consumer/enrollee handbook

Everyone can live productive lives.Partners believes that everyone is resilient.

Everyone can recover from adversity, trauma, tragedy, threats, or other stresses.

PartnersBehavioral Health ManagementCorporate Offices901 S. New Hope Rd. • Gastonia, NC 28054

NEED HELP?1.888.235.HOPE (4673)

For more information on the webWWW.PARTNERSBHM.ORG


NEED HELP?1.888.235.HOPE (4673)

Consumer/Enrollee Handbook

We hope this handbook will provide you with information to help on your journey toward independence and recovery.

Please note that we mail many updates and you should keep your address up to date with Partners Behavioral Health Management and your provider. If you have Medicaid, you must change your address with the county Department of Social Services who approved your Medicaid. A list of Department of Social Services phone numbers are available in the back of the handbook.

Partners believes that everyone is resilient. Everyone can recover from adversity, trauma, tragedy, threats, or other stresses. Everyone can live productive lives.

Record Your Provider Information Here:

My primary care provider’s name and number: __________________________________________________

My behavioral health care provider’s name and number: __________________________________________

My behavioral health care provider’s Crisis Line: _________________________________________________

My Care Coordinator’s name and number: ______________________________________________________

Welcome to Partners Behavioral Health Management!


NEED HELP?1.888.235.HOPE (4673)

2 I Consumer Handbook February 2016


NEED HELP?1.888.235.HOPE (4673)

What is Partners Behavioral Health Management? What does Partners Behavioral Health Management do? ............................................................................ 4 How do I contact Partners Behavioral Health Management? ....................................................................... 4 What if I am not receiving any services? ......................................................................................................... 5 How do I get a copy of the Consumer/Enrollee Handbook? ......................................................................... 5 WherearethePartnersBehavioralHealthManagementofficeslocated? ................................................. 5 How do I get a list of the Network of Providers? ............................................................................................. 5

How do I get services? Access to services ............................................................................................................................................. 6 When should I call Customer Service? ............................................................................................................ 6 What if I am hearing impaired? ....................................................................................................................... 7 How will the Customer Service Call Center assess my needs? ..................................................................... 7 What if I need a Second Opinion? .................................................................................................................... 8 How are emergency/crisis situations handled? ............................................................................................. 8 What if I have private insurance? ..................................................................................................................... 8 What if I experience a crisis and am unable to make a decision about my care? ...................................... 8 What do I do with my Advance Directives? ..................................................................................................... 9 How long do my Advance Directives stay active? ........................................................................................... 9

What services are available? How do I know if am eligible for services managed by Partners Behavioral Health Management? ................................................................................................. 10 What if I have insurance other than Medicaid? ............................................................................................10 What if my Medicaid stops?............................................................................................................................11 State-Funded Services for Adults and Children without Medicaid ..............................................................11 Am I eligible for state-funded services? ........................................................................................................11 Are services different for those individuals with intellectual/developmental disabilities? ......................11 What else has to be done before I start receiving my service? ..................................................................12 What is Medical Necessity? ............................................................................................................................13 What is Care Coordination ..............................................................................................................................13

What are the functions of Care Coordination? .............................................................................................13

How do I choose a provider? How do I choose a provider? ..........................................................................................................................15 What if I need an out of the area provider? ................................................................................................. 15 Will my provider provide transportation to appointments? .........................................................................15 How can I change providers or stop services completely? ..........................................................................16 What do I do if my provider goes out of business or stops offering the service I need? ..........................16

What if I am denied services? How will I know if my services have changed? .............................................................................................17 What is an appeal? ..........................................................................................................................................17

Table of Contents

Improving Lives. Strengthening Communities. I 3


NEED HELP?1.888.235.HOPE (4673)

What happens to my service if I choose to appeal? .....................................................................................17 HowdoIfileanappeal? ..................................................................................................................................18 What if I do not agree with Partners’ outcome regarding the Reconsideration decision? .......................19 Terms to know ..................................................................................................................................................19 What if I lose my appeal? ................................................................................................................................20 Tips, Reminders and Timelines ......................................................................................................................20

What if I am not happy with my services? What is a concern, complaint or grievance? .................................................................................................21 WhatdoIdoifIwanttofileacomplaintorgrievance? ...............................................................................21 WhathappensifIamnotsatisfiedwiththeresolutiontomycomplaintorgrievance? ...........................22

What are my rights and responsibilities? What are my rights? ........................................................................................................................................23 Do I have additional rights if I am less than 18 years of age? ................................................................... 23 Do I have additional rights if I have an intellectual/developmental disability? ........................................ 24 What are my rights if I am in a 24-hour facility? ...........................................................................................24 Can my rights be restricted? ...........................................................................................................................24 What if my rights have been violated? ...........................................................................................................25 What are my responsibilities? ........................................................................................................................25 What is self determination? ........................................................................................................................... 25 Reporting Provider Fraud and Abuse .............................................................................................................26

Are there advocacy committees and/or groups in this area? What is the Consumer and Family Advisory Committee (CFAC)? ................................................................27 What are the roles and responsibilities of CFAC? .........................................................................................27 What is the Human Rights Committee? ........................................................................................................27 What is recovery? ............................................................................................................................................28 Resources for all individuals ...........................................................................................................................28

What if English is my second language OR I do not speak English? The Call Center has translation services available. The Call Center staff is able to help and get you connected to services even if you do not speak English. Translation services are available for any call and are available from the Call Center and your provider at no cost.

¿Qué hago si Ingles es mi segunda lengua o si no hablo nada de Ingles?El Call Center cuenta con servicios de traducción disponibles. El personal de Call Center es capaz de ayudar y conseguir que conectado a los servicios, incluso si usted no habla Inglés. Servicios de traducción están disponibles para cualquier llamada y están disponibles en el Centro de Atención Telefónica y su proveedor sin costo.

Alternate formats of written materials are availtable as needed (Braille, large print, audio.) To request these materials, please call Consumer Relations at 1-888-235-HOPE (4673).

Formatos alternativos de materiales escritos pueden estar disponibles según sea necesario (Braille, letra grande, audio.) Para solicitar estos materiales, por favor llame al 704-884-2519.



NEED HELP?1.888.235.HOPE (4673)

Partners Behavioral Health Management (Partners) is a local governmental agency. We help individuals with Mental Health, Intellectual/Developmental Disabilities, and Substance Abuse needs. Partners covers an eight county area. The eight county area is Burke, Catawba, Cleveland, Gaston, Iredell, Lincoln, Surry, and Yadkin Counties. We are committed to ensuring that you or your family member receives the right service.

What does Partners Behavioral Health Management do? Partners Behavioral Health Management provides access to: • a wide array of services to meet the needs of individuals around the clock • Customer Service (365 days a year and 24 hours a day) • crisis services • emergent, urgent, and routine services • state-funded services management for individuals without private health insurance or Medicaid • a network of providers and a variety of services that meet the needs of members and families • management of the network of providers to make sure that quality services are available throughout the community • management of all concerns, complaints, grievances and requests for appeals about service changes in a timely manner • promotion of recovery and a person-centered approach to individual strengths, hope, and choice • access to services for individuals entering the community from hospitals, jails, state residential facilities, and treatment centers

Collaboration is the key to success for all individuals receiving services. Partners is committed to creating and maintaining partnerships with individuals, families, providers and other stakeholders. Together we can meet the challenges and needs in our community.

How do I contact Partners Behavioral Health Management? Partners Behavioral Health Management maintains two toll-free numbers:

1-888-235-HOPE (4673) is the toll-free number to access services and crisis services. The Customer Service Call Center is available 24 hours a day and every day of the year. It is always answered by a liveperson,isfree,andisconfidential.Youmayalsoaskquestionsaboutcommunityresources;makeconcerns,complaints,compliments,orgrievances;changeproviders;andscheduleappointments. We want to help.

Our administrative number is 1-877-864-1454 --mainly used by the network of providers and to reach administrative functions. This number is available Monday through Friday from 8 AM to 5 PM. It has a menu ofoptionstofinddepartments.

What is Partners Behavioral Health Management?



NEED HELP?1.888.235.HOPE (4673)

What if I am not receiving services?If you have never received services but would like to, or want to ask about services, call 1-888-235-HOPE (4673). If you have received services in the past and want to receive them again, you can call 1-888-235-HOPE (4673). The Customer Service Call Center staff will make an appointment with the provider you choose.Youandyourproviderwilldecidewhatservicesarebestfor you.

How do I get a copy of the Consumer/Enrollee Handbook? YouwillreceiveaWelcomeLetterfromPartnersafteryouhavescheduledyourfirstappointment.Theletterwilllistaphonenumber to call to have a Handbook mailed to you and/or a family member as they enter services. If a member wishes to receive an additional copy or needs the information again, please call 1-888-235-HOPE (4673)orusetheTTYsystemat1-800-749-6099.Youcan also go to our website at www.partnersbhm.org to see, print or save a copy.

How do I get a copy of the Notice of Privacy Practices (NoPP)?A NoPP is mailed with your Welcome Letter. The current notice is posted in every Partners’ facility and on our website at www.partnersbhm.org.Toobtainaprintedcopy,visitoneofouroffices,downloadonefromour website or call 1-888-235-HOPE (4673) (TTY-1-800-749-6099) to have one mailed to you.

Partners is required by law to: • Maintaintheprivacyofyourpersonalhealthinformation(PHI); • Provideyouwithanoticeofourlegaldutiesandprivacypracticesrelatedtoyourhealthinformation; • Obey the terms of the NoPP.

Where are Partners Behavioral Health Management offices located? Partnershasthreeofficesthroughoutoureightcounties.OfficesarelocatedinElkin,Gastonia, and Hickory, NC.

CORPORATE OFFICE:901 South New Hope Rd. Gastonia,NC28054

ELKIN REGIONAL OFFICE:200 Elkin Business Park Dr.

Elkin, NC 28621

HICKORY REGIONAL OFFICE:1985 Tate Blvd. SE Hickory, NC 28602

How do I get a list of Network Providers? Asamember,youhavetherighttochooseyourprovider.Youhavetherighttochangeprovidersatanytime.Youcanaccessalistofallcurrentprovidersatwww.partnersbhm.org.Youcanlookforprovidersbyname,by service and by location.

Partners mails many updates. You should keep your address up to date with Partners and your provider. If you have Medicaid, you must change your address with the county Department of Social Services who approved your Medicaid. A list of Department of Social Services phone numbers is available in the back flap of this Handbook.

What is Partners Behavioral Health Management?



NEED HELP?1.888.235.HOPE (4673)

How do I get services? You have already accessed our services but this information may be useful to you

in the future or for someone you know.

Access to services Partners Behavioral Health Management has a toll-free number available 24 hours a day, 7 days a week, and365daysayear.Thisnumbergivesyouaccesstoalicensedclinician,hasnocostandisconfidential.The toll free number for the Customer Service Call Center is 1-888-235-HOPE (4673)

The staff who answer in the Customer Service Call Center are able to help you: • Enroll in the Mental Health, Intellectual/Developmental Disabilities, and Substance Abuse service system • Complete a brief telephone screening to determine how quickly you need to have an appointment • Schedule an appointment for an assessment with a network provider • Provide information on community resources • Provide limited crisis intervention by telephone • Arrange for face-to-face crisis intervention services

When should I call the Customer Service Call Center? YoucancallCustomerServiceifyou: • Want information on the services provided in your area • Want more information on Mental Health, Intellectual/Developmental Disabilities, and Substance Abuse services • Worry about an emotional or behavioral problem • Worry about a drug or alcohol problem • Need to connect with a provider • Arehavingtroublefindingaprovidertomeetyourneedsorareunhappywithyourservices • Feel afraid of thoughts, mood, or emotions • Feel depressed or anxious • Are looking for support for your child, friend, caregiver or relative • Have someone suggesting that you get help

TheCustomerServiceCallCenterstaffcanconnectyoutoaproviderthatwillmeetyourneeds.Youwillbeofferedachoiceofproviders.Youwillbeabletochooseoneyouthinkwillbestmeetyourneeds.TheCallCenter staff will schedule an appointment with the provider you chose.

If you are a minor (under the age of 18 years), you have the right to agree to the following treatments without the consent of your parent or guardian: • Use of controlled substances or alcohol • Emotional disturbance has behavior that presents a threat to life or physical well-being.



NEED HELP?1.888.235.HOPE (4673)

What if I am hearing impaired? If you are hearing impaired, the Customer Service Call Center can take callsthroughstandardTTYsystemsat1-800-749-6099. Call Center staffistrainedandreadytoreceivecallsfromtheTTYsystem.

How will the Call Center assess my needs? The Call Center staff groups all needs into three categories: Emergent, Urgent, and Routine. Information you share with the Call Center staff will determine which category you fall.

The team member will ask you questions like: “How do you feel today? What services have you have received in the past? What medications are you are taking? Have you had any hospital stays?” to identify yourneeds.Theanswerstothesequestionsareconfidentialandonlyusedtohelpsuggestthenextstepsyou should take.

If you have an: This means: What will happen:

EmergencyNeed

You are experiencing a life-threatening condition in which you are: • Suicidal • Homicidal • Actively psychotic • Displaying disorganized thinking • Reporting hallucinations and delusions which

may result in self-harm or harm to others • Unable to care for yourself.

The Call Center will provide you with face-to face care within two hours of your call.

For life-threatening emergencies, 911 is called and face-to-face care is provided immediately.

Urgent Need

You are in a condition where you:• Are not actively suicidal or homicidal • Deny having a plan, means or intent for suicide

or homicide, but express feelings of hopelessness, helplessness or rage.

• Have the potential to become actively suicidal or homicidal without immediate intervention

• Display a condition that could rapidly deteriorate without immediate intervention

• Will progress to the need for emergent service and care without diversion and intervention

• OrYouareinaconditioninwhichyouareanimmediaterisk to yourself or others and unable to adequately care for yourself.

The Call Center will provide an appointment for a face-to face service assessment within two days of the request for care.

Routine Need

You are in a condition where signs and symptoms: • Cause an impairment or disruption in performing

life tasks • Interfere with your ability to participate in daily living • Decrease your quality of life

The Call Center will provide you with an appointment for a face-to-assessment and/or treatment within fourteen days of the date of request for care.

Pregnant women who abusing substances and persons injecting drugs receive priority in scheduling an appointment. You will receive the first appointment as soon as possible.



NEED HELP?1.888.235.HOPE (4673)

What if I need a Second Opinion?Youhaveaccesstoasecondopinionbyaqualifiedhealthcareprofessionalwithinthenetwork,oryoucanreceive assistance in arranging one outside the network, at no cost. To access a second opinion, you may call Customer Service at 1-888-235-HOPE (4673).

What if I need a specialty provider?Call Customer Services at 1-888-235-HOPE (4673). Staff in Customer Services and other Partners departments know about the medical necessity criteria to receive specialty services and may help with a referral.

How are emergency/crisis situations handled? If you have a life-threatening physical health emergency, call 911. You can also go to the nearest Emergency Room. You do not need to call the Customer Service Call Center before calling 911!

During a behavioral health emergency, you should speak with your service provider as soon as possible. Behavioral health emergencies are serious. Behavioral health emergencies may not always require a visit to the Emergency Room. Most behavioral health emergencies can be handled by calling the Customer Service Call Center at 1-888-235-HOPE (4673), your service provider, or your doctor. They can listen to your concerns and help you receive emergency care. If you need emergency services, you have the right to use any hospital or other setting for emergency care. No prior authorization is required.

If you currently have a provider, the Call Center will try to contact them. If the Call Center is unable to reach your provider, they may access other services. For life-threatening emergencies, 911 is called and face-to-face care is provided immediately. Crisis services are available in all eight counties. If the Call Center is unable to contact your provider or decide you need immediate help, the staff may also send a Mobile Crisis Team to your location or may meet you at an emergency room. Or, you may be directed to a Walk-in Center. These centers can meet some urgent needs (see list in this package) to keep you from using the emergency room until needed.

What if I have private insurance?Crisis services are provided at no cost. This includes those who have private insurance. Crisis services do not require prior authorization.

What if I Experience a Crisis and am Unable to Make a Decision About my Care? Youhavetherighttomakeinstructionsforyourtreatmentinadvance.Therearethreetypesofadvancedirectives. These legal documents allow you to let your wishes be known in the event you are unable to make decisions for yourself. These are: • Psychiatric Advance Directives or the Advance Directive for Mental Health Care • Health Care Power of Attorney • Living Will

Tofindtheseforms,pleasegotothefollowingwebsite:http://www.secretary.state.nc.us/ahcdr/Forms.aspx. If you do not have internet access, please call us at 1-888-235-HOPE (4673) and we will be happy to help you.



NEED HELP?1.888.235.HOPE (4673)

Psychiatric Advance Directives (PAD), or the Advance Directive for Mental Health Care is a legal document that states the instructions for the type of mental health treatment you would want to receive ifyouareinacrisisandunabletomakedecisionsforyourself.YourserviceproviderorCareCoordinatorshould be able to assist you in the development of this document. The instructions give information about: • What you think helps calm you. • How you feel about seclusion or electric shock treatments. • What medicines you do not want to take. • Which doctor you want to be in charge of your treatment.

A Health Care Power of Attorney allows you to designate someone who can make decisions for you if you are unable to make your own choices about treatment.

A Living Will is a document that tells others that you want to die a natural death if you are incurably sick and cannot receive nutrition or breathe on your own.

All three of these documents must be written and signed by you while you are able to understand your conditionandtreatmentchoicesandareabletomakeyourwishesknown.Twoqualifiedpeoplemustwitness all three types of advance directives. The Living Will and the Health Care Power of Attorney must be notarized.

What Do I Do With my Advance Directives? Be sure to keep a copy in a safe place and give copies to your family, your treatment team, your doctor andthehospitalwhereyouarelikelytoreceivetreatment.YoucanalsohaveyourPADfiledinanationaldatabase or registered with the North Carolina Advanced Health Care Directive Registry, which is part of the Department of the North Carolina Secretary of State (www.sosnc.com). There is a $10.00 fee to register aPAD.Thisincludestheregistration,arevocationform,registrationcardandpassword.Youcanusetherevocation form at any time if you change your mind.

How Long Do my Advance Directives Stay Active? YourAdvanceDirectivesareactiveuntilyoucancelthem.YoumaycancelorchangeyourPADatanytime.If you cancel or change your Advance Directives, be sure to communicate the change to anyone who has a copy of the PAD.



NEED HELP?1.888.235.HOPE (4673)

What services are available?Partners Behavioral Health Management manages services for individuals

with the following needs:

Mental Health • Substance Abuse • Intellectual or Developmental Disabilities

The current service array is based on the state-funded North Carolina Division of Mental Health/Developmental Disabilities/Substance Abuse Services and Division of Medical Assistance Service listing (Medicaid) for Behavioral Health and Developmental Disabilities Services. A complete list of services is available on the website at www.partnersbhm.org. If you do not have internet access, please call us at 1-888-235-HOPE (4673) and we will be happy to help you.

IfaMedicaidservicebenefitisaddedorchanged,youwillbenotifiedinwritingthirtycalendardaysbeforethe change happens.

How Do I Know if I am Eligible for Services Managed by Partners? Partners ensures that there are services available for individuals without health insurance and for those withMedicaid.Currently,abroaderarrayofservicesisavailabletoindividualswithMedicaid.Youmaywishto check with your local Department of Social Services to determine if you are eligible for Medicaid.

To be eligible for Medicaid-covered services within the Partners Behavioral Health Management Region you must: • Be a U.S. citizen or provide proof of eligible immigration status. • Be a resident of North Carolina. • Have a Social Security number or have applied for one. • ApplyandbeapprovedforMedicaidatyourlocalDepartmentofSocialServices(DSS)Office. • BeinoneoftheMedicaidaidcategoriesthatqualifiesyouunderthePartners Behavioral Health Management Health Plan.

If you are currently receiving Social Security Insurance (SSI), Special Assistance to the Blind, Work First Family Assistance, or Special Assistance for the Aged or Disabled, you are automatically eligible for Medicaid and do not have to apply at DSS.

Partners does not require co-payments, deductibles or other forms of cost sharing from Medicaid consumers for Medicaid services per the contract with North Carolina Department of Medical Assistance. In addition, consumers are not expected to pay for missed appointments.



NEED HELP?1.888.235.HOPE (4673)

What if I Have Insurance Other than Medicaid? YoushouldtellbothPartnersandyourproviderifyouhaveinsuranceotherthanMedicaid.Thiscouldinclude Medicare or private insurance. Federal regulations require Medicaid to be the “payer of last resort.” Medicaid pays for services after your other insurance has processed the claim and made a payment determination.

