Prior approval referenced in policy

The Table of Contents and policy sections reference Prior Approval and Prior Approval Requirements; prior approval is referenced in policy organization and may apply where specified elsewhere in policy.

EPSDT and prior approval — under‑21 note

For beneficiaries under 21, EPSDT does not remove prior approval requirements — if a service requires prior approval elsewhere, that requirement still applies; providers should consult NCTracks and the EPSDT provider page for details.

• If the service requires prior approval, being under 21 does NOT eliminate that requirement (chunk 20).
• EPSDT allows exceeding policy limits if provider documentation demonstrates medical necessity to correct or ameliorate a condition (chunk 18).

No prior approval required for this level of care

Medicaid shall not require prior approval for Medically Monitored Intensive Inpatient Services; the policy states no general or specific prior approval requirements apply.

• Section 5.1: Medicaid shall not require prior approval for these services (chunk 37).
• Sections 5.2.1 and 5.2.2 state 'None Apply' for general and specific prior approval requirements (chunks 38–39).

Billing codes and claims guidance

Report the most specific billing code; use H0013 for adults and H0013-HA for adolescents, with 1 billing unit = 1 day, and follow NCTracks and NC Medicaid claims/billing guidance.

• H0013 — Adult; Billing Unit = 1 Day (chunk 70).
• H0013-HA — Adolescent; Billing Unit = 1 Day (chunk 70).
• Comply with NCTracks Provider Claims and Billing Assistance Guide and National Coding Guidelines (chunks 67–68).

Code selection and unlisted procedure reporting

When no specific CPT/HCPCS code exists, follow current HCPCS National Level II and CPT instructions for unlisted procedures and provide special reports as required; report the most specific code that accurately describes the service.

• Follow CPT Unlisted Procedure or Service instructions and Special Report (chunk 71).
• Follow HCPCS National Level II Unlisted Procedure instructions and Special Report (chunk 73).
• Policy requires reporting the most specific billing code and using unlisted codes if none exist (chunk 70).

Timing of medical and clinical assessments

Admission must include RN alcohol/other drug‑focused nursing assessment at admission and a physician/PA/NP physical exam within 24 hours; a licensed professional must complete the CCA or DA within 10 calendar days.

• RN conducts alcohol/other drug-focused nursing assessment at time of admission; RN monitors progress and medication administration (chunk 26).
• Physician/PA/NP must conduct a physical exam within 24 hours of admission (chunk 26; chunk 100 for adults).
• A comprehensive clinical assessment (CCA) or diagnostic assessment (DA) must be completed within 10 calendar days of admission (chunk 26).

Prior authorization — none required

Prior authorization is not required for Medically Monitored Intensive Inpatient Services per policy (no additional prior authorization process specified in these chunks).

General coverage prerequisites — medical necessity

Services must be individualized, specific, consistent with diagnosis/symptoms, not in excess of needs, safely furnished, and provided when no equally effective, more conservative or less costly statewide treatment is available.

• Service must be individualized, specific, and consistent with symptoms or confirmed diagnosis and not in excess of beneficiary's needs (chunk 22).
• Service must be safely furnished and no equally effective, more conservative or less costly statewide treatment is available (chunk 22).
• Service must not be primarily for convenience of beneficiary, caretaker, or provider (chunk 22).

Medication access and MAT arrangements

Provide access to all FDA‑approved MAT medications on the Medicaid formulary for beneficiaries meeting medical necessity; MAT may be administered on‑site or via MOA/MOU with a provider no more than 60 minutes from the facility.

• Access to all FDA‑approved MAT medications covered by the Medicaid formulary when medically necessary (chunks 56, 103).
• MAT may be administered by the provider or via MOA/MOU with another provider no further than 60 minutes from the facility (chunks 56, 103, 85).
• Providers must ensure on‑site naloxone availability and staff training for overdose response (chunk 104).

MAT access — formulary and MOA/MOU distance

Facilities must ensure access to FDA‑approved MAT medications on the Medicaid formulary for beneficiaries meeting medical necessity; arrangements may be via MOA/MOU within 60 minutes.

• Adolescent programs: MAT access per formulary; MOA/MOU with another provider ≤ 60 minutes (chunk 85).
• Adult programs: MAT access per formulary; MOA/MOU with another provider ≤ 60 minutes (chunk 103).

Provider obligation to ensure MAT access

Providers shall ensure access to all FDA‑approved MAT medications covered by the Medicaid formulary for beneficiaries meeting medical necessity; MAT may be administered onsite or via agreement with a provider no more than 60 minutes away.

EPSDT documentation — beneficiaries under 21

For beneficiaries under 21, document medical necessity showing how the requested service corrects or ameliorates a condition per EPSDT criteria when exceeding policy limitations.

• Provider documentation must show how the service corrects, ameliorates, or prevents worsening of a health problem to meet EPSDT criteria (chunk 18).
• If prior approval is required elsewhere, EPSDT does not remove that requirement (chunk 20).

Required admission documentation and assessments

Initial abbreviated assessment at admission must document presenting problem, needs and strengths, provisional/admitting diagnosis, pertinent social/family/medical history, and other appropriate evaluations; RN must perform an alcohol/other drug‑focused nursing assessment at admission.

• Initial abbreviated assessment must include: presenting problem; needs and strengths; provisional/admitting diagnosis; pertinent social/family/medical history; other evaluations as appropriate (chunk 26).
• RN shall conduct an alcohol or other drug‑focused nursing assessment at time of admission and monitor progress and medication administration (chunk 26).
• Use the abbreviated assessment as part of the Person‑Centered Plan (PCP) development (chunk 26).

Continued stay and discharge documentation — ASAM dimensions

Review and document each of the six ASAM dimensions in the service record for continued stay, discharge, or transfer decisions; documentation must support PCP modifications or transfer/discharge determinations.

• Each ASAM dimension (1–6) must be reviewed and documented for continued stay, discharge, or transfer (chunk 27).
• Documentation must substantiate the determination and support modifications to the PCP or transfer/discharge decisions (chunks 27–29).

Service order requirement and timing

A signed service order must be completed prior to or on the first day of service by an authorized professional; backdating is not permitted; verbal orders are allowed only in urgent situations and must be documented and countersigned within 72 hours.

• Service order must be signed and dated by the authorizing professional and indicate the date ordered; must be in place prior to or on the first day of service to bill Medicaid (chunk 44).
• Backdating the service order is not permitted (chunk 44).
• Verbal service orders require documentation on the date given and must be countersigned within 72 hours (chunk 44).

Clinical documentation and shift/MAR requirements

Maintain accurate service and shift notes per DHHS Records Management and Documentation Manual; service requires a shift note for every shift and additional service notes when events require; MAR/eMAR must meet regulatory requirements.

• Complete a shift note for every shift of service provided; document events requiring additional service notes (chunk 45).
• Service and shift notes must meet DHHS Records Management and Documentation Manual; MAR/eMAR must meet 10A NCAC 27G .0209(c)(4) or equivalent (chunk 47).
• Staff providing the service are responsible for accurate documentation of services billed and reimbursed by Medicaid (chunk 47).

Administrative documentation and compliance

Comply with HIPAA, record retention, NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins and fee schedules, and NC Medicaid clinical coverage policies when maintaining administrative documentation.

• Providers shall comply with all applicable federal, state and local laws and regulations including HIPAA and record retention (chunk 61).
• Follow NCTracks Provider Claims and Billing Assistance Guide and NC Medicaid billing guidance (chunk 67).

Billing and documentation — code reporting and separate E/M billing

Report the appropriate codes that determine billing units and follow HCPCS National Level II instructions, modifier guidelines, and billing unit rules; physicians may bill E/M codes separately for assessments and tests.

