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Medicaid & N.C. Health Choice
Clinical Coverage Policies and Provider Manuals

Pursuant to N.C. Gen. Stat. § 108A-70.21(b): Except as otherwise provided for eligibility, fees, deductibles, copayments, and other cost sharing charges, health benefits coverage provided to children eligible under the North Carolina Health Choice (NCHC) Program shall be equivalent to coverage provided for dependents under the North Carolina Medicaid Program except for the following:

• No services for long-term care.
  
• No nonemergency medical transportation.
  
• No EPSDT.
  
• Dental services shall be provided on a restricted basis in accordance with criteria adopted by the Department to implement this subsection.

All NCHC clinical coverage policies are posted electronically with the North Carolina Medicaid Program clinical coverage policies and provider manuals listed below.

Because of the legislative directive to have Medicaid equivalent benefits, DMA has developed a joint clinical coverage policy template for Medicaid and NCHC.  Please read each policy section carefully for program specific coverage, exceptions and limitations. 

Prior approval (PA) may be required for some services, products or procedures to verify documentation of medical necessity.

• Due Process Special Bulletin, May 2011
• Medicaid Recipient Due Process Rights and Prior Approval Policies and Procedures
• Medicaid Recipient Due Process and Prior Approval Policies and Procedures Seminar Presentation January 2011
• More about prior approval

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) information is not included in all provider manuals.  For information about EPSDT:

• EPSDT Provider Page
• EPSDT Policy Instructions

The Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), as amended by the Health Care and Education Recovery Act of 2010 (P.L. 111-152), together referred to as the Affordable Care Act (ACA) requires state Medicaid programs to be compliant with the National Correct Coding Initiative (NCCI) in claims processing by March 31, 2011.  DMA has implemented the NCCI for all Medicaid and NCHC claims. Each provider shall comply with NCCI methodologies and can access information about NCCI and its impact on claims processing.

Unless directed otherwise, institutional claims must be billed in accordance with the National Uniform Billing Guidelines.  All claims must comply with National Coding Guidelines.

CPT codes, descriptors, and other data only are copyright 2012 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

The free Adobe Acrobat Reader is required to view and print these PDF files.

No Longer Active Policies

• For a listing of No Longer Active Policies go here.

Program-Specific Clinical Coverage Policies

Practitioners/Clinics (1A through 1T)

