NC Medicaid Community Alternatives Program for Children (CAP/C)
Customize your policy alerts
Sign up for alliance_health_nc Policy 3K-1 alerts
Get alerted when Policy 3K-1 changes without checking for updates manually.
Monitor payer policy activity
Defines CAP/C eligibility, covered services, provider requirements, documentation, prior approval, and program operations for Medicaid beneficiaries (age-specific provisions noted) participating in North Carolina's CAP/C waiver program.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
inv-01: Coverage overview
When the Procedure, Product, or Service Is Covered; General and Specific Criteria Covered are listed in the TOC.
See Table of Contents for section locations.
inv-02: General CAP/C coverage criteria
Covered when ALL of the following are met
Services must be documented on a person-centered service plan.
Waiver provides community alternative to institutional care.
Waiver supplements existing supports.
inv-03: Initial and ongoing CAP/C coverage criteria
Covered when ALL of the following are met
Subsection 3.1 requirements apply.
Refer to Appendix F for reasonable indication of need.
Refer to Subsection 5.7.3 and Appendix F regarding cost and supports.
Emergency/disaster plan is mandatory.
See Subsection 2.1.2 and Appendix F.
Subsection 3.2.1(c) and 5.5 specify plan requirements.
inv-04: Consumer direction criteria
When electing consumer direction, ALL of the following must be met
Refer to Appendix G for details and required documentation.
Assessment must detail training needs and assurances for health, safety, and emergency planning.
inv-05: HCBS Nursing Facility Level of Care Criteria
Covered when the beneficiary meets HCBS nursing facility level of care as defined by the following criteria sets
LOC reassessment can be triggered by change in condition using the SRF.
Listed as qualifying examples.
Applies when medical condition is stable per treatment plan.
Multiple discrete qualifying service needs listed.
Document specifies combined-condition logic.
Items listed as Category I.
Items listed as Category II.
inv-06: Community Transition
Covered when ALL of the following are met
Services must be documented and included in the person-centered service plan.
inv-07: Community Integration
Covered when ALL of the following are met
As identified and justified in the person-centered service plan.
inv-08: Coordinated Caregiving
Covered when ALL of the following are met
Provided in-home or community settings when not LEA responsibility.
inv-09: Home Accessibility and Adaptation
Covered when ALL of the following are met
Identified in the comprehensive assessment and person-centered service plan.
inv-10: Goods and Services (individual-directed and provider-led)
Covered when ALL of the following are met
Must be included in the person-centered service plan and approved.
Must be included in the person-centered service plan and approved.
inv-11: Nutritional Services
Covered when ALL of the following are met
Must be physician-ordered and included in the person-centered service plan.
inv-12: Pest Eradication
Covered when ALL of the following are met
Home must be owned/occupied by beneficiary; not covered if lease includes pest control.
inv-13: Pediatric Nurse Aide Services
Covered when ALL of the following are met
Assessment must validate medical condition and need.
inv-14: Respite Services (Institutional and In-Home)
Covered when ALL of the following are met
Combined institutional and in-home respite cap applies.
Subject to EVV; combined institutional and in-home respite not to exceed 30 calendar days or 720 hours per fiscal year.
inv-15: Specialized Medical Equipment and Vehicle Modifications
Covered when ALL of the following are met
Equipment must be identified in the person-centered service plan and meet documentation requirements.
Modifications must meet standards and be approved in service plan.
inv-16: Training, Education and Consultative Services
Covered when ALL of the following are met
Documented in person-centered service plan.
inv-17: General coverage criteria for CAP/C participation
Covered when ALL of the following are met
Provider must submit required documents within stated timeframes.
inv-18: Initial enrollment and ongoing authorization criteria
Covered when ALL of the following are met
Telephonic initial assessment allowed for safety but face-to-face required within timelines when indicated.
Annual plan approval and expiration rules apply (13 months service plan expiration).
inv-19: Service plan revisions and retroactivity
Covered when ALL of the following are met
Specified plan change submission and approval timelines apply.
