardinal Innovations deems necessary, in its sole
discretion, to complete the termination audit. Cardinal Innovations shall complete its contract
termination audit, if it elects to conduct a termination audit in its sole discretion, within sixty (60)
days of receipt of all necessary Contractor records. If Cardinal Innovations has elected, at its sole
discretion, to not withhold future payments to the provider upon the notification date of
termination, Cardinal Innovations still reserves the right to make adjustments for amounts due to
Cardinal Innovations from the provider through recoupment, payback or any other method.
If advance payments have been made for services not provided as of the notification date of
termination, Cardinal Innovations will invoice the CONTRACTOR for the amount due to be repaid
to Cardinal Innovations. The provider shall submit payment within thirty (30) calendar days of the
invoice date.
All continuing obligations of the provider shall remain in effect after termination in including, but
not limited to, those set forth in the Contract and in the Cardinal Innovations Healthcare Solutions
Provider Manual, Innovations and NC MH/DD/SAS Plan Manuals.
N. Review and Determination Process
The Cardinal Innovations Review and Determination Process is to be utilized by Cardinal
Innovations Network Providers that are seeking a re-evaluation of a claim denial or an
authorization issue. See http://www.cardinalinnovations.org/providers/review.asp. Network
Providers are responsible for following all existing guidelines surrounding claims and authorization
processes as referenced in the Provider Manual, communication bulletins and the individual
Provider’s contract.
1. Authorization Issues:
Cardinal Innovations authorizes payment for services prior to the date rendered. However,
authorization for care after the consumer has been admitted to a level of care or treatment has
been completed may be considered through a retroactive authorization. A retroactive
authorization would be requested by contacting the Cardinal Innovations MHSA Care Manager, DD
Care Manager or Access Unit Manager.
109
SECTION X: GETTING PAID-FINANCE REQUIREMENTS
For Acute Services and MH/SA population:
For I/DD population:
Cardinal Innovations UM Care Manager
4855 Milestone Avenue
Kannapolis, NC 28081
Main: 704-939-7700
Fax: 704-743-2130
[email protected]
Cardinal Innovations DD Care Manager
4855 Milestone Avenue
Kannapolis, NC 28081
Main: 704-939-7700
Fax: 704-743-2130
[email protected]
If the Provider is not satisfied with the resolution communicated by the Cardinal Innovations Care
Manager, a Review and Determination Request may be made within sixty (60) calendar days from
the date of service for the authorization issue
2. Claim Denial:
When a Provider incurs billing or claim issues/denials, they can contact their assigned Cardinal
Innovations Claims Specialist. The Claims Specialist is determined by your
Provider Agency’s name.
Hospitals and their affiliated Physician Groups, Institutional Facilities:
A-L
(704) 939-7755
M-Z
(704) 939-7858
All other Providers:
A-D
(704) 939-7732
E-J and N-P (704) 939-7759
I-K
( 704) 939-7743
Q-Z
(704) 939-7620
If the Provider is not satisfied with the resolution communicated by the Cardinal Innovations
Claims Specialist, a Review and Determination Request may be made within one hundred twenty
(120) days from the date of service for the claim denial.
Exceptions: Providers will not be required to request a Review and Determination for claims
denials related to retroactive Medicaid. Providers must contact their assigned Claims Specialist
to address claim denials for retroactive Medicaid.
3. Review and Determination Request:
A Cardinal Innovations Network Provider must first exhaust resolution on current claims and
authorization guidelines/processes before proceeding to the Review and Determination Process.
The process for initiating a Review and Determination request are:



110
Provider completes all fields on the Review and Determination Request Form.
Provider submits supporting documentation (if applicable) and a detailed explanation
regarding the claim denial or authorization issue in order for Cardinal Innovations to adjudicate
the Review and Determination process.
Provider submits the Review and Determination Request Form in writing to the Cardinal
Innovations Appeals Unit by mail, email or fax.
SECTION X: GETTING PAID-FINANCE REQUIREMENTS
Appeals Unit
Cardinal Innovations Clinical Operations
4855 Milestone Avenue
Kannapolis, NC 28081
Fax: 704-743-2130
[email protected]



The Clinical Operations Department/Appeals Unit will make a decision within thirty (30)
calendar days from date of request receipt. There may be certain times when Cardinal
Innovations extends the timeframe to respond to the request.
A Review and Determination Process decision letter to uphold or overturn the denial of the
claim or authorization issue will be mailed to the Provider and uploaded to the Provider’s
electronic Outbound folder.
The Provider may choose to file a grievance within fifteen (15) calendar days from the date of
the decision letter if they are not satisfied with the Review and Determination Process’
decision. The decision letter will provide grievance filing information.
For further information, please contact your assigned Network Specialist. Information
regarding Network Specialists may be accessed by calling the Provider customer service line at
1-800-958-5596.