• Physicians
  • 1A-2, Preventive Medicine Annual Health Assessment (3/12/12)
  • 1A-3, Noninvasive Pulse Oximetry (3/12/12)
  • 1A-4, Cochlear and Auditory Brainstem Implants (3/12/12)
  • 1A-5, Case Conference for Sexually Abused Children (3/12/12)
  • 1A-6, Electrical Osteogenic Stimulators (3/12/12)
  • 1A-7, Neonatal and Pediatric Critical and Intensive Care Services (3/12/12)
  • 1A-8, Hyperbaric Oxygenation Therapy (3/12/12)
  • 1A-9, Blepharoplasty/Blepharoptosis (Eyelid Repair) (3/12/12)
  • 1A-11, Extracorporeal Shock Wave Lithotripsy (3/1/12)
  • 1A-12, Breast Surgeries (1/15/13)
  • 1A-13, Ocular Photodynamic Therapy (3/12/12)
  • 1A-14, Surgery for Ambiguous Genitalia (3/12/12)
  • 1A-15, Surgery for Clinically Severe Obesity (6/15/12)
  • 1A-16, Surgery of the Lingual Frenulum (8/15/12)
  • 1A-17, Stereotactic Pallidotomy (3/1/12)
  • 1A-18, Scanning Laser Glaucoma Test
    (Policy incorporated in 1T-2 Special Ophthalmological Services 1/15/13)
  • 1A-19, Transcranial Doppler Studies (3/12/12)
  • 1A-20, Sleep Studies and Polysomnography Services (4/1/13)
  • 1A-21, Endovascular Repair of Aortic Aneurysm (3/12/12)
  • 1A-22, Medically Necessary Circumcision (3/12/12)
  • 1A-23, Physician Fluoride Varnish Services (3/12/12)
  • 1A-24, Diabetes Outpatient Self-Management Education (3/12/12)
  • 1A-25, Spinal Cord Stimulation (4/1/13)
  • 1A-26, Deep Brain Stimulation (3/12/12)
  • 1A-27, Electrodiagnostic Studies (4/1/13)
  • 1A-28, Visual Evoked Potential (VEP) (3/12/12)
  • 1A-31, Wireless Capsule Endoscopy (3/12/12)
  • 1A-32, Tympanometry and Acoustic Reflex Testing (3/12/12)
  • 1A-33, Vagus Nerve Stimulation for the Treatment of Seizures (7/1/12)
  • 1A-36, Implantable Bone Conduction Hearing Aids (BAHA) (2/1/13)
  • 1A-38, Special Services: After Hours (3/12/12)
• Physicians Drug Program
  • 1B, Physician's Drug Program (3/12/12)
  • 1B-1, Botulinum Toxin Treatment: Type A (Botox) and Type B (Myobloc) (9/1/12)
  • 1B-2, Rituximab (Rituxan) (3/1/12)
  • 1B-3, Intravenous Iron Therapy (3/1/12)
• Podiatry
  • 1C-1, Podiatry Services (3/12/12)
  • 1C-2, Medically Necessary Routine Foot Care (5/1/12)
• Clinics
  • 1D-1, Refugee Health Assessments Provided in Health Departments (3/12/12)
  • 1D-2, Sexually Transmitted Disease Treatment Provided in Health Departments (9/15/12)
  • 1D-3, Tuberculosis Control and Treatment Provided in Health Departments (3/1/12)
  • 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics (10/15/12)
• Obstetrics & Gynecology
  • 1E-1, Hysterectomy (1/1/13)
  • 1E-2, Therapeutic and Non-therapeutic Abortions (3/1/12)
  • 1E-3, Sterilization Procedures (3/12/12)
  • 1E-4, Fetal Surveillance (3/12/12)
  • 1E-5, Obstetrics (9/1/11)
  • 1E-6, Pregnancy Medical Home (8/15/12)
• 1F, Chiropractic Services (11/1/07)
• Burn Treatments
  • 1G-1, Burn Treatment (3/12/12)
  • 1G-2, Bioengineered Skin (1/4/13)
• 1H, Telemedicine and Telepsychiatry (7/1/12)
• 1-I, Dietary Evaluation and Counseling (3/12/12)
• Radiology
  • 1K-1, Breast Imaging (3/12/12)
  • 1K-2, Bone Mass Measurement (8/1/12)
  • 1K-6, Radiation Oncology (3/1/12)
  • 1K-7, Prior Approval for Imaging Services (3/12/12)
• Anesthesia
  • 1L-1, Anesthesia Services (3/1/12)
  • 1L-2, Moderate (Conscious) Sedation, AKA Procedural Sedation and Analgesia (PSA) (5/1/13)
• Maternal Support Services (Baby Love)
  • 1M-2, Childbirth Education (3/12/12)
  • 1M-3, Health and Behavior Intervention (3/12/12)
  • 1M-4, Home Visit for Newborn Care and Assessment (3/12/12)
  • 1M-5, Home Visit for Postnatal Assessment and Follow-up Care (3/12/12)
  • 1M-6, Maternal Care Skilled Nurse Home Visit (3/12/12)
• Allergies
  • 1N-1, Allergy Testing (2/1/13)
  • 1N-2, Allergen Immunotherapy (2/1/13)
• Reconstructive Surgery
  • 1-O-1, Reconstructive and Cosmetic Surgery (11/1/12)
  • 1-O-2, Craniofacial Surgery (3/12/12)
  • 1-O-3, Keloid Excision and Scar Revision (10/1/12)
  • 1-O-5, Rhinoplasty and/or Septorhinoplasty (3/1/12)
• Cardiac Procedures
  • 1R-1, Phase II Outpatient Cardiac Rehabilitation Programs (7/1/12)
  • 1R-4, Electrocardiography, Echocardiography, and Intravascular Ultrasound (7/1/12)
• Laboratory Services
  • 1S-1, Genotyping and Phenotyping for HIV Drug Resistance Testing (1/1/13)
  • 1S-2, HIV Tropism Assay (3/12/12)
  • 1S-3, Laboratory Services (6/15/12)
  • 1S-4, Cytogenetic Studies (2/1/13)
• Ophthalmological Services
  • 1T-1, General Ophthalmological Services (3/12/12)
  • 1T-2, Special Ophthalmological Services (1/15/13)

