Tailored Care Management

What is TCM?

Tailored Care Management (TCM) is coordination across a member’s whole-person needs, including physical health, behavioral health, 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 care management comprehensive assessment to identify the member’s needs and the development of a Care Plan to address those needs.

NC Standardized Care Management Monitoring Tool

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

TCM Provider Q&A

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

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.

For more information, please complete the Claims Inquiry Form or contact your assigned claims specialist.