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Tailored Care Management

What is Tailored Care Management (TCM)?

TCM provides coordination across a member’s whole-person needs, including physical health, behavioral health, intellectual/developmental disability (I/DD), traumatic brain injury, and pharmacy services, as well as Long-Term Services and Supports (LTSS) and assistance addressing unmet health-related resource needs. TCM involves conducting a care management comprehensive assessment to identify the member’s needs and making a care plan to address those needs.

Three types of organizations may provide TCM: Local Management Entities/Managed Care Organizations (such as Vaya), Advanced Medical Home Plus (AMH+) practices, and Care Management Agencies (CMAs). 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 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 is 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 helps TCM providers support members and caregivers participating in the Individual and Family Directed Services (IFDS) option of the NC Innovations Waiver.

Participants learn about the IFDS option, the Employer of Record and Agency with Choice models, how to share information about the role of the Care Manager and Employer of Record, and proper documentation and monitoring processes.

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 is T1017, with the HT modifier for adult and child members who do not participate in the Innovations Waiver. 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.
  • Providers should submit the location where the service was rendered, such as in a school, home, or place of employment per CMS approved codes. Telehealth is not a valid billable service or place of service code if the service was performed in person. However, it may be used for telephonic or video services.
  • Diagnosis codes should be billed to the highest level of specificity and must include at least one Medicaid-recognized diagnosis code for claims to process.
  • The billed rate must be the provider’s usual and customary rate and is paid based on the type of Medicaid for which the member is eligible. Please note rates are different for members receiving Medicaid 1915(i) services than for Innovations Waiver participants.

View the Vaya Health TCM Business Processes guide for providers.

For more information, complete the Provider Service Desk Form or contact your assigned Claims Specialist.