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.

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

TCM Provider Billing Guidance

The following guidance provides an overview for providers billing Vaya Health for TCM services for dates of service between Dec. 1, 2022, and March 31, 2023.

Standard Rates

  • TCM service code T1017 with the HT modifier for non-Innovations Waiver adult and child members:$269.66.
  • TCM service code T1017 with the HT CG modifier for Innovations Waiver participants: $269.66 + 78.94 (add-on rate) = $348.60.

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 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 contact your assigned claims specialist or email claims@vayahealth.com.

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