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NC Department of Health and Human Services
NC Division of
Medical Assistance
 
 

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.

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

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No Longer Active Policies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

Ambulance Services

Facility Services

Community Based Services

Dental Program

Medical Equipment

Vision Services

Hearing Aid Services

Behavioral Health

Pharmacy Services

Specialized Therapies

Transplants and Transplant-Related Services

Targeted Case Management

Auditory Implant External Parts

No Longer Active Policies

  • For a listing of No Longer Active Policies go here.