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:
- Initial LOC for Innovations
- Individual Goods and Services
- 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
- Specialized Consultative Services
- Vehicle Modifications
State-Funded Services Checksheets
Mental Health and Substance Use Services
Medicaid and State-Funded Service Checksheets:
- Assertive Community Treatment Team (ACTT)
- Community Support Team (CST)
- Facility Based Crisis (FBC)
- Family Centered Treatment (FCT)
- 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)
- includes Outpatient Therapy
- 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: