A female patient sitting, talking with a therapist who is holding a pen to take notes.

Tailored Care Management

What is TCM?

Tailored Care Management (TCM) is coordination across a member’s whole-person needs, including physical health, behavioral health, intellectual and developmental disabilities (I/DD), traumatic brain injuries (TBI), pharmacy, long-term services and supports (LTSS), and unmet health-related resource needs and other social determinants of health (SDOH). TCM involves a conducting a care management comprehensive assessment to identify the member’s needs and making a care plan to address those needs.

The vision of the North Carolina Department of Health and Human Services (NCDHHS) is that care managers affiliated with Advanced Medical Home Plus (AMH+) practices and Care Management Agencies (CMAs) provide TCM, in addition to LME/MCOs. The Tailored Care Management Provider Manual is a resource for provider organizations that are considering becoming or are already certified as an AMH+ or a CMA.

The requirements in the manual apply to AMH+ practices, CMAs, and LME/MCOs in their role as TCM providers. The manual includes:

  • A description of the TCM model and the functions AMH+ practices and CMAs are expected to perform
  • The criteria for AMH+ and CMA certification
  • The process for certification
  • General information about payment
  • Information about AMH+ and CMA oversight

NC Standardized Care Management Monitoring Tool

The NC Standardized Care Management Monitoring Tool will be used to conduct annual monitoring of plan- and provider-based TCM per the TCM Provider Manual. The tool was developed by LME/MCOs in collaboration with NCDHHS.

Individual and Family Directed Services Training

This course is designed to help Tailored Care Management providers support members and caregivers participating in the Individual and Family Directed Services (IFDS) option of the NC Innovations Waiver.

Participants will learn about the IFDS option, the Employer of Record and Agency with Choice models, how to disseminate information about the role of the care manager and Employer of Record, and proper documentation and monitoring processes to support the member.

TCM Provider Q&A

Click here to view the TCM Provider Q&A PDF. 

This document will be updated regularly as receive more questions from TCM providers. TCM providers can submit questions to provider.info@vayahealth.com. 

Billing Guidance

  • Providers may bill electronically via the Provider Portal.
  • All claims for TCM should be on a CMS-1500 form or 837p. The service code for TCM services is T1017, with the HT modifier for non-Innovations Waiver adult and child members. The TCM service code for Innovations Waiver participants is T1017 HT CG.
  • Providers should bill for a member’s first TCM interaction for a given month based on the date of service.
  • TCM service codes are billed as facility-based services. The billing NPI should be the facility NPI on the claim.
  • Taxonomy codes should be appropriate for both the Provider Portal clinician information and registration information in NCTracks.
  • Place of service (POS) codes must be where the services were rendered. A community hospital is an acceptable POS for TCM billing.
  • Diagnosis codes should be billed to the highest level of specificity and must include at least one Medicaid recognized diagnosis code to process.
  • The billed rate must be the provider’s usual and customary rate and will be paid based on the type of Medicaid for which the member is eligible. Please note: Rates for Medicaid 1915(b) plan members and Innovations Waiver participants are different.

Click here to view the External TCM Business Processes PDF.

For more information, please complete the Provider Service Desk Form or contact your assigned claims specialist.