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Utilization Review

(b)(3)

Additional information is now being requested for (b)(3) services. Have the requirements changed?

The service requirements have not changed. UM is requesting additional information as part of the review process. The documentation requested is the standard documentation that providers should have always maintained in their records this is now just submitted to UM.

Can a member receive State Funded Residential Supports and B3 Respite in the same authorization period?

No, the (b)(3) Respite service definition indicates that Respite cannot be provided or billed during the same authorization period as State Funded Residential Services.

Can you clarify the requirements for (b)(3) plans when members are in other services such as Residential or enhanced services?

In these cases all services should be on the members PCP using the state template. If the PCP is already in place, an update to add the additional (b)(3) services should be completed using PCP update form, which should then contain all services.

It is best practice for goals to be centered around the member’s need, and may be addressed by multiple providers, but interventions may differ depending on the service being received.

There is a Community Guide Needs Assessment that in Innovations the care coordinators develop with individual. Is it required with (b)(3) guide services?

The Community Guide Needs Assessment (CGNA) is intended to be used to guide the discussion with the individual and family about what activities through Community Guide they feel they need assistance with. However, the CGNA is not a required Assessment. Care Coordinators may complete these assessments for both individuals with Innovations services and those with (b)(3) services. UM is also aware that a number of the Community Guide providers complete their own internal assessments on top of anything the Care Coordination Department complete to help guide these services.

When a member receives multiple (b)(3) services, are these required to be on one plan?

Based on the principles of person-centered planning, it is best practice for the member to have one plan that contains all services; however, a treatment plan/service plan will be accepted if the provider has a plan for coordination of services when a member is not in any enhanced or residential services and is only receiving (b)(3) services. If services are authorized and reauthorization is requested and there is no evidence of coordination, these will be addressed on a case by case basis as coordination of care should be occurring.

Authorizations & TARs

Are there procedures in place to provide services in an expeditious manner or add additional sites to the contract due to emergencies?

Cardinal expedites all requests for initial services. If a “routine” member specific agreement is required in order to add an additional site to a Providers’ contract the process can take up to 25 days from start to finish because of the different departments involved and the information each requires to ensure compliance. If a situation is an emergency please reach out to the Network Specialist to discuss options.

Can UM pend the TAR and give the provider time to respond rather than submitting a new TAR and restarting the 14 day process?

After reviewing TARs, UM often requests additional information. Each time that this happens the TAR is unprocessed and the provider must enter a new TAR with the additional information which restarts the 14 day period for review.

  • If UM requests “additional information” the TAR is not marked “Unable to Process.”” The TAR is returned to the provider so that they can answer the questions and resubmit the request. The start date of the service requested does not change when it is resubmitted. It is the same date as the original submission.
  • There is a difference between requesting additional information (RAI) versus unable to process (UTP). RAI-requests are regarding additional clinical information or compliance clarification. UTP actions- are incomplete standard items that are listed as requirements in the service records manual i.e. - invalid PCP.
How will Cardinal Innovations address the issue of providing timely service within seven to eight days after a Comprehensive Clinical Assessments (CCAs), but the approval of the initial TARS can take up to 15 days or more?

Cardinal Innovations is dedicated to reviewing initial service requests as quickly as possible. Based on 42CFR and N.C. Division of Medical Assistance (DMA) contract requirements, Utilization Management is required to render a decision within 14 days. This decision could include an extension of the review, which would include notification to the member or guardian of the extension of the review. If there are consistent patterns with returning TARs for specific providers, technical assistance can be provided to determine trends.

Is there a way to prioritize TARs that have been reviewed and have been sent back with questions?

UM is interested in improving the efficiency and quality of reviews. A recent focus has been compiling data on the average number of days to process requests from each disability - mental health, substance use disorder and intellectual and developmental disabilities. UM is vested in developing processes for prioritizing reviews of initial requests. On a separate note, reauthorization requests can be submitted up to 30 days in advance and are recommended to be submitted at least 15 days in advance of the start date listed on the TARs. This allows for any potential return of TARs for additional information.

Please provide clarification regarding the difference between TARs that are marked as Unable to Process and TARs that are returned requesting additional information?

If a request is submitted and is missing a required element (PCP, required signatures, required assessments) the action taken is unable to process.

UM only restarts the review timeline if a request is marked Unable to Process (UTP). A new request is required in these cases.

If additional clinical information is necessary for clarification related to the request, but the required elements were submitted, these TARs are returned in order to obtain that information and the original start date remains.

The Care Manager marked my TAR Unable to Process on day one because the PCP, CCA, CCP, etc. was not attached. I thought I had 14 days to upload documentation. Will UM honor my original start date?
While UM has up to 14 days to review, we make every effort to review TARs in a timely manner. Therefore, all documentation should be uploaded at the time of TAR submission so we have a complete request for review. Providers are encouraged to refrain from submitting TARs w/o required documentation.  Start date for the authorization cannot be prior to submission date with all complete paperwork.
 
We have been asked to do discharge Treatment Authorization Requests (TARs) for individuals who do not have an active authorization in the system. Can you provide clarification?

If you no longer treat the member and he or she has been discharged from your services, your agency will need to submit a discharge TAR so that we have the most updated information regarding who is being served. If we do not have a discharge TAR that includes details about follow-up care and referrals, UM may assume that you are still working with the member and family.

What are the basic requirements or data items that are needed for UM to approve a plan (for example, SIS®, preference assessment, skills, assessment, etc.)?

The documentation required to be submitted varies depending on the services being requested. For Innovations specific services, providers should be working with their care coordinator to determine what data will be required.

What are the expectations for submission of discharge TARs when authorizations have ended?

Providers are required to submit discharge TARS when members are discharged from care, regardless of active authorizations. This is for planned and unplanned discharges.

Submission of a discharge TAR provides the most updated information regarding the member’s care. Discharge TARs also offer the details regarding follow-up care and referrals.

If providers do not formally discharge members they may still be expected to provide support and coordination to the member and their family.

What are the options for expediting requests when a site is not on the contract? Are there procedures in place for these types of emergencies?

In these situations providers should outreach to their Network Specialist or one of the UM Supervisors.