What if my Medicaid stops?YourMedicaidmaystopautomatically,whichiscalleddisenrollment,whenyou: • Move out of the eight counties that Partners covers and your county of residence (eligibility) changes • Are deceased • Gotojailorprisonformorethanthirtydaysatonetime • No longer qualify, which could include receiving Medicare, are younger than three years old (except Innovations Waiver), are medically needy in deductible status, have a change in your alien or refugee status, or had temporary eligibility • Are admitted to an Institution for Mental Disease and are between the ages of 22 and 64

State-Funded Services for Adults and Children Without Medicaid Partners offers a range of services that are available to individuals without Medicaid coverage. A copy of available state-funded services can be found on our website, www.partnersbhm.org. Part of the state-funded service eligibility process is based on a consumer’s or family’s income level, in addition to clinical needs. There are some crisis services available to consumers within the Partners region that are available regardless of a consumer’s ability to pay.

Partners has a limited amount of state funds to pay for treatment services. Therefore, service entry requirementsandbenefitmaximumsmaybedifferentthantheMedicaidrequirementsforthesameservice. At times, consumers seeking state-funded services may be placed on a waiting list (or the Registry of Unmet Needs) when: • Demand for service exceeds available resources (non-Medicaid funds only), or • Service capacity is reached as evidenced by no available provider for the state-funded service.

Am I Eligible for State-Funded Services? Every consumer enrolled with Partners is evaluated to determine their ability to pay for state-funded services. The combination of a consumer’s adjusted gross income and the number of dependents will show if they have the ability to pay. Partners’ established rates will apply when determining the amount the consumer might potentially pay for state services. If a consumer’s income exceeds the amount allowed for the sliding fee schedule, the individual will be required to pay 100% of the cost for the state-funded services provided to him or her. Consumers who receive state-funded services are subject to a sliding fee scale, which means that they may be responsible for some percentage of the cost of services.

All State Funded Services are subject to availability of funding and are not an entitlement.



NEED HELP?1.888.235.HOPE (4673)

Are services different for those individuals with intellectual and developmental disabilities? Yes,informationaboutintellectualanddevelopmentaldisabilityservicescanbelocatedonthePartners’website at www.partnersbhm.org. If you do not have internet access, please call us at 1-800-235-HOPE (4673) and we will be happy to help you.

What else has to be done before I start receiving my service? Does my service need to be authorized?When you call for an appointment, you will be referred to a Partners’ network provider who will assess yourneedsanddiscussservicesuggestionsthatwillmeetyourneeds.Yourproviderwilldevelopaplanof treatment with you using the service suggestions and submit that information to Partners Utilization Management Department for a review and authorization prior those services starting.

Many services require “prior authorization.” Information about services, requirements, and whether prior authorizationisrequiredispostedonthePartnerswebsiteforeachbenefitplan(MedicaidandStateFunded).

Service Authorization Timeframes and Extensions:Partners must make a decision and provide notice within 14 days of receiving a request for authorization of services with a possible extension of an additional 14 calendar days if: • Youoryourproviderrequestsanextensionor • Partners demonstrates to the North Carolina Division of Medical Assistance that there is need for additional information and the delay is in your best interest.

Partners must make a service authorization decision within 72 hours of receiving a request for an expedited request. Expedited requests occur when following the standard timeframe could seriously jeopardizeyourlife,healthorabilitytoattain,maintainorregainmaximumfunction.Youalsohavetheoption of an extension of an additional 14 calendar days if: • Yourequestanextensionor • Partners can demonstrate to North Carolina Division of Medical Assistance that there is need for additional information and the delay is in your best interest.



NEED HELP?1.888.235.HOPE (4673)

What is Medical Necessity?In order to receive a service, you must need that service. The need is decided by reviewing the assessment you received from the provider to see if you have a medically documented need for the service.

Medically-necessary treatments are procedures, products and services provided to all consumers. The Partners Utilization Management Department uses the following medical criteria during the authorization process: • Necessary and appropriate for the prevention, diagnosis, palliative, curative or restorative treatment of a mental health or substance use/addition condition. • Consistent with national or evidence-based standards, North Carolina Department of Health andHumanServicesdefinedstandards,orverifiedbyindependentclinicalexpertsatthetime the procedures, products and the services are provided. • Provided in the most cost-effective, least restrictive environment that is consistent with good clinical standards of care. • Not provided solely for the convenience of the consumer, consumer’s family, custodian or provider. • Not for experimental, investigational, unproven or solely cosmetic purposes. • Furnished by, or under the supervision of, practitioners licensed under state law in the specialty for which they are providing the service and in accordance with 42 CFR, the North Carolina Administrative Code, Medicaid coverage policies and other applicable federal and state directives. • Sufficientinamount,durationandscopetoreasonablyachievetheirpurpose. • Reasonably related to the diagnosis for which they are prescribed regarding type, intensity and duration of service and treatment setting.

Medically necessary treatments are designed to: • Be provided in accordance with a Person Centered Treatment Plan. • Conform to any Advance Medical Directives the individual has prepared. • Respond to the unique needs of individuals who have English as a Second language and be furnished in a culturally-relevant manner. • Prevent the need for involuntary treatment or institutionalization.

What is Care Coordination? Care Coordination is an administrative function within the Partners Behavioral Health Management managed care system that is designed to proactively intervene and ensure optimal care to high-need, high-risk individuals. It is available to members in all three disability groups. Care Coordinators will: • Assist individuals who are at high risk for hospitalization or institutionalization. • Manage the individual’s care across the service continuum. • Work directly with the individual, providers and others to improve outcomes for the individual. • Ensure that individuals receive appropriate clinical assessment, treatment planning, and access to clinical and medical specialists.



NEED HELP?1.888.235.HOPE (4673)

What are the Functions of Care Coordination? • Identify high-risk and high-need individuals: • Intellectual/Developmental Disabilities (IDD) –work with families, providers and case managers to ensure access to psychological evaluations, adaptive behavior assessments and other assessments as indicated. • Mental Health/Substance Abuse (MH/SA) – completing or securing clinical assessment of individuals who have special health care needs in order to identify needs related to treatment and monitoring. • Ensure that a Person-Centered Plan is available for all individuals with special needs. • ForindividualsinidentifiedMH/SAspecialhealthpopulations,ensurethataPerson-CenteredPlan is completed by the Behavioral Health Home. • Proactivelyengageindividualsidentifiedasspecialneedstoensuretheyreceiveneededservices. • Convene key providers and others to address the special needs of the individual, including the Care Coordinator for those participating in Care Coordination. • Identify the gaps in needed services and intervening to ensure the individual receives appropriate care. • Coordinate services for the individual across the system and with other systems of care, including primary care. • Measure results of intervention and treatment, including reduction in high-risk events and inappropriate service utilization. • Coordinate medical care with the Community Care of North Carolina’s Care Coordinators in accordance with state protocols so all areas of health are covered for those with disabilities.