Ambulance Services

• Ambulance Services Provider Manual (7/1/99)

Facility Services

• 2A-1, Acute Inpatient Hospital Services (12/1/12)
• 2A-2, Long Term Care Hospital Services (3/1/13)
• 2A-3, Out-of-State Services (4/1/13)
• 2B-1, Nursing Facilities (3/12/12)
• 2B-2, Geropsychiatric Units in Nursing Facilities (1/3/13)

Community Based Services (3A through 3K)

• 3A, Home Health Services (12/1/11)
• 3B, PACE (Program of All-Inclusive Care for the Elderly) (3/12/12)
• 3D, Hospice Services (11/1/12)
• 3G, Private Duty Nursing (12/1/12)
• 3H-1, Home Infusion Therapy (8/15/12)
• 3K-1, Community Alternatives Program for Children (CAP/C) (3/1/12)
• 3K-2, Community Alternatives Program for Disabled Adults and Choice Option (CAP/DA-Choice) (3/12/12)
• 3L, Personal Care Services (1/1/13)

Dental Program (4A and 4B)

• 4A, Dental Services (3/1/13)
• 4B, Orthodontic Services (3/12/12)

Medical Equipment (5A and 5B)

• 5A, Durable Medical Equipment (3/1/13)
• 5B, Orthotics & Prosthetics (11/1/12)

Vision Services

• Select Vision Care Services Provider Manual (10/5/11)
• 6A, Routine Eye Exam and Visual Aids for Recipients Under Age 21 (7/15/12)

Hearing Aid Services

• 7, Hearing Aid Services (6/15/12)

Behavioral Health (8A through 8N)

• 8A, Enhanced Mental Health and Substance Abuse Services   (5/1/13)
• 8B, Inpatient Behavioral Health Services (11/1/12)
• 8C, Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers (12/1/12)
• 8D-1, Psychiatric Residential Treatment Facilities for Children under the Age of 21 (8/1/12)
• 8D-2, Residential Treatment Services (8/1/12)
• 8E, Intermediate Care Facilities for Individuals with Intellectual and Developmental Disabilities (5/1/13)
• 8I, Psychological Services in Health Departments and School-Based Health Centers Sponsored by Health Departments to the under-21 Population (3/12/12)
• 8J, Children's Developmental Service Agencies (CDSAs) (8/1/12)
• 8L, Mental Health/Substance Abuse Targeted Case Management (9/1/12)
• 8M, Community Alternatives Program for Individuals with Intellectual/Developmental Disabilities (CAP-I/DD) (10/01/12)
• 8N, Intellectual and Developmental Disabilities Targeted Case Management (6/1/11)
• 8-O, Services for Individuals with Intellectual and Developmental Disabilities and Mental Health or Substance Abuse Co-Occurring Disorders (3/12/12)

Pharmacy Services

• 9, Outpatient Pharmacy Program (2/7/13)
• 9A, Over-The-Counter Products (3/1/12)
• 9B, Hemophilia Specialty Pharmacy Program (1/31/13)
• 9C, Mental Health Drug Management Program Administrative Procedures (7/1/12)
• 9D, Off Label Antipsychotic Safety Monitoring in Beneficiaries Through Age 17 (7/1/12)
• 9E, Off Label Antipsychotic Safety Monitoring in Beneficiaries 18 and Older (7/1/12)

Specialized Therapies (10A through 10D)

• 10A, Outpatient Specialized Therapies (6/1/12)
• 10B, Independent Practitioners (IP) (3/12/12)
• 10C, Local Education Agencies (LEAs) (3/1/12)
• 10D, Independent Practitioners Respiratory Therapy Services (3/1/12)

Transplants and Transplant-Related Services (11A through 11H)

• Stem Cell Transplants
  • 11A-1, Hematopoietic Stem-Cell or Bone Marrow Transplantation for Acute Lymphoblastic Leukemia (ALL) (3/12/12)
  • 11A-2, Hematopoietic Stem-Cell and Bone Marrow Transplant for Acute Myeloid Leukemia (12/15/12)
  • 11A-3, Hematopoietic Stem-Cell & Bone Marrow Transplantation for Chronic Myelogenous Leukemia (3/12/12)
  • 11A-5, Allogeneic Hematopoietic & Bone Marrow Transplant for Genetic Diseases and Acquired Anemias (3/12/12)
  • 11A-6, Hematopoietic Stem-Cell & Bone Marrow Transplantation in the Treatment of Germ Cell Tumors (3/12/12)
  • 11A-7, Hematopoietic Stem-Cell & Bone Marrow Transplantation for Hodgkin Lymphoma (3/12/12)
  • 11A-8, Hematopoietic Stem-Cell Transplantation For Multiple Myeloma and Primary Amyloidosis (3/1/12)
  • 11A-9, Allogeneic Stem-Cell & Bone Marrow Transplantation for Myelodysplastic Syndromes & Myeloproliferative Neoplasms (3/1/12)
  • 11A-10, Hematopoietic Stem-Cell & Bone Marrow Transplantation for Central Nervous System (CNS) Embryonal Tumors & Ependymoma (3/12/12)
  • 11A-11, Hematopoietic Stem-Cell & Bone Marrow Transplant for Non-Hodgkin’s Lymphoma (3/1/12)
  • 11A-14, Placental and Umbilical Cord Blood as a Source of Stem Cells (3/12/12)
  • 11A-15, Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood (3/1/12)
  • 11A-16, Hematopoietic Stem-Cell Transplantation for Chronic lymphocytic leukemia (CLL) and Small lymphocytic lymphoma (SLL) (3/1/12)
• Solid Organ Transplants
  • 11B-1, Lung Transplantation (8/1/12)
  • 11B-2, Heart Transplantation (8/1/12)
  • 11B-3, Islet Cell Transplantation (8/1/12)
  • 11B-4, Kidney Transplantation (3/12/12)
  • 11B-5, Liver Transplantation (8/1/12)
  • 11B-6, Heart/Lung Transplantation (8/1/12)
  • 11B-7, Pancreas Transplant (8/1/12)
  • 11B-8, Small Bowel and Small Bowel/Liver and Multivisceral Transplants (8/1/12)
• 11C, Ventricular Assist Device (3/12/12)

Targeted Case Management

• 12A, Case Management Services for Adults and Children at Risk for Abuse, Neglect, or Exploitation (3/12/12)
• 12B, Human Immunodeficiency Virus (HIV) Case Management (3/12/12)

Auditory Implant External Parts

• 13A, Cochlear and Auditory Brainstem Implant External Parts Replacement and Repair (3/12/12)
• 13B, Soft Band and Implantable Bone Conduction Hearing Aid External Parts Replacement and Repair (2/1/13)

No Longer Active Policies

• For a listing of No Longer Active Policies go here.