Requests can be submitted via Member Specific requests on paper prior to sites being fully active in the system.

There still may be health and safety site verification or Home and Community Based (HCBS) verification that must occur prior to a service being authorized.

What constitutes an expedited request?
  • Expedited requests are reserved for individuals currently experiencing life-threatening situations due to their current psychiatric symptoms or behaviors. Requests that are marked expedited should include clinical justification to support the need for an expedited review.
  • Pursuant to 42 C.F.R. §438.210, an expedited request is one which “a provider indicates, or the MCO... determines, that following the standard timeframe could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function.”
What criteria does Cardinal Innovations use to determine a decision to overrule a physician’s/provider’s recommendation for a medically necessary treatment for an individual?

UM reviews service requests based on the Medicaid, State, and Federal guidelines including the waiver, service definitions, and clinical practice guidelines to determine a decision. A recommendation alone does not mean that UM is able to determine that all necessary criteria is met. The best way to support this is for the individual making the recommendation to fully outline why he/she is making the recommendation including supporting how the service criteria is met, why alternative services or less intensive treatment would be unable to meet the individual’s needs, and how what the service/treatment being requested is consistent with best practices when applicable. There are many reasons why additional information may be required or a denial might be issued even when a recommendation has been received.

What does UTP mean? Why does UM UTP some requests but not others?

UTP stands for “Unable to Process.” UM will UTP a service request if administrative information is missing. Some examples are:

  1. A TAR is submitted and an authorization is already in place for the same services/frequency.
  2. A member’s funding is for a County outside of Cardinal’s coverage area.
  3. Medicaid is not valid for the dates of service being requested.
  4. Provider is not contracted for the services or sites requested.
  5. The Plan received is missing required element(s) such as guardian, QP or service order signature, or service/frequency not listed on plan goals.
What form(s) do I use for a Review & Determination?
There are two forms on the website under Provider Resources:
What if a provider requests authorization for services that a Cardinal Innovations member already has authorization for from another provider?

UM is not able to provide authorization for a new provider of the same service until the original provider discharges (or submits a TAR indicating when the discharge is occurring. Depending on the service the plan may support a short overlap for transition purposes). There are a few exceptions where two providers may be authorized for the same services during the same authorization period; however, there must be a coordinated plan in these cases to ensure the authorization guidelines are not exceeded.

What is Review and Determination?

R&D is the process by which a provider would submit a treatment authorization request for re-review, used when a provider has made an inadvertent error on a prior submission. R&D cannot be used if there is not a valid PCP or an auth in place. Providers need to be in our Network for R&D. There are related resources in the resource library.

What is the process for seeking authorization during emergencies?

Where there is an immediate health and safety concern, authorization requests can be submitted as expedited. The TAR in these cases should clearly outline what the immediate health and safety needs are.

Providers can also outreach directly to the UM team supervisors to explain the unique circumstances for which they are requesting prioritization of a review.

Why are there times when UM will mark TARs Unable to Process without contacting us to resolve the problem first?
  • Marking a TAR as UTP is a quick way for UM Care Managers to prioritize requests that come to us correct.
  • UM has begun to only UTP 1 time per request if a TAR is submitted and is UTP’d once it cannot be UTP’d again. The UM CM has to reach out to the provider to discuss the request. However, the CM will put in a provider concern for trending which will tell us how many times a specific provider is receiving a UTP.
Why must paperwork required for authorization approvals (CCA, CCP, PCP) be scanned if the information also is included/needed in the TAR itself?

The TAR includes standard clinical questions and provides the most current information for Utilization Management to review, but it only allows for a limited amount of information. The additional information provides Cardinal Innovations with a full clinical picture of the member provided through the CCA. The PCP outlines goals and interventions to support the request for the service recommended, as well as, a service order for the service. The Comprehensive Crisis Prevention (CCP) plan outlines how the member will be served in the event a crisis occurs. The additional documentation allows Cardinal Innovations to provide a comprehensive clinical review of the member to determine medical necessity for the service being requested. It is recommended that any clinical information beyond the required documents be submitted in the event that this documentation may provide additional support for the review.

Will existing authorizations be changed if a plan is submitted by another agency?

The existing authorization will not be changed without discussion with the authorized provider; however, if UM receives a signed request by the guardian requesting to change providers, the guardian’s request will be honored.

Billing

How and when will I receive funding?

If you are a non-hospital provider, you must submit claims for payments within a certain time frame. Submit claims within 90 calendar days to ensure payment, unless specified in your contract.

Hospital claims and claims involving coordination of benefits (COB) must be received within 180 days of the service date. We will deny claims submitted outside of the allowable billing days.

Claims are paid by electronic funds based on the check-write schedule. Review information regarding Electronic Fund Transfer (EFT) for details.

How do I file a claim or a claim inquiry to receive payment?
Submit claims through Provider Direct or an 837 file, unless your contract states another method. We encourage you to produce routine billings on a weekly or bi-monthly basis. The Provider Direct Manual gives specific instructions on information needed to complete a claim form. The Provider Direct Manual is available on the portal.

Communication Bulletins

Is there a Communication Bulletin update that addresses an associate and/or provisionally licensed professional signing medical necessity documents for Peer Support? The service definition does not specify.

We have previously requested clarification from DMA regarding the service order for Peer Support. Cardinal Innovations was advised that the service order is required to be signed by a fully licensed therapist indicating that this does not include provisionally licensed clinicians.

Is there a Communication Bulletin update that addresses the submission of PCPs for Peer Support after the individual has been enrolled in services for a year?

There is no Communication Bulletin regarding members remaining in Peer Supports beyond one year. Similar to other services, if services are being requested beyond the end date of the current plan, an annual plan will need to be developed that justifies continued Peer Support Services. With each Peer Support request, the RAS will be required. This allows the provider the ability to monitor outcomes and discuss future goals and interventions.

The InfoSource newsletter has mentioned supervision of medical doctors by a psychiatrist. Is this just for doctors that are prescribing psychotropics? Can you provide clarification?

This applies to any non-psychiatric physicians (medical doctors and doctors of osteopathy), nurse practitioners, and physician’s assistants that are credentialed through Cardinal innovations and would be billing for services. Additional information can be found in “Provider Communication Bulletin FY 1617 NM 14.”