• Report codes that determine billing units and follow HCPCS National Level II instructions and modifier guidelines (chunk 75).
• Physician/PA/NP can bill Evaluation and Management CPT codes separately for admission assessment, CCA, physical exam, and medical evaluation; diagnostic assessment may be billed separate from the inpatient service (chunk 78).
• Use most specific CPT/HCPCS/UB-04 codes; if none exist use appropriate unlisted codes (chunk 70).

Eligibility verification at each encounter

Verify each Medicaid beneficiary's eligibility at every service encounter; failure to verify eligibility may affect payment or eligibility for coverage.

• An eligible beneficiary must be enrolled in NC Medicaid and providers shall verify eligibility each time a service is rendered (chunk 12).
• Beneficiary may have service restrictions due to eligibility category that could make them ineligible (chunk 12).

General denial triggers — eligibility and criteria failures

Services are not covered if the beneficiary does not meet Section 2.0 eligibility, does not meet Section 3.0 criteria, duplicates another provider's service, or is experimental or part of a clinical trial.

• Noncoverage triggers include failure to meet eligibility (Section 2.0) or criteria (Section 3.0), duplication of services, or experimental/clinical trial services (chunk 31).

Specific non‑covered services — billing prohibitions

Do not bill Medicaid for specific non‑covered activities such as transportation, habilitation, recreational time not tied to planned social skill assistance, childcare, academic instruction, interventions not on the PCP, services for others, or room and board.

• Transportation for beneficiary or family members is not covered (chunk 32).
• Habilitation activities and recreational time unless tied to planned social skill assistance are not covered (chunks 32–34).
• Childcare, academic instruction, interventions not on the PCP, services for others not directly related to beneficiary, and payment for room and board are not covered (chunk 34).

Denial risk — billing without valid service order

Billing without a valid service order in place prior to or on the first day of service will result in denial; backdating is not permitted and verbal orders must meet strict documentation and countersignature rules.

• Service order must be in place prior to or on the first day of service to bill Medicaid; without it billing will be denied (chunk 44).
• Verbal service orders must be documented the date given and countersigned within 72 hours to be valid (chunk 44).

Denial risk — incomplete shift notes or MAR documentation

Failure to complete required shift notes, service notes, and MAR/eMAR documentation per DHHS Records Management and Documentation Manual and 10A NCAC 27G .0209 may result in denial or nonpayment.

• Shift note required for every shift and additional service notes as needed (chunk 45).
• MAR/eMAR must meet regulatory requirements; documentation responsibilities rest with the staff who provided the service (chunk 47).

Coding and reporting risk — unlisted procedures and specificity

Failure to report unlisted procedures per CPT/HCPCS guidance or to use the most specific CPT/HCPCS/ICD‑10 codes could trigger claim denials; providers must refer to current codebook instructions and special report requirements.

• Follow CPT and HCPCS instructions for unlisted procedures and include Special Report when required (chunks 71, 73).
• Policy requires reporting the most specific billing code that accurately describes the service (chunk 70).

Prohibited service — conversion therapy

North Carolina Medicaid will not reimburse for conversion therapy; billing for conversion therapy is prohibited.

Licensure requirement — NC 10A NCAC 27G .3400

Services must be provided in a facility licensed under 10A NCAC 27G .3400 (Residential Treatment Rehabilitation for Individuals with Substance Abuse Disorders) or under an approved rule waiver; lack of required licensure may risk noncoverage or denial.

• Adolescent and adult program licensure requirement under 10A NCAC 27G .3400; facilities must be licensed or operate under an approved rule waiver (chunks 85, 104).
• Tribal/IHS/638 programs follow federal provisions where applicable (chunk 85).

Training documentation — retention and waiver rules

Failure to maintain documentation of initial staff training or documentation of approved waivers may result in noncompliance; providers must retain training records and may waive initial training if staff provide documentation of equivalent training within 48 months prior to hire.

• Initial training requirements may be waived if staff document appropriate training completed within 48 months before hire (chunks 95, 115).
• Providers must maintain documentation of training activities; staff hired prior to the policy effective date must complete required training within one year of the original effective date (chunk 95).