Smoky Mountain LME/MCO | For Immediate Help Call 1-800-849-6127
For Customer Services, Call 1-888-757-5726                    For TTY Calls, contact Relay NC at 711
    Welcome to Smoky Mountain LME/MCO SMC TTY InformationSMC Calendar of EventsNews and AnnouncementsEmployment OpportunitiesContact UsHelp
2015 Smoky Mountain LME/MCO Health Plan Consumer & Family Handbook
Consumers and FamiliesService ProvidersCommunity PartnersFind a ProviderAbout Us
providers
SMC Zixmail (Secure Email)
Provider Network Enrollment
Provider Credentialing
Provider Monitoring
SM LME/MCO Provider Advisory Council
Authorization Info
Claims / Eligibility and Enrollment
Communications Bulletins
Request for Proposal
Forms and Other Documents
Provider Events Calendar
Provider Training Calendar
AlphaMCS Provider Portal
AlphaMCS Training
Traumatic Brain Injury Info
Geriatric and Adult Mental Health Specialty Team
Smoky Mountain Care Coordination Department
NC-TOPPS
Intellectual and Developmental Disability Services
Community Care of NC (CCNC) Initiative
Housing Information
Supported Employment
System of Care
Our Regional Offices
Smoky Mountain Technical Help
Smoky Mountain Clinical Plan - UPDATED 2-24-2015
Smoky Mountain Clinical Practice Guidelines
-------------------
Western Regional Partnership
SMC Key Management Contacts
2014-2015 Smoky Provider Directory (UPDATED 12/23/2014)
Transition to Community Living (DOJ Settlement)
Mission / Vision / Values
Smoky Mountain LME/MCO Procurement (RFPs and Bids)
Announcements
SMC New You Can Use Newsletter
Organizational Plans
Helpful Links
SMC Commonly Used Acronyms
SMC Frequently Asked Questions
Directions to Regional Offices

Consumers’ privacy rights are addressed in Smoky Mountain LME/MCO’s Notice of Privacy Practices.
Authorization Info
Contacts

  • Toni Shelow, Psy.D., Senior Director Clinical Operations - 828-586-5501 ext. 1223
  • Judith Collins, LPA, Care Management Director - 828-586-5501 ext. 1260
  • Rachael Smith, MS, LPC, I/DD Care Management Manager - 828-586-5501 x1139
  • Laura Woodrup, MS, LMFT, MH/SA Adult Team, Care Management Manager - 828-586-5501 ext. 5152
  • Catherine Harlan, LPC, LCAS-A, MH/SA Child Team, Care Management Manager - 828-586-5501 ext. 1165
To speak to any available Care Manager please call 1-866-990-9712 and select Menu Option 5 when connected.

December 2014 - Care Management Alerts Newsletter
Based on the feedback from you - the providers - Smoky Mountain LME/MCO is pleased to present "Care Management Alerts". Providers like you picked the name and gave feedback. The purpose of these alerts is to keep you updated regarding changes in authorization and education on how to request service authorization. This newsletter is sent out monthly in the Provider Communication emails.

Click here to view previous issues of the Care Management Alerts Newsletter

Index
Please click the arrow next to each section to expand it.

Clinical Coverage Policies and Service Definitions

Enhanced MH/SA Services Inpatient Behavioral Health Services Outpatient Behavioral Health Services PRTF for Children Under 21 Residential Treatment Services Intermediate Care Facility/IDD Psychological Services in Health Dept./School MH/DD/SAS Service Definitions Manual - 1/15/03 State Funded MH/SA Enhanced Services State Funded Supported Employment Safety Supervision Medicaid B3 Services NC Innovations - Clinical Coverage Policy 8P Developmental Therapy Service Definition 2006

Smoky Mountain Benefit Plans

Level of Care Tools

Child Mental Health - CALOCUS Scoresheet

Adult Mental Health - LOCUS Scoresheet

Child/Adolescent Substance Use - ASAM Worksheet for Adolescents

Adult Substance Use - ASAM Worksheet for Adults

Service Plan Manuals

Smoky Mountain Review Tools and Information

Intellectual/Developmental Disabilities Child and Adolescent Services Adult Services MH/SA Residential Hospital Medical/Clinical Necessity Criteria SMC Level of Care Review Information for Providers

Special Processes Documents

Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

State Funded Residential Referral Profile Form

Smoky Mountain LME/MCO Postion Statement For Youth Who Have Engaged In Sexually Abusive Behavior

TRACK (Therapeutic Respite Addressing Crisis for Kids) for Children with I/DD

Assertive Community Treatment Team (ACTT)

Substance Abuse Intensive Outpatient Program (SAIOP) and 30-day pass-through

Authorization Request Information

Smoky Mountain Service Authorization Request Form
Please use the links below to download a copy of the Service Authorization Request form in Microsoft Word format. Please only use this form if you are having difficulty with our electronic Managed Care System, AlphaMCS.

This document will need to be filled out, printed and faxed into our Care Management department for entry into our electronic Managed Care System.

Peer Review, Denial and Appeal Information

New Peer Review, Denial and Appeal Information documents coming soon!

Inpatient and FBC Enrollment, Admission and Continued Stay Procedures

Hospital Processes

Smoky Mountain LME/MCO Referral and Authorization Procedures

Inpatient Services:
  1. ALL Notifications of Inpatient admissions must be made to Smoky Mountain ASAP following admission and no later than 12:00 noon the first business day after admission.
  2. Notification, via the Regional Assessment and Referral Form (RARF), or equivalent clinical information, is faxed to Smoky Mountain secure Hospital Fax line: 877-260-6517.
  3. Smoky Mountain UM staff will receive the notification of admission and will enter the SAR and enter an authorization for pass-through days that will avoid weekend and holiday review
  4. Hospital providers do not need to call Access; their respective authorizations will be in AlphaMCS and provider can view the effective and end dates in AlphaMCS

Smoky Mountain Inpatient Concurrent Review Form for DSM-V

3-Way Contracts:
  1. Notification of admission and pass-through process is defined above
  2. For 3-Way Contracted Beds, hospitals are restricted to their contracted number of beds at any time. Hospitals are responsible for monitoring this limit and must know that Smoky Mountain cannot authorize 3-Way Contracted patients beyond that limit. (Cannon and Haywood Hospitals have a different arrangement involving other state funds-please confirm those arrangements with your Smoky Mountain Contract Manager.)
  3. Concurrent authorization requests must be made by submission of a complete and current Smoky Mountain Inpatient Concurrent Review Form faxed no later than 12:00 noon of the last covered day to 877-260-6517.

Facility Based Crisis Units (Synergy, Balsam Center, Neil Dobbins, Daymark Recovery)
  1. ALL Notifications of FBC admissions must be made to Smoky Mountain as SOON as possible following admission and no later than 12:00 noon the first business day after admission.
  2. Following notification, UM staff will enter an authorization for a 7-day pass-through for service unless the last covered day ends on a weekend or holiday, in which case Smoky Mountain will authorize until the next business day.
  3. For requested continued stay beyond 7 days, the Smoky Mountain Inpatient Concurrent Review Form is required to be faxed to Smoky Mountain by 12:00 noon of the last covered day at 877-260-6517.

Alcohol and Drug Abuse Treatment Center (ADATC) Detox:
These ADATC Detox Referral Processes are effective 3/1/2015
  1. Referrals to ADATC Detox service begin with the referring provider contacting ADATC (828-257-6400) to conduct a telephonic review. If ADATC accepts the referral for admission, ADATC staff will give a verbal approval to the referring provider and will provide the name of the ADATC attending physician.
  2. Upon ADATC acceptance of the consumer, the referring provider faxes their Regional Assessment and Referral Form (RARF) and the ADATC attending physician's name to Smoky Mountain LME/MCO Customer Services at 1-877-917-9887. If the referring provider does not do a RARF, they will complete the 3 page state Regional Referral Form (RRF), and fax to Smoky Mountain LME/MCO Customer Services at 1-877-917-9887.
  3. The referring provider then contacts Smoky Customer Services at 1-800-849-6127 to notify them that the RARF or RRF and referral information have been faxed.
  4. Smoky Customer Services staff will complete an enrollment for the individual if needed, generate an ADATC referral number and fax the RARF or RRF and referral information to ADATC, signifying LME approval of the referral.
  5. Upon receiving ADATC's confirmation, Smoky Customer Services staff will contact the referring provider to inform that the authorization has been faxed to and received by the ADATC.
  6. Referring provider or hospital should follow up with ADATC regarding readiness for transport.

    The Regional Referral Form

Alcohol and Drug Abuse Treatment Center (ADATC) Rehab:
  1. For ADATC Rehab admissions, the referring provider faxes the State Referral Form with all required documentation to Smoky Mountain at 877-651-9968.
  2. Smoky Mountain will notify the referring facility of available Rehab admission date. If the consumer has been discharged from a referring inpatient facility, Smoky Mountain will contact consumer directly and not the referring provider.
  3. Concurrent review is required for ADATC Rehab stays longer than 14 days; the ADATC will fax the continued stay- state Form 59912 to Smoky Mountain at 828-452-3473.
  4. A Smoky Mountain Care Manager will review for medical necessity and with fax the continued stay state form to ADATC.

For Referrals to Broughton State Hospital (BSH):
These Broughton State Hospital Referral Processes are effective 3/1/2015
  1. The referring provider faxes their RARF /clinical assessment and other clinical information directly to BSH for review at 828-433-2082.The referring provider completes the 3-page state Regional Referral Form (RRF) and faxes it together with the RARF (and/or Clinical documentation) to Smoky Mountain LME/MCO Customer Services at 1-877-917-9887.
  2. The referring provider then contacts Smoky Customer Services at 1-800-849-6127 to notify staff that the RRF and the RARF have been faxed requesting Broughton referral.
  3. Smoky Customer Services staff will complete an enrollment for the individual if needed.
  4. Smoky Customer Services staff will review the referral information and fax to BSH with the referral number and LME/MCO signature.
  5. Smoky Customer Services staff will inform referring provider when the referral has been faxed and received by BSH.
  6. The referring provider or hospital will then follow up directly with Broughton regarding referral status.
  7. For requests to transfer a patient from another Inpatient Psychiatric Unit to BSH, the facility should contact the Smoky Mountain Care Management Department during business hours at 866-990-9712, option 5 to discuss the requested transfer.

    The Regional Referral Form

For referrals to Broughton when there is a diagnosed or suspected diagnosis of Intellectual Disability (ID) and co-occuring mental illness:
The SB 859, also known as the Diversion Law, prohibits the admission of an individual with intellectual and developmental disabilities (I/DD), or a reasonable suspicion of such, and a co-occurring mental illness, to any of the North Carolina state psychiatric hospitals unless the individual meets specific criteria. See the Worksheet for Requesting Exceptions to the Diversion Law (SB859) for the 4 exceptions.

The individual must meet one of 4 eligibility requirements for the exception to be considered. Exception #3 is the most common- extreme dangerousness to others (suicidal and/or property destruction alone does not meet extreme dangerousness criteria). Additionally, The Exception Worksheet must be reviewed and signed by someone who is on the state approved list to grant exceptions. Smoky Customer Services has staff that is approved to grant the exceptions.
  1. If the individual appears to meet criteria for an exception to the diversion law, the referring provider faxes their RARF /clinical assessment and other clinical information directly to BSH for review at 828-433-2082. Then, the referring provider needs to complete the required 4 page state Worksheet for Requesting Exceptions to the Diversion Law (SB859) as well as the Regional Referral Form (RRF), following the steps on the worksheet and considerations below:
    1. A diversion hospital must be contacted for any IDD/MI consumer. These are listed on Diversion Exception Worksheet. You must have a total of 4 attempts/denials from private inpatient facilities, with priority for contact being the most appropriate hospital located closest to the consumer's home community.
    2. If the individual is an Adult (18 or over), NC START must be contacted. Document contact on the Diversion Exception Worksheet. Proceed with the Worksheet and RRF. You do not have to wait for NC Start to come and assess; it is just important to ensure that NC Start is aware of the consumer and can begin to work with consumer's team.
  2. The referring provider will fax both the RRF and the Worksheet for Requesting Exceptions to the Diversion Law to the Smoky Customer Services fax line - 1-877-917-9887 - and call Smoky Customer Services at 1-800-849-6127 to inform of your request for Broughton referral for an IDD/MI individual.
  3. Smoky Customer Services staff will complete an enrollment if needed.
  4. Smoky Customer Services staff will review the RRF and IDD Exception worksheet ensuring it is complete and that appropriate diversion options have been attempted. If approved, designated Customer Services staff will sign the Exception and fax both RRF and Worksheet for Requesting Exceptions to Diversion Law to Broughton, confirming receipt of the complete referral with Broughton.
  5. The Smoky Customer Services staff will inform referring provider that the RRF and IDD Exception Worksheet have been faxed to Broughton and received.
  6. The referring provider will follow-up with Broughton regarding referral status.
  7. For requests to transfer a patient from another Inpatient Psychiatric Unit to BSH, the facility should contact the Smoky Mountain Care Management Department during business hours at 866-990-9712, option 5 to discuss the requested transfer.

Psychological Testing

Psychological testing is the use of formal procedures employing reliable and valid instruments to measure intellectual, cognitive, emotional and behavioral functioning. Psychological testing may be used to identify psychopathology, personality style, interpersonal processes, and adaptive skills. Neuropsychological testing is a specialized area of psychological testing that can identify the presence of brain damage, injury or dysfunction and associated functional deficits. Both types of testing require the application of appropriate normative data for interpretation or classification. Testing may be used to guide differential diagnosis in the treatment of psychiatric disorders and disabilities or to provide an assessment of cognitive and intellectual abilities, personality and emotional characteristics and neuropsychological functioning.

Smoky Mountain LME/MCO recognizes the importance and value of psychological testing to address specific diagnostic questions necessary for an individual's treatment that cannot be answered through diagnostic interview and psychiatric evaluation. Before conducting psychological testing, it is important to obtain current clinical information through a Comprehensive Clinical Assessment and/or Psychiatric Evaluation. It is also important to inquire about other psychological testing that may have been conducted with the individual and to obtain copies of such evaluations before conducting psychological testing.

Smoky Mountain Psychological Testing - Guidelines - [Adobe PDF]
UPDATED: 10/21/2014

Smoky Mountain Psychological Testing - Request Form - [Word 2007 DOCX]
UPDATED: 3/26/2013

Smoky Mountain Psychological Testing - Q&A - [Adobe PDF]
UPDATED: 3/26/2013

Disclaimer:
The links in this document are provided as a convenience to readers of this webpage. Smoky Mountain LME/MCO is not responsible for their content. In addition, please note that information provided here is not a substitute for professional clinical advice.
URAC Accredited Health Call Center, Health Network, Health Utilization Management


Serving individuals with mental health, developmental disability and substance use issues in
Alexander, Alleghany, Ashe, Avery, Buncombe, Caldwell, Cherokee, Clay, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Polk, Rutherford, Swain, Transylvania, Watauga, Wilkes and Yancey counties
For Immediate Help, Call 1-800-849-6127                    For Customer Services, Call 1-888-757-5726                    For TTY Calls, contact Relay NC at 711
Compliance Hotline: 1-866-916-4255 Copyright © 2009 - 2015      Smoky Mountain LME/MCO      All Rights Reserved Privacy Policy