Contact us

How do I report a concern, fraud, or abuse?

You can report a concern via telephone, online, or by mail. Review examples of fraud and abuse.

Online
Complete our suspected fraud and abuse reporting form.

Telephone

Call our toll-free Fraud and Abuse Line to leave a confidential voicemail at 1-800-357-9084.

Mail

Cardinal Innovations Healthcare

Attention: Program Integrity Unit

550 S. Caldwell St., Suite 1500

Charlotte, North Carolina 28202

Coordination of Care

For IDD providers, who is responsible for getting the psych and evaluation documentation - the provider or the care coordinator?

The team should work together to gather this information, keeping in mind the rules around re-release of information.

How does a provider know if a member is receiving other services?

As part of the intake process, providers should ask detailed questions to determine if the member is receiving other services. UM will alert the provider if there is another mental health or IDD already authorized and inform them who the provider is for coordination of care once a request is submitted.

Mobile Crisis providers receive information from Cardinal Innovations staff about a person in crisis. Why did this change?

Cardinal altered the methods of dispatch to increase the measurement of appointments kept within the timeframes (2.15 hours from the call to the call center). By doing this we changed our stats from 82% in Q4 to 92% in Q1. Additional concerns/ questions can be directed to Access Clinical Manager, Scott Evans.

There is a perception that UM has added additional requirements for B3 and State funded services. Providers have been reporting to us that since we added these “new requirements” that more TARS are being marked as Unable to Process.

We want to clarify that UM has not added additional requirements. What we discovered through Utilization Reviews and other internal audits was that providers were not consistently following the service definitions and/or the service records manual expectations regarding PCPs. When UM would ask for information to be submitted sometimes it wasn’t available. That was a concern for us because we want to make the best clinical decision and we can’t do that if we don’t have the most up to date clinical information or valid PCPs. This resulted in UM asking for this information rather than just “assuming” providers had it in their records.

What are the requirements for (b)(3) services? Where can providers find these requirements?

The requirements for (b)(3) services can be found within the UM Authorization guidelines. Each individual (b)(3) service definition also outlines requirements specific to the service. We also have tips for submission that may assist providers on our website’s resource library.

What is the process for providers to follow that does not cause an authorization gap when a member is moving from one AFL site to another within the agency?

A PCP is required for State Funded Residential Services. A Client Specific Agreement is required to add an AFL site to the contract for a member that receives State Funded Residential Services.

It is best if the member is not moved until an authorization is issued. The provider can submit the request for an MSA (member specific agreement) up to 30 days prior to the move date. Additionally, it is recommended that a discharge TAR is submitted. If the situation is an emergency please reach out directly to your Network Specialist (see question and answer #3)

Credentialing

How is my application to the provider network processed?
Cardinal Innovations Network Operations and Cardinal Innovation Service Center process enrollment. These groups ensoure that provider enrollment is in line with our mission. 
How quickly can I become a provider?
While we can't guarantee a specific turnaround time, it is our goal to process your application promptly. 

Denial/Appeals

Can I file an appeal on behalf of my patient?

A provider may file an appeal on behalf of a member with the member’s written consent in accordance with 42 CFR 438.402. Cardinal Innovations will not prohibit or otherwise restrict a healthcare provider acting within the lawful scope of practice from advising or advocating on behalf of a member who is his or her patient.

Is there a way to receive temporary authorizations during the reconsideration process?

  • At this time Cardinal Innovations will not provide temporary authorizations during the reconsideration process.
  • Providers can deliver the same amount and type of service they were delivering to the member prior to the denial. If the decision is not overturned during the reconsideration process the provider does run the risk of having a pay back. Providers cannot “bill” during this time period but they will have 90 days to submit claims in the event the decision is overturned.

Why was maintenance of service eliminated?

Maintenance of service is not eliminated. It applies when a current service authorization is adjusted prior to the authorizations expiration date. If there is an authorization from January 1, 2016, to March 1, 2016, but in February UM makes an adjustment to the authorization based on new information, the member has the right to appeal and have the service maintained at the originally approved frequency while exercising their due process rights.

Is there a way to receive temporary authorizations during the reconsideration process?
  • At this time Cardinal Innovations will not provide temporary authorizations during the reconsideration process.
  • Providers can deliver the same amount and type of service they were delivering to the member prior to the denial. If the decision is not overturned during the reconsideration process the provider does run the risk of having a pay back. Providers cannot “bill” during this time period but they will have 90 days to submit claims in the event the decision is overturned.
Why was maintenance of service eliminated?

Maintenance of service is not eliminated. It applies when a current service authorization is adjusted prior to the authorizations expiration date. If there is an authorization from January 1, 2016, to March 1, 2016, but in February UM makes an adjustment to the authorization based on new information, the member has the right to appeal and have the service maintained at the originally approved frequency while exercising their due process rights.

Enrollment

How do I enroll new patients referred to me through the Access Call Center?

Patients may seek enrollment as a new patient with a provider through the Access Call Center, or they may walk in to a provider location seeking services as a new patient. If you are a Cardinal Innovations network provider, here are two ways you can enroll a Cardinal Innovations member as a new patient:

Enrolling new patients who are referred by the Access Call Center:

  • If a caller has been referred to you for an assessment, the enrollment data will be forwarded to you via Provider Direct.
  • You’ll conduct your own assessment and complete the “Additional Enrollment Data” on the enrollment form.
  • You’ll collect information on the person's ability to pay.
  • You will submit the completed enrollment to Cardinal Innovations via Provider Direct.
  • We will review the enrollment for completeness.

Enrolling walk-ins as new patients:

  • If someone walks in to your location who is not a Cardinal Innovations member but you think they may be eligible, please refer them to our website and our 24/7 Access Call Center at 1-800-939-5911.
How do I help my patients confirm eligibility?

Individuals with IDD/MH/SUD who receive Medicaid in our coverage areas are eligible. Our team confirms each person's health plan based on specific criteria. For more information, refer to the Members page.

Guidelines

Are there guidelines for titration of services primarily for Peer Support?