What is Community Care NC and how can they help me with additional services?Community Care of North Carolina (CCNC) provides care coordination to individuals enrolled in Medicaid that have high-risk health needs. Participation with CCNC is voluntary. To learn more about CCNC, visit www.communitycarenc.com.



NEED HELP?1.888.235.HOPE (4673)

How do I choose a provider?

When you call the Customer Service Call Center at 1-888-235-HOPE (4673), the staff will offer you a choice of providers. The Call Center staff can provide information to help you

choose a provider. The information they share is location, service and language.

TheProviderNetworkcanchange.Providersleaveandothersjoin.Youhavetherighttochooseandchangeprovidersatanytime.Theprovideryouchoosewillneedtoofferthesamelevelofservices.YoucanusetheProvider Search tool at www.partnersbhm.org tofindaprovider.

Providers are reviewed before becoming approved. They sign a contract or agreement with Partners Behavioral Health Management . The provider is expected to give high quality services to you at all times. The providers are also expected to be culturally competent.

If you receive state funded services, you will need to select a provider that has a contract to offer state fundedservices.Notallprovidersinthenetworkareabletoofferstatefundedservices.Youcancontactthe Customer Service Call Center at 1-888-235-HOPE (4673) if you need help. When you go to your appointment, you should take with you: • A list of your current medications with you (prescribed and over-the-counter). • A list of programs you have attended prior to your appointment (including dates). • A list of your hospitalizations (including dates). • YourMedicaidIDcardandotherinsurancecard,ifapplicable. • Proofofincometodeterminefinancialeligibilityforservices.

What if I need an out-of-the-area provider? If you receive Medicaid, this is OK! The Partners Network Management Department will work with the provider to make sure that they are endorsed and able to offer the services you need. However, if the serviceisprovidedwithoutpriorauthorization,youmayberesponsibleforpaymentofthisservice.Youshould ask the provider before receiving the service to make sure they have received authorization (unless it is a crisis service which does not require prior approval.)

If you receive state funded services, it is best to use a provider in Partners network. If a provider cannot be foundinthecurrentnetwork,youcanmakearequesttouseaprovideroutofthenetwork.Youcancontactthe Network Management Department at 1-877-864-1454 to get help with this process.

Will my provider offer transportation to appointments? If you receive Medicaid, you can use the Medicaid Transportation Service. The list of local agencies is in the back of this handbook. If you do not have Medicaid, you can request to have the initial appointmentinyourhomeiftransportationisanissue.Youcanmakeaplanfortransportationtofuture appointments.


How can I change providers or stop receiving services completely? YoucancalltheCustomerServiceCallCenterat1-888-235-HOPE (4673) or tell your provider directly that youwanttopickanotherprovideroryouaredonewithservices.Youdonothavetogiveareason.Ifyouaredone with services completely, the provider and/or the Call Center staff may ask you to sign a statement thatshowsYOUdecidedtostopreceivingservices.

What do I do if my provider goes out of business or stops offering the service I need? How will I know if my provider goes out of business or stops offering the service I need?Youwillbenotifiedbyaletterbeforeaproviderchangesservicesordecidestoclosetheirbusiness.Partnerswillmailalettertoyourproviderconfirmingthelastdayofservicedelivery.YouwillreceiveyourletterwithinfifteencalendardaysofthedatePartnersletterwasmailedtotheprovider.

Partners mails many updates. You should keep your address up to date with Partners and your provider. If you have Medicaid, you must change your address with the county

Department of Social Services who approved your Medicaid. A list of Department of Social Services phone numbers is available in the

back flap of this Handbook.

Tips & Reminders: • Youcanusethe“FindaProvider”websearchtoolorcall 1-888-235-HOPE (4673)tofindaprovidernearyou. • Youhavetherighttochangeprovidersatanytime. Yourprovidercanassistyouinthisprocessoryoucancall 1-888-235-HOPE (4673). • If you experience a behavioral health crisis, call your provider and follow your crisis plan. Or, you can go to one of the Walk-in Centers (listed in the back of the handbook) before you call 911 or go to the Emergency Room.



NEED HELP?1.888.235.HOPE (4673)

What if I am denied services? There may be times that you disagree with Partners’ decision regarding

a request for authorization of services.

If you are a Medicaid recipient and receive a letter from Partners saying that some or all of your Medicaid benefitshavebeenreduced, suspended, terminated, or denied, you have the right to appeal the decision. However,youcannotrequestanappealforaservicenolongerofferedinthePartners’MedicaidBenefitPlan.

You have the right to appeal a decision about your services

What is an appeal?An Appeal means a request for review of the denial, reduction, suspension, or termination of a service.

What happens to my services if I choose to appeal?If Partners terminates, suspends, or reduces your current Medicaid services before the expiration of the authorization period, you may continue to receive those Medicaid services if you meet all of the following conditions: • YourequestaReconsiderationReviewwithin10calendardaysfromthedateontheNotice of Action letter or intended effective date of Partners’ proposed action • The services were ordered by an authorized provider • The authorization period has not expired • Yourequestthatyourservicescontinue

If all of the above conditions are met, you may continue to receive your current services until: • YouwithdrawyourrequestforaReconsiderationReview • Ten days after the date of the upheld Reconsideration Review decision, unless you request a State fair hearingwiththeNorthCarolinaOfficeofAdministrativeHearingswithinthosetendays • AStatefairhearingdecisionismadeintheLME/MCO’sfavor;or • The authorization for the services expires or authorization service limits are met.


NEED HELP?1.888.235.HOPE (4673)


How do I file an appeal?Request a Reconsideration Review of Partners’ decisionYoumustrequestaReconsiderationReviewwithin30daysfromthedateofthenotificationletter statingyourbenefitswillbereduced,suspended,terminated,ordenied.Youcall704-884-2650 or 1-888-235-4673andaskfortheReconsiderationReviewRequestForm.Yourprovidercanassistincompleting the request form. • Aprovider,actingonyourbehalfandwithyourwrittenconsent,mayfileanappeal.Aprovider may request a State fair hearing on your behalf and act as your authorized representative in doing so,withyourpermission.Inaddition,Partners’staffcanhelpyoufileanappeal.Ifyouhaveany questions or need assistance, you can call the Appeals Department at 704-884-2650 and ask for help with completing the written request. • Return the form by fax, mail, or in person, or tell us over the phone if you would like to request a Reconsideration Review. (Unless you are requesting an expedited review, requests made over the phone also require submission of a completed Reconsideration Review form). • Once the Appeals Department receives your request to appeal a decision, Partners will send you a letter within one business day, which informs you that your request for appeal has been received. If you requested an expedited appeal, you will receive a telephone call within the same day Partners receives this request, in addition to written follow-up from Partners. • Youhavetherighttosubmitanyadditionalinformationyouthinksupportsyourrequest for Medicaid services. • Youhavetherighttoreviewanyinformationusedduringthereconsideration. • A decision will be made within 30 days of Partners receiving your request for reconsideration. Partners will notify you of the Reconsideration decision within this time period. An expedited Reconsideration Review may be granted upon the determination of health and safety concerns. Thisincludes,butisnotlimitedtothefollowingservices:Inpatient,CrisisBed,andDetoxification treatment. These reviews will take place within 72 hours of the request. Contact Partners to request an expedited review. • Both the standard appeal timeframe of 30 days and the expedited appeal timeframe of 72 hours canbeextendedforanadditional14days.Youoryourprovideractingonyourbehalfmayrequest an extension. Partners may also request an extension if they can demonstrate to the Division of Medical Assistance (DMA) that there is need for additional information and that the extension is in your best interest. If Partners makes such an extension request, Partners will inform you (the consumer) in writing and make reasonable effort to also inform you verbally. • If Partners denies a request for an expedited appeal, Partners must transfer the appeal to the standard timeframe of no longer than 30 days from when the appeal was requested. Partners must also attempt to provide oral notice followed by written notice within two calendar days. The written notice must include the action taken, the reason for the action/ decision, give you the right to request that the decision be reconsidered and how to make that request.