Service/equipment cannot be procured prior to start of retroactive date.
External review not needed for provider agency change.
inv-20: Denial, disenrollment, and reentry
Conditions and timelines for disenrollment, reentry, and denial
DSS notified of disenrollment and Medicaid status.
inv-21: Assessment content requirements
Comprehensive assessment must include ALL of the following modules
Assessment completed by licensed NC Nurse with MDT consultation per Subsection 5.4.
inv-22: Equipment and modification approval criteria
Requests for equipment, modifications, or adaptive car seats are approved when ALL applicable items below are provided
Items continuing need must be identified during annual reassessment and planned in service plan.
Beneficiary shall not take possession of vehicle with existing lift prior to approval when applicable.
inv-23: Operational and eligibility criteria
Coverage and operational requirements for CAP/C services and entities
Subsection 6.0 requirements.
10A NCAC compliance referenced.
CME takes possession if beneficiary transfers back to provider-led planning.
CIAE must follow NC Medicaid guidelines including prior authorization and utilization management.
Case manager continuing education 9 hours/year required.
inv-24: Administrative and Provider Eligibility Criteria
Covered when ALL of the following administrative and provider capacity conditions are met:
Supports administrative coverage and program integrity.
Local Approval Authority approves CAP/C services and overall plan of care.
Provider attestation required per Subsection 6.6.
EVV requirements apply where statutory; CME may submit MMIS claims for home modifications as indicated.
CME is local entry point for CAP/C enrollment and management.
inv-25: Provider qualifications and operational criteria
Providers must meet the following qualifications and operational rules to render CAP/C services:
Refer to Subsection 6.6.3.
CME and provider must monitor respite hours to avoid exceeding limits.
Refer to Subsection 6.6.2 and 6.6.6.
EVV compliance required where applicable.
EVV compliance required where applicable.
Refer to Subsection 6.6.8.
Refer to Subsection 6.6.9.
Refer to Subsection 6.6.9 and 7.3 documentation requirements.
inv-26: Documentation timing and monitoring rules
Monitoring and documentation requirements must be met as follows:
Refer to Subsection 7.4.
Refer to Subsection 7.3.
Refer to Subsection 7.6.
Refer to Subsection 7.6 and 7.6. Frequency details.
inv-27: Monitoring visits
Monitoring frequency and modality requirements
Electronic/technology monitoring limited to two occurrences per quarterly scheduling period.
inv-28: Monthly monitoring and response
Monthly monitoring requirement
Refer to Subsection 7.6 and 7.6.d-e.
inv-29: Individual Risk Agreement criteria
Use of Individual Risk Agreement and consequences
Refer to Subsection 7.11 and 7.10 consequences.
inv-30: Health and safety exclusion conditions
Health, safety, and well-being conditions leading to denial or disenrollment
Any of these unmitigable conditions may justify denial or disenrollment per Subsection 7.10.
inv-31: Absence, hospitalization, and facility admission criteria
Absence, hospitalization, and nursing facility rules
CME notifies DSS and discharge planner and revises service plan if needed.
Medicaid eligibility changes affect CAP/C participation.
Providers must be notified of placement.
CME must contact providers and track absence; notify DSS for extended approved absences.
inv-32: Disenrollment criteria
Disenrollment may occur for any of the following reasons:
Occurrences e–j may lead to disenrollment after three occurrences or after one occurrence if risk to health/welfare cannot be mitigated.
inv-33: Mandated Waiver Assurances
Mandated waiver assurances and expectations (state must monitor and uphold these assurances):
Includes conflict-of-interest rules prohibiting dual roles except in limited rural circumstances with safeguards.
inv-34: CME performance and dual-role safeguards
CME performance and dual-role safeguards:
Dual-role approval is exceptional and monitored by Long-Term Services and Supports Section.
inv-35: HCBS and residential setting requirements
HCBS and residential setting characteristics required for providers:
Any modification of these conditions must be supported by a specific assessed need in the person-centered service plan.
