Information for Providers of Services
Effective July 1, 2014
Revised Process for ICF/MR LOC Utilization Review Requests
An ICF/MR LOC electronic form is located on onnnur website at www.sandhillscenter.org.
Every 180 days, following each facility’s typical Utilization review cycle, the facility is required to complete Level of Care Eligibility Determination tool for each resident.
The Sandhills Center ICF/MR LOC electronic form has to be completed in its entirety for Utilization Review(and Medical Evaluation form if applicable).The form may be signed by the facility’s physician at the time of the scheduled Utilization Review. The form is good for 30 days from the date the physician signs/dates the form and checks the member continues to meet ICF/MR LOC. The member’s utilization review reauthorization must start within 30 days of the date of the physician’s signature.
The provider must submit a Service Authorization Request(SAR) in the Alpha system for the utilization review period for each member. The provider must attach the LOC form(and medical evaluation if applicable) to the SAR in the Alpha system.
The CM/UM Care Manager will review the SAR and the information from the assessments and verifies that the documentation supports the eligibility criteria documented on the Sandhills Center ICF/MR Level of Care Eligibility Determination Tool.
If the documentation continues to support ICF/MR eligibility criteria, The CM/UM Care Manager will print the LOC from the SAR and sign it to approve continued ICF/MR reauthorization. The SAR will be approved in the Alpha system.
The CM/UM department will make a pink copy of the approved LOC and mail to the provider. The CM/UM department will also make a blue copy of the approved LOC and mail to DSS.
*When utilization review is completed by the provider, the ICF/MR Utilization Request Form(can be downloaded from our website) still has to be completed in its entirety and mailed asap to:
Sandhills Center, Attn: CM/UM Department , ,
,P.O. Box 9
,West End, NC 27376
Initial LOC Determinations:
Completed/updated IQ and adaptive skills evaluation(Intellectual Disabilities)
Completed/updated Medical assessment-if applicable(Medical conditions)
Completed MCO Level of Care Eligibility Determination Tool(LOC)
Completed ICF/MR Utilization Review Request form
*How current does the psychological evaluation need to be? For an initial request, 3 years for persons 18 and older or within one year for children less than 18.
All required documents are mailed to Sandhills Center MCO, Attn: CM/UM department
Upon receipt, the CM/UM Care Manager reviews the information from the assessment/evaluation and verifies that the documentation supports the eligibility criteria that are documented on the LOC. If eligibility is verified, the CM/UM Care Manager builds a Service Authorization Request(SAR) in Alpha for the ICF/MR residential service. A blue copy of the approval is mailed to DSS and a pink copy is mailed to the receiving facility.If the assessment/evaluations do not support that the person meets ICF/MR Level of Care criteria, Sandhills Center MCO Medical Director will review the information and make the final determination.
LOC Form Sandhills Center
Important Diagnostic Data Entry Reminders
July 9, 2014
Sandhills Center Provider:
Below are a few AlphaMCS reminders related to Diagnosis entry and the upcoming DSM 5 implementation.
When identifying a diagnosis during Client Enrollment or Update, please make sure that the diagnosis code you select matches the verbiage for the Diagnosis the Client will be treated for, and is a complete code. For example Diagnostic code 296.90, could mean “Unspecified Affective Psychosis” – or – “Mood Disorder NOS”. If you are not clear which diagnosis you select and enter an alternate description than what has been selected in the AlphaMCS system as part of the SAR there could be a discrepancy during the Utilization Management review and cause a delay.
When performing a Client Update, after you as the provider have confirmed that the member is enrolled, make sure to view the diagnosis(es) that are currently in the AlphaMCS system for that member. If any of the diagnosis(es) that you will be treating the member for are not in the system, be sure to add them using the Client Update feature.
Please remember to select an AXIS and a Class for your diagnoses. If your diagnosis is the initial diagnosis also please remember that the Principal and Primary Diagnosis (B diagnosis) is the reason for admission and will remain the member’s principal and primary diagnosis for the entire admission.
As previously announced by DHHS (Communication Bulletin #142), the number of Benefit Plans is being reduced from 35 to 10 effective August 1, 2014. If a member you are serving is in a Benefit Plan to be discountinued, use the Benefit Plan Crosswalk provided by DHHS to identify the member’s new Benefit Plan. The member’s new Benefit Plan information should then be submitted using the Client Update feature within AlphaMCS.