NEED HELP?1.888.235.HOPE (4673)


What if I do not agree with Partners’ outcome regarding the Reconsideration decision?You may appeal that decision to the North Carolina Office of Administrative Hearings. • The letter you receive informing you of the Reconsideration Review decision will include a State Fair Hearing Request form. • Youmustusethisformtofileyourrequestforan appealtotheNorthCarolinaOfficeofAdministrative Hearing (OAH) within 30 days from the date of the Reconsideration Review decision. • Youwillbeofferedtheopportunitytohaveyourappeal case mediated. • If you accept mediation, it must be completed within 25 days of your request to OAH. • If you decline mediation or if your mediation is unsuccessful, you will proceed to a hearing. • After the hearing, the administrative law judge will make a recommendation regarding your appeal.

More about Mediation: • Youwillbegiventheopportunitytohaveyourcase mediated, where a mediator facilitates a solution between the involved parties. • If you decline mediation, or if mediation is not successful, your appeal will move to a hearing before an administrative law judge. • A NC Administrative Law Judge makes the Final Decision.

To learn more about the North Carolina Office of Administrative Hearings appeals process, call 919-431-3000. At any time during the appeal process, you may represent yourself or you may retain an attorney to represent you.

What if I don’t agree with the North Carolina Office of Administrative Hearings decision?Appeal that decision to NC Superior Court.Youwillneedtoretainanattorneytohelpguideand represent you through this process. Free Legal Aid may be available to assist you. To locate an attorney near you call 1-800-662-7660.

Denial: Partners does not approve a service because the request does not meet criteria to support the authorization.

Reduction, Suspension, or Termination: Services you currently receive are reduced, suspended or terminated because the service does not meet clinical guidelines or no longer meets medical necessity for the frequency, amount or duration of the service.

Notification of Service Denial, Reduction, Suspension, or Termination: A letter by US Mail from Partners to Medicaid recipients informing the recipient of a denial, reduction, suspension, or termination of service. The letter also explains how to request a Reconsideration Review.

Reconsideration Review: A request submitted toPartnerswithin30daysofnotificationasking for the decision to be reviewed. This is yourfirststepintheappealsprocess.

Request for Expedited Reconsideration Review: A request for a review within 72 hours due to health and safety concerns. This request can be made by contacting Partners.

Notice of Reconsideration Review Decision: A letter sent by US Mail from Partners to inform the recipient of the Reconsideration decision regarding a denial, reduction, suspension, or termination of service. This letter, sent within 30 days, of the request for reconsideration provides the determination and information on how to appeal the decision.

North Carolina Office of Administrative Hearings:Astateofficethatprovidesanindependent forum for prompt and impartial resolution of administrative law contested cases involving citizens and state agencies. http://www.oah.state.nc.us/

TERMS TO KNOW



NEED HELP?1.888.235.HOPE (4673)

What if I lose my appeal?The decision of the Superior Court is the final decision. Ifthefinaldecisionisnotinyourfavor,inotherwords,theNCDepartmentofHealthandHumanServices(NC DHHS) upholds Partners’ decision to deny, reduce, suspend or terminate the requested service, Partners has the right to recover the cost of the services furnished to you during the appeal process.

Tips & Reminders • Keep letters and records • Make notes of dates and keep track of time limits for responses • Read information carefully – pay attention to details and deadlines • Take each step as outlined

Timelines•IfaMedicaidserviceisdenied,youwillbenotifiedinwritingwhenthatdecisionismade.•Youhave30daysfromthedateoftheNoticeofActionlettertorequestaReconsiderationReview.• IfaMedicaidserviceisreduced,suspendedorterminated,youwillbenotified10daysinadvanceofthe decision taking effect (when there is an authorization in place).•Youmustfileanappealwithin10daysofthedateofthemailingoftheMCO’snotificationofreduction, suspension and termination to be eligible for continuation of the Medicaid service (s) in question. • Partners will notify you within 30 days of Reconsideration Review decision.• An expedited Reconsideration Review may be requested if it is determined that your health or safety is in jeopardy. An expedited Reconsideration Review will be reviewed within 72 hours.•YoucanfileanappealwiththeNorthCarolinaOfficeofAdministrativeHearingwithin30daysfromthe date of the Notice of Resolution Letter.

Contact UsIf you have questions, give us a call at 704-884-2650 or 1-888-235-4673.

Please mail or hand-deliver forms to: Partners Behavioral Health Management Attn: Appeals Unit 901 S. New Hope Road Gastonia,NC28054

Please Fax forms to: 704-884-2720 or Call 704-884-2650



NEED HELP?1.888.235.HOPE (4673)

What if I am not happy with my services?

What is a concern, complaint or grievance? Grievances(alsocalledcomplaints)aredefinedasanexpressionofdissatisfactionaboutmattersinvolvingPartnersoritsProviderNetwork.Grievancesareexpressionsofdissatisfactionaboutanymattersother than an “action” (summarized as Utilization Management decisions to deny, reduce, suspend or terminateanyrequestedservices).Acomplaintorgrievancecanbefiledbyyouorbyanyoneonbehalfofaconsumer/enrollee. Some examples of complaints or grievances are: • Concerns about staff not keeping an appointment • Staff not being respectful to you • Someone who does not speak your language • Dissatisfaction with quality of care, or access to services • Attitude of providers • Billingandfinancialissues

What do I do if I want to file a complaint or grievance? We encourage you to discuss your concerns directly with your provider. However, we are aware that there are times when issues cannot be resolved. Sometimes you may also feel that you are not able to discuss your concerns with your provider.

If you would like to talk about your complaint or grievance with someone other than your provider, you can callPartners.Youcancall1-877-864-1454, option 3.Ateammembercanhelpyoufileyourcomplaintorgrievance.

