Revised January 2019; effective March 2, 2019

1 Revised September 16, 2020; effective October 16, 2020 2 TABLE OF CONTENTS SECTION I: INTRODUCTION AND 7 A. WELCOME TO ALLIANCE HEALTH .. 7 B. MESSAGE FROM THE ALLIANCE CHIEF EXECUTIVE 8 C. WHO WE 9 D. ALLIANCE MISSION, VISION AND 10 E. THE ALLIANCE CLINICAL MODEL, TREATMENT PHILOSOPHY AND COMMUNITY STANDARDS OF 10 F. MEDICAID WAIVER: WHAT IS THE NC MH/DD/SAS HEALTH PLAN?.. 14 G. ABOUT THE NC INNOVATIONS 15 H. OTHER PUBLICLY-FUNDED 17 SECTION II: PROVIDER RESPONSIBILITIES AND 18 A. PROVIDER 18 B. PROVIDER 22 SECTION III: NETWORK DEVELOPMENT AND 23 A.

2 ALLIANCE 23 B. SUFFICIENCY OF THE PROVIDER 24 C. NETWORK PROVIDER TYPES AND 24 D. OUT-OF-NETWORK/EMERGENCY SERVICES 27 E. CULTURAL 27 F. NONDISCRIMINATION AND NO-REJECT 28 G. AFTER HOURS 29 H. QUALITY OF 30 I. PROVIDER COMMUNICATION AND 31 Revised September 16, 2020; effective October 16, 2020 3 J. CREDENTIALING AND 33 K. SELECTION (INITIAL PARTICIPATION) 38 L. RETENTION 39 M. APPLYING FOR ADDITIONAL SITES OR 40 N. REPORTING CHANGES AND LEAVE OF 40 O. MONITORING AND 42 P.

3 QUALITY 43 Q. DOCUMENTATION AND CONFIDENTIALITY 44 R. RECORDS RETENTION AND 46 SECTION IV: INDIVIDUAL RIGHTS AND 48 A. INDIVIDUAL 48 B. INDIVIDUAL 51 C. CONSENT FOR 51 D. RESTRICTIVE 52 E. ADVANCE INSTRUCTION FOR MENTAL HEALTH 52 F. 53 G. USE OF INFORMATION WITHOUT PRIOR 54 H. I N D I V I D U A L RIGHTS 54 I. INDIVIDUAL AND FAMILY ADVISORY COMMITTEE (CFAC).. 55 J. PROHIBITED RESTRICTIONS ON 55 K. SECOND 56 L. INDIVIDUAL APPEALS OF DECISIONS TO DENY, REDUCE, SUSPEND OR TERMINATE A MEDICAID 56 M.

4 FREQUENTLY ASKED QUESTIONS ABOUT INDIVIDUAL MEDICAID 58 N. STATE-FUNDED SERVICES APPEALS 60 O. 61 Revised September 16, 2020; effective October 16, 2020 4 P. 65 Q. CLIENT RIGHTS 66 SECTION V: BENEFIT 67 A. ELIGIBILITY FOR THE MEDICAID 67 B. MEDICAID WAIVER 68 C. ELIGIBILITY FOR REIMBURSEMENT BY 69 D. REGISTRATION/ENROLLMENT OF 70 E. SERVICE DEFINITIONS AND SERVICE 71 F. HOSPITAL 72 G. MEDICAID TRANSPORTATION 72 SECTION VI: CLINICAL 73 A. 73 B. ACCESS AND INFORMATION CENTER: (800) 74 C.

5 ACCESS TO 76 D. PROCESS FOR TELEPHONIC ACUTE CARE 79 E. REGISTRY OF UNMET 80 F. INDIVIDUAL 81 G. INITIAL ASSESSMENT AND REQUEST FOR 82 H. INITIAL 83 I. CONTINUED AUTHORIZATION OF 86 J. DISCHARGE 86 K. UTILIZATION 87 Revised September 16, 2020; effective October 16, 2020 5 L. CARE 88 SECTION VII: CLAIMS AND 92 A. 92 B. INDIVIDUAL ENROLLMENT AND ELIGIBILITY 92 C. AUTHORIZATIONS REQUIRED FOR 95 D. PAYMENT OF CLAIMS AND CLAIMS 96 E. SERVICE CODES AND RATES CONTRACT 99 F.

6 DEFINITION OF CLEAN 99 G. COORDINATION OF 100 H. RESPONSE TO 101 SECTION VIII: PROVIDER COMPLIANCE AND PROVIDER 102 A. 102 B. CODE OF 102 C. CORPORATE 102 D. COMPLIANCE HOTLINE AND INVESTIGATIONS OF 104 E. GUARDING AGAINST FRAUD AND 104 F. SANCTIONS AND ADMINISTRATIVE 107 G. IDENTIFICATION AND RECOVERY OF OVERPAYMENT AND 109 H. INCIDENT 113 SECTION IX: DISPUTE RESOLUTION PROCESS FOR 115 Revised September 16, 2020; effective October 16, 2020 6 SECTION X: RESOURCES FOR 119 A.

7 TRAINING AND TECHNICAL 119 B. WEB-BASED PROVIDER 119 APPENDIX A: GLOSSARY OF 120 APPENDIX B: COMMONLY USED 133 APPENDIX C: EXAMPLE OF MEDICAID 141 APPENDIX D: NOTICE OF PRIVACY 142 Revised September 16, 2020; effective October 16, 2020 7 SECTION I: INTRODUCTION AND OVERVIEW A. Welcome to Alliance Health B. Message from the Alliance Chief Executive Officer C. Who We Are D. Alliance Mission, Vision and Values E. The Alliance Model, Treatment Philosophy and Community Standards of Practice F. Medicaid Waivers: What is the NC MH/DD/SAS Health Plan?

8 G. About the NC Innovations Waiver H. Other Publicly-Funded Services A. WELCOME TO ALLIANCE HEALTH Welcome to the Alliance Provider Network. As a member of our Network you join a select, progressive group of providers who are dedicated to providing quality care for the Individuals of publicly-funded mental health (MH), intellectual and developmental disabilities (IDD) and substance use (SU) services in Cumberland, Durham, Johnston and Wake counties. As a provider, you represent the Network to the people we serve, and join us in our mission to help people with disabilities and special needs improve the quality of their lives.

9 As a contracted provider with Alliance Health (Alliance), it is your responsibility to be familiar and comply with all federal and state laws, rules and regulations governing the provision of MH/IDD/SA services and the processes outlined in this Manual. Failure to comply with this Manual may constitute a material breach of your Contract with Alliance and could result in sanction or administrative action by Alliance, up to and including termination from the Network. This Manual documents information about Alliance including our purpose, mission, vision, and core values and describes our processes related to participating in the Provider Network including obtaining referrals and authorizations, submitting claims and resolving many issues or problems.

10 We have also included a glossary of frequently used terms for your reference and links to necessary forms. Your compliance with the requirements of this Manual will assist Alliance in providing you with timely service authorizations and claims reimbursement. Please note that this Manual will change over time in response to changes in Alliance practices, federal and state law, rules, regulations and Department of Health and Human Services (DHHS) directives. In order to ensure high quality care, Alliance reserves the right to adopt more restrictive processes, policies and procedures than are required by state and federal rules and regulations.