4. The Network Provider Review and Determination (R&D) Request Form, along with additional
information
may
be
accessed
from
our
provider
website
at
http://www.cardinalinnovations.org/providers/review.asp
111
SECTION XI: STANDARDS AND REGULATORY COMPLIANCE
SECTION XI:
STANDARDS AND REGULATORY COMPLIANCE
A. Introduction
Cardinal Innovations is committed to working in collaboration with the Provider Network to
achieve the highest standards of quality in service delivery.
B. Quality Improvement
Cardinal Innovations maintains a strong commitment to continual improvement of its
services and those services provided directly to consumers. A focus on quality requires basic
principles, which include




Involvement of the consumers in all areas and levels of the service system in regards to
analysis, planning, implementing changes, and assessing quality and outcomes;
Strengthen systems and processes by viewing the system as a collection of
interdependent processes we can understand how problems occur and resolution can
strengthen the system as a whole;
Encourage participation and teamwork of every member of the system to assure quality
and empower them to solve problems and recommend improvements;
Make decisions based on reliable information by collecting and analyzing accurate,
timely and objective data; and encourage different members of the system to work
together to improve quality by sharing information freely and coordinating their
activities.
Cardinal Innovations maintains an established quality structure that ensures the
participation of all persons and agencies involved in the service system.
The continual self-assessment of services and operations and the development and
implementation of plans to improve outcomes to consumers is a value and expectation that
Cardinal Innovations extends to its Network Providers. Network Providers are required to
be in compliance with all Quality Assurance and Improvement standards outlined in North
Carolina Administrative Code as well as the Cardinal Innovations Provider Contract. These
items include


112
Establishment of a formal Quality Committee to evaluate services, plan for
improvements and assess progress made toward goals.
Assessment of need as well as the determination of areas for improvement is 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 Cardinal Innovations at the Provider’s Performance Profile review.
SECTION XI: STANDARDS AND REGULATORY COMPLIANCE
C. Performance Measurement
1. Data collection and verification - Cardinal Innovations is required to measure outlined
performance indicators in the following domains: Access, Availability, Quality of Care,
Quality of Services, Appropriateness of Services, System Performance, and Satisfaction,
in order to assure compliance with DMH and DMA contract requirements;
2. Performance improvement - Cardinal Innovations will complete Quality Improvement
Activities (QIAs) as indicated in DMH and DMA contracts and NCQA Standards. These
QIAs may require Provider participation; and
3. Provider Performance Profile – In collaboration with the Global Quality Improvement
Committee, Cardinal Innovations Quality Management has designed 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. Licensed Independent Practitioners (LIPs)
are ranked by their performance into categories: Preliminary and Preferred.
D. Performance Monitoring
An important part of Cardinal Innovations’ role as a LME/MCO is to monitor the
performance of Providers in its Network. Cardinal Innovations maintains the following
systems to assist in monitoring the health and safety of consumers, rights protections, and
quality of care:
1. Monitoring of Incidents:
An incident is an event at a facility or in a service that is likely to lead to adverse effects
upon a consumer. 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 a consumer. This
includes all state reporting regulations in relation to the documentation and reporting of
critical incidents. In addition, Providers must submit all Level II and Level III incident
reports to Cardinal Innovations and a summary of all Level I incidents must be submitted
quarterly.
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



113
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 at improvement as well as an evaluation of ongoing
progress;
SECTION XI: STANDARDS AND REGULATORY COMPLIANCE


Mandatory reporting requirements are followed; and
Adhering to compliance with entering Level II and III incidents into the state’s
Incident Response Improvement System (IRIS).
There are specific state laws governing reports of abuse, neglect or exploitation of
consumers. It is important that the Provider’s procedures include all of these
requirements. If a report alleges the involvement of a Provider’s staff in an incident of
abuse, neglect or exploitation, the Provider must ensure that consumers 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.
2. Cardinal Innovations Incident Review Process:
Under the North Carolina Administrative Code, Cardinal Innovations is required to
monitor certain types of incidents that occur within the Provider Network, as well as
Providers in Cardinal Innovations’ catchment areas. Regulations regarding the
classification of incidents (Levels I, II, or III), as well as requirements related to the
submission of incident reports to home and host LME/MCOs and state agencies can be
located in the North Carolina Administrative Code. Cardinal Innovations is also required
to monitor the state IRIS system. For more information regarding these classifications,
also please see the following websites:
https://iris.dhhs.state.nc.us/
http://www.ncoah.com/
Cardinal Innovations’ Quality Management Department shall review all incidents when
received for completeness, appropriateness of interventions, achievement of short- and
long-term follow up both for the individual consumer, as well as the Provider’s service
system. If questions or concerns are noted when reviewing the incident report, QM will
work with the Provider to resolve these. If concerns are raised related to the consumer’s
care or services or the Provider’s response to an incident, QM may elect to conduct an
on-site review of the Provider. If possible, the review will be coordinated with the
Provider and, if deficiencies are found, QM will work with the Provider on the
implementation of a plan of correction.
