All behavioral health, intellectual/developmental disability (I/DD), and traumatic brain injury (TBI) providers in Vaya Health’s network are required to maintain appropriate after-hours and emergency coverage and to respond in a timely and appropriate manner to any member/recipient who is in crisis. Unless an emergency is life-threatening, 911 should never be the first line of contact for a behavioral health issue.
Level of coverage requirements
The level of coverage required is based on the array of services you provide:
Providers of basic benefit services, such as outpatient clinics or licensed independent practitioners and other services without first responder requirements, must have the capacity to provide 24/7 telephonic crisis intervention/response to individuals they serve. Basic benefit providers must:
- Offer an answering service or voicemail with the provider’s after-hours contact number. The message must not direct individuals to 911 or the emergency department unless the emergency is life-threatening. All individuals must be provided with the mobile/pager/answering service number of the clinician who is on call. If the provider is using an answering service, the provider must return the call to the individual within one hour. After-hours recordings and voicemail messages must include the applicable emergency contact information.
- Develop crisis plans with members/recipients that include the provider’s daytime and after-hours/emergency contact information, along with helpful strategies to mitigate a crisis. Make sure the individual has a copy.
- Have 24/7 access to crisis plans and other information in the individual’s treatment record to guide crisis intervention.
- Be able to respond telephonically. However, the provider may access Mobile Crisis Management (MCM) services for the individual if telephone contact cannot mitigate the crisis.
Behavioral Health Clinical Homes (BHCHs) and providers of enhanced services must have “first responder” capabilities in accordance with the NC Medicaid Clinical Coverage Policy for the enhanced service. Note the following requirements:
- All the above stipulations listed for basic benefits apply to BHCHs and enhanced services providers.
- In addition, these providers must be available 24/7 to respond to members/recipients experiencing a crisis, both telephonically and face to face as needed.
- BHCHs and providers of the following enhanced services must respond face to face if telephone contact does not mitigate the crisis:
- Assertive Community Treatment Team (ACT)
- Community Support Team (CST)
- Intensive In-Home (IIH)
- Multisystemic Therapy (MST)
- Substance Abuse Intensive Outpatient Program (SAIOP)
- Substance Abuse Comprehensive Outpatient (SACOT)
- First responders are responsible for obtaining involuntary commitment petitions, if necessary.
Providers of 24-hour Residential Treatment Services, as well as providers of Day Treatment and Psychosocial Rehabilitation, assume the BHCH and first responder functions immediately upon the individual’s admission to one of the enhanced services above. Outpatient therapists assume clinical home functions if outpatient services are being delivered and none of the above services are a part of the member’s person-centered plan. If the individual is not connected with another provider upon discharge, the BHCH retains emergency response duties for 60 days post-discharge.
All Innovations Waiver providers are required to respond to emergencies/crises on weekends and evenings as outlined in the applicable Innovations Waiver service definition. Under NC Medicaid Clinical Coverage Policy No. 8-P, providers of the following services must have 24/7 capacity to offer primary crisis services for individuals under their care or have an arrangement (memorandum of agreement) with a primary crisis services provider:
- Community Living and Support
- Residential Supports
- Supported Living
Please note the following:
- Providers of the services listed above must educate members and their paid/unpaid supports on how to access the designated crisis responder. The designated crisis responder’s contact information must be clearly outlined in the member’s care plan and be accessible in their home setting or settings where they receive services.
- At a minimum, you must assess by phone to determine if face-to-face support and/or crisis response services are necessary. Providers are responsible for knowing how to access crisis services.
- MCM is not considered a primary crisis responder for individuals receiving the services listed above unless, after an initial assessment, the responsible provider believes MCM is needed to alleviate the crisis.
- Crisis plans must include behavioral and physical health supports and their contact information. All providers listed in a crisis plan must know and understand their role if the member experiences a behavioral or physical health crisis.
Direct care providers of State-funded (non-Medicaid) I/DD services must develop appropriate crisis plans for individuals they serve. Providers must educate recipients and their supports on how to implement the plan, and all individuals and providers in the crisis plan must know and understand their roles in crisis response.
Individuals with I/DD who are not receiving services or linked to a provider should use MCM in a behavioral health crisis. Any eligible individual who is linked to MCM for emergency response will be connected with a provider for follow-up services as needed. For help connecting individuals you serve to an I/DD provider, call our Provider Support Service Line at 1-866-990-9712.