Due to the cancelation of the contract for the Comprehensive Independent Assessment Entity (CIAE), NC Medicaid implemented a temporary interim workaround project on Oct. 19, 2020, to manage requests to receive Community Alternatives Program (CAP) services from interested applicants. Two distinct functions outlined in the scope of the canceled contract will be carried out by NC Medicaid until a new CIAE vendor is awarded. These two functions are completing the service request form that determines the level of care (LOC) and reviewing the initial assessments to decide enrollment in the CAP waiver.
At the launch of this project, stakeholders were informed that from October 2020 - March 2021, NC Medicaid would be flexible in processing referral requests and not strictly apply the timelines for the receiving, processing and closing out referral requests to ensure full understanding of the new referral process. Beginning April 1, 2021, NC Medicaid will begin strictly applying its timeline business rules, described in the chart below, in the processing, reviewing and closing out referral requests.
To ensure all CAP stakeholders are notified of the timeline enforcement that begins April 1, 2021, referral requests missing the consent form or Physician LOC worksheet, a notice will be generated to inform the applicant of the status of the referral. Notices were mailed on March 8, 2021. If no response is received by April 2, 2021, action will be taken on April 5, 2021 to close the referral. The applicant is encouraged to follow the instructions in the notice.
Important things to consider when completing a referral
- Collect as much information as possible from the applicant to provide future assistance in obtaining CAP services, including:
- No informal support system available
- Non-English speaker
- Needs assistance with reading
- Check in with the applicant after five (5) business days to see if the consent packet was received and offer support.
- Closely monitor the e-CAP referral tracker and reach out when an applicant appears non-responsive in returning the required forms.
- Inform all applicants of the timeline from the date a referral is made to the date that a decision can be reached. The total timeline can take up to 105 days once all required documents are received. The timeline includes:
- 45 calendar days to complete the service request
- 30 calendar days for an initial assessment to be completed
- 30 calendar days for the assessment to be reviewed to determine the final decision.
Important timelines that will be enforced during this interim project
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Business Workflow |
Timeline |
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Processing a referral – The prompting of a disclosure packet that includes the consent, the physician’s LOC recommendation and the selection of a case management entity |
3 business days from the date the referral was received in CAP business systems |
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Tracking the receipt of required documents included in the disclosure notice – The uploading of a signed/dated consent form, a completed physician’s LOC worksheet to the applicant’s file to begin the processing of the service request to determine the LOC. |
7 business days from the date the disclosure packet is received by the applicant |
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Voiding out a referral – The closeout of a referral due to the non-receipt of the consent form and the Physician’s LOC worksheet after the mailing of a notice. |
15 calendar days from the date of the non-receipt notice letter |
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Completing the Service Request – The LOC's determination from the review and analysis of data from the Physician’s LOC worksheet paid claims and other supporting documentation based on the CAP clinical coverage policies (3K-1 and 3K-2), outlined in Section 3.0. This process also includes requesting additional information and the closeout of the workflow for requests that cannot be processed because of missing information. |
45 calendar days from the date the consent form or the Physician’s LOC worksheet is received. |
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Issuing a technical denial for a service request that can’t be processed – The closeout of a service request due to missing information. |
On or after the 46th calendar day from the receipt of the consent form or the physician LOC worksheet |
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Reviewing initial assessments - The conducting of a reasonable indication of need review to determine risk, determinants of health, impact on the l family and the need for at least one waiver service. This process may include the request for additional information. The review process includes a multidisciplinary engagement to confirm findings in the assessment to complete a review summary and close out. |
30 calendar days from the date the case is assigned to assessment/assignment in the CAP business system |
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Reviewing and Approving CAP/C Service Plans – The review of the service plan to ensure services in the POC align with the needs of the waiver participant based on assessed risk, determinants of health, and stress on the family. |
30 calendar days from the date of the received service plan. |