The service definition and authorization guidelines outline the titration of Peer Support Services specific to initial and reauthorization requests. Titration of services should be personalized based on continued progress in treatment and specific to the needs of the member.

Can UM provide clarification and/or documentation about the authorization guidelines/benchmark documents that are utilized to make decisions on services that are requested in the plan?

Both the waiver “Hard Limits-Benchmarks for providers and families” and “Authorization Guidelines” can be found on the Cardinal Innovations website under the provider resources. If you have specific questions, email the designated UM mailboxes.

How does Cardinal Innovations plan to address that the new Uniform Data System (UDS) guidelines for Medicaid are contradictory to Cardinal Innovations Healthcare best clinical practice recommendations?

Cardinal Innovations has been involved in discussion with the state related to the concerns on this policy. This is currently under review at the state level based on the concerns that have been expressed.

IDD & NC Innovations

In the service definitions for IDD providers are required to complete an NC-SNAP for each person receiving state funding. What are the expectations for having NC-SNAP? As an examiner, we have to complete at least one SNAP in a 12 or 18 month period. How will this be tracked to maintain certification?

NC-SNAP was added to the service definition by the state in 2014 and is required for all IDD state-funded services for members that do not have a SIS. Providers are required to track who in their agency is certified to conduct the NC SNAP, and Cardinal Innovations is required to submit information to the state database when we receive an assessment.

It is expected that all providers will submit these by December 2017 with their service request. Additional information will be provided through the InfoSource and Communication Bulletins.

Additional information for the NC-SNAP can be found here: NC Support Needs Assessment Profile

What are overall long-term and short-term outcomes UM is seeking?

UM has to approve Innovations services as directed by the waiver. Generally, we have to ensure waiver compliance, health and welfare. We have to ensure all services are being delivered efficiently and effectively and align with best practices.

What are the steps that a provider should take to ensure they will receive authorization and payment after providing an emergency or crisis service?
  • Providers could consider working with the planning team to add Innovations Crisis Services to the annual ISP. This way the service will be in the plan and an update will not have to be submitted unless something more significant changes with regard to the member’s services.
  • Consideration will be given to the request for additional training.
What documents do you need to make the ISP approval process more streamline? My last ISP took 7 days for approval?

UM reviews requests as timely as possibly but as all Innovations annual plan requests are submitted on the first of the month, this can require up to the allowed time frames to complete all reviews. This is why ISPs are submitted a month in advance of the effective dates and updates should be submitted at least to 15 days in advance. For urgent situations, the Care Coordinator would work with UM to prioritize. For any concerns, the provider should discuss with the Care Coordinator.

What’s the timeframe for emergency slots?

When an Emergency Innovations Slot request is received it is staffed with a Psychologist or Psychiatrist as soon as possible. A letter is generated and sent to the LRP or member informing them of the next steps. There are several things that must happen before a waiver slot can be activated, especially if the member does not have Medicaid, a SIS or psychological testing to validate their diagnosis. An Emergency slot will help the member get Innovations waiver services faster however, it could take the planning team up to 90 days to complete all required steps. Crisis Services and/or other funding sources should be utilized if the member’s health and safety are in jeopardy and services are needed immediately.

When ISPs are reviewed are their documents that are more important?

Providers should reference the waiver and the Clinical Coverage Policy 8P. The Clinical Coverage Policy in section 5.3.4 outlines the documents that are required for submission with the ISP for approval. Section 5.3.5 outlines the service specific requirements for each unique service beyond the general documents that must be submitted.

Will Cardinal Innovations Healthcare start accepting school based psychological evaluations that include the components of cognitive and adaptive testing?

We currently accept school based evaluations as supporting documentation, however we still need an independent diagnosis by an appropriately licensed professional.

A School Psychologist can offer information to guide services under IDEA, however they are not always able to offer a diagnosis of IDD due to scope of practice limitations. Therefore, you can take information provided by the school to your attending primary physician and he or she can confirm the diagnosis and can then write a letter or summary explaining their conclusions.

Members

Can I file an appeal on behalf of my patient?
A provider may file an appeal on behalf of a member with the member’s written consent in accordance with 42 CFR 438.402. Cardinal Innovations will not prohibit or otherwise restrict a healthcare provider acting within the lawful scope of practice from advising or advocating on behalf of a member who is his or her patient.
How can I help my patient confirm eligibility?
Individuals with IDD/MH/SUD who receive Medicaid in our coverage areas are eligible. Our team confirms each person's health plan based on specific criteria. For more information, refer to the Members page.

Network & operations

Do UM Care Managers Specialize in the service being requested on TARs? Does Cardinal need to hire more UM Care Managers?

Each UM team has an area of expertise. We have 3 Managers and 8 Supervisors. Each team has between 6 and 8 Care Managers depending on the volume of TARS received by each team.

  • Child MH Non-Residential Team
  • Child MH Residential Team
  • Adult MH team
  • Complex team (State funded MH and IDD services and (b)(3) services)
  • SUD/Inpatient Team
  • Registry Team (Innovations and State funds list)
  • Innovations Waiver Team

The need for more or less UM Care Managers is considered regularly and is driven by data. In UM we track productivity monthly and that includes measuring Turn-Around-Time, the expectation is that services get processed sooner and preliminary data is showing that this is happening. We will have more definitive information on the next UM Dashboard to be presented in the next Cardinal Provider Council meeting. UM is noticing great strides especially with PRTF reviews we are now averaging a 4-5 days to approval of the service.

Does Cardinal Innovations have a list of Dialectical Behavior Therapy (DBT) providers?

Cardinal Innovations does not have a current list of all specialty outpatient providers based on all evidence-based treatment modalities. Cardinal Innovations’ Network Development team has been working to survey providers who adhere to DBT fidelity and has recently identified 13 providers. Reach out to your Network Specialist if you need specific information.

Does Cardinal Innovations have a list of psychologists that do psychological evaluations for individuals who have Medicare and Medicaid?

Cardinal Innovations’ Network Development team is working to survey psychologists to determine if they are willing to serve members with Medicare and Medicaid. A listing of providers can found on the Provider Search page.

How do I get a Provider Direct login?

Contact Network Management to access provider enrollment information.

