Medicaid is a federal and state funded health insurance program for low-income parents, children,
seniors and people with disabilities. The N.C. Department of Health and Human Services (DHHS) administers
the State’s Medicaid Program through its Division of Medical Assistance (DMA), which is responsible for
the daily logistics of delivering services to eligible participants. DMA has a total budget of over $11
billion, which includes a Behavior Health Services budget of $2.1 billion.
The ultimate purpose of Eastpointe Medicaid UR is to assure:
(a) that such services are medically necessary, appropriate to the person’s individual needs, and approved in accordance with standards of good care; and
(b) that such services meet the requirements of the Medicaid State Plan and NC Clinical Policy.
The immediate purpose of Eastpointe Medicaid UR is to secure the services of a highly qualified LME Vendor for:
(a) Utilization Review (UR) of Medicaid-covered mental health and substance abuse services (including inpatient, outpatient and rehabilitative services);
(b) UR of developmental disability targeted case management services; and
(c) UR of CAP MR/DD Waiver Services