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

Annual Visit Limit

Proposed Changes to Annual Visit Limits

Session Law 2007-323, section 10.36.(e)(2) and Session Law 2013-360, section 12H.13.(d)(1) made changes and further defined visit limits for NC Medicaid beneficiaries. Webinars were held on December 12, 2013 and December 16, 2013. Proposed changes to "Clinical Policy 1A-29 Annual Medical Visit Limitation" was open for stakeholder comments through March 5, 2014.

The recordings of the webinars and the PowerPoint Presentations are available at the following Websites:

General Information on Annual Visit Limits

On August 1, 2008, DMA implemented a new annual visit limitation for Medicaid recipients effective with dates of service July 1, 2007, and after. This change is the result of Session Law 2007-323.

The Code of Federal Regulations (CFR) defines the services that must be provided by each state Medicaid program. These services are mandatory services. Each state may decide which, if any, optional services, as defined by the CFR, will be covered. Optional services that are covered by the N.C. Medicaid Program include optometry, chiropractic services, and podiatry.

According to the Centers for Medicare and Medicaid Services (CMS), a visit limit may not combine both mandatory and optional services.

Mandatory Services

Annual Visit Limit Period - July 1 through June 30
Number of Visits - 22
Provider Types Included in Visit Count:

  • Physicians (except for physicians enrolled in N.C. Medicaid with a specialty of oncology, radiology, or nuclear medicine)
  • Nurse practitioners
  • Nurse midwives
  • Health departments
  • Rural health clinics
  • Federally qualified health centers

Optional Services

Annual Visit Limit Period - July 1 through June 30
Number of Visits - 8
Provider Types Included in Visit Count:

  • Chiropractors
  • Optometrists
  • Podiatrists

CPT Procedure Codes Subject to the Annual Visit Count

DMA has designated specific CPT procedure codes that are counted towards the annual visit limitation. The codes will be reviewed on a regular basis and updated as appropriate.

CPT Procedure Codes Spreadsheet

ICD-9-CM Diagnosis Codes that Are Not Subject to the Annual Visit Limitation

DMA has designated specific ICD-9-CM diagnosis codes that do not count towards the annual visit limitation. The codes will be reviewed on a regular basis and updated as appropriate.

ICD-9-CM Diagnosis Code Spreadsheet

Recipients Who Are Not Subject to the Annual Visit Limitation

The following recipients are exempt from the annual visit limitation.

  1. Recipients under the age of 21
  2. Recipients enrolled in a Community Alternatives Program (CAP)
  3. Pregnant recipients who are receiving prenatal and pregnancy-related services

Requesting an Exception

If a provider anticipates that additional care will be needed for a specific condition, and the care is medically necessary, the provider may request an exception to the annual visit limit for mandatory services.

Requesting an exception in NC Tracks is done through the provider PA portal.  To submit a request for an exception, providers should access the prior approval module through the NCTracks secure provider portal. Providers must enter their NCID, then click on "Prior Approval" and submit a Prior Approval request selecting PA Type 23. Providers should present information explaining why additional visits are needed.

The exception must be requested and approved before the service is rendered. If a claim is submitted prior to receiving approval for an exception, and the claim is denied for exceeding the visit limit, the provider may submit an electronic adjustment.  A copy of the recipient's medical record documenting the visit with the specific condition and medical necessity of the visit to actively manage or treat the condition must be submitted with the adjustment. The adjustment request and supporting documentation will be reviewed for medical necessity by the Medical Director.

Revision to the Annual Visit Limit (“Clinical Policy 1A-29 Annual Medical Visit Limitation”) are pending. Those with questions regarding the pending policy changes should contact the CSC help desk at 1-800-688-6696.

Notification Process

In addition to the visit limit change, the law requires the N.C. Department of Health and Human Services (DHHS) to

  • establish a visit limitation threshold that indicates that a recipient is nearing the total allowed visits
  • implement a process of notification to the appropriate Community Care of North Carolina/Carolina ACCESS (CCNC/CA) network or primary care provider when a recipient reaches the visit limitation threshold

A process has been implemented to assist primary care providers in managing their patients' visits that count toward the annual visit limitations. The CCNC/CA network is notified when a recipient has used five or more visits (in any combination) of the mandatory services listed above. CCNC/CA will notify the recipient’s primary care provider.

 

 




State of North Carolina Home Page
August 14, 2014