Service Authorization Requests

Partners’ Utilization Management (UM) department’s function is to make authorization decisions by conducting initial, continuing care and retrospective reviews of services based on whether medical necessity is substantiated in the request for authorization. The UM department utilizes guidelines based on the North Carolina Division of Health Benefits (DMA) Clinical Coverage Policies and Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH) State Funded Service Definitions.

Providers will submit a Service Authorization Request (SAR) via ProAuth to request delivery of services to individuals. A Service Authorization Request must include:

• Provider name and site code for where services to be offered
• Authorization date range
• Services requested per Benefit Plan (Medicaid B, Medicaid C, Medicaid B3, and State)
• Guardian/relationship to individual
• Individual’s disability: Mental Health, Intellectual/Developmental Disabilities, Substance Use
• ASAM level is required for all individuals with a substance use and co-occurring disorders that include a substance use diagnosis
• A CANS (Child and Adolescent Needs and Strengths tool) scoring sheet is required for mental health service authorization requests for children ages 3-5. (For information about the CANS tool, please access the PRAED Foundation’s website at https://praedfoundation.org/tools/the-child-and-adolescent-needs-and-strengths-cans/. To obtain the Training and Certification needed to administer the CANS, please register at https://canstraining.com/login. Once you register, the North Carolina, General Bundle will be available for purchase.)
• LOCUS/CALOCUS scores for individuals with a mental health diagnosis only and co-occurring disorders that include a mental health diagnosis
• NC-SNAP or Supports Intensity Scale for Individuals with Intellectual/ Developmental Disabilities
• Primary Care Physician and release of information
• Medications’ dosage, frequency, and compliance with medications
• ICD-10 diagnoses
• Substance use details
• Justification for services (provider comments)
• Uploaded documents as indicated on the current benefit plan
• Authorization Requests Documents for Review

Providers can see reviewer comments in comments section. If additional information is requested by UM, and when possible, the provider has five days to respond to the request. Failure to respond could lead to the request being administratively or clinically denied.

Updated: May 31, 2023