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NC Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse Services
 
 

Glossary

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

 
Acronyms

ACCESS

The ability to get array of available treatments, services and supports needed.

ACTION

The denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of previously authorized service; the denial, in whole or in part, of payment for service; the failure to provide services in a timely manner, as defined by the State; the failure of the LME to act within the timeframes provided in 42 C.F.R. 438.408(b).

ACCREDITATION

Certification by an external entity that an organization has met a set of standards.

ALCOHOL AND DRUG EDUCATION TRAFFIC SCHOOL [ADETS]

An approved curriculum which shall:
1.    Include 10 to 13 contact hours in a classroom setting;
2.    Be provided by area programs or their designated agencies with certified ADETS instructors; and
3.    Be designed for persons:

a.   who have only one DWI conviction [lifetime];
b.   whose assessment did not identify a "Substance Abuse Handicap;" and    
c.   whose alcohol concentration was .14 or less.

AMERICAN SOCIETY OF ADDICTION MEDICINE [ASAM] PLACEMENT CRITERIA

The Patient Placement Criteria for the Treatment of Substance-Related Disorders produced by the American Society of Addiction Medicine. These criteria are used as guides for the provision of substance abuse treatment that is appropriate for the individual.

APPEAL

A request for administrative review of an Action.

ARRAY OF SERVICES

The range of services available.

ASSESSMENT

A comprehensive examination and evaluation of a person’s needs for psychiatric, developmental disability, or substance abuse treatment services and/or supports according to applicable requirements.  See also Comprehensive Clinical Assessment.

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BASIC BENEFITS

Traditional behavioral health services under the Medicaid State Plan, including physician services, often referred to as outpatient treatment or medication management services, which include those services covered in Medicaid’s Clinical Coverage Policy 8C – Outpatient Behavioral Health Services Provided by Direct Enrolled Providers.  These services may also be provided to individuals who meet medical necessity criteria for MH/DD/SA Community Intervention Services, but for whom services are limited to outpatient and/or medication management services only. 

BEST PRACTICE(S)

Interventions, treatments, services, or actions that have been shown to generate the best outcomes or results. The terms, “evidence-based” or “research-based” might also be used.

BLOCK GRANT

Funds received from the federal government [or others], in a lump sum, for services specified in an application plan that meet the intent of the block grant purpose.  The Division of MH/DD/SAS receives three block grants: the Mental Health Block Grant, the Substance Abuse Prevention and Treatment Block Grant, and the Social Services Block Grant.

CAP-MR/DD

The acronym for the Community Alternatives Program for Persons with Mental Retardation/Developmental Disabilities.  CAP-MR/DD provides home and community-based care as an alternative to care in an Intermediate Care Facility for persons with Mental Retardation/Developmental Disabilities [ICF-MR].

CAP-MR/DD WAIVER

A Medicaid community care funding source for persons with an intellectual or developmental disability [I/DD] and who require an ICF/MR level of care that offers specific services in the community.

CAPITATION PAYMENT

A fixed payment remitted at regular intervals by DMA to the LME(s) operating a PIHP.  The LME determines whether their providers are paid fee for service or on a capitated basis.

CARE COORDINATION

Activities conducted by a provider agency for the purposes of managing an individual’s care to ensure that he or she receives the most appropriate services and supports.  Care coordination includes the sharing of pertinent clinical information in order to cooperate in serving the same individual, or in order to transfer care for an individual between providers.  It includes participation in person-centered planning, convening Child and Family Teams [for children and youth], and discharge planning for individuals in state facilities, other inpatient services, and other services.  Care coordination also includes facilitating appropriate connections to clinical home providers, if none has been identified, and to other MH/DD/SA service providers and primary health care services, when warranted.  For LMEs, the care coordination function is defined within the organizational structure of the LME cost model.

CARE MANAGEMENT

A multidisciplinary, disease centered approach to managing medical care using outcome measures to identify best practices.  The purpose of care management is to identify level of risk, stratify of services according to risk, and prioritize recipients for services.  The approach utilizes collaboration of services, systematic measurement and reporting and resource management. 

CATCHMENT AREA

A designated geographic area within the state served by a specific county/area program or LME.

CENTERS FOR MEDICARE AND MEDICAID SERVICES [CMS]

The US federal agency that administers Medicare, Medicaid, and the State Children’s Health Insurance Program.  This agency approves the North Carolina Medicaid Plan.

CFAC (CONSUMER AND FAMILY ADVISORY COMMITTEE)

A self-governing and self-directed committe that required by NC General Statute which consists of adults and family members of individuals who receive services for mental health, developmental disabilities and substance abuse.

CLAIM

An itemized statement of services, performed by a provider network member or facility, which is submitted for payment. 

CLEAN CLAIM

A clean claim is a claim that can be processed without obtaining additional information from the provider of the services or from a third party.  It does not include a claim under review for medical necessity, or a claim that is from a provider that is under investigation by a governmental agency for fraud or abuse. 

COMMISSION for MENTAL HEALTH, DEVELEMENTAL DISABILITIES and SUBSTANCE ABUSE SERVICES

The Commission for MH/DD/SAS of the North Carolina Department of Health and Human Services was created in 1973 as part of the Executive Organization Act. Its creation, powers, and duties are set forth, in part, in N.C.G.S. § 143B-147. Its mission is to promote excellence in prevention, treatment, and rehabilitation programs for persons with mental illness, developmental disabilities, and substance abuse disorders in North Carolina.
The Commission has the authority to adopt, amend and repeal rules to be used in the implementation of state and local mental health, developmental disability, and substance abuse service programs. The Commission also has the authority to modify specific storage, security, transaction limits, and record-keeping requirements that apply to particular pseudoephedrine products.

COMMUNITY INTERVENTION SERVICE [CIS] AGENCY

Term used as a provider agency classification to confirm that the agency has met the eligibility criteria for entering into a participation agreement with the Division of Medical Assistance to provide certain specific services that have been endorsed or approved by the entity [the LME for MH/DD/SAS] responsible for determining such eligibility.  Once approval or endorsement has been awarded, the service provider agency may then achieve approved status as a Medicaid Provider of Community Intervention Services and enter into a participation agreement to provide the services.

COMMUNITY INTERVENTION SERVICES

Specific MH/DD/SA services that are delineated in Clinical Coverage Policy 8A and subject to provider endorsement by the LME and direct enrollment with DMA for Medicaid-covered services. 

COMPREHENSIVE CLINICAL ASSESSMENT

An intensive clinical and functional face-to-face evaluation by a Licensed Professional of an individual’s presenting mental health, developmental disability, and/or substance abuse condition that results in the issuance of a written report, providing the clinical basis for the development of a Person-Centered Plan [PCP] and recommendations for services/supports/treatment.

CONFIDENTIAL INFORMATION

Any information, whether recorded or not, relating to an individual served by any provider.  Confidential information does not include statistical information from reports and records or information regarding treatment or services shared for training, treatment, habilitation, or monitoring purposes that does not identify individuals either directly or by reference to publicly known or available information.

CONFIDENTIALITY

Keeping information private.  Allowing records or information to be seen or used only by those with legal rights or permission.

CONSUMER

An individual seeking, referred to, or receiving MH/DD/SA services.

CONSUMER DATA WAREHOUSE [CDW]

A database containing data regarding demographic, clinical outcomes, and satisfaction data regarding individuals served by MH/DD/SA service providers.  The data stored in the CDW is the main source of information regarding block grant programs and is used to fulfill legislative requests. The information is also used for planning and evaluation of services.

CONTIUUM OF CARE

The coordinated delivery, management, and organization of age and diagnosis specific services related to treatment, care, rehabilitation, and health promotion in a manner that allows the consumer to access different levels of care, depending upon treatment needs and medical necessity.

CORE SERVICES [CABHAs only]

The term, "Core Services," as applied to CABHAs, means Medication Management, Outpatient Therapy, and Comprehensive Clinical Assessment, as described in medical coverage policies.  [These services are also referred to as basic benefit services.]

CORE SERVICES

Services that are necessary for the basic foundation of any service delivery system.  Core services under the Division of MH/DD/SAS are of two types: front end service capacity, such as screening, assessment, triage, emergency services, service coordination, and referral; and indirect services, such as prevention, education, and consultation at a community level.  Membership in a target population is not required to access a core service.  [taken from State Plan 2001: Blueprint for Change, November 1, 2001, page 2]

COST SUMMARY

A document summarizing the costs of CAP-MR/DD services for a CAP-MR/DD Program participant.  The cost summary must match all waiver services that are reflected in the Person-Centered Plan and cover a twelve-month period.

COVERED SERVICES

The services identified in the waiver application and in the contract that the LME agrees to manage pursuant to the terms of the contract.

CRISIS PLAN

A crisis plan is developed as part of the individual’s Person-Centered Plan and is designed to facilitate stabilization in response to stressful life events that may seriously interfere with a person's ability to cope or manage his or her life. The event may be emotional, physical, or situational in nature. The event is the perception of and response to the situation, not the situation itself. Essential elements include:
1.  A proactive component that identifies early known warning signals and triggers of an impending
crisis.
2.  An intervention component for steps when the individual is experiencing emotional, physical, or situational difficulties that interfere with his/her ability to manage immediate needs without assistance.
3.  Information about the process or procedure which will be followed when a crisis event or emergency situation occurs, such as who to call as First Responder, what actions to take with the individual in crisis, and what crisis services or hospitals should be used.

CRITICAL ACCESS BEHAVIORAL HEALTH AGENCY [CABHA]

A Critical Access Behavioral Health Agency, which is certified by the Department of Health and Human Services, is a new category of provider agency in North Carolina, designed to ensure that critical services are delivered by a clinically competent organization with the appropriate medical oversight and the ability to deliver a continuum of services.  The CABHA will move the public system over time to a more coherent service delivery model that reduces clinical fragmentation at the local level.

CULTURAL COMPETENCY

The understanding of the social, linguistic, ethnic, and behavioral characteristics of a community or population and the ability to translate systematically that knowledge into practices in the delivery of mental health, developmental disabilities and substance abuse services.

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DAY/NIGHT SERVICES

Services provided on a regular basis, in a structured environment that is offered to the same individual for a period of three or more hours within a 24-hour period.  This term generally refers to services that are a part of daily or regular group programming, but are not 24-hour residential services.  Some examples of day/night services are: Substance Abuse Intensive Outpatient Program, Day Treatment Programs and Partial Hospitalization, Developmental Day, Psychosocial Rehabilitation, ADVP, and Supported Employment.

DAYS

Unless otherwise noted, refers to calendar days.  “Working day” or “business day” means day on which DHHS is officially open to conduct its affairs.

DEPARTMENT OF HEALTH AND HUMAN SERVICES [DHHS]

The North Carolina agency that oversees state government health and human services programs and activities.  The Division of MH/DD/SAS and the Division of Medical Assistance [North Carolina Medicaid] are housed under this department.

DEVELOPMENTAL/INTELLECTUAL DISABILITY

A severe, chronic disability of a person which:
1.  is attributable to a mental or physical impairment or combination of mental and physical impairments;
2.  is manifested before the person attains age 22, unless the disability is caused by a traumatic head injury and is manifested after age 22;
3. is likely to continue indefinitely;
4. results in substantial functional limitations in three of more of the following areas of major life activity; self-care, receptive and expressive language, capacity for independent living, learning, mobility, self-direction and economic self-sufficiency; and
5. reflects the person’s need for a combination and sequence of special interdisciplinary, or generic care, treatment, or other services which are of lifelong or extended duration and are individually planned and coordinated.

DIAGNOSTIC AND STATISTICAL MANUAL [DSM-5]

A reference book, published by the American Psychiatric Association, of special codes that identify and describe MH/DD/SA disorders and their symptoms.

DISCHARGE PLANNING

A process used with and/or on behalf of a service recipient to decide what he or she needs in order to ensure a smooth move from one level of care to another.  Discharge planning begins when the service is initiated/  The plan contains recommendations for further services designed to enable the person to live and function as normally as possible.

DIVISION OF MENTAL HEALTH, DEVELOPMENTAL DISABILITIES AND SUBSTANCE ABUSE SERVICES [DMH/DD/SAS]

A part of the North Carolina Department of Health and Human Services, responsible for administering and overseeing public mental health, developmental disabilities and substance abuse programs and services.

DMA

The acronym for the North Carolina Division of Medical Assistance located in the Department of Health and Human Services.  This is the agency that operates the North Carolina Medicaid Program.

DRUG EDUCATION SCHOOL [DES]

A prevention and intervention service which provides an educational program for drug offenders as provided in the North Carolina Controlled Substances Act and Regulations.

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EARLY PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT SERVICES [EPSDT]

Services provided under Medicaid to children under age 21 to determine the need for mental health, developmental disabilities or substance abuse services.  Providers are required to provide needed service identified through screening.

ELECTRONIC RECORD

A computer-based service record that resides in a system specifically designed to support users by providing accessibility to complete and accurate data, alerts, reminders, clinical support systems, links to medical knowledge, and other aids.  A record is not considered computer-based if it is only stored electronically in a computer as a word-processing file and not as a part of an electronic database.

ELECTRONIC SIGNATURE

A computer process whereby service documentation authorship and/or approval can be documented by a specific individual.  Guidelines for electronic signatures must be followed to ensure proper review of documentation, secure passwords, and individual documented agreement with the electronic signature guidelines.

EMPLOYEE ASSISTANCE PROGRAM [EAP]

A worksite-based program designed to assist: [1] work organizations in addressing productivity issues, and [2] employees in identifying and resolving personal concerns, including, but not limited to, health, marital, family, financial, alcohol, drug, legal, emotional, stress, or other personal issues that may affect job performance.

ENROLLEE

A person who is on Medicaid and in one of the mandatory eligibility groups included in the waiver is automatically enrolled in the PIHP regardless of whether s/he ever access services.

EVIDENCE-BASED PRACTICE

Evidence Based Practice [EBP] is a term that refers to a research-based treatment approach, protocol, or model that has been found to have clinical efficacy and effectiveness for individuals with certain behavioral health challenges.  EBPs are prevention and treatment practices that are based in theory and have undergone scientific evaluation, in contrast to practices based on tradition, convention, belief, or anecdotal evidence.

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FEE-FOR-SERVICE

A method of making payment directly to the health care providers enrolled in the Medicaid program for the provision of health care services to Recipients based on the payment methods set forth in the State Plan and the applicable policies and procedures of DMA.

FIRST RESPONDER

The provider designated in the PCP to provide crisis response on a 24/7/365 basis.  Typically, the first responder is the provider who has the most sustained contact and familiarity with the clinical dynamics of the individual being served.

FOLLOW-UP

A process of checking on the progress of a person who has completed treatment or other services, has been discharged, or has been referred to other services and supports.

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GRIEVANCE

An expression of dissatisfaction by or on behalf of an Enrollee about any matter other than an action, as “action” is defined in this section.  The term is also used to refer to the overall system that includes grievances and appeals handled at the LME level and access to State fair hearing process.

GRIEVANCE AND APPEAL PROCEDURE

The written procedures pursuant to which Enrollees may express dissatisfaction with the provision of services by the LME and the methods for resolution of Enrollee grievances and appeals by the LME.

GUARDIAN

An individual who has been given the legal responsibility to care for a child or adult who is incapable of taking care of themselves due to age or lack of capacity.  The appointed individual is often responsible for both taking care of the child or incapable adult and their affairs.  A legal guardian may provide permission for an individual to receive treatment.  Also, a person appointed as a guardian of the person or general guardian by the court under Chapters 7A or 35A or former Chapters 33 or 35 of the General Statutes.

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HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT [HIPAA]

A federal Act that protects people who change jobs, are self-employed, or who have pre-existing conditions.  The Act aims to make sure that prospective or current recipient of services are not discriminated against based on health status. HIPAA also protects the privacy and security of an individual’s protected health information.

HEARING

A formal proceeding before an Office of Administrative hearing Law Judge in which parties affected by an action or an intended action of DHHS shall be allowed to present testimony, documentary evidence and argument as to why such action should or should not be taken. 

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INCIDENT AND DEATH REPORT

A report of any incident, unusual occurrence, medication error, or death of a person that occurs while an individual is under the care of a service provider.  In order to maintain authorization to provide publicly-funded MH/DD/SA services and good licensure status, a provider must follow the requirements for incident response and reporting as set forth in 10A NCAC 27G .0600, in accordance with Section 4.5 of NC Session Law 2002-164 [Senate Bill 163].  For full details on these requirements, consult the Administrative Code and the DHHS Incident and Death Reporting Form QM02 and Manual, which can be found under “Forms” at:
http://www.ncdhhs.gov/mhddsas/statspublications/Forms/index.htm

INDEPENDENT PRACTITIONER

A licensed practitioner who does not need to be endorsed by an LME and who may be directly enrolled with Medicaid to provide basic benefit services. 

INNOVATIONS WAIVER

The current NC 1915 C home and community based services waiver (HCBS) currently operated by PBH and for which application has been made for statewide implementation.  The innovations Waiver replaces the Community Alternatives Program for Persons with Mental Retardation and Developmental Disabilities (CAP-MR/DD) in the Piedmont counties.

INPATIENT

A person who is hospitalizedAn inpatient facility may be hospital or non-hospital based, such as a Psychiatric Residential Treatment Facility [PRTF]. 

INSOLVENCY

The inability of the LME to pay its obligations.

INTELLECTUAL/DEVELOPMENTAL DISABILITY

A severe, chronic disability of a person which:
1.  is attributable to a mental or physical impairment or combination of mental and physical impairments;
2.  is manifested before the person attains age 22, unless the disability is caused by a traumatic head injury and is manifested after age 22;
3. is likely to continue indefinitely;
4. results in substantial functional limitations in three of more of the following areas of major life activity; self-care, receptive and expressive language, capacity for independent living, learning, mobility, self-direction and economic self-sufficiency; and
5. reflects the person’s need for a combination and sequence of special interdisciplinary, or generic care, treatment, or other services which are of lifelong or extended duration and are individually planned and coordinated.

