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Updates to North Carolina Medicaid

18 Sep 2018 2:54 PM | Zachary Edgar (Administrator)

Prior Approval changes to NC Medicaid coverage for adults.

Removal of diagnosis specific coverage and replaced with general prior authorization requirement and service limit:

Prior approval is required at the start of all treatment services. 

Detailed information and instructions for registering and submitting requests is available on The Carolinas Center of Medical Excellence (CCME) website https://www.medicaidprograms.org/NC/ChoicePA The provider shall submit a request to DHHS utilization review contractor to start the approval process. Please note that approval, if granted, is for medical approval only and does not guarantee payment or ensure beneficiary eligibility on the date of service. 

The first prior approval request within a calendar year shall be for no more than three therapy treatment visits and one month. The PA review vendor will authorize these three treatment visits to begin as early as the day following the submission of the PA request. Any subsequent PA may be obtained for up to 12 therapy treatment visits and six months. A beneficiary can receive a maximum of 27 therapy treatment visits per calendar year across all therapy disciplines combined (occupational therapy, physical therapy and speech/language therapy). 

Each reauthorization request must document the efficacy of treatment.


About Me

Zachary Edgar JD, LLM is Therapy Comply's managing partner.  Zachary is a healthcare attorney who specializes in federal and state healthcare regulatory issues particularly for physical, occupational, and speech therapy practices.  

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