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Local Management Entities Utilization Management Information

The North Carolina General Assembly House Bill 2436 Section 10.15 (x) requires the Department of Health and Human Services to return service authorizations, utilization reviews, and utilization management functions to the Local Management Entities (LMEs) for all clients. 

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Announcements

The target date for the transition of utilization management functions to the Local Management Entities has been extended. The new target date is September 20, 2010.

Additional information is available in the Medicaid Bulletin.

• Prior Authorization of Medicaid-Funded Mental Health, Developmental Disability, and Substance Abuse Services by The Durham Center and Eastpointe LME, September 2010
• Prior Authorization of Medicaid-Funded Mental Health, Developmental Disabilities, and Substance Abuse Services for Recipients with Eligiility in Durham, Duplin, Lenoir, Sampson, and Wayne Counties, August 2010
• Local Management Entity Utilization Management Project, March 2009
• Implementation of Utilization Management by Local Mangement Entities, June 2009

LME UM Training Presentations, March 2010

• Utilization Review:
  • Overview (PDF, 47 KB)
  • Updates (PDF, 589 KB)
• Medical Necessity:
  • Adult Mental Health (PDF, 72 KB)
  • Child Mental Health (PDF, 95 KB)
• Services:
  • CAP/MR-DD (PDF, 203 KB)
  • Targeted Case Management for MR/DD (PDF, 288 KB)
• Due Process (PDF, 387 KB)
• Patient Placement Criteria, American Society of Addiction Medicine (PDF, 103 KB)

LME Director's Meeting, September 24, 2008

• Meeting Presentation (PDF, 145 KB)

LME UM Requirements and Procedures Policy

• Requirements and Procedures (PDF, 199 KB) (updated 7/10/09)
• Requirements Attachments (PDF, 4.2 MB) (updated 7/10/09)

LME UM Proposals

• November 14, 2008 Cover Letter (PDF, 53 KB)
• General Information on Submitting LME UM Proposals (PDF, 16 KB)
• Proposal Evaluation Criteria (PDF, 10 KB)
• LME Response to Utilization Management Readiness Criteria (PDF, 40 KB)
• Rates for Utilization Management/Prior Authorization Reviews (9 KB)
• LME Utilization Management Questions and Answers (PDF, 89 KB)
• Information on QIO-like Entities (PDF, 22 KB)
• Guidance on QIO-like Entities (PDF, 23 KB)
• Report on Informal Appeals of Behavioral Health Decisions (PDF, 14 KB)
• Report on Appeals of Behavioral Health Decisions for Services Other than Community Support (PDF, 12 KB)
• Report on Appeals of Behavioral Health Decisions for Community Support Services (PDF, 9 KB)
• Report on Appeals of Behavioral Health Decisions (PDF, 9 KB)