1. health and fitness
2. addiction

STATE-FUNDED SERVICES
SERVICE
SERVICE CODE
AUTHORIZATION GUIDELINES
REV 10.10.14
REQUIRED DOCUMENTS (Initial) REQUIRED DOCUMENTS
(Reauth)
EXCLUSIONS
Developmental Therapy H2014HM-Individual 10 hours/week max., up to 1 year (or end of PCP)
(DT)
H2014U1-Group
Psychological Evaluation, PCP, NC
SNAP
NC SNAP, Updated PCP,
Progress Information
New Admissions: children ages 3-21. At
age 22, must transition to PC. Need Prior
Auth, not LME referral. Cannot receive
PA, ADVP, Day Activity.
Personal Assistance
(ages 5 and up)
YP020
10 hours/week max., up to 1 year (or end of PCP)
Psychological Evaluation ,PCP, NC
SNAP
NC SNAP, Updated PCP,
Progress Information
Must live in Natural Home or AFL.
Cannot receive ADVP, Day Activity or DT.
Respite
YP010
20 hours/month, up to one year (or end of PCP)
ADVP
YP620
30 hours/week, up to one year (or end of PCP)
Annual NC SNAP (Updated
PCP-IF other services are
provided)
NC SNAP, Updated PCP,
Progress Information
Must live in Natural Home or AFL.
Available for adults and for children ages
3 and up.
Cannot receive DT, Personal Assistance
or Day Activity.
Day Activity
YP660
36 hours/week, up to one year (or end of PCP)
Annual NC SNAP
IF other services are being provided
MUST be on PCP.
No New Admissions to this service
other than those admitted to HDS
DDA homes. NC SNAP, PCP,
Psychological
No New Admissions to this service
other than those admitted to HDS
DDA homes. Psychological
Evaluation, PCP, NC SNAP
NC SNAP, Updated PCP,
Progress Information
Cannot receive DT, Personal Assistance
or ADVP.
IDD Long-Term
Vocational Support
Services (Extended
Services)
Group Living and
Supervised Living
YA389
10 hours/week, up to one year (or end of PCP)
Psychological Evaluation, PCP, NC
SNAP
NC SNAP, Updated PCP,
Progress Information
Cannot receive any other periodic
services.
YP770 Group Living-365 units/year, up to one year (or end of PCP)
Moderate
YP710 Supervised
Living-Low
Psychological Evaluation, PCP, NC
SNAP
NC SNAP, Updated PCP,
Progress Information
Cannot receive DT, Personal Assistance,
or Respite. New Admissions must be
stepping down from a higher level of
care.
IDD Benefit Guidelines
STATE-FUNDED SERVICES
SERVICE
SERVICE CODE
AUTHORIZATION GUIDELINES
REV 10.10.14
REQUIRED DOCUMENTS (Initial) REQUIRED DOCUMENTS
(Reauth)
Family Living
YP750
365 units/year, up to one year (or end of PCP)
Psychological Evaluation, PCP, NC
SNAP
Developmental Day
YP610
10 hours/day
N/A- No prior authorization required N/A- No prior
authorization required
IDD Benefit Guidelines
NC SNAP, Updated PCP,
Progress Information
EXCLUSIONS
Open admisssions for people stepping
down from higher level of care
(Institutional Care).
Available for children from 3-12
B3 MEDICAID SERVICES
SERVICE
SERVICE CODE
AUTHORIZATION GUIDELINES
REV. 10.10.14
REQUIRED DOCUMENTS (Initial)
B3 Respite (hourly)
(over age 3)
H0045 U4- Individual Maximum 16 hours (64 units) per day
Max NC SNAP yearly, testing that confirms the I/DD diagnosis (either formal psychological, school psychological
H0045 HQ U4-Group of 384 hrs (1,536 units/24 days) per 12 month or other diagnostic information relevent to the scope of practice of the professional completing the
assessment)
period, any combination B3 respite
Prior Auth Required, every 12 months
B3 Respite
(community) (over
age 3)
S5151 U4
B3 Respite (crisis)
(over age 3)
H0018 U4
B3 Community Guide T2041 U4
(over age 3)
B3 Initial and
Intermediate
Supportive
Employment (age 16
and older)
H2023 U3 U4
B3 Long Term
Vocational Support
(age 16 and older)
H2026 U3 U4
Maximum 16 hours (64 units) per day
Maximum 24 Days (1536 units) per 12
month period, of any combination of B3
respite codes.
Prior Auth Required, every 12 months
NC SNAP yearly, testing that confirms the I/DD diagnosis (either formal psychological, school psychological
or other diagnostic information relevent to the scope of practice of the professional completing the
assessment). Needs PCP if receiving other services.
Maximum 16 hours (64 units) per day
Maximum 24 Days (1536 units) per 12 month
period, of any combination of B3 respite codes.
Prior Auth Required, every 12 months
NC SNAP yearly, testing that confirms the I/DD diagnosis (either formal psychological, school psychological
or other diagnostic information relevent to the scope of practice of the professional completing the
assessment), Needs PCP if receiving other services.
**For Crisis only,
TAR and docs may be submitted within 48 hours after admission
1 unit/month, up to one year (or end of PCP)
Prior Auth Required, every 12 months
PCP, NC SNAP yearly, testing that confirms the I/DD diagnosis (either formal psychological, school
psychological or other diagnostic information relevent to the scope of practice of the professional
completing the assessment).
PCP/treatment plan/vocational plan, service order, NC SNAP yearly, testing that confirms the I/DD
Initial job development, training and
support: a Maximum of 86 hours/344 units diagnosis (either formal psychological, school psychological or other diagnostic information relevent to the
per month the First 90 days; Intermediate scope of practice of the professional completing the assessment). Note if receiving an enhanced service
must use PCP.
training and support: a Maximum of 43
hours/172 units per month for the Second
90 days.
Prior Auth
Required, every 3 months
Max 10 hours (40 units) month,
Prior Auth Required, every 3 months
PCP, NC SNAP yearly, testing that confirms the I/DD diagnosis (either formal psychological, school
psychological or other diagnostic information relevent to the scope of practice of the professional
completing the assessment)
IDD Benefit Guidelines
B3 MEDICAID SERVICES
B3 Individual Supports T1019 U4
(age 18 and older)
B3 One time
Transitional Costs
H0043-U4
REV. 10.10.14
Max 240 units (60 hrs) month,
Prior Auth Required, every 3 months
PCP annually, reflects the strengths, needs and preferences of the person served. The goals incorporated
into the Service Plan must justify the hours requested, and must include a step-down plan which identifies
and utilizes natural supports, LOCUS score, Progress information/report to support ongoing requests
To be consistent with the NC Innovations
community Transitions service definition
and limitations. Max $5000, lifetime limit.
Prior Authorization Required
PCP, NC SNAP yearly, testing that confirms the I/DD diagnosis (either formal psychological, school
psychological or other diagnostic information relevent to the scope of practice of the professional
completing the assessment), to be consistent with the NC Innovations community Transitions service
definition and limitations.
IDD Benefit Guidelines
INNOVATIONS SERVICES
SERVICE
SERVICE CODE
REV. 09.29.14
MAXIMUM AUTHORIZATION LENGTH
ECBH Care Coordinators submit ALL Authorization requests (TARS) for Initial Plans, Annual Plans, or Revisions that change service or frequency. Providers are
Assistive Technology Equipment and Supplies
T2029
Plan Year
Community Guide
T2041
Plan Year
Community Guide-Training
T2041 U1
3 Months
Community Networking*
H2015
6 months
Community Networking - Classes and Conferences
H2015 U1
Plan Year
Community Transition
T2038
Plan Year
Primary Crisis Response
H2011 U1
Plan Year if it is a planned intervention, or up to 14 days per
unplanned crisis episode. TAR must be submitted within one (1)
business day of service occuring if unplanned
Crisis Behavioral Consultation
T2025 U3
Plan Year if it is a planned intervention, or up to 14 days per
unplanned crisis episode. TAR must be submitted within one (1)
business day of service occuring if unplanned
Out of Home Crisis
T2034
Plan Year if it is a planned intervention, or up to 14 days per
unplanned crisis episode. TAR must be submitted within one (1)
business day of service occuring if unplanned
Day Supports - Individual*
T2021
Plan Year
Day Supports- Group*
T2021 HQ
Plan Year
Day Supports - Developmental Day*
T2027
Plan Year
Home Modifications
S5165
Plan Year
In-Home Intensive Support*
T1015
Every 90 days
In Home Skill Building*
T2013
6 months
In Home Skill Building - Group*
T2013 HQ
6 months
Individual Goods and Services
T1999
Plan Year
Natural Supports Education
S5110
Plan Year
Natural Supports Education - Conference
S5111
Plan Year
Personal Care*
S5125
Plan Year
Residential Supports Level 1 *
H2016
Plan Year
Level 1 AFL*
H2016 CG
Residential Supports Level 2 *
T2014
Plan Year
Level 2 AFL *
T2014 CG
Residential Supports Level 3 *
T2020
Plan Year
Level 3 AFL*
T2020 CG
IDD Benefit Guidelines
INNOVATIONS SERVICES
SERVICE
SERVICE CODE
REV. 09.29.14
MAXIMUM AUTHORIZATION LENGTH
Residential Supports Level 4*
H2016 HI
Plan Year
Level 4 AFL*
H2016 HI CG
Respite - Individual
S5150
Plan Year
Respite - Group
S5150 HQ
Plan Year
Respite - RN
T1005TD
Plan Year
Respite - LPN
T1005TE
Plan Year
Respite - Facility
S5150 US
Plan Year
Specialized Consultation Services
T2025
Plan Year
Supported Employment*
H2025
Plan Year
Supported Employment - Group*
H2025 HQ
Plan Year
Vehicle Modifications
T2039
Plan Year
* Providers must submit the most recent progress summary for any reauthorization during the plan year, and must submit all available progress summaries
IDD Benefit Guidelines
ICF SERVICES
Service
Service Code
Intermediate Care Facility
(ICF)
100
Therapeutic Leave
183
REV. 06.12.14
Maximum Authorization Length
Authorization may be up to one year.
LOC forms must still be submitted every 180 days from doctor's signagure by fax or mail, even when there is an
authorization.
RUBICON members must follow the process outlined by RUBICON. For Rubicon members, do not send LOCs
directly to ECBH, please forward to RUBICON Management.
All other facilities forward LOCs to the following ADDRESS:
ECBH I/DD UM, PO Box 20743, Greenville, NC 27858-0743
FAX: ECBH UM/UR – Attention I/DD UM at 252-215-6875
Auth for Calendar Year (Jan-Dec) Maximum of 60 units
IDD Benefit Guidelines