What does Cardinal Innovations Healthcare help me provide to patients?

As a Cardinal Innovations provider, you're helping ensure care to our members with complex needs. Our core values shine through our providers' work and permeate everything they do.

Where are the UM Clinical Q&A Webinar FAQs posted?
They are posted on our website on the Provider Resources page under Forms and General Resources.

Network providers

How do I get a Provider Direct login?
Contact Network Management to access provider enrollment information.
How is my application to the provider network processed?
Cardinal Innovations Network Operations and Cardinal Innovations Service Center process enrollment. These groups ensure that provider enrollment is in line with our mission.
How quickly can I become a provider?
While we can't guarantee a specific turnaround time, it is our goal to process your application promptly.
What does Cardinal Innovations help me provide to my patients?
As a Cardinal Innovations provider, you're helping ensure care to our members with complex needs. Our core values shine through our providers' work and permeate everything they do.

Outpatient

Can medication management and outpatient therapy be billed on the same day?

Yes, as long as it is not the same practitioner. According to Clinical Coverage Policy 8C, only one psychiatric CPT code from this policy is allowed per beneficiary per day of service from the same attending provider. This includes medication management services. Only two psychiatric CPT codes from this policy are allowed per beneficiary per date of service. These codes must be provided by two different attending providers. (5.3, pg. 10)

Do I need to submit a discharge TAR for Outpatient, if services were under the unmanaged units?

Yes, a discharge TAR should be submitted for all services. This provides clinical information on reason for discharge and any recommendations for future planning.

For outpatient therapy, when the service plan is due to expire and it is reviewed, is there a signature page to sign to close out the expired treatment plan and new signature page for the new treatment plan?

The new service plan will supersede the previous plan. There is no need to sign a separate signature page to end a current service plan. The most recent signature page that corresponds to the new or updated treatment/service plan is sufficient.

How often are service plans required to be reviewed prior to their expiration date annually for outpatient therapy?

A new service plan is required at least annually. If goals are determined to be ineffective and there is continued lack of progress throughout the life of the plan, providers should work with members and families to modify goals to ensure that goals are obtainable, measureable, and personalized.

I submitted my Outpatient TAR for Service Code 90837 Psychotherapy, 60 min instead of for “All Services” and now my Claims are denying. How can I get this corrected and will you honor my original start date?
Outpatient providers are encouraged to submit their TARs under, “OUTPATIENT TREATMENT – ALL SERVICES” for each therapy category to ensure there will be no delay in processing of claims as your authorization is only valid for that code. UM cannot back date forms and honors submitted on and any future dates. For more information, please reference Outpatient Therapy Submission Tips. For individual cases, UM will review with leadership and finance to determine if corrections can be made.
 
In providing medication management, is a CCA required recommending medication management?

According to Clinical Coverage Policy 8C, a CCA is not required for medical providers to bill E & M codes for medication management. (Ch. 7.3.3.3. pg. 15)

Is a goal required for medication management on the service plan for outpatient therapy for clients receiving both services?

You can have a specific med management goal but you can also incorporate med management as an intervention within another goal.

Is prior authorization required for the Trauma Informed CCA or TF-CBT with the specialty code?
Yes, prior authorization is required for these services. A TICCA should be requested prior to requesting TF-CBT and not concurrently as the TICCA is intended to drive treatment recommendations. A TICCA is not required to request TF-CBT with the specialty code and providers should submit a CCA with their TF-CBT request.
Is the intake outpatient service code 90791 included in the bundled request for Outpatient Services (All)?
No, the 90791 Service Code is not included in the Outpatient All Individual bundle but it can be included in the Outpatient Treatment Screening/Evaluation bundle request for outpatient. Or it can be requested individually.
 
Is there a hard limit on the amount of OPT that can be provided in a one month period?

The system limits currently allow two sessions per week (provided on different days) for each therapy category (individual, family, and group). Any higher frequency would require pre-authorization. However, It is important to ensure justification for services is documented. If there are extensive outpatient services provided over time with no progression in care, referrals would need to be made to alternative services. Group, individual, and family sessions can be provided throughout the same month. According to Clinical Coverage Policy 8C, as discussed on a previous question, only two psychiatric CPT codes from this policy are allowed per beneficiary per date of service. These codes must be provided by two different attending providers. (5.3, pg. 10). Based on these parameters, group, family, and individual therapy may be provided within the same week, however, there are parameters regarding these services within the same day.

When do Outpatient Units reset?

These reset on July 1 of each fiscal year.

Plans

Can providers and families be provided more information on the documentation needed for ISPs?

Clinical Coverage Policy 8P offers information or providers, individuals and families concerning documentation requirements. This should be discussed within the teams and with the Care Coordinator if there are specific questions from the member/their guardian.

Do we use the NC PCP or the ISP for (b)(3) services?

Either is acceptable for (b)(3) services as long as all the elements required for the plans based on the services are met. For example, mental health (b)(3) services require service orders by a licensed clinician.

How can I ensure the other provider completes the plan updates?

Best practice is that the plan be developed during a coordinated treatment team or child and family team so that all parties have input and receive the same document. Providers should work collaborative and discuss how information about the member will be communicated.

How will authorizations be in sync with one another? The TAR often expires before the plan does. For example, if an agency has been using a modified plan and another agency starts services, will the authorization end dates change to the PCP end date? What if the PCP ends in the middle of the month?

It is common for non-Innovations services that the plans are developed with goals for the full year. Authorizations are based on the established guidelines for the service and in many cases are for a shorter time period than the plan is valid for. Plans and goals should be reviewed by the team monthly to document progress, and update plans (that do not exceed the original plan end date) can be done as necessary to adjust goals/add new services, etc. Plans can be valid for up to 1 year (from date plan developed or signatures whichever is first) but can be less if providers prefer these end at the end of a month. New annual plans can be developed at any time to best coordinate goals and services for the member.

Is a PCP required for an initial and/or reauthorization request for PSS? I know that they have to be in the individual’s chart but do they have to be submitted?

Yes, the treatment plan or PCP is required for PSS requests. Reference the current Cardinal Innovations Authorization Guidelines for additional information.