YourcomplaintorgrievancewillbehandledbyQualityManagementstaff.Partnersworkstoresolveconcernsasfullyandquicklyaspossible.Youwillreceiveaninitialwrittenororalresponsetoyourgrievanceorcomplaintwithinfiveworkingdaysasconfirmationthattheresolutionprocesshasstarted.Agrievance/complaintwillberesolved,alongwithwrittennotificationoftheresolution,nolaterthan90days from when Partners received it, unless additional time, up to 14 additional days, is needed for special circumstances. Special circumstances include if the concern was made by or on behalf of a consumer and you request this additional time, or Partners demonstrates that additional information is needed and the delay is in the best interest of the consumer.

Inmostcases,Partnersisabletoresolveconcernswithinamuchshortertimeframe;however,thehighestpriority is to assure a thorough process with the best possible outcome and in compliance with the various binding rules, regulations, and laws.



NEED HELP?1.888.235.HOPE (4673)

If you are a consumer, or acting by or on behalf of a consumer, and would like to request an extension to the resolution of the grievance/complaint, this request should be submitted either in person, by calling 1-877-864-1454, option 3, or in writing to the following address (including the grievance/complaint referencenumberlocatedatthetopoftheGrievanceAcknowledgementletterintherequest):Partners Behavioral Health Management, c/o Grievances, 901 South New Hope Road, Gastonia, NC 28054.

Ifthereareconcernsaboutthestatusofagrievance,pleasecontacttheQualityManagementDepartmentat 1-877-864-1454, option 3.

What happens if I am not satisfied with the resolution of my complaint or grievance? Ifyouareunhappywiththeresolutionofyourcomplaintorgrievance,youmayappealthedecision.YouwillbegiveninstructionsonhowtofileanappealofthisdecisionintheletteryoureceivefromtheQualityManagementstaff.AllissueswouldbeappealedtoapanelselectedbytheChiefExecutiveOfficer(CEO)ofPartnersBehavioralHealthManagementforfinalresolution.ThepanelwillmakearecommendationtotheCEOforafinaldecision.ThedecisionoftheCEOisfinalandnotsubjecttoappealundertheNCAdministrative Appeals Act. A Medicaid enrollee, or a provider representing that enrollee, has no right to appealtheresolutionofagrievancetotheOfficeofAdministrativeHearingsoranyotherforum.

Tips & Reminders:Youcanfileaconcern,complaint,orgrievanceby • Visiting www.partnersbhm.org and completing the online form. • Calling 1-877-864-1454 and selecting option 3 • Mailing a letter addressing the concern, complaint or grievance to: Partners Behavioral Health Management c/o Grievances 901 South New Hope Rd. Gastonia NC 28054



NEED HELP?1.888.235.HOPE (4673)

What are my rights and responsibilities?

What are my rights? TheNorthCarolinaGeneralStatutesandAdministrativeCodeoutlinesrulesandregulationsaboutConsumer Rights. It is important that your rights are protected. It is important that your rights are not violated. Partners Behavioral Health Management expects that all providers notify you of your rights and help you understand them.

You have the following rights. Consumers are free to exercise their rights and the exercise of those rights shall not adversely affect the way that Partners or its providers treat the consumer. Rights include: A) Therighttobetreatedwithrespectanddueconsiderationofdignityandprivacy; B) Therighttoreceiveoralinterpreterservicesatnocost; C) The right to be free from any form of restraint or seclusion used as a means of coercion, discipline,convenience,orretaliation; D) The right to receive information on available treatment options and alternatives, presented inamannerappropriatetotheconsumer’sconditionandabilitytounderstand; E) Therighttorequestandreceiveacopyofhisorhermedicalrecord,exceptassetforthinMCGS 122C-53(d), and to request that the medical record be amended or corrected in accordance with 45CFRPart164; F) Therighttoparticipateindecisionsregardinghealthcare,includingtherighttorefusetreatment; G) Therighttofilegrievancesandappeals;and H) The right to a State Fair Hearing. I) Therighttolimitedspecifictreatmentconsentsasaminor.

Unless you have been declared incompetent by a court of law, and have a legal guardian appointed to you, you have the same basic rights as everyone else. This includes a right to: A) Dispose of property B) Make purchases C) Enter into contractual relationships D) Vote E) Marry and divorce F) Develop a discharge plan prior to being discharged G) Receiveacopyofyourtreatmentplan

Do I have additional rights if I am less than 18 years of age? If you are under the age of 18, you have the right to: • Proper adult supervision and guidance • Age appropriate activities, special education and vocational training if needed • Appropriate structure and treatment separate from adults



NEED HELP?1.888.235.HOPE (4673)

Do I have additional rights if I have a developmental disability? Information on additional rights for individuals with an intellectual or developmental disability are found in The Mental Health, Developmental Disabilities, and Substance Abuse Act of 1985. (1985, c. 589, s.2;1989,c.625,ss.1,2.),availableontheinternetat http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/ByChapter/Chapter_122C.html.

What are my rights if I am in a 24-hour facility? If you receive care in a 24-hour facility, you have the rights listed above as well as the following: • Receive necessary medical care if you are sick. If your insurance does not cover the cost, then you will be responsible for payment. • Send and receive unopened mail. Have access to writing material, postage, and staff assistance if requested. • Contact and consult with the Concerns/Complaints/Consumer Rights Coordinator at 1-888-235-HOPE (4673). • Contact and see a lawyer, your own doctor, or other private professionals. This will be at your own expense, not at the expense of the facility. • Contact and consult with your parent or legal guardian at any time, if you are under 18 years of age. • Makeandreceiveconfidentialtelephonecalls.Alllongdistancecallswillbeatyourexpense, not at the expense of the facility. • Receive visitors between the hours of 8:00 a.m. and 9:00 p.m. Visiting hours must be available six hours each day. Two of those hours must be after 6 p.m. If you are under the age of 18, visitors cannot interfere with school or treatment. • Communicate and meet with individuals that want to communicate and meet with you. This may be under supervision if your treatment team feels this is necessary. • Make visits outside the facility, unless it has been included in your Person Centered Plan that this is not recommended. • Be outside daily. Access facilities and/or equipment for physical exercise several times per week. • Have individual storage space for your private belongings. • Keep personal possessions and clothing, except those items that are prohibited by law. • Keep and spend a responsible sum of your own money. • Participate in religious worship if you choose. • Retain a driver’s license, unless you are not of age or have been prohibited to do so by a court of law.

Can my rights be restricted? Yourrightscanonlyberestrictedforreasonsrelatedtoyourcareortreatmentbyyourtreatmentteam.Youmustbepartofyourtreatmentteamandthedecisionmakingprocess.Youhavetherighttohavean advocate or someone you trust involved. A restriction of your rights must go through a Human Rights Committee for approval. Any restriction will be documented and kept in your medical record.



NEED HELP?1.888.235.HOPE (4673)

What if my rights have been violated? If you feel that your rights have been violated, we want to hear from you! Please contact us at 1-888-235-4673, option 3, or follow the instructions on page 21 (What if I am not happy with my services?) tofileaconcern,complaint,orgrievance.