3. Monitoring to Ensure Quality of Care:
The Cardinal Innovations Quality Management Department is charged with conducting
compliance reviews and audits of medical records, administrative files, the provider’s
physical environment and cultural competency reviews. Quality Management is the
department at Cardinal Innovations that performs compliance safety reviews of
facilities; monitors Providers; reviews critical incidents; death reports; and restrictive
114
SECTION XI: STANDARDS AND REGULATORY COMPLIANCE
interventions, as an important role in assuring the protection of rights and the health
and safety of consumers.
The Quality Management Department reviews incidents reported and determines
whether any follow up is needed. The Quality Management Department may conduct
investigations of incidents reported directly by Providers on Incident Reports, as well as
reports provided by consumers, families and the community. Cardinal Innovations must
submit a quarterly report to the State on reported incidents and the company’s
monitoring activities.
4. Grievances:
Cardinal Innovations management of grievances is carefully monitored by DMA and
Cardinal Innovations maintains a data base where all grievances and resolutions are
recorded. Cardinal Innovations may receive grievances from Providers, stakeholders,
consumers, families, legal guardians or anonymous sources regarding Cardinal
Innovations’ Provider Network, and/or a specific Provider’s services or staff. Based on
the nature of the grievance, Cardinal Innovations may choose to investigate the
grievance in order to 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. Cardinal
Innovations must take all grievances very seriously until resolution.
If problems are identified, the Provider involved may be required to complete a plan of
correction.
5. Consumer Satisfaction Surveys and Mystery Shopping Program:
Cardinal Innovations values the satisfaction of consumers, family members and
stakeholders with services provided in the Provider Network. Cardinal Innovations
maintains avenues by which consumer satisfaction is measured. These include annual
surveys and “mystery shopping.” The goal of these initiatives is to gather feedback on
how various Cardinal Innovations departments perform during random and anonymous
monitoring. This system has provided information that has been used to pinpoint the
need for additional staff training. Cardinal Innovations has expanded the use of these
tools to monitor Provider customer service.
115
SECTION XI: STANDARDS AND REGULATORY COMPLIANCE
E. Corporate Compliance
Cardinal Innovations expects all its providers’ employees and contractors to practice
honesty, directness and integrity in relationships with one another, business partners, the
public, the business community, internal and external stakeholders, consumers, families,
suppliers, elected officials and government authorities.
1. Primary Areas Covered by Corporate Compliance:
Corporate Compliance deals with the prohibition, recognition, reporting and
investigation of suspected fraud, defalcation, misappropriation and other similar
irregularities.
The term “fraud” includes dishonest or fraudulent acts, embezzlement, forgery or
alteration of negotiable instruments such as:
 checks and drafts
 misappropriation of a provider agency’s, employee, customer, partner or
supplier assets
 conversion to personal use of cash, securities, supplies or any other provider
agency assets
 unauthorized handling or reporting of provider agency transactions
 falsification of a provider agency’s records, claims or financial statements for
personal or other reasons
The above list is not all-inclusive, but is intended to be representative of situations
involving fraud. Fraud may be perpetrated not only by a provider agency’s employees,
but also by agents and other outside parties. All such situations require specific action.
Within any provider agency, management bears the primary responsibility for detection
of potentially fraudulent activities.
2. 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


116
An internal audit process to verify that services billed were furnished by
appropriately credentialed staff and appropriately documented.
Revisions to ensure that staff performing services under the Cardinal Innovations
contract have not been excluded from participation in Federal Health Care Programs
under either Section 1128 or 1128A of the Social Security Act. The Agency consults
SECTION XI: STANDARDS AND REGULATORY COMPLIANCE







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 now found at SAM.gov (see http://exclusions.oig.hhs.gov/;
http://sam.gov/).
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 consumers and
protections for those reporting.
Provisions for internal monitoring and auditing.
Procedures for response to detected offenses and for the development of corrective
action plans.
Reporting to monitoring and law enforcement agencies, including Cardinal
Innovations.
Note: All Providers must monitor the potential for abuse and fraud, and take immediate
action to address reports or suspicion. The first two bulleted items above are required
of all Cardinal Innovations Providers, regardless of the amount of funding received. This
list may not be all inclusive, and provider agencies should consult all applicable rules,
laws, and regulations to determine what elements may need to go in their compliance
plan.
F. Monitoring and Auditing
Cardinal Innovations 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 by the company’s employees.
Cardinal Innovations has established a reporting system to support efforts to identify noncompliance issues. Providers may access this reporting system’s toll free number at 1-888213-9687. Callers can make reports anonymously or leave their names. Reports may also be
made by calling 704-939-7700 and asking for the Corporate Compliance Officer or Chief
Operating Officer.
It is a violation of Cardinal Innovations policy to intimidate or impose any form of
retribution on an employee, agent, or Provider that utilizes the company’s 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).
117
SECTION XI: STANDARDS AND REGULATORY COMPLIANCE
G. Investigation of Violations
When Cardinal Innovations receives information regarding an alleged Corporate Compliance
violation, an investigation will occur to evaluate such information as to gravity and
credibility. Cardinal Innovations also may 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/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.
See http://www.ncdhhs.gov/mhddsas/statspublications/Manuals/apsm451confidentialityrules1-1-05total.pdf.
Each Provider must follow the APSM – 10-3 Records Retention and Disposition Manual.
See http://www.ncdhhs.gov/mhddsas/statspublications/policy/
Clinical Coverage Policies
See http://www.ncdhhs.gov/mhddsas/providers/servicedefs/
Each Provider must comply with HIPAA Privacy Regulations.
See http://hipaa.dhhs.state.nc.us/ and http://www.hhs.gov/ocr/hipaa/
I. Management Information Systems
Each Provider must have Internet Capacity.
Each Provider must comply with HIPAA Security Regulations.
Please go to the Centers for Medicare and Medicaid Services (CMS) website as a further
resource: http://www.cms.hhs.gov
118
SECTION XII: RECONSIDERATION REVIEW PROCESS FOR PROVIDERS
SECTION XII: RECONSIDERATION REVIEW PROCESS FOR PROVIDERS
This section explains the process by which providers can request reconsideration of certain
actions Cardinal Innovations has taken.
A. Reconsideration Process
1. Request for Reconsideration
a. When a Provider receives notice of one of the actions outlined below, the
Provider has seven (7) calendar days to request reconsideration of the action.
All requests for reconsideration must be in writing and must be directed to the
Chair of the Reconsideration Committee. Requests for Reconsideration should
be sent return-receipt requested. If delivered in person, a receipt shall be issued
to the Provider by Cardinal Innovations. It is the Provider’s responsibility to
request a receipt if one is not offered. The Provider must provide any additional
written documentation to be considered during the Reconsideration Process at
the time the Request for Reconsideration is filed.
b. Reimbursement may continue during the Reconsideration Process, unless the
provider is cited for gross negligence, the provider is suspected of committing
fraud or abuse, or at the sole discretion of Cardinal Innovations. Continued
reimbursement is likely to increase any payback amount due.
i. Cardinal Innovations may require the Provider to submit documentation
of services provided in order to continue to receive reimbursement
during the Reconsideration process. Such required documentation must
be in either original or certified copy form.
c. Request forms and additional information regarding the Provider
Reconsideration process can be accessed from the provider website at:
http://www.cardinalinnovations.org/providers/reconsideration.asp
2. The Cardinal Innovations Reconsideration Process
a. The standard timeframe for the Reconsideration Committee to make a decision
is sixty (60) days.
b. The Reconsideration Committee, at its discretion, may extend the time it has to
make a decision by up to an additional thirty (30) days. If the Reconsideration
Committee chooses to extend this timeframe the Provider will be notified in
writing. The Provider may be allowed to submit additional information during
this time.
c. Once the Reconsideration Committee makes its decision, the Provider will be
notified in writing. If the sanction under reconsideration is a payback, paybacks
are due and payable by the Provider to Cardinal Innovations upon completion of
the reconsideration decision and receipt of notification by the Provider.
119
SECTION XII: RECONSIDERATION REVIEW PROCESS FOR PROVIDERS
3. What can a Provider request Reconsideration of?
a. A Provider may request reconsideration of the following decisions:
i. Imposition of a payback for out of compliance areas
ii. Imposition of a Plan of Correction
iii. Imposition of a Referral Freeze
iv. Terminations
v. A finding that the provider is out of compliance with Medicaid or Cardinal
Innovations documentation requirements
b. With the exception of paybacks, Cardinal Innovations’ decisions are not pended
while the Reconsideration process is occurring.
c. A Provider may file a grievance if they are dissatisfied with the Reconsideration
Committee’s decision.
120
SECTION XIII: OFFICIAL COMMUNICATION
SECTION XIII: OFFICIAL COMMUNICATION
A. Cardinal Innovations Website
The Cardinal Innovations website can be accessed at www.cardinalinnovations.org. This
website provides information for consumers and family members, stakeholders, providers,
government officials and others who may have an interest in services for mental health,
intellectual/developmental disabilities or substance use/addiction. On the Cardinal Innovation
website, you will find LME/MCO events and operations, links to other websites, evaluations and
outcomes, and information specific to Providers such as Communication Bulletins and other
important information. The website also features a search function that allows consumers and
family members to search for a provider by selection criteria that includes county, disability and
service.