INTERMEDIATE CARE FACILITY FOR PERSONS WITH MENTAL RETARDATION OR DEVELOPMENTAL DISABILITIES [ICF MR/DD]

A facility that provides ICF level of care to eligible individuals who have intellectual/developmental disabilities.

INTERNATIONAL CLASSIFICATION OF DISEASES [ICD-9-CM]

The International Classification of Diseases,  9th Revision, Clinical Modification, Volumes 1 and 2, US Department of Health and Human Services, US Government Printing Office, Washington, DC.  This document provides diagnostic categorization and coding of illnesses.

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INVOLUNTARY COMMITMENT

An order for an individual to receive treatment for mental illness or substance abuse on an inpatient or outpatient basis where the individual has not sought treatment voluntarily but has been determined to be mentally ill or a substance abuser who is a danger to self or others. Mental illness is defined in GS 122C-3(21) as "Mental illness" means: (i) when applied to an adult, an illness which so lessens the capacity of the individual to use self-control, judgment, and discretion in the conduct of his affairs and social relations as to make it necessary or advisable for him to be under treatment, care, supervision, guidance, or control; and (ii) when applied to a minor, a mental condition, other than mental retardation alone, that so impairs the youth's capacity to exercise age adequate self-control or judgment in the conduct of his activities and social relationships so that he is in need of treatment.

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JAIL DIVERSION

A program designed to assist people who are arrested and jailed as a result of behaviors caused by their mental illness by working to get the person out of jail and into treatment.

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LEGALLY RESPONSIBLE PERSON

When applied to an adult, who has been adjudicated incompetent, a guardian; when applied to a minor, a parent, guardian, a person standing in loco parentis, or a legal custodian other than a parent who has been granted specific authority by law or in a custody order to consent for medical care, including psychiatric treatment; or when applied to an adult who is incapable as defined in G.S. 122C72(c) and who has not been adjudicated incompetent, a health care agent named pursuant to a valid health care power of attorney as prescribed in Article 3 of Chapter 32 of the General Statutes.

LICENSURE

A state or federal regulatory system for service providers to protect the public health and welfare.  Examples of licensure include licensure of individuals by professional boards, such as the NC Psychology Board, or the NC Substance Abuse Professional Practice Board. Examples of licensure also include licensure of facilities used to provide MH/DD/SA services by the NC Division of Health Service Regulation [DHSR].  Licensure may apply to both individuals and to facilities.

LOCAL MANAGEMENT ENTITY [LME]

The local agency that plans, develops, implements, and monitors services within a specified geographic area, according to requirements of the Division of MH/DD/SAS.  Includes developing a full range of services that provide inpatient and outpatient treatment, services, and/or supports for both insured and uninsured individuals. 

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MANAGED CARE ORGANIZATION (MCO)

An umbrella term for health plans that provide health care in return for a predetermined monthly fee and coordinate care through a defined network of providers, physicians and hospitals.

MEDICAID

A jointly-funded federal and state program that provides hospital and medical expense coverage to low-income individuals, certain elderly people, and people with disabilities.

MEDICAL NECESSITY

Criteria established to ensure that treatment is necessary and appropriate for the condition or disorder for which the treatment is provided in order to meet the specific preventive, diagnostic, therapeutic, and rehabilitative needs of the individual.  In order for a service to be eligible for reimbursement by Medicaid or the State, the individual must have an established diagnosis reflecting the medical necessity criteria inherent in the service. 

MEDICARE

A federal government hospital and medical expense insurance plan primarily for elderly people and people with disabilities.

Methamphetamine

A powerfully addictive stimulant that affects the central nervous system.  The drug is easily made in clandestine laboratories with relatively inexpensive over-the-counter ingredients.  It is a Schedule II stimulant - meaning it has high potential for abuse and is available only through prescription that cannot be refilled.  It is a white, odorless, bitter tasting crystalline powder that can be easily dissolved in water or alcohol.  The Methamphetamine Lab Prevention Act of 2005 establishes requirements for selling pseudoephedrine products, authorizes the Commission for Mental Health, Developmental Disabilities and Substance Abuse Services to add or delete specific pseudoephedrine products and modify specific storage, security, transaction limits, and record-keeping requirements applicable to particular pseudoephedrine products, and provides for civil and criminal penalties for violations of the law.

Methamphetamine Lab Prevention Act of 2005

Because pseudoephedrine products in the form of tablets, caplets or gel caps can be used illegally to make methamphetamine, the law establishes requirements for selling those productsThe law also authorizes the Commission for Mental Health, Developmental Disabilities and Substance Abuse Services to add or delete specific pseudoephedrine products and modify specific storage, security, transaction limits, and record-keeping requirements applicable to particular pseudoephedrine products and provides for civil and criminal penalties for violations of the law.

MINOR [OR UNEMANCIPATED MINOR]

Any person under the age of 18 who has not been married or has not been emancipated pursuant to Article 35 of Chapter 7B of the General Statutes.

MR-2 [OR MR2]

A form used in the CAP/MR-DD program.  The ICF-MR Level of Care determination is assessed and documented on the MR2 form by a physician or clinical psychologist licensed by the State of North Carolina.  The physician/licensed psychologist providing the assessment will complete the MR2 for individuals that, based on the assessment results, appear to meet the ICF-MR level of care.

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NETWORK PROVIDER

A provider of mental health, developmental disabilities and substance abuse services that meets the LME’s criteria for enrollment, credentialing and/or accreditation requirements and has signed a written agreement to provide services. 

NORTH CAROLINA ADMINISTRATIVE CODE [NCAC]

State rules and regulations.  The rules governing MH/DD/SA service can be found in 10A NCAC, Chapters 26-31, linked here: http://reports.oah.state.nc.us/ncac.asp?folderName=\Title%2010A%20-%20Health%20and%20Human%20Services .

NORTH CAROLINA TREATMENT OUTCOMES AND PROGRAM PERFORMANCE SYSTEM [NC-TOPPS]

Refers to the program by which the North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services [DMH/DD/SAS] measures outcomes and performance for Substance Abuse and Mental Health service recipients.  NC-TOPPS captures key information on a person's current episode of treatment, aids in evaluation of active treatment services, and provides data for meeting federal performance and outcome measurement requirements.

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OUTCOMES

At the individual level, events used to determine the extent to which service recipients improve their levels of functioning, improve their quality of life, or attain personal life goals as a result of treatments, services and/or supports provided by the public and/or private systems.  At the system level, outcomes are events used to determine if the system is functioning properly.

OVERSIGHT

Activities conducted by a government regulatory or funding agency [or other responsible agency] for the purpose of determining how a provider agency is functioning financially or programmatically.  This includes LME activities related to provider endorsement and ongoing monitoring, service authorization, claims payment, and pre- and post-payment reviews.  Oversight also includes audits, investigations, and other regulatory activities conducted by DMH/DD/SAS, DHSR, DMA, DSS, of other state agencies with responsibility for ensuring compliance with state and federal law, the quality of services, and/or the safety of consumers.   

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PERIODIC SERVICES

A service provided on an episodic basis, either regularly or intermittently, through short, recurring visits for persons a with a mental health, intellectual/developmental disability, or substance use diagnosis. 

PERSON-CENTERED PLANNING

An approach in which the individual directs his/her own planning process with the focus being on the expressed preferences, needs, and plans for his/her future.  This process involves learning about the individual's whole life, not just the issues related to the person's disability.  The process involves assembling a group of supporters, on an as-needed basis, who are selected by the individual with the disability and who have the closest personal relationship with them and are committed to supporting the person in pursuit of real life dreams.  Those involved with the planning process are interested in learning who the person is as an individual and what he/she desires in life.  The process is interested in identifying and gaining access to supports from a variety of community resources, one of which is the community MH/DD/SA service system that will assist the person in pursuit of the life he/she wants.  Person-centered planning results in a written individual support plan.

PERSON-CENTERED PLAN

An individualized and comprehensive plan that specifies all services and supports to be delivered to the individual eligible for mental health and/or developmental disability and/or substance abuse services according to NC Mental Health Reform requirements.  A person-centered plan generates action or positive steps that the person can take towards realizing a better and more complete life.  Plans also are designed to ensure that supports are delivered in a consistent, respectful manner and offer valuable insight into how to assess the quality of services being provided.

PREPAID INPATIENT HEALTH PLAN (PIHP)

An entity that 1) provides medical services to Enrollees under contract with the State Medicaid agency; 2) on the basis of prepaid capitation payments or other payment arrangements does not use State plan payment rates; 3) provides arranges for or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its Enrollees; and 4) does not have a comprehensive risk contract. 

PREVENTION

Activities aimed at teaching and empowering individuals and systems to meet the challenges of life events and transitions by creating and reinforcing healthy behaviors and lifestyles and by reducing risks contributing to mental illness, developmental disabilities and substance abuse.  Universal prevention programs reach the general population; selective prevention programs target groups at risk for mental illness, developmental disabilities and substance abuse; indicated prevention programs are designed for people who are already experiencing mental illness or addiction disorders.

PRIOR AUTHORIZATION

Also called Prior Approval, Prior Authorization is a managed care process that approves the provision of services before they are delivered.  Most Medicaid and state-funded MD/DD/SAS services require prior authorization.

PROTECTED HEALTH INFORMATION [PHI]

PHI is individually identifiable health information that is transmitted by, or maintained in, electronic media or any other form or medium.  This information must relate to 1) the past, present, or future physical or mental health, or condition of an individual; 2) provision of health care to an individual; or 3) payment for the provision of health care to an individual.  If the information identifies or provides a reasonable basis to believe it can be used to identify an individual, it is considered individually identifiable health information. See Part II, 45 CFR 164.501.

PROVIDER

A person or an agency that provides MH/DD/SA services, treatment, supports.

PROVIDER NETWORK

The agencies, professional groups, or professionals under contract to the LME that meet LME standards and that provide authorized Covered Services to eligible and enrolled persons.

Pseudoephedrine

Used to make cough, cold and allergy drug products.  Common trade names of products containing pseudoephedrine include: Triaminic, Sudafed, PediaCare, Claritin, Allegra & Alavert Pseudoephedrine can be used to make methamphetamine.  The Methamphetamine Lab Prevention Act of 2005 establishes requirements for selling pseudoephedrine products, authorizes the Commission for Mental Health, Developmental Disabilities and Substance Abuse Services to add or delete specific pseudoephedrine products and modify specific storage, security, transaction limits, and record-keeping requirements applicable to particular pseudoephedrine products, and provides for civil and criminal penalties for violations of the law.

PUBLIC MENTAL HEALTH, DEVELOPMENTAL DISABILITIES AND SUBSTANCE ABUSE SERVICES SYSTEM

The network of managing entities, service providers, government agencies, institutions, advocacy organizations, commissions and boards responsible for the provision of publicly-funded services to individuals.

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QUALIFIED PROFESSIONAL

Any individual with appropriate training or experience in the fields of mental health, developmental disabilities, or substance abuse treatment as specified by the General Statutes or by rule.

QUALIFIED PROVIDER

A provider who meets the provider qualifications as defined by rules adopted by the Secretary of Health and Human Services.

QUALITY ASSURANCE [QA]

A process to assure that services are minimally adequate, individual rights are protected, and organizations are fiscally sound. QA involves periodic monitoring of compliance with standards.  Examples include: establishment of minimum requirements for documentation, service provision, licensure and certification of individuals, facilities, and programs; and investigation of allegations of fraud and abuse.  See also, QUALITY MANAGEMENT.

QUALITY IMPROVEMENT [QI]

A process to assure that services, administrative processes, and staff are constantly improving and learning new and better ways to provide services and conduct business. 

QUALITY MANAGEMENT [QM]

A framework for assessing and improving services and supports, operations, and financial performance.  Processes include: quality assurance, such as external review of appropriateness of documentation, monitoring, and quality improvement, such as design and implementation of actions to address access.  See also QUALITY ASSURANCE AND QUALITY IMPROVEMENT.

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RECIPIENT

A person authorized for Medicaid or other program or insurance coverage.  Also, an individual receiving a given service.

RECONSIDERATION

An enrollee’s first step in the appeal process after an adverse organization determination; the LME-PIHP shall have procedures to reevaluate an adverse organization determination, findings upon which it was based, and any other evidence submitted or obtained. 

RECOVERY

The processes by which people are able to live, work, learn and participate fully in their communities.

RECORD RETENTION AND DISPOSITION SCHEDULE FOR STATE AND AREA FACILITIES

This schedule determines the procedures for the management, retention, and destruction of records by the Division of MH/DD/SAS facilities, and the LMEs and their contractors.  Please find link here:
http://www.ncdhhs.gov/mhddsas/statspublications/Policy/apsm10-3retentionupdated5-05.pdf

REFERRAL

The process of establishing a link between a person and another service or support by providing authorized documentation of the person's needs and recommendations for treatment, services, and supports.  It includes follow–up in a timely manner consistent with best practice guidelines.

RESILIENCE

The personal and community qualities that enable individuals to rebound from adversity, trauma, tragedy, threats, or other stresses and to live productive lives. 

RISK CONTRACT

A contract under which the contractor: 1) assumes risk for the cost of the services covered under the contract; and 2) incurs loss if the cost of furnishing the services exceeds the payments under the contract.  This contract is a risk contract because the LME assumes that risk that the cost of providing Covered Services to Enrollees may exceed the capitation rate paid by DHHS. 

RISK RESERVE

A restricted reserve account maintained by the LME to fund payments for outstanding obligations, such as cost overruns related to Medicaid program services. 

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SCREENING

An abbreviated assessment or series of questions intended to determine whether the person needs referral to a provider for additional services. A screening may be done face-to-face or by telephone, by a clinician or paraprofessional who has been specially trained to conduct screenings. Screening is a core or basic service available to anyone who needs it, whether or not they meet criteria for target or priority populations.

SCREENING, TRIAGE AND REFERRAL

This process involves a brief interview designed to first determine if there is a MH/DD/SA service need, the likely area[s] of need, as well as the immediacy of need [emergent, urgent, or routine].  The individual is then connected to an appropriate provider for services based upon the area and level of need indicated.

SELF DETERMINATION

Self-determination refers to the right of individuals to have full power over their own lives, regardless of presence of illness or disability.  Self-determination in the mental health system refers to individuals’ rights to direct their own services, to make the decisions concerning their health and well-being (with help from others of their choice, if desired), to be free from involuntary treatment, and to have meaningful leadership roles in the design, delivery, and evaluation of services and supports.

SERVICE MANAGEMENT RECORD

A record of Enrollee demographics, authorizations, referrals, actions and services billed by Network Providers. 

 SERVICE ORDER

Written authorization by the appropriate professional as evidence of the medical necessity of a given service.  

SERVICE PROVIDER

Any person or agency giving some type of service to children or their families.  A service provider, or service provider agency, is part of the provider community under Mental Health Reform.

SERVICE RECORD

A document that is required to demonstrate evidence of a documented account of all service provision to a person, including pertinent facts, findings, and observations about a person’s course of treatment/habilitation and the person’s treatment/habilitation history.  The individual’s service record provides a chronological record of the care and services that the individual has received and is an essential element in contributing to a high standard of care. 

STAKEHOLDER

A person, group, organization or system who affects or can be affected by an organization's actions.

STANDARDS

Activities generally accepted to be the best method of practice. Also, the requirements of licensing, certifying, accrediting, or funding groups.

STATE PLAN [DMH/DD/SAS]

The annually updated statewide plan that forms the basis and framework for MH/DD/SA services provided across the state.

STATE PLAN [NORTH CAROLINA MEDICAID]

All of the formal policies, processes, and procedures approved by the US federal agency Centers for Medicare & Medicaid [CMS] regarding the Medicaid Program in North Carolina.  This includes approval of Medicaid services and service definitions.

SUBCONTRACT

An agreement which is entered into by the LME in accordance with Section 11.

SUBCONTRACTOR

Any person or entity which has entered into a contract with the LME.

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TARGETED CASE MANAGEMENT

A service approved only for individuals with a developmental disability that involves locating, obtaining, coordinating, and monitoring social, habilitative, and medical services, as well as other services and supports related to maintaining an individual’s health, safety and well-being in the community.

TARGET POPULATIONS

A categorization in IPRS that applies to the classification of individuals who meet eligibility requirements in order to receive benefits for mental health, developmental disabilities, or substance abuse conditions, according to the North Carolina State Plan for Mental Health Reform.  In general, individuals who meet Target Population eligibility are those with the most serious or severe unmet challenges and needs.

THIRD PARTY RESOURCE

Any resource available to a Member for payment of expenses associated with the provision of Covered Services (other than those which are exempt udner Title XIX of the Act), incluiding but not limited to insureres, tort-feasors, and worker's compensation plans.

TREATMENT ACCOUNTABILITY FOR SAFER COMMUNITIES [TASC]

A service designed to offer a supervised community-based alternative to incarceration or potential incarceration, primarily to individuals who are alcohol or other drug abusers, but also to individuals who are mentally ill or developmentally disabled and who are involved in crimes of a nonviolent nature.  This service provides a liaison between the criminal justice system and alcohol and other drug treatment and educational services.  It provides screening, identification, evaluation, referral, and monitoring of alcohol or other drug abusers for the criminal justice system.

TWENTY-FOUR HOUR FACILITY

A facility wherein a service is provided to the same individual on a 24-hour continuous basis, and includes residential and hospital facilities.

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UTILIZATION MANAGEMENT [UM]

A process to regulate the provision of services in relation to the capacity of the system and the needs of individuals. This process should guard against under-utilization as well as over-utilization of services to assure that the frequency and type of services fit the needs of individuals.  UM is typically an externally-imposed process, based on clinically defined criteria.

UTILIZATION REVIEW [UR]

An analysis of services, through systematic case review, with the goal of reviewing the extent to which necessary care was provided and unnecessary care was avoided.  UR is typically an internally- imposed process that employs clinically established criteria.

WAIVER

The document by which DHHS, DMA, requests section of the Social Security Act (SSA) be waived, in order to operate a capitated managed care system to provide services to enrolled recipients.

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