After-Hours Coverage

All Vaya Health network providers are required to maintain appropriate after-hours and emergency coverage and to respond in a timely and appropriate manner to any member who is in crisis. Unless an emergency is life-threatening, 911 should never be the first line of contact for a behavioral health issue. The level of coverage required is based on the array of services you provide:

Providers of basic benefit services

Providers of basic benefit services (e.g., outpatient clinics or licensed independent practitioners (LIPs) and other services without first responder requirements must have capacity to provide 24/7 telephonic crisis intervention/response to members 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 members to 911 or the emergency department (ED) unless the emergency is life-threatening. All members 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 member within one hour. After-hours recordings and voicemail messages must include the applicable emergency contact information.
  • Crisis plans must be developed with all members and include the provider’s daytime and after-hours/emergency contact information, along with helpful strategies to mitigate a crisis. Members should have copies of the crisis plan and pertinent contact/crisis after-hours numbers for providers.
  • Basic benefit providers responding to members in crisis must have 24/7 access to crisis plans and other information in the member’s treatment record to guide crisis intervention.
  • Basic benefit providers must be able to respond telephonically but may access Mobile Crisis Management (MCM) services for the member if telephone contact cannot mitigate the crisis.

Behavioral Health Clinical Home and providers of enhanced services

Behavioral Health Clinical Homes (BHCH) and providers of enhanced services are required to have “first responder” capability for their members, in accordance with the applicable NC Medicaid Clinical Coverage Policy for the enhanced service being provided.

  • All of the above stipulations listed for basic benefit apply to BHCH and enhanced services providers.
  • In addition, these providers must be available 24/7 to respond to members receiving services from them both telephonically and face-to-face for crisis response, as needed.
  • BHCH and providers of the following enhanced services must respond with a face-to-face contact if telephone contact is not successful in mitigating the crisis:
    • Assertive Community Treatment Team (ACTT)
    • 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 (IVC) petitions, if necessary.

Providers of 24-hour Residential Treatment, as well as of providers of Day Treatment and Psychosocial Rehabilitation services, assume the BHCH and first responder functions for members immediately upon admission to one of the enhanced services listed above. Outpatient therapists assume clinical home functions in the event that outpatient services are being delivered and none of the above services are a part of the member’s Person-Centered Plan (PCP). If the individual is not connected with another provider upon discharge, the BHCH will retain emergency response duties for 60 days post-discharge.

Innovations Waiver providers of direct care services

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 are required to have capacity to offer primary crisis services for emergencies that occur with participants in their care 24 hours per day, seven days per week, 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 above-listed services must train members and their paid/unpaid supports in how to access the designated crisis responder. The designated crisis responder’s contact information must be clearly outlined in the participant’s care plan and be accessible in the participant’s home setting or settings where he or she receive services.
  • The minimum standard is that you must first assess by phone to determine if face-to-face support is needed. The assessment will include determining if crisis response services are necessary. You are responsible for knowing how to access crisis response services and implement them to fit the nature of the crisis.
  • MCM is not considered a primary crisis responder for individuals receiving the above-listed services unless, after an initial assessment, the responsible provider feels that MCM is needed to alleviate the crisis.
  • Crisis plans must include mental health or medical health supports and their contact information. All providers listed on a crisis plan must know and understand their role in a crisis for that participant, including MCM. Crises can occur in the form of mental health, behavioral or medical needs.

Direct care providers of non-Medicaid IDD services

Direct care providers of non-Medicaid intellectual/developmental disability (IDD) services, such as Individual Habilitation/Personal Assistance, must also develop appropriate crisis plans for individuals they serve. Members and their support persons must be trained in implementing the plan, and all individuals/providers included in the crisis plan must know and understand their role in crisis response.

Individuals with an IDD who are not receiving services or linked to a provider should utilize 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 assistance linking members you serve to an IDD provider, call our Member Services Department at 1-800-849-6127.