B. Official Communication Bulletins
All Official Communication Bulletins are posted on Cardinal Innovations’ Provider web pages
at http://www.cardinalinnovations.org/Providers/bulletins.asp. Communication Bulletins
from specific departments or areas are designated below:
1. Area Administration:
FY-(fiscal year)-AA-(# of Bulletin)-(Title of Bulletin).
Example: FY-1213-AA-01-Title
2. Finance:
FY-(fiscal year)-FN-(# of Bulletin)-(Title of Bulletin).
Example: FY-1213-FN-01-Title
3. Network Operations:
FY-(fiscal year)-NM-(# of Bulletin)-(Title of Bulletin).
Example: FY-1213-NM-01-Title
4. Quality Management (QM):
FY-(fiscal year)-QM-(# of Bulletin)-(Title of Bulletin).
Example: FY-1213-QM-01-Title
5. Access (Access):
FY-(fiscal year)-Access-(# of Bulletin)-(Title of Bulletin).
Example: FY-1213-Access-01-Title
6. Medicaid Program (MP):
FY-(fiscal year)-MP-(# of Bulletin)-(Title of Bulletin).
Example: FY-1213-Medicaid Programs-01-Title
121
SECTION XIIl: OFFICIAL COMMUNICATION
7. Utilization Management (UM):
FY-(fiscal year)-UM-(# of Bulletin)-(Title of Bulletin).
Example: FY-1213-UM-01-Title
122
SECTION XIV: GLOSSARY OF TERMS
SECTION XIV: GLOSSARY OF TERMS
Ability-to-Pay Determination: The amount a consumer is obligated to pay for services. The
ability to pay is calculated based on the consumer’s income, and number of dependents. The
Federal Government Poverty Guidelines are used to determine the consumer’s payment
amount. See http://www.cms.gov/ or http://aspe.hhs.gov/poverty/index.cfm
Abuse: 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. (Guidelines for Addressing Fraud and Abuse in Medicaid Managed Care, October
2000)
Access Center: Access management is a critical function of Cardinal Innovations. The LME/MCO
is responsible for timely response to the needs of consumers and for quick linkages to qualified
Network Providers. To ensure the simplicity of the system requested by consumers and
stakeholders, the LME/MCO maintains a toll-free call system to receive all inquiries. This
includes information, access to care, emergency, and Network Provider assistance. The toll-free
call system relies on information systems management software to assist in tracking and
responding to calls.
Adjudicate: A determination to pay or reject a claim.
Administrative Review: A review of documentation to determine whether Cardinal Innovations
procedures were followed, and if any additional information provided warrants a change in a
previous determination.
Agency: An Area Facility as defined by NCGS 122C-3 subsection 14A. An Agency may deliver a
number of services, and submits, and 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 a patient's care, custody or medical
treatment in the event that the patient 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.
123
SECTION XIV: GLOSSARY OF TERMS
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 LME/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 resources are
available, to non-Medicaid individuals meeting Target Population criteria. A consumer requiring
this level of benefit is in need of more than the twenty-four (24) unmanaged visits for adult and
child Medicaid consumers or eight (8) unmanaged visits for State Funded Adults and twelve (12)
unmanaged visits for State Funded Children under the Basic Benefit in order to maintain or
improve his/her level of functioning. An Authorization for the services available in this level will
need to be requested through Cardinal Innovations Clinical Operations Department.
Authorization is based on the consumer’s need and medical necessity criteria for the service
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 nonMedicaid 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 Local Management Entity, 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 eighteen (18)
and older and twelve (12) visits for Children and Adolescents below age eighteen 18) for NonMedicaid (State Funded) consumers and twenty-four (24) Visits for Medicaid consumers under
the Basic Benefit package from any Provider enrolled in the LME/MCO’s Provider Network.
Psychiatric services do not count against the allotted visits under the Basic Benefit.
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 a preliminary
evidence of effectiveness of treatment.
Billing Audit: An audit conducted by the Cardinal Innovations to assess the presence of
appropriate documentation to support claims submitted for payment by Cardinal Innovations.
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 measure of
level of care needs for children and adolescents.
124
SECTION XIV: GLOSSARY OF TERMS
CAQH: The Council for Affordable Quality Healthcare (CAQH) (www.caqh.org) is a nonprofit
alliance of the nation’s leading health plans and networks working to simplify healthcare
administration. CAQH serves as a Licensed Independent Practitioner (LIP) application
clearinghouse for participating LME/MCOs.
Care Coordination Department (CCD): A department of Cardinal Innovations that provides
outreach and treatment planning Case Management functions for Special Needs Populations.
Care Management: Non-face-to face monitoring of an individual consumers care and services,
including follow–up activities, as well as assistance to consumers in accessing care on non –plan
services, including referrals to Providers and other community agencies.