What are my responsibilities? In addition to your rights as a recipient of services, you can ensure the best outcomes for yourself by assuming the following responsibilities: • Giveinformationtohelpthosethatprovideyourcare • Follow the plans that you have agreed to • Understand your health, and participate in developing treatment goals • Tell the doctor or nurse about any changes in your health • Ask questions when you do not understand your care or what you are expected to do • Invite people who will be helpful and supportive to your treatment planning • Respect the rights and property of other members and program staff • Respect other members’ needs for privacy • Work on the goals of your Person Centered Plan • Keep all the scheduled appointments that you can • Cancel an appointment at least 24-hours in advance • Inform staff of any medical condition that is contagious • Take medications as prescribed for you • Tell your doctor if you are having side effects from your medications • Tell your doctor if your medications are not helping you feel better • Tell your doctor or therapist if you do not agree with their recommendations • Tell your doctor or therapist when and if you want to end treatment • Carry your Medicaid or other insurance card with you at all times • Cooperate with those trying to care for you

YoualsohavetherightandresponsibilitytogivePartnersinputonpoliciesandservices.Thebestwaytogive this input is to attend a Consumer and Family Advisory Committee meeting. These meeting dates and times are on the www.partnersbhm.org website or you can call 1-877-864-1454 and press zero “0” to speak to the operator who can assist you.

What is self determination? Self determination means that you have full power over your life, regardless of your disability. Youhavetherightto: • Select your own provider • Direct your services • Make decisions concerning your health and well being • Be free from involuntary treatment • Maintain a leadership role in the services you receive.



NEED HELP?1.888.235.HOPE (4673)

Reporting Provider Fraud and Abuse Medicaidfraudandabuseisplanneddeceptionormisrepresentationthatresultsinabenefitsuchaspayment or coverage. Examples of Medicaid fraud and abuse include: • An individual does not report all income when applying for Medicaid. • An individual does not report other insurance when applying for Medicaid. • A non-Medicaid recipient uses a Medicaid recipient’s card with or without the recipient’s permission. • A provider’s credentials are not accurate. • A provider bills for services that were not rendered. • A provider performs and bills for services not medically necessary.

YouareencouragedtoreportmattersinvolvingMedicaidfraudandabuse.Ifyouwanttoreportfraudorabuse, you can remain anonymous. However, sometimes in order to conduct an effective investigation wemayneedtocontactyou.Yournamewillnotbesharedwithanyonewhoisbeinginvestigated.(Inrarecases involving legal proceedings, we may have to reveal who you are.)

Youmayreportfraudandabusebydoinganyofthefollowing:• Call the 24 hour toll-free Partners Behavioral Health Management Compliance AlertLine at 1-866-806-8777 • Call the Medicaid Fraud, Waste and Program Abuse Tip Line at (877) DMA-TIP1 or 1-877-362-8471



NEED HELP?1.888.235.HOPE (4673)

Are there advocacy committees and/or groups in this area?

What is the Consumer and Family Advisory Committee (CFAC)? The Consumer and Family Advisory Committee (CFAC) is made up of members and family members who have received services. They have participated in services at some point in their life for mental health, developmental disabilities or substance abuse issues. The committee represents all services and counties. The CFAC serves as an advisory committee to the Area Board of Directors and Partners Behavioral Health Management administration.

What are the roles and responsibilities of CFAC? NorthCarolinalawrequiresPartnersBehavioralHealthManagementtohaveaCFACandclearlydefines the responsibilities: • Review, comment on, and monitor the implementation of the local business plan • Identify service gaps and underserved populations • Make recommendations and monitor the development of additional services • Review and comment on the budget • Participate in quality improvement measures and performance indicators • SubmitfindingsandrecommendationstotheStateConsumerandFamilyAdvisoryCommittee. These recommendations are regarding ways to improve the delivery of mental health, intellectual developmental disabilities, and substance abuse services.

The CFAC operates under its own bylaws. It has been a strong voice in the communities served by Partners. The Consumer and Family Advisory Committee brings the member and family perspective to many processes.

CFAC meets the second Monday of each month and the times and locations are on the Calendar at www.partnersbhm.org. If you are interested in becoming a CFAC member or learning more about CFAC, call 1-888-235-HOPE (4673) .

What is the Human Rights Committee? The Human Rights Committee has an important job. It protects the rights of people receiving services. The committee is made up of members, family members, community partners, and Partners Behavioral Health Management Board members. The committee reviews all incident reports, restrictive interventions, behavioral intervention plans, and complaints or grievances that involve individuals who receive enhanced services. The Human Rights Committee provides valuable feedback to the area board on improvement andoveralltrendissues.YourprovidermayhaveaHumanRightsCommittee.Callyourproviderformoreinformation.


Partners’ Human Rights Committee meets at least six times each year and the times and locations are on the calendar at www.partnersbhm.org. If you are interested in becoming a member or learning more about the Human Rights Committee, call Consumer Relations at 1-877-864-1454.

What is recovery? Partners Behavioral Health Management believes that everyone is resilient. Everyone can recover from adversity, trauma, tragedy, threats, or other stresses. Everyone can live productive lives. Recovery is the process in which people are able to live, learn, and fully participate in their communities. Partners Behavioral Health Management promotes and encourages recovery to the fullest extent for every person.

Belowareanumberofrecoveryandadvocacyresourcesavailable.Ifyoudonotseeonethatfitsyourneeds, please visit at www.partnersbhm.org or call Partners at 1-888-235-HOPE (4673) to get additional information.

Resources for all individuals:NC DHHS Customer Service and Community Rights Team: https://www.ncdhhs.gov/assistance/mental-health-substance-abuse/advocacy-customer-service

Intellectual and Developmental Disability Resources:The Arc North Carolina: www.arcnc.orgAutism Society of North Carolina: www.autismsociety-nc.orgBrain Injury Association of North Carolina: www.bianc.netThe Association of Self-Advocates of North Carolina: www.asa-nc.orgFirst in Families of North Carolina: www.fifnc.org

Mental Health and Substance Use:NAMI North Carolina: www.naminc.orgMental Health America of the South Mountains: www.mhasouthmountains.orgAlcoholics Anonymous: www.aa.orgNarcotics Anonymous: www.NA.orgSubstance Abuse and Mental Health Services Administration: www.SAMHSA.govUS Department of Health and Human Services Mental Health: www.mentalhealth.gov

Stay connected to Partners: • By Email at [email protected] • On the web at www.partnersbhm.org. • Through Facebook. “Like” our Page--Partners Behavioral Health Management • Subscribe to our Email Communications at www.partnersbhm.org.

Everyone can live productive lives.Partners believes that everyone is resilient.

Everyone can recover from adversity, trauma, tragedy, threats, or other stresses.

PartnersBehavioral Health ManagementCorporate Offices901 S. New Hope Rd. • Gastonia, NC 28054

NEED HELP?1.888.235.HOPE (4673)



NEED HELP?1.888.235.HOPE (4673)

Consumer/Enrollee Handbook

consumer/enrollee handbook

Documents