Clinical Criteria Check Sheets are used by Partners’ Utilization Management department to approve service authorization requests. The criteria in these documents determines medical necessity. Check sheets are available for all services.
Some of the documents are in Microsoft Word format. When opening these documents, a box may appear asking you to enter your credentials. Simply close the box by clicking on the x in the corner and the document will appear.
Checksheets are organized below by service funding type:
Intellectual and Developmental Disabilities Services
Mental Health and Substance Use Services
Intellectual and Developmental Disabilities Services
Medicaid and State-Funded Services Checksheets
Innovations/Medicaid-Funded Service Checksheets:
- Assistive Technology Equipment and Supplies
- (b)(3) Community Guide
- (b)(3) Community Guide Periodic
- (b)(3) Functional Eligibility for Innovations
- (b)(3) In Home Skill Building
- (b)(3) Respite – Individual and Group
- (b)(3) Supported Employment
- Base Budget Services
- Community Navigator
- Community Transition
- Crisis Services
- Financial Support
- Home Modifications
- Initial LOC for Innovations
- Individual Goods and Services
- Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)
- ISP Provider Change
- ISP Revision Checksheet
- Medicaid-Long-Term Community Supports
- Natural Supports Education
- Nursing Respite Addendum
- NC Innovations Waiver Review Tool
- Residential Supports and Supported Living
- Research Based Behavioral Health Treatment (RB-BHT)
- Specialized Consultative Services
- Vehicle Modifications
State-Funded Services Checksheets
Mental Health and Substance Use Services
Medicaid and State-Funded Service Checksheets:
- Ambulatory Detox
- Assertive Community Treatment Team (ACTT)
- Community Support Team (CST)
- Facility Based Crisis (FBC) – Adult
- Facility Based Crisis (FBC) – Child
- Family Centered Treatment (FCT)
- Inpatient Case review Outline with Criteria
- Intensive Alternative Family Treatment (IAFT)
- Level I Residential Treatment (Level I)
- Level II Therapeutic Foster Care (Level II TFC)
- Level III Residential Treatment (Level III)
- Multisystemic Therapy (MST)
- Non-Hospital Medical Detox
- Outpatient Behavioral Health Services (OBHS)
- Outpatient Opioid Treatment (OOT)
- Office Based Opioid Treatment (OBOT) Bundle
- Partial Hospitalization (PH)
- Psychiatric Rehabilitation Treatment Facilities (PRTF)
- Psychiatric Rehabilitation Treatment Facilities Diversion & Assessment Program (PRTF-DAP)
- Psychological Testing
- Psychosocial Rehabilitation (PSR)
- Substance Abuse Comprehensive Outpatient Treatment (SACOT)
- Substance Abuse Intensive Outpatient Treatment (SAIOP)
- Substance Abuse Medically Monitored Community Residential Treatment (MMCRT)
- Substance Abuse Non-Medical Community Residential Treatment (NMCRT)
- Trauma Focused Cognitive Behavioral Therapy (TF-CBT)
- Therapeutic Foster Care Trauma Focused (TFC-TF)
Medicaid-Funded Service Checksheets:
- ACTT Youth
- (b)(3) Community Respite Overnight
- (b)(3) Community Transition
- (b)(3) Individual Support
- (b)(3) MHSA Supported Employment
- (b)(3) Peer Support
- (b)(3) Psychiatric Consultation
- Critical Time Intervention
- Electroconvulsive Therapy Checklist (ECT)
- High Fidelity Wraparound (HFW)
- IMD-Mental Health
- IMD-Substance Use
- Intensive In-Home
- Intercept Service
- Level IV Residential Service Review Criteria
- Mobile Outreach, Response, Engagement and Stabilization (MORES)
- Outpatient Plus
- Rapid Response Crisis Service for Children
- Trauma Informed Comprehensive Clinical Assessment (TiCCA)
- Treatment Alternatives for Sexualized Kids (TASK)
- Young Adults in Transition
State-Funded Service Checksheets:
- Alternative Service-Hospital Discharge Transition Service
- Assertive Engagement Alternative Service
- Child and Adolescent Day Treatment (CADT)
- Critical Time Intervention-YP400
- Family Living – Moderate Intensity YP750
- Group Living – High Intensity YP780
- Group Living – Low Intensity YP760
- Group Living – Moderate Intensity YP770
- Individual Supportive Employment with Long-Term Vocational Supports (LTVS)
- Inpatient 3-way Bed Enhanced