The policy TOC identifies a section titled "When the Procedure, Product, or Service Is Not Covered" that groups general and specific noncoverage rules. Details for those Not Covered provisions are located elsewhere in the full document and are referenced in the table of contents for provider review.
Within the excerpts provided there are no line-item exclusions spelled out; the policy fragments here show service headings and appendix references but the explicit lists of excluded procedures or services are found in the Not Covered sections elsewhere in the complete policy.
CAP/C waiver services are intended to supplement supports when informal or community resources cannot meet assessed needs. The policy states services are for situations where no household member, relative, caregiver, landlord, community agency, volunteer agency, or third-party payer is able or willing to meet the beneficiary's assessed medical, psychosocial, and functional needs.
The subsection labeled "Medicaid Additional Criteria Covered" is present in the Specific Criteria Covered area of the TOC and explicitly states "None Apply." This indicates no extra Medicaid-only coverage criteria are defined in that subsection.
Subsection 3.2.2 in the policy text is titled "Medicaid Additional Criteria Covered" and plainly states "None Apply." Providers should not expect additional Medicaid-only coverage rules in that subsection.
The policy specifies services are not covered when eligibility or the coverage criteria are not met; when the procedure/product/service duplicates another provider's service; when the item is experimental, investigational, or part of a clinical trial; or when required assessments, recertifications, or forms (e.g., SRF) are incomplete or not submitted within stated timeframes.
Explicit noncoverage conditions include: absence of the required nurse/social worker assessment; SRF incomplete/denied or missing required information within timeframes; failure to complete annual recertification within required windows; beneficiary contact not established for >90 calendar-days; beneficiary not active for Medicaid or in sanction; and beneficiaries who reach their 21st birthday.
Certain categories are subject to specific restrictions: retroactive approval is limited for goods and services, training/education/consultative services, home and vehicle modifications, and assistive technology (these may only be considered under urgent need rules); CAP/C beneficiaries remain eligible for other Medicaid services except where those policies restrict participation or create duplication; providers must attest to nonuse of restraints and seclusions; and unauthorized restraints, seclusion, or drugs used as restraints are prohibited.
The policy reiterates that CAP/C beneficiaries are eligible to receive all Medicaid services according to Medicaid policies, except when another Medicaid policy or procedure restricts participation or the service would duplicate coverage under another payer.
CAP/C providers are required to complete CAP/C overview and orientation training and must attest to policies ensuring the nonuse of restraints and seclusions. This attestation is a condition of participation and reflects program expectations for health and welfare safeguards.
Relatives (spouse, parent, child, sibling) may be employed to provide certain CAP/C services only when they meet age and aide qualification requirements or are deemed competent by a licensed supervisory professional, meet live-in caregiver requirements when applicable, and their employment does not interfere with or supersede the beneficiary's identified care needs.
The policy prohibits CAP/C providers and caregivers from using unauthorized or unnecessary interventions that restrict movement, access, rights, or employ aversive methods. Specifically, personal and mechanical restraints, drugs used as restraints, and seclusion are not permitted (with narrow safety-device exceptions described in the policy).
A CAP/C provider agency, vendor, or contractor must not provide direct services to a CAP/C beneficiary in situations that create a prohibited conflict or otherwise violate program integrity rules; agencies are also prohibited from offering gifts or inducements to influence beneficiary choice of provider.
The Table of Contents and Not Covered sections indicate that specific noncoverage criteria are defined elsewhere in the policy. Providers should consult the Not Covered and Specific Criteria Not Covered subsections for definitive lists of exclusions applicable to CAP/C services.
The policy clarifies that the CAP/C waiver exists to fill needs that cannot be met by other supports. Services are provided when informal and formal supports are unable or unwilling to meet the beneficiary's assessed needs; the waiver thereby supplements, but does not replace, services available under the Medicaid State Plan or other payers.
When conditions specified in the General Criteria Not Covered or Specific Criteria Not Covered apply—or when services are undocumented on the approved person-centered service plan, unauthorized by NC Medicaid, or not medically necessary—the services are considered Not Medically Necessary and may be denied. Such undocumented or unauthorized services may be referred to Medicaid's Program Integrity unit for evaluation and possible recoupment.
Coverage denial is triggered when a beneficiary fails to meet eligibility in Section 2.0, does not meet criteria in Section 3.0, when services duplicate another provider's services, or when services are experimental/clinical trial-related. In addition, lack of required assessments, missing SRF or service-plan signatures within prescribed windows, inability to establish contact for >90 calendar-days, or services not documented and authorized will lead to denial or referral to Program Integrity.
The policy directs that services not documented on the approved service plan, not authorized by NC Medicaid, or not medically necessary may be reported to Medicaid's Program Integrity unit for review and potential recovery of funds. Home care agencies providing non-medically necessary care or care not performed per authorizations may likewise be referred for evaluation and possible recoupment.
Undocumented services or services deemed not medically necessary that are billed to Medicaid are subject to referral to Program Integrity for investigation and potential recoupment, and providers or agencies found noncompliant may face administrative actions.
The policy states that Program Integrity will evaluate services that are not documented in the service plan, unauthorized by NC Medicaid, or not medically necessary; such cases may lead to recoupment of reimbursement and regulatory referrals where falsified records or other misconduct are identified.
Codes, Limits, and Key Numeric Rules
| CAP/C in-home aide (IHA) | CAP/C in-home aide (IHA) |
| Care advisor | Care advisor |
| Community integration services | Community integration services |
| Community transition service | Community transition service |
| Coordinated Caregiving | Coordinated Caregiving |
| Goods and services - Participant, Individual-directed, Pest eradication, Nutritional services and Non-medical transportation | Goods and services - Participant, Individual-directed, Pest eradication, Nutritional services and Non-medical transportation |
| Assistive technology | Assistive technology |
| Attendant Nurse Care | Attendant Nurse Care |
| Case management | Case management |
| Financial management services | Financial management services |
| HCPCS Codes (see Attachment A) | HCPCS Codes referenced for services billable under the CAP/C Waiver as listed in Attachment A |
Prior Approval, Documentation, Billing, and Compliance
Obtain Prior Approval Before Providing CAP/C Services
Prior approval is required for CAP/C level-of-care services; providers must obtain prior approval before rendering CAP/C services as specified in the policy.
Prior Authorization Details Located Elsewhere in Policy
This Table of Contents segment lists service sections and page numbers but does not specify prior authorization rules or affected codes; refer to the Prior Approval sections elsewhere in the policy for details.
Prior Authorization Rules Not Included in This Excerpt
The excerpt provided here does not contain the full prior authorization rules; prior authorization requirements and affected documentation are defined in later sections (see Subsections 5.1–5.2).
Beneficiary Must Be Enrolled in CAP/C Waiver
Beneficiaries must be approved for the CAP/C waiver and have an assigned waiver slot; services are provided only as specified on the person-centered service plan under CAP/C waiver authority.
EPSDT Does Not Waive Prior Approval for Under‑21 Beneficiaries
If a service requires prior approval, beneficiaries under age 21 still require prior approval; EPSDT does not remove the prior approval requirement.
Deliver Services Only Per an Approved Person‑Centered Service Plan
Services must be listed in an approved person-centered service plan that identifies amount, duration, frequency, and provider taxonomy; an approved service plan is required for CAP/C participation and service delivery.
Specify and Document Services in the Service Plan Before Approval
Many waiver services (including Community Transition, home/vehicle modifications, assistive technology) require approval and must be specified in the person-centered service plan; vendor/provider requirements and required supporting documentation apply before approval.