Is it mandatory to have one PCP if more than one (b)(3) service is requested? If there is not a uniform PCP with all services listed in the one document, will UM UTP the TAR?

Based on Person-Centered Planning practices, members should have a unified plan containing all services for the member.

This allows for greater collaboration, enhanced member focused-service delivery, increased continuity of care and for the most efficient utilization of resources.

If a member is receiving more than one (b)(3) service the UM team will not Unable to Process a TAR for a PCP that does not have all the member services listed in the one document. However, this may be trended for further follow-up.

The clinical recommendation will be that providers should coordinate care and ensure members have one unified plan. Technical assistance will be provided (as needed) as well as ongoing education related to member-centered planning.

If trends are noted with providers that are not working towards coordination of care, additional follow-up actions may be taken.

Is the entire PCP required to be placed on the Update/Revision form when the Annual PCP is altered?

If either the service type, or the frequency/intensity change, than yes an update is needed and the update must carry over all relevant information from the annual PCP.

If the provider or staff names are listed on the PCP and they change, an update is required. However, it is not mandated that specific providers or staff be documented on the PCP.

What are the target dates?

A Target Date is the date the team projects the person can achieve this goal. Target dates may not exceed 12 months (365 days) from the PCP Completion Date.

What constitutes a valid PCP Update?

Goals and interventions for all active services should be added (rewritten) on the PCP (Update/Revision) page, along with the Update/Revision Plan Signatures Pages being fully completed. If new services are being requested, a Service Order is also required.

What constitutes a valid Service Order?

A Service Order is valid if it is signed by the appropriate professional per the specific service definition. If new services requiring a service order are added during an Update/Revision to the PCP, a new service order must be obtained and is valid only for the remainder of that 12 month period.

Example:

  • PCP is effective on 10/13/16 and on 09/1/17 a new service order is issued
  • The new Service Order is only valid from 09-1-17 to 10/12/2017.
What is the PCP Completion Date?

The PCP Completion Date is the date that the QP/LP [per the Service Definition] completes and signs the PCP.

What is time period that a PCP is Valid?

The PCP is valid for 12 months (365 days) from the PCP completion date.

The PCP Completion Date is the date that the Qualified Professional/Licensed Professional (per service definition) completes and signs the PCP.

No signatures, Qualified Professional, Licensed Professional or Legally Responsible Person can precede the PCP Completion Date. If any of the 3 signatures were entered after the PCP Completion Date the latest signature is the date the PCP is effective and the date that billing for the service may begin, however, the PCP Completion Date is still in effect for target dates, and the date the annual rewrite is based.

Example:

  • PCP Completion Date: 11/6/16
  • LRP signs on: 11/10/16
  • Plan is effective and can be billed against on: 11/10/16
  • Plan target dates and annual expiration date are still based on 11/6/16 which means the PCP expires on 11/5/17.
What signatures are required on a plan?

The PCP manual documents the required signatures on this document. This includes the need for the member signature, even when under 18 in cases where plans contain SUD information. The service order section must also be fully completed. For service plan/treatment plans, these must be signed at a minimum by the guardian, the provider completing the plan, the member where SUD information is contain, and a service order when this is required for the individual service.

When is a Person-Centered Plan (PCP) considered valid for service authorization and provider billing?

A PCP is valid when the last of the 3 required signatures are in place:

  1. Dated signature of the person to whom the PCP belongs and/or the LRP signs and checks the necessary boxes.
  2. Dated signature of the QP or LP who wrote the PCP, with checks in the necessary boxes.
  3. Dated signature of the person ordering the service(s) with appropriate boxes checked.
When should the Comprehensive Crisis Plan (CCP) be developed?

Constructing a Comprehensive Crisis Plan (CCP) requires careful thought and knowledge of the person for whom it is being developed.

The CCP should not be developed when the member is in the midst of a crisis, as thoughtful planning is often difficult to accomplish at such times.

It should be updated/completed on the same schedule as the PCP, AND/OR shortly after any crisis episode occurs, AND/OR anytime there is a significant change in the course of treatment -- including medication changes.

When there are multiple providers, who is responsible for completing and updating the PCP?

The clinical home is responsible for the Person-Centered Plan. This is typically the higher level of care, such as residential treatment, but would be determined by the team.

Best practice is for the treatment team to meet (as a whole) to develop the PCP and to ensure all goals and services are listed on the plan.

Any member of the treatment team with QP status can update the PCP, however, this individual will need to ensure that all updates are shared with the full team.

When unified plans are required, should all agencies affiliated with it be penalized when it is returned as “unable to process?”

Not having a unified plan is not a reason for the UM Care Manager to mark something as Unable to Process, however, the UM Care Manager will recommend that the plan be unified and a provider concern will be entered into the CI system for tracking and trending. The request for service should be returned and additional information should be requested versus UTP.

Who is considered the Clinical Home provider that is responsible for the plan?

Typically, this would be the residential or enhanced service provider, however, as part of the person-centered process, this should be determined by the team and is not determined by Cardinal Innovations.

Registries

Can a provider assist a member to be placed on the Registry of Unmet Needs or does it need to be the guardian?

Yes, once the legally responsible person whether the member or another individual is contacted and interest is confirmed, the Registry Coordinators routinely work with providers to assist with procuring the information needed to access and/or remain on.

How do we get members on the Registry of Unmet Needs for Innovations? State Funded IDD Services? What is the Criteria for each?

There are several ways to get someone on the registry for IDD Innovations services at this time:

  • Send information to the registry department stating that the individual would like to be placed on the registry to wait for specific services: for state services the referral form will need to be attached.
    • Email: registry@cardinalinnovations.org
    • Fax: 1-704-743-2130
    • Call the Registry voicemail and leave a message at 1-704-939-7980
    • For all venues please leave the name; DOB; guardian contact information and County of Medicaid or residence.

Criteria:

  • Documented diagnosis of an intellectual disability and/or a closely related condition as defined in GS 122 C-3 12a.
  • Must meet Intermediate Care Facility Level of Care (ICF-LOC) and be able to benefit from active treatment as defined in Clinical Coverage Policy 8E.
  • Members that have a closely related diagnosis to an intellectual disability, must show three or more functional deficits as measured through an Adaptive Behavior Assessment or equivalent.
  • The Registry Coordinator will assist the member and/or the family in determining the needed assessments depending on age; age at the time of assessment; diagnosis; and relevancy.