As a reminder, DSM 5 codes will be required for all dates of service beginning August 1, 2014. Please make sure to begin using complete DSM 5 codes when requesting SAR’s and submitting your billing.
Please contact Carol Brown, ME&E Lead Intake Specialist at 910-673-7325 with questions.
DSM-5 Update from Sandhills Center
May 15, 2014
The Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was released in May 2013. DHHS will implement DSM-5 coding requirements effective August 1, 2014. The DSM-5 codes will be required for all dates of service beginning August 1, 2014.
The DSM-5 changes will be in place in the AlphaMCS system for August 1, 2014. All NON-Complete codes in ICD9 will be end dated and only Complete Codes will be available. Continue submitting SARs and Claims using Complete ICD9 codes as ICD10 has been extended until October 2015.
Sandhills Center recommends that providers begin preparing for this change by submitting Client Update Requests for members whose Diagnosis Code is not a Complete Code, begin using Complete Codes when requesting SAR’s and/or begin billing using Complete Codes. If you bill using a Complete Diagnosis Code, the Diagnosis Code will be added to the members file and the claim should pay, assuming it meets all other criteria for payment.
Additionally, the ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, Third Edition was published at the end of 2013 and goes into effect on August 1, 2014.
Sandhills Center will not be offering additional provider training on DSM-5. Please see our website for more information related to DSM-5 http://www.sandhillscenter.org/ click on For Providers and scroll towards the bottom. There are many links for online training and other helpful information.
For questions, please contact the Sandhills Center Provider Help Desk at 1-855-777-4652 or via Email: ProviderHelpDesk@sandhillscenter.org .
Sandhills Center is approaching our fiscal year end for 2013-2014. Providers who bill for State services, please make sure all of your services are being billed weekly.
Alpha is available once again. Sandhills cut off is still extended through 4/30/2014 at 5:00 pm.
Sandhills Center is committed to insuring the provision of quality services and supports to consumers with mental health, developmental disabilities, and substance abuse needs. Inherent to this, is consumer choice and a community of providers that are responsive to consumer needs and preferences.
Sandhills Center Network Operations will provide information in a timely manner to ensure that providers have access to all state and federal regulations, Division guidelines, and training opportunities for the continued development and maintenance of quality and efficient services for our consumers.
Unmanaged Outpatient Sessions
Victoria Whitt, CEO
March 11, 2014
Effective March 31, 2014, Sandhills Center is increasing the number of Medicaid and IPRS unmanaged visits for outpatient therapy to 24 units for both adults and children. This is an increase from the current unmanaged visit maximum of 8 sessions for adults and 16 sessions for children. Any outpatient services beyond those initial 24 units will require prior approval.
Additionally, with the transition to Alpha MCS, from the current NetSmart package, it will no longer be necessary for Sandhills Center’s Member Eligibility and Enrollment staff to link IPRS members to providers in Provider Connect. Providers will have the ability to enroll members directly. Therefore, effective March 31, 2014, ME&E staff will no longer issue IPRS service registrations in Provider Connect for initial and/or crisis services. Since providers will have the ability to enroll IPRS members directly, just as with Medicaid, initial authorizations for IPRS services will be requested through the Alpha Provider Portal just as with Medicaid services.
March 31, 2014
Sandhills Center has transitioned to our new software
AlphaMCS Provider Portal.
The DSM-5 (Diagostic and Statistical Manual of Mental Disorders) is the 2013 update to the American Psychiatric Association's classification and diagnostic tool.
"From DSM-IV-TR to DSM-5 What Specifically is Changing?"
Upcoming DSM-5 trainings:
Presentation about the DSM-5:
DSM-5 update part 1:
DSM-5 update part 2:
DSM-5 update part 3:
The ASAM Criteria: Treatment Criteria for Addictive, Substance –Related, and Co-Occurring Conditions, Third Edition was published in October 2013. According to the American Society of Addiction Medicine, the new manual is a user-friendly guide to understanding the core principles, processes and procedures in the ASAM criteria. This new manual is also compatible with the DSM-5. All clinical policies, rules, protocols, etc. are updated in this new manual.
The implementation date for The ASAM Criteria Third Edition will be August 1, 2014. The use of ASAM is required for both the Division of Mental Health Developmental Disabilities and Substance Abuse Services and the Division of Medical Assistance in the determination of levels of care for substance abuse services.
The deadline to comply with ICD-10 has been extended to October 1, 2015.
All Providers are accepting new members
Letters from Victoria Whitt
Important announcement from Anthony Ward,
NOTICE EFFECTIVE DECEMBER 1, 2012: As a 1915 (b)/(c) Medicaid waiver site Sandhills Center is no longer offering contracts to all interested providers for the current 8 county area. Sandhills Center will enroll providers based on the needs of the local recipients and on provider network performance. Sandhills Center is an operational waiver site as of December 1, 2012 and held its open enrollment period during the months preceding implementation of the Medicaid waiver.
NOTICE EFFECTIVE APRIL 1, 2013:
As Guilford County moved under the 1915 (b)/(c) Medicaid waiver on April
Help Desk Questions & Answers (12/01/13 -
PowerPoints from Provider Orientation
The PowerPoints below were used during the March 14, 2013, and March 26, 2013, Sandhills Center Provider Orientation.
DELAY NOTICE: RAs for this week's check write (July 29, 2014) will be delayed by one business day.
NEW NC TOPPS 2014-15 User Guide and Tools #143 http://www.ncdhhs.gov/mhddsas/communicationbulletins/index.htm
NEW IMPORTANT: CHECK-WRITE EXTENSION FOR 4/1/14 CUTOFF SANDHILLS CENTER WILL BE EXTENDING THE CUTOFF OF 4/1/14 TO 4/3/14 TO ASSIST PROVIDERS IN GETTING THEIR BILLING IN FOR CHECK-WRITE DATE OF4/8/2014. ANY QUESTIONS, PLEASE E-MAIL email@example.com or contact your assigned Claims Specialist.
NEW Notice to Providers – Consumer Admission Forms (Originally posted 01/13/2014)
NEW Notice to Providers – Timely Filing of Claims (Originally posted 01/13/2014)
Top Provider Errors Preventing Data Entry of the Consumer Admission Form (Originally posted 09/24/2013)
ATTENTION PROVIDERS WHO SUBMIT ELECTRONIC CLAIMS:
Please note that effective August 23, 2013 processed
837 files will be deleted from Sharefile. Sandhills Center will no longer
maintain process 837 files within Sharefile.
Notice to Providers – Discharge Summaries (Originally posted 09/03/2013)
Notice to Providers – Online Mistakes (Originally posted 07/29/2013)
Vacancy Announcement for Network Leadership Committee (Originally posted 07/29/2013)
May 2013 Provider Meeting Questions and Answers (Originally posted 07/10/2013)
ATTENTION: Due to the length of the VO authorizations, billing instructions for Foster Care and Provisional/Associates has been modified: If you have Value Option authorizations that extend past the 4/01/13 Guilford Medicaid Waiver start date, you will need to continue to use the Guilford information as the billing provider until your VO authorization expires. Once you request a TAR in Provider Connect you will need to start using Sandhills information as the billing provider. (Originally posted 06/11/2013)
LME/MCO Provider Billing (Originally posted 06/11/2013)
ATTENTION MEDICAID PROVIDERS: Due to a system issue, Payment scheduled on 5/15/2013 has been rescheduled for 5/16/2013. A notice will be sent to you as soon as payment is completed. - Remittance Advice information will be available to you after payment is completed. (Originally Posted 05/07/2013)
ATTENTION: Unmanaged Visits are now available for IPRS members (Originally Posted 05/07/2013)
DMH/DD/SAS announcements (Originally posted 04/26/2013)
Questions about NCTracks (Originally posted 04/26/2013)
April 2013 Medicaid Bulletin (Originally posted 04/22/2013)
April 2013 Medicaid Special Bulletin (Originally posted 04/22/2013)
DMH/DD/SAS announcements (Originally posted 04/22/2013)
DMH/DD/SAS announcements (Originally posted 04/12/2013)
ATTENTION: An Important Announcement to All Sandhills Center Guilford County Providers (Originally posted 03/05/2013)
New Announcements from DMH/DD/SAS... (04/03/2013)
The 1915 b/c Medicaid
A Local Management Entity - Managed Care Organization
Victoria Whitt- Chief Executive Officer
Sandhills Center Resources
Quarterly Provider Meetings