- Community Transition expenditures must be necessary, documented, and limited to one year (chunk 109).
- Requests for assistive technology, home/accessibility, and vehicle modifications require MDT/professional recommendations, cost estimates, training plans, and other documentation (chunks 158–160).
Prior Approval Required — Submit SRF, Assessment, and Service Plan
Prior approval (prior authorization) is required for CAP/C level-of-care services; providers must submit required records (SRF, comprehensive assessment, and person-centered service plan) and obtain prior approval before providing services.
- Provider must obtain PA before rendering CAP/C services (chunk 132).
- SRF, multidisciplinary assessment, and draft person-centered service plan must be submitted to obtain approval and PA transfer to NCTracks (chunks 134–135).
Complete the SRF Within 45 Calendar‑Days
The HCBS Service Request Form (SRF) must be completed within 45 calendar-days of initiation or it will be voided; SRF slots are not reserved beyond 45 days.
- All SRF sections and fields must be fully completed to establish eligibility determination (chunk 134).
CME Issues Service Authorizations and Confirms Provider Acceptance
The Case Management Entity (CME) shall authorize selected providers per the approved service plan through service authorizations that detail period, services, tasks, amount, duration, frequency, and type; the CME must confirm provider receipt/acceptance timelines.
- CME must confirm provider receipt and acceptance within 72 hours; providers must accept/reject within three business days (chunk 157).
- Once provider accepts in CAP Business System, a prior approval record is transmitted to the DHHS fiscal contractor (chunk 157).
CIAE Coordinates SRF Completion and Prior‑Authorization Documentation
The Comprehensive Independent Assessment Entity (CIAE) coordinates referrals and obtains consent and necessary information to complete the Service Request Form (SRF); CIAE responsibilities include assisting with documentation required for prior authorization.
- CIAE processes referrals and coordinates with applicants to obtain consent and documentation to complete SRF (chunk 170).
- CIAE conducts multidisciplinary assessments and completes critical incident reports within 72 hours (chunk 170).
Obtain LAA/CME Authorizations; CME May Submit MMIS Claims for Some Items
CAP/C services require authorization by the local approval authority (LAA) and the CME via service authorizations; prior authorization requirements apply and the CME may be listed to submit MMIS claims for certain home modification taxonomy items.
- Local Approval Authority approves CAP/C services and overall plan of care (chunk 182).
- When indicated, CME may submit MMIS claims for home modification taxonomy and reimburse contractors via invoice (chunk 197).
CME Must Issue Service Authorization for Providers to Bill Medicaid
The CME must provide a service authorization to qualifying selected providers to render approved CAP/C services and to submit claims to Medicaid; in some home modification cases the CME is listed as the MMIS submitter and reimburses the contractor via invoice.
- CME authorizes providers to render services and submit claims (chunk 200).
- When indicated, CME is listed to submit MMIS claims for home modifications and then reimburse contractors via invoice (chunk 197).
Submit Required Pre‑Approval Documentation for Equipment, Modifications, and Training
Prior to approval and implementation of assistive technology, home adaptations, specialized equipment/supplies, training, and vehicle modifications, the CME must obtain required supporting documentation (e.g., MDT recommendation, physician attestation, training plan, cost/quote, and equipment life expectancy).
- MDT or professional recommendation with cost and training plan is required (chunks 158–159).
- Physician attestation/order and supplier invoice, life expectancy of equipment, and documented training outcomes are required (chunks 219, 218).
Provide Services Only as Specified in Person‑Centered Service Plan
Services must be listed in and delivered according to the person-centered service plan specifying type, scope, amount, duration and frequency; providers must follow the plan and applicable HCBS characteristics.
Use an EVV Solution for In‑Home Aide Visits
Providers subject to EVV requirements must use an EVV solution (mobile app, telephony, or fixed device) to capture in‑home aide visits; EVV validation components and effective dates are specified in policy.
- EVV is required effective January 1, 