Medicaid Child and Adult Non-Innovations I/DD Utilization Review Guidelines

Medicaid Adult MH/SA Utilization Review Guidelines

Smoky Mountain LME/MCO is updating the requirements for providers in order to come into compliance with the NC Consumer Data Warehouse (CDW) data submissions. 

Please click link for a list of required data fields and the CDW communication

The monitoring of Unlicensed Alternative Family Living (AFL) homes shall be conducted by the Contract Performance Team of the Smoky Mountain Provider Network Department to ensure a safe environment for the consumer.

See link for the entire Communication  

Smoky Mountain LME/MCO is updating the local modifier that is attached to the Level 4 Behavioral Health Residential Long-Term Treatment procedure code, previously referenced in the Smoky AlphaMCS system as H0019U4.

Click link to learn more                          

Dear Provider,

Smoky Mountain LME/MCO is re-affirming our commitment to meeting outcome measures required by the State regarding NC TOPPS reporting.

NC TOPPS is an important part of our Behavioral health delivery system because:

• It can be utilized to drive Quality Improvement Projects as required by Accrediting Bodies.
• It can demonstrate the value of services to policymakers, as well as the need for additional funding for underserved consumer populations.
• It allows providers and individual clinicians to see how a consumer is progressing over time.

The data out of the system is only as good as the data put into the system.

Amy Douglas-Green and Alison McCall, members of the provider network monitoring team, are the newly appointment Superusers for Smoky NC TOPPS. Beginning 7/1/14 each provider will begin receiving notification on a recurring basis about the NC TOPPS interviews currently due and past due. Smoky expects all providers to be in compliance with required submission timeframes within 30 days. Failure to comply will now result in consequences to be determined by Smoky Executive Leadership.

Smoky is dedicated to helping your agency be successful with this project. We will begin offering monthly training with the location rotating throughout the Smoky catchment area. There also will be a webinar posted to the Smoky website providing convenient access to training for your staff. Also, the NCTopps helpdesk for Smoky is available to assist with questions or problems. For the most immediate response from the helpdesk, please email your needs to nctopps@smokymountaincenter.com.

Weekly information will be sent out in the Provider Communication including current issues and trends being identified.

As part of the transition of NC TOPPS to the oversight of Provider Network, we are updating the user database. Please send a list of your agency sites, including the physical address, your Superusers, QP users and data entry users. This information must be returned to Smoky via the nctopps@smokymountaincenter.com website within seven calendar days.

On behalf of the NC TOPPS Improvement team, I look forward to working with your agency to improve the service delivery to consumers in our catchment area through data-driven refinement of quality service.

Disability Employment Initiative Grants Available!

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Attn.: All Innovation Waiver Providers

This is of concern to all providers who operate under the Innovations Waiver; more specifically, to the staff who complete and submit Innovations Back Up Staffing Incident Reports (Appendix S). 

As of June 20^th, 2014, providers will be able to enter back up staffing reports to Smoky electronically in Alpha. Smoky Mountain LME/MCO (Smoky) has worked with ALPHA MCS to develop and implement a mechanism within the ALPHA MCS system to be compatible with Back Up Staffing reports. Submission through Alpha MCS allows for a more reliable and effective process between providers and Smoky.  Any questions can be addressed by contacting Grievance & Incident Team specialists within Smoky' s QIO Department or by emailing incidentreport@smokymountaincenter.com . 

Effective July 1, 2014, ALPHA MCS will be the only method of submitting Back Up Staffing Incident Reports for Smoky to verify and review.  (Between the dates of June 20, 2014 and June 30, 2014, Smoky will accept both electronic-in Alpha-and faxed or emailed reports.)  In the event that paper (by fax or email) reports are sent to Smoky after July 1^st, they will be returned to the provider with instructions to submit reports via Alpha MCS.

Thank you for making this transition with us to improve processes.  

The PowerPoint for the NCHIMA Behavioral Health Conference has been posted to the Provider Monitoring Conferences page at http://www.ncdhhs.gov/mhddsas/

Changes have been made to the Provider Monitoring tools and can be found on the Provider Monitoring page at http://www.ncdhhs.gov/mhddsas/

LIP REVIEW TOOL --As a quick reference, a note has been added to let people know that this tool is used with LIPs who provide outpatient/basic benefit services only and that the sample size for a solo practice and group practice are also noted. There is also a note explaining that the Routine Agency Tool is used when a LIP works in an agency that provides services other than basic benefit services.

LIP OFFICE SITE REVIEW TOOL --The guideline for item #1 re: the accessibility of the office for individuals who have physical disabilities clarified the options available when the clinician's office is located in a building that is not wheelchair accessible.

--The note in the guideline for item #11 re: the practice hours, provisions for 24 hour coverage being posted as only being applicable to Cardinal Innovations was deleted since this requirement applies to all LIPs, not just those who contract with Cardinal Innovations and to be consistent with the tool.

AGENCY REVIEW TOOL --On the Unlicensed AFL Tool, the guidelines for emergency information and the requirement for crisis services training have been inserted and the guidelines for items #5 and #6 which were combined have been separated to be consistent with the tool.

--The following lists have been added to the workbook to allow reviewers to document the individuals included in the samples for incidents, complaints, restrictive interventions and for funds management and the medication review. The Individual Records List and the Post-Payment Review List have been consolidated into one list -- the Sample Based on Paid Claims List -- in order to reduce redundancy.

--The formula for the Diagnostic Assessment on the Overview Summary page was corrected.

--A note was placed on the Routine Agency Tool to indicate that this tool is used for LIPs who work in an agency that provides services other than basic benefit services (e.g., CABHAs).

Documentation Training for Non-Licensed Staff

Cultural Diversity Training

This TBI training is a free training course intended for service providers in North Carolina public service agencies, including: Local Management Entities (LMEs), vocational rehabilitation or independent living offices, educators, case managers, substance abuse or mental health professionals, social security or social services professionals, advocacy or support agencies, or anyone else who serves people with brain injury.

Register Early to save on Current Trainings

The Free Clinic is sponsoring a Smoking Cessation Class

Date: July 31, 2014 (8:30a-5:00p) - McDowell

Presenters: Melissa Ledbetter & Robin Winkler, SMC Community Specialist

 Training and Registration Information

Date: August 7, 2014 (8:30a-5:00p) - Polk

Presenters: Ann Dupre Rogers & Marilyn Kaylor, SMC Community Outreach Team

Training and Registration Information

Steward of Children is a prevention training program that teaches adults how to prevent, recognize, and react responsibly to child sexual abuse.

August 5, 2014-Caldwell

5:00 pm to 8:00 pm

Smoky Mountain Office

825 Wilkesboro Boulevard, Lenior, NC

Training and Registration Information 

October 14, 2014-McDowell

9:00 am to 12:00 pm

Smoky Mountain Office

408B Spaulding Road, Marion, NC

Training and Registration Information