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Eligibility and Enrollment Overview

Partners Health Management coordinates care for individuals with behavioral health, substance use disorders (SUD), intellectual/developmental disabilities (I/DD), traumatic brain injury (TBI) and related needs. Depending on eligibility and enrollment, services may be available through the Partners Tailored Plan, NC Medicaid Direct or State-funded programs.

The Enrollment and Eligibility Department works with providers to support access to these services based on available funding and individual needs.

Behavioral Health and Intellectual/​Developmental Disabilities Tailored Plans (Tailored Plan)

The Partners Tailored Plan provides integrated care for eligible Medicaid members, including services for:

  • Mental health
  • Substance use disorder
  • Intellectual/developmental disability
  • Traumatic brain injury (TBI)
  • Physical health
  • Pharmacy (subject to funding and eligibility)
NC Medicaid Direct

North Carolina’s health care program for Medicaid beneficiaries who are not enrolled in a Standard Plan. It includes:

Physical Health Services

    • Available from any provider who accepts Medicaid in North Carolina
    • Includes checkups, maternity care, hospital services, vision care, pharmacy and nursing home services
    • Care management is provided by Community Care of North Carolina (CCNC)

Behavioral Health & Related Services

  • Managed by Local Management Entities/Managed Care Organizations (LME/MCOs)
  • Partners serves as your LME/MCO for:
    • Mental health
    • Substance use disorder (SUD)
    • Intellectual/developmental disabilities (I/DD)
    • Traumatic brain injury (TBI)
    • Care management may be provided by Partners or CCNC
State-Funded Services

For individuals who are not eligible for Medicaid, Partners Health Management offers access to State-funded services, including:

  • Mental health care
  • Substance use treatment
  • I/DD and TBI services
Contact Information

For questions about member or recipient eligibility and enrollment:

How to Enroll a Member or Recipient

To request enrollment:

  • Visit: Alpha+ Home Page > Enrollments

  • For further guidance: University > Provider Portal Handbook > Enrollments

Need training?
Email EligibilityEnrollment@PartnersBHM.org to schedule a one-on-one session.
Note: Microsoft Teams with screen-sharing is required for training.

State-Funded Eligibility Requirements

To qualify for State-funded services through Partners, an individual must:

  • Be indigent/uninsured and live in Partners’ service area:
    Burke, Cabarrus, Catawba, Cleveland, Davie, Davidson, Forsyth, Gaston, Iredell, Lincoln, Rutherford, Stanly, Surry, Union, or Yadkin County
    OR
  • Have Partners-managed Medicaid and need a State-funded service

Additional requirements:

  • Must have a valid Social Security Number
    (Not required for crisis services such as Mobile Crisis or hospital contract admissions)
  • Must meet financial eligibility criteria:
    • Income ≤ 300% of the Federal Poverty Level (FPL)
    • View 2025 FPL Guidelines
      Income limits are waived for crisis services (Mobile Crisis, I/DD, TBI or hospital contract admissions).

Financial Eligibility and Exceptions

Financial Eligibility

Individuals with third-party insurance (including Medicaid) may still qualify if:

  • The insurance does not cover the State-funded service, and no clinically appropriate alternative is available
  • The insurance covers a State-funded substance use disorder (SUD) service, but the cost-sharing is unaffordable

Exceptions include:

  • Mobile Crisis Services or hospital contract admissions
  • Services listed on the Third-Party Liability (TPL)/Medicare Bypass List
  • I/DD and TBI services, which have:
    • No income limits
    • Insurance status:
      • Uninsured, or
      • Insured, but coverage does not include the State-funded service and no alternative is available
      • Applicant must have applied for Medicaid

270/271 EDI Transaction Submission

Partners supports 270/271 EDI transactions to allow providers to verify eligibility and benefits for behavioral and physical health services.

  • 270 Transaction: Request eligibility/benefits info
  • 271 Transaction: Partners’ response with requested member data

Step-by-Step: How to Submit 270/271 Transactions

Step 1: Notify Partners
Contact Partners to initiate the process:

Step 2: Complete Trading Partner Agreement (TPA)

Note: If a TPA already exists, this will serve as an addendum.

Step 3: Confirmation
Partners will confirm receipt and provide:

  • Onboarding instructions
  • Access credentials
  • Technical support contact

Step 4: Review Implementation Materials
You’ll receive:

Step 5: Prepare EDI Files
Ensure your EDI files:

  • Use the correct file structure and syntax
  • Contain complete, accurate data
  • Meet all implementation specifications

Step 6: Testing and Validation
Before production submissions, Partners will coordinate a testing phase to ensure file compatibility and compliance.

  • A test environment or designated testing window will be provided.
  • Partners will review submitted sample files and offer feedback.
  • Providers are responsible for resolving any identified issues in coordination with technical support.

Step 7: Production Submission
Once testing is successful:

  • Begin submitting live 270 transactions
  • Follow the submission schedule
  • Monitor for and resolve any errors

Step 8: Ongoing Support
Stay in contact with Partners for:

  • Reporting EDI changes
  • Updated requirements
  • Troubleshooting

Need help?

Additional Resources

Visit NCTracks – FY 2025 Documents for:

  • DMH DX Code Array
  • Eligibility Criteria
  • Concurrency Table
  • Service Array
Updated: