APPENDIX E: PROGRAM DESCRIPTIONS:

APPENDIX E: PROGRAM DESCRIPTIONS:

Medicaid Billable Services

Clinical Service Definitions and Required Components

Diagnostic Assessment (MH/DD/SA)

A Diagnostic Assessment is an intensive clinical and functional face to face evaluation of a recipient’s mental 

health, developmental disability, or substance abuse condition that results in the issuance of a Diagnostic 

Assessment report with a recommendation regarding whether the recipient meets target population criteria, and 

includes an order for Enhanced Benefit services that provides the basis for the development of an initial Person 

Centered Plan. For substance abuse-focused Diagnostic/Assessment, the designated Diagnostic Tool specified 

by DMH (e.g., SUDDS IV, ASI, SASSI) for specific substance abuse target populations (i.e., Work First, DWI, etc.) 

must be used. In addition, any elements included in this service definition that are not covered by the tool must 

be completed.

The Diagnostic Assessment must include the following elements: 

A. a chronological general health and behavioral health history (includes both mental health and

substance abuse) of the recipient’s symptoms, treatment, treatment response and attitudes about 

treatment over time, emphasizing factors that have contributed to or inhibited previous recovery 

efforts;

B. biological, psychological, familial, social, developmental and environmental dimensions and identified 

strengths and weaknesses in each area;

C. a description of the presenting problems, including source of distress, precipitating events, 

associated problems or symptoms, recent progressions; and current medications

D. a strengths/problem summary which addresses risk of harm, functional status, co-morbidity, recovery 

environment, and treatment and recovery history;

E. diagnoses on all five axes of DSM-IV; 

F. evidence of an interdisciplinary team progress note that documents the team’s review and discussion

of the assessment; 

G. a recommendation regarding target population eligibility; and 

H. evidence of recipient participation including families, or when applicable, guardians or other

caregivers

This assessment will be signed and dated by the MD, DO, PA, NP, licensed psychologist and will serve as the 

initial order for services included in the PCP. Upon completion, the PCP will be sent to the LME or the state’s 

designated vendor for administrative review and authorization of services under the purview of the LME.

For additional services added after the development of the initial PCP, the order requirement for each service is 

included in the service definition.

Provider Requirements

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Diagnostic/Assessments must be conducted by practitioners employed by a mental health/substance 

abuse/developmental disability provider meet the provider qualification policies, procedures, and standards 

established by DMH and the requirements of 10A NCAC 27G. These policies and procedures set forth the 

administrative, financial, clinical, quality improvement, and information services infrastructure necessary to 

provide services. Provider organizations must demonstrate that they meet these standards by being endorsed by 

the LME. Within three years of enrollment as a provider, the organization must have achieved national 

accreditation. The organization must be established as a legally recognized entity in the United States and 

qualified/registered to do business as a corporate entity in the State of North Carolina.

Staffing Requirements

The Diagnostic/Assessment team must include at least two QPs, according to 10A NCAC 27G .0104, both of 

whom are licensed or certified clinicians; one of the team members must be a qualified practitioner whose 

professional licensure or certification authorizes the practitioner to diagnose mental illnesses and/or addictive 

disorders. One of which must be a MD, DO, nurse practitioner, physician assistant, or licensed psychologist. For 

substance abuse-focused Diagnostic/Assessment, the team must include a SIC or LCAS. For developmental 

disabilities, the team must include a Master’s level qualified professional with at least two years experience with 

the developmentally disabled.

Service Type/Setting

Diagnostic/Assessment is a direct periodic service that can be provided in any location.*

*Note: For Medicaid recipients this service cannot be provided in an Institute for Mental Disease or IMD (for 

adults) or in a public institution, (jail, detention center,)

Program Requirements

An initial Diagnostic/Assessment shall be performed by a Diagnostic/Assessment team for each recipient being 

considered for receipt of services in the mental health, developmental disabilities, and/or substance abuse 

Enhanced Benefit package.

Utilization Management

A recipient may receive one Diagnostic/Assessment per year. An assessment equals one event. For individuals 

eligible for Enhanced Benefit services, referral by the LME for Diagnostic/Assessment is required. Additional 

events require prior authorization from the statewide vendor or LME.

If it is Medicaid-covered service, utilization management will be done by the state vendor or the DHHS- approved 

LME contracted with the Medicaid agency. If it is a non-covered Medicaid service or non- Medicaid client, then 

the utilization review will be done by the LME.

Entrance Criteria

The recipient is eligible for this service when 

A. there is a known or suspected mental health, substance abuse diagnosis, or developmental 

disability diagnosis

OR

B. initial screening/triage information indicates a need for additional mental health/substance 

abuse/developmental disabilities treatment/supports.

Continued Stay Criteria

Not applicable.

Discharge Criteria

Not applicable.

Note: Any denial, reduction, suspension, or termination of service requires notification to the recipient and/or 

legal guardian about their appeal rights.

Expected Outcomes

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A Diagnostic/Assessment determines whether the recipient is appropriate for and can benefit from mental health, 

developmental disabilities, and/or substance abuse services based on the recipient’s diagnosis, presenting 

problems, and treatment/recovery goals. It also evaluates the recipient’s level of readiness and motivation to 

engage in treatment. Results from a Diagnostic/Assessment include an interpretation of the assessment 

information, appropriate case formulation and an order for immediate needs and the development of Person 

Centered Plan. For substance abusers, a Diagnostic/Assessment recommends a level of placement using N.C. 

Modified A/ASAM criteria. This assessment will include signing the order for the initial PCP. That order will 

constitute the order for the services in the PCP.

Documentation Requirements

The Diagnostic/Assessment must include the following elements: 

A. a chronological general health and behavioral health history (includes both mental health and

substance abuse) of the recipient’s symptoms, treatment, treatment response and attitudes about 

treatment over time, emphasizing factors that have contributed to or inhibited previous recovery 

efforts;

B. biological, psychological, familial, social, developmental and environmental dimensions and identified 

strengths and weaknesses in each area;

C. a description of the presenting problems, including source of distress, precipitating events, 

associated problems or symptoms, recent progressions; and current medications

D. a strengths/problem summary which addresses risk of harm, functional status, co-morbidity, recovery 

environment, and treatment and recovery history;

E. diagnoses on all five axes of DSM-IV; 

F. evidence of an interdisciplinary team progress note that documents the team’s review and discussion

of the assessment; 

G. a recommendation regarding target population eligibility; and 

H. evidence of recipient participation including families, or when applicable, guardians or other

caregivers

Service Exclusions/Limitations

A recipient may receive one Diagnostic/Assessment per year. Any additional Diagnostic/Assessment within a 1-

year period must be authorized by the DHHS-approved LME or the statewide vendor prior to the delivery of the 

service. Diagnostic/Assessment shall not be billed on the same day as Assertive Community Treatment, Intensive 

In-Home, Multi-systemic Therapy or Community Support Team. If psychological testing or specialized 

assessments are indicated, they are billed separately using appropriate CPT codes for psychological, 

developmental, or neuropsychological testing.

Note: For recipients under the age of 21, additional products, services, or procedures may be requested even if 

they do not appear in the N.C. State Plan or when coverage is limited to those over 21 years of age. Service 

limitations on scope, amount, or frequency described in the coverage policy may not apply if the product, service, 

or procedure is medically necessary