For State funded services such as ADVP and/or IDD Residential, please fill out the referral form and submit to the following:

  • Email: registry@cardinalinnovations.org
  • Fax: 1-704-743-2130
  • Criteria: The individual must have a diagnosis of an intellectual disability and/or a closely related diagnosis with functional deficits.
How does a provider fill vacancies in their residential placements using state funds?
To fill vacancies for IDD/MH residential, the provider needs to fill out the Provider Vacancy Announcement (PVA) for IDD vacancies or Mental Health vacancies. There are several key components to this form.
  • Address of the vacancy.
  • The Cardinal Innovations identification number (CI number) of the member that is leaving the residence or creating the vacancy.
  • The person vacating the residence must have received funds through Cardinal Innovations and is currently receiving state funds.
  • In addition, the member must not be utilizing state funds in another residential setting.
How does a provider or family make a referral for IDD services?
To make a referral for IDD services or to get placed on one of the Registries, please visit the Cardinal Innovations website and select “IDD services referral form” on the Provider Resources page.  Follow the instructions on the form to complete it and then forward the document to the Registry department. If you don’t have access to the internet feel free to call the registry line at 704-939-7980.
How does a provider refer members to one of the registries?
  • Both referral/applications are located on the Cardinal Innovations Website under Provider Resource Forms.
  • Each Form stipulates where and how to submit the referral/application.
How many registries does Cardinal Innovations manage?

Cardinal Innovations manages three IDD registries and one mental health registry on behalf of the State. These registries are as follows:

  • State Funded IDD Residential
  • State Funded MH Residential
  • State funded IDD Adult Vocational Developmental Program (ADVP)
  • NC Innovations Waiver, Registry of Unmet Needs

The availability of State funded IDD Residential, State Funded MH Residential and State-funded IDD ADVP services is based on urgency of need and the date a member is assigned to the registry. This is to ensure the fair and equitable distribution of state dollars across our 20 county catchment. The NC General Assembly decides how many individuals across the state can receive services through the Innovations Waiver, and slots are filled from the Registry on a first-come, first-serve, per-capita basis according to two factors: the date they are placed on the Registry, and the number of slots already existing within the county. These two factors are considered to ensure that slots are filled equitably across the state.

If someone on registry receives a wavier and lives in State Funded Residential program, can they remain living in the State Funded program but use other services through waiver? Or are they required to move to Medicaid residential?

Cardinal Innovations wants and works to support member preference as much as possible and routinely works with members/ families and providers to assist in residential preferences. The primary issues that exist are a)is the existing residential provider contracted with Cardinal Innovations AND b)does the existing Group Home meet the Waiver requirements. The Registry Team will assist in helping families and members being informed prior to accepting the slot offer as to whether remaining in their current living arrangement will be an option. If a member has the ability to access Medicaid dollars for services as opposed to State funds it is recommended they do so in order to free up “State” dollars for members without access to Medicaid. If a member is receiving Waiver Funding and in Residential Placement, the member must utilize Waiver services to support their IDD habilitation needs within that environment.

Once on the registry how do members get placed?
  • As Funding becomes available for the State-Funded IDD Residential, State-funded MH Residential and State Funded IDD ADVP, individuals are placed in order of the date that they were placed on the registry and the urgency of their need.
  • As Funding becomes available for Innovations Waiver, individuals are a first-come, first-serve, per-capita basis according to two factors: the date they are placed on the Registry, and the number of slots already existing within the county
  • When a provider has a vacancy, they will need to submit the Vacancy Announcement Form to the Clinical Support Mailbox for mental health; or the Registry Mailbox for IDD.
  • The Vacancy Announcement Form is located on the Website under Provider Resource Forms
  • Any form submitted with missing information will be returned as Unable to Process

Residential & housing

What are the requirements for submitting rent subsidy documentation?
Providers must submit documentation that verifies costs related to the placement (i.e., rent, subsidy to the family, household expenses, etc.)
Family Living Low and Family Living Moderate
  • Only costs related directly to the placement (rent, subsidy to the family, etc.) shall be counted in this service cost which will be 100% of costs.
Supervised Living Low, Supervised Living Moderate, and Supervised Living I-VI
  • A service should be considered as Supervised Living when some (or all) of the rent or other household expenses are paid for as part of this service rate.
Rent subsidized by HUD or any other rental assistance program does not count when the requirement in a service definition indicates that some or all of the rent is paid for by the provider as this is subsidized by an outside source, not the provider. Providers must submit documentation that clearly indicates this criteria is met.
What costs are considered as operating expenses?
Reasonable financial assistance provided to the member for a portion of their utilities or other costs directly related to the homes operation.
What is rent subsidy?
Financial assistance provided to a member for a portion of their rent or specific operating expenses of the home, above what the member’s disability or other income already covers.
When is rent subsidy required?
Rent subsidy is required with Family Living Low, Family Living Moderate, and Supervised Living service requests. 
When should the psychiatric or psychological evaluation be completed for Level III?
These evaluations should be completed between 120 and 180 days in service and it should be an independent psychiatric/psychological evaluation. The assessment should be completed by a psychologist. Please note this is a state requirement. The intent of the evaluation is to inform treatment planning and to ensure appropriate linkage and level of care.
 

Substance Use Disorder (SUD)

Are there members with priority admission?
We require priority admission to all women who are pregnant and injecting drugs, women who are pregnant and using substances, and for other individuals who are injecting drugs.
Can we use the pass through for SAIOP (or SACOT) twice in the same year? For example, the member uses 5 days of the pass through, then leaves treatment. When he returns 3 months later in the same calendar year, can the pass through be used again?
SAIOP: The initial 30 calendar days of treatment do not require a prior authorization. Services provided after this initial 30-day “pass-through” period require authorization from the Medicaid or NCHC approved vendor. This pass-through is available only once per treatment episode and only once per state fiscal year.

SACOT: The initial 60 calendar days of treatment do not require a prior authorization. Services provided after this initial 60-day “pass-through” period require authorization from the Medicaid or NCHC approved vendor. This pass-through is available only once per treatment episode and only once per state fiscal year.
 
Could a conversation be held about increasing unmanaged visits based on diagnosis code? Our substance use disorder members are using all of their unmanaged visits due to strict program requirements.

Depending on the catchment or region served, there is a potential to request authorization for continued services through the end of the fiscal year (June 30). This means that the responsibility will be on the provider to track the unmanaged sessions and submit for authorization upon five remaining sessions. For additional guidance on outpatient therapy, see the outpatient therapy tips posted to the Cardinal Innovations website, under provider resources.

How should SAIOP be written on the PCP?
According to the service definition for SAIOP, SAIOP is offered “at least 3 hours a day, at least 3 days a week”. The initial 30 calendar days of treatment do not require a prior authorization, reauthorization shall not exceed 60 calendar days, and under exceptional circumstances, one additional reauthorization up to 2 weeks can be approved. To make this simpler, UM asks that you write this on the PCP: SAIOP, 3 hours a day, at least 3 days a week, for up to 14 weeks.
 
What are the authorization guidelines for Substance Use Disorder (SUD) services? First, how are the guidelines different from urgent versus routine referrals? Second, what is the timetable for approvals on authorizations for enhanced services?

Authorization guidelines are located on the Cardinal Innovations website and these guidelines vary depending on the service. There are two types of reviews in Utilization Management: expedited and routine. Expedited TARs are required to include information to support the health and safety concerns. Expedited requests that justify health and safety concerns will be processed within 72 hours. Routine requests are required to be processed within 14 days unless additional information is necessary and an extension is requested. We are working to increase efficiencies related to our SUD residential services due to the time in care.

What are the guidelines for a client receiving SUD services to be seen by a mental health (MH) professional for a psychiatric evaluation?

For members who request SUD services, but who also present with mental health symptoms/needs, Cardinal Innovations may request these members be seen by a psychiatrist for evaluation. This is to ensure that comprehensive treatment is provided to our members and meets all of their needs. Cardinal Innovations expects providers to appropriately refer for services to support the needs of members. If a provider does not have a specific service in their service array, but the member needs to be referred, the expectation is that the provider will ensure that a referral to the appropriate level of care is completed.

What are the guidelines for a client receiving SUD services to be seen by a mental health professional for a psychiatric evaluation?

For members in SUD services, who also present with mental health symptoms/needs, the best practice is to ensure full assessment and treatment for both conditions. This may be done through a psychiatric assessment and/or coordination with other mental health professionals.

Providers are responsible for coordination of care with mental health and primary care physicians as needed to ensure comprehensive treatment for the member.

What is the rationale for the changes made for Substance Abuse Intensive Outpatient Program (SAIOP) authorization changes?

There have been no changes to our SAIOP authorization guidelines. Our UM department follows the service definition guidelines for this service, allowing a 30-day pass through for 12 weeks of service with a possible additional two weeks if clinically indicated.

Traumatic Brain Injury (TBI)

Are TBI screens required for all new intakes now because Cardinal Innovations did not follow through with the TBI training?

Yes, the TBI trainings are posted online for providers to review on Cardinal Innovations’ website under Provider/Training at: http://view.vzaar.com/8854175/video.

Can you please provide some clarification on TBI screens? How will data be collected? What is our obligation as providers if we determine further care is needed?

TBI data will be submitted to Cardinal Innovations by accesses and completing the form on our website (under Provider Resources/Forms). UM will collect the data and report quarterly to the N.C. Department of Health and Human Services (DHHS). If a provider determines that additional treatment is necessary they should make referrals as appropriate.

For individuals who have care coordinators, will the care coordinator do the TBI screening?

The assessing and/or treating provider completes the TBI screening.

If someone has Innovations, is the TBI screening needed?

Yes, the TBI screening is for all new and existing members.

My understanding from the TBI training was that the TBI screening is only required for agencies completing a CCA. Can you clarify?

The TBI screening is for any provider who treats a member with TBI. The form is assessable on our external website under Provider Resources in the “Provider Resource Forms” section.

What is the Traumatic Brain Injury screening project and what is the assessment? How do providers make a referral for testing once a suspected (TBI) is confirmed through assessment?

The (TBI) screening, which is the Ohio State Traumatic Brian Injury Identification Method, is a tool that the state requested to identify TBI needs statewide.

A “Complete TBI Screening Form” should be completed with all comprehensive clinical assessments.
Any member who identifies a past head injury or brain injury being served by a provider should also be screened to capture this information.

Data from the assessments will be collected and sent to the state in order to identify need.

If a member needs additional testing after a provider completes the screening, assistance can be provided to identify resources for additional testing. Contact the Registry Team for a list of providers that can assist. They can be reached by email at registry@cardinalinnovations.org or through the main number 1-704-939-7980.

Where are the screening centers for the Traumatic Brain Injury (TBI) screening pilot project? Where is the data from these centers? How do providers make a referral for testing once a suspected TBI is confirmed through assessment?

The TBI screening, which is the Ohio State Traumatic Brian Injury Identification Method is a three to five minute assessment that can done at any provider agency. This should be completed on any member who identifies a past head injury or brain injury during enrollment. The data from the assessments will be collected and sent to the NC Legislature to determine if additional programs/funding is needed for TBI treatment. If a member needs additional testing after a provider completes the screening, Cardinal Innovations’ Access Center or registry team can assist with resources for testing. Additional information, the form and training for the TBI screening can found on Cardinal’s website under the resource library.

Why are providers required to do the TBI screening when Cardinal Innovations staff are not?

The TBI screening is intended to be assessed during a Comprehensive Clinical Assessment (CCA), update to a CCA, or when any new findings present themselves in current treatment with a member.

Utilization Review

Are there specific tools that are used in Routine Reviews and in Focused Utilization Reviews?

Yes. Each service we choose to review has a tool developed by the clinical team in conjunction with the data science team to ensure it is a fair measure. These tools contain information directly from the service definition, the state manuals, and clinical standards of care (clinical guidelines, evidenced based practice, discharge planning, coordination with other providers/primary care etc.)

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