Catchment Area: A geographic service area, meaning a defined grouping of counties.
Clean Claim: 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 NC General Statutes 122C-3 (6).
CMS: Centers for Medicare and Medicaid Services
Comprehensive Community Clinic (CCC): Cardinal Innovations has selected designated provider
agency sites as Comprehensive Community Clinics (CCCs). CCCs must provide robust basic
assessment, therapy and medication management services to both children and adults for the
treatment of both substance use and mental health conditions. These clinics are established by
county and provide the full array of basic services in the county where the designation is
granted. These clinics are considered the MH/SA safety net in these counties. In counties where
the population cannot support a full CCC site, neighboring county CCCs may provide services at
satellite sites for a limited number of hours per week, as volume demands.
In addition to providing robust basic services, CCCs are expected to meet the following clinical
standards:
1.
2.
3.
4.
5.
6.
125
Provide high quality assessments;
Primarily provide "basic" services;
Offer no less than 24hrs/week of prescriber services;
Primarily utilize on-site prescribers with psychiatric specialty certification
Provide flexible and open-access scheduling;
Provide access to services within 48hrs for urgent needs, and 14 days for routine needs
SECTION XIV: GLOSSARY OF TERMS
7. Meet quality standards for consumer engagement in services and low consumer
utilization of crisis system resources;
8. Provide timely 24/7/365 telephonic crisis response to consumers in basic services;
9. Have Psychiatrist medical leadership at the Agency level; and,
10. Demonstrate a willingness to help address system service and access gaps.
Additional expectations may include utilization of injectable antipsychotics, clozapine and/or
Suboxone when medically indicated, provision of medication management to underserved or
difficult-to-serve populations, acceptance of patients on outpatient commitment, billing of nonMedicaid payers (including Medicare), and effective/efficient interactions with Cardinal
Innovations regarding treatment authorization requests and claims processing.
Critical Access Behavioral Healthcare Agency (CABHA) Providers: A Provider who delivers a
comprehensive array of mental health and substance abuse services. This does not include
developmental disability 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 consumer 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.
Concurrent Review: A review conducted by the LME/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: A person that needs services for treatment of a mental health, intellectual and/or
developmental disability, or substance use/additions condition.
Contractor: An entity providing services to the LME/MCO described in either the Procurement
Contract for Provision of Services to consumers with Disabilities or the Consultant Contract for
the Provision of Services.
Covered Services: The services which the LME/MCO may pay for and/or arrange for providers
to provide to all consumers enrolled in its benefit plan.
Credentialing: The review process to approve a Licensed Independent Practitioner (LIP) that has
applied to participate in the LME/MCO Network of Providers.
Crisis Intervention: Unscheduled assessment and treatment for the purpose of resolving an
urgent/emergent situation requiring immediate attention.
Crisis Plan: A Crisis Plan is an individualized written plan developed in conjunction with
consumer and treatment team. The Plan contains information to assist in deescalating a crisis
126
SECTION XIV: GLOSSARY OF TERMS
as well as clear directives to the individual crisis workers or others involved. Crisis plans are
developed for consumers at-risk for inpatient treatment, incarceration, or out-of-home
placement.
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 cross-cultural 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 days or "business day"
means day on which the LME/MCO is officially open to conduct its affairs.
Developmental Disabilities (DD): North Carolina General Statute 122C-3(12a) defines a
developmental disability as "a severe, chronic disability of a person which:
 Is attributable to a mental or physical impairment or combination of mental and
physical impairments;
 Is manifested before the person attains age 22, unless the disability is caused by
traumatic head injury and is manifested after age 22;
 Is likely to continue indefinitely;
 Results in substantial functional limitations in three or more of the following areas of
major life activity: self-care, receptive and expressive language, capacity for
independent living, learning mobility, self-direction and economic self-sufficiency;
 Reflects the person's need for a combination and sequence of special interdisciplinary,
or generic care, treatment, or other services which are of a lifelong or extended
duration and are individually planned and coordinated; or
 When applied to children from birth through four years of age, may be evidenced as a
developmental delay.
Denial of Service: A determination made by the LME/MCO in response to a Network Providers
request for approval to provide in-plan services of a specific duration and scope which the
LME/MCO denies the request entirely, or approves the request in an amount or frequency less
than what was requested.
Dispute Resolution Process: Cardinal Innovations process to address verbal concerns,
grievances, and/or disputes by Providers in a consistent manner.
DMA: The State of North Carolina Department of Health and Human Services, Division of
Medical Assistance
127
SECTION XIV: GLOSSARY OF TERMS
DMH/DD/SAS: The State of North Carolina Department of Health and Human Services, 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:
1. 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
2. Serious impairment to bodily functions, or
3. Serious dysfunction of any bodily organ or part
Emergency Services: With respect to a member covered inpatient and outpatient services that:
1. Are furnished by a Provider that is qualified to furnish such services; and,
2. Are 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, 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.
Enhanced Benefit Plan: Includes those services, which will be made available to Medicaidentitled 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
use/addiction disorders, and with more complex service and support needs as identified in the
person centered planning process.
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 LME/MCO as a
Medicaid waiver eligible recipient.
128
SECTION XIV: GLOSSARY OF TERMS
EPSDT: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is the federal law that
says Medicaid must provide all medically 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 in 1905 (a) of the Social Security Act
and if all EPSDT criteria are met.
Facility: As defined in 122-C subsection 14.
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 Certified Public Account 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 disclosers 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 LME/MCO which includes a
review of the Contractor’s evaluation of client’s income, client’s determined ability to pay, third
party insurance verification, first and third party billing, receipts and denials. A review of Cost
Of Business information will also be conducted to verify support of claimed amounts submitted
to LME/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/DD/SAS.
Fraud: An intentional deception or misrepresentation made by a person with the knowledge
that the deception could result in some unauthorized benefit to himself/herself or some other
person. It includes any act that constitutes fraud under applicable Federal or State law.
(Guidelines for Addressing Fraud and Abuse in Medicaid Managed Care, October 2000)
GAF: Global Assessment of Functioning.
129
SECTION XIV: GLOSSARY OF TERMS
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 LME/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, and aspects of interpersonal relationships such as rudeness of a Provider or
employee, or failure to respect the consumer’s rights).
Grievance Procedure: The written procedure pursuant to which consumers may express
dissatisfaction with the provision of services by the LME/MCO and the methods for resolution
of consumer’s grievance by the LME/MCO
HIPAA: 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): Approval of medically necessary services
at a given level of care prior to services being rendered.
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.
Licensed Independent Practitioner: Medical Doctors (MD), Practicing Psychologists (PhD)
Psychologist Associates (Master’s Level Psychologist [LPA]), Master’s Level Social Workers
(LCSW), Licensed Marriage and Family Therapists (LMFT), Licensed Professional Counselors
(LPC), Certified Clinical Addiction Specialists (CCAS), Advanced Practice Psychiatric Clinical Nurse
Specialists, Psychiatric Nurse Practitioners, and Licensed Physician Assistants who are eligible to
bill under their own license.
LME: Local Management Entity, a local political subdivision of the state of North Carolina as
established under General Statute 122C.
LME/MCO Authorization: Approval of medically necessary services for continued service
delivery.
LME/MCO Authorization Request Form: The most currently approved Treatment
Authorization Request 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 mental health consumer.
130
SECTION XIV: GLOSSARY OF TERMS
MCO: Managed Care Organization
Medicaid Identification (MID) Card: The Medical Assistance Eligibility Certification card issued
monthly by DMA to Medicaid entitled individuals.
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.
Medical Assistance (Medicaid) Program: The Division's 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. seq.
Medical Record: A single complete record, maintained by the Provider of services, which
documents all of the treatment plans developed for any behavioral health, intellectual
developmental disability and substance use/addiction services received by the consumer.
Medically Necessary Services: A range of procedures or interventions that are appropriate and
necessary for the diagnosis, treatment, or support in response to an assessment of a
consumer’s condition or need. Medically necessary means services and supplies that are:
1. 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
2. Necessary for and appropriate to the conditions, symptoms, intervention, diagnosis, or
treatment of a mental health, developmental disability or substance abuse condition, and
3. Within generally accepted standards of medical practice, and
4. Not primarily for the convenience of an consumer, and
5. Performed in the least costly setting and manner appropriate to treat the consumer’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
MIS: Management Information System.
Natural Resource Linking: Processes that maximizes the use of family and community support
systems to optimize functioning.
131
SECTION XIV: GLOSSARY OF TERMS
NC Innovations Waiver: A 1915(c) Home and Community Based Wavier for
Intellectual/Developmental Disabilities. This is a waiver of institutional care, and allows
someone who would otherwise be served in an ICF/MR facility or institution to be served in the
community.
NC MH/DD/SAS Health Plan: A 1915 (b) Medicaid Managed Care Waiver, which allows for a
waiver of freedom of choice of Providers so that the LME/MCO can determine the size and
scope of the Provider Network. This also allows for use of Medicaid funds for alternative
services.
NCQA: National Committee for Quality Assurance is an independent, 501(c)(3) non-profit
organization whose mission is to improve health care quality through accreditation ( a rigorous
on-site review of key clinical and administrative processes); through the Health Plan Employer
Data and Information Set (HEDIS®)- a tool used to measure performance in key areas; and
through a comprehensive member satisfaction survey.
NC Tracks: Multi-payer Medicaid Management Information System for the N.C. Department of
Health and Human Services (N.C. DHHS).
Network Council: The Cardinal Innovations Network Council consists of elected Provider
representatives, consumer representatives and LME/MCO staff who serve as an advisory body
to Cardinal Innovations.
Network Provider: A Provider of behavioral health services that meets the LME/MCO’s criteria
for enrollment, credentialing and/or accreditation requirements and is under written
agreement to provide services.
No Reject: Provider 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 LME/MCO and the Provider.
Non-paneled staff: Staff who provide services that are not approved for billing by the
consumer’s third party insurer or Medicare.
Out-of-Area Provider: A contracted Agency or Licensed Independent Practitioner, who provides
services to a consumer of the LME/MCO outside of the catchment area per the LME/MCO
Policy and Procedure.
Out-of-Plan Services: Healthcare 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-forservice basis.
Out-of-Network Provider: A Provider who has been approved as an Out-of-Network-Provider
under the Cardinal Innovations Out-of-Network-Policy and Procedure and has developed a
132
SECTION XIV: GLOSSARY OF TERMS
Memorandum of Agreement with Cardinal Innovations. The Memorandum of Agreement is
client-specific and the Out of Network Provider is not offered as a choice to Cardinal
Innovations consumers.
Outlier: An event that falls outside a particular range (e.g., average length of stay is significantly
greater than the norm).
Penetration Rate: The degree to which a defined population cohort is served.
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 personcentered planning process involves families, friends and professionals as the individual desires
or requires. The resulting treatment document is the person centered plan which outlines
strengths, needs, goals and other relevant information regarding the individual’s proposed
course of treatment.
Primary Clinician: Professional assigned after the initial intake that is ultimately responsible for
implementation/coordination of the Treatment Plan/ Person Centered 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 use/addiction disorders with complicating life circumstances
conditions, and /or situations which impact the person’s capacity to function, often resulting in
high risk behaviors.
Protected Health Information (PHI): Individually identifiable health information that is or has
been electronically transmitted by a covered entity, as well as such information when it takes
any other form.
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 LME/MCO.
Prompt payment guidelines: State mandated timelines LME/MCOs must follow when
adjudicating and paying claims.
Provider: Any person or entity providing services.
133
SECTION XIV: GLOSSARY OF TERMS
Provider Network: The agencies, professional groups, or professionals under contract to the
LME/MCO that meet LME/MCO standards and that provide authorized, covered services to
eligible and enrolled persons.
QHP: Qualified Health Plan.
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 fields of mental health
or 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.
Recipient (beneficiary): A consumer who is receiving services.
Reconsideration Review: A review and determination 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 LME/MCO Network Provider.
Re-qualification: Process to assess Network Providers for continued participation as a Cardinal
Innovations contracted 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 Use/Addiction: 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):
 Age seventeen (17) or under;
 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;
 Global Assessment Scale (GAS) score less than sixty (60).
134
SECTION XIV: GLOSSARY OF TERMS
Service Location: Any location at which a consumer may obtain any covered service from a
Network Provider.
SMI (Persons with Severe Mental Illness):
 Age eighteen (18) or older;
 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;
 Global Assessment Scale (GAF) score less than or equal to fifty (50) OR
 One (1) or more psychiatric hospitalizations or crisis home admissions in the last year.
Special Needs Population: Population cohorts defined by diagnostic, demographic and
behavioral characteristics that are identified in a Managed Care Waiver. The LME/MCO
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
consumer must incur before Medicaid coverage begins during a specified period of time.
SPMI (Persons with Severe and Persistent Mental Illness):
 Age eighteen (18) or older;
 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;



Global Assessment Scale (GAF) score less than or equal to thirty (30) AND
Three (3) or more psychiatric hospitalizations or crisis home admissions in the last
year.
Includes all persons diagnosed with:
1. Bipolar Disorders
296.00-296.96
2. Schizophrenia
295.20-295.90
3. Major Depressive Disorders
296.20-296.36
Support Plan: A component of the Person-Centered Plan that addresses the treatment needs,
natural resources, and community resources needed for the consumer to achieve personal
goals and to live in the least restrictive setting possible.
TAR: Treatment Authorization Request
Third-Party Billing: Services billed to an insurance company, Medicare or another agency.
Treatment Planning Case Management: A managed care function that ensures that consumers
meeting Special Needs Population criteria receive needed assessments and assistance in
accessing services. Cardinal Innovations Care Coordinators carry out this function working with
Providers if the consumer is already engaged with Providers, or assists in connecting and
engaging the consumer with Providers that will provide the necessary services to meet his/her
135
SECTION XIV: GLOSSARY OF TERMS
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
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 Use/Addiction: 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 Person Centered Plan or services and supports provided.
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, high-quality care in a
cost-effective manner.
Utilization Review Manager: LME/MCO qualified professional who reviews a consumer's
clinical data to determine the clinical necessity of care and authorizes services associated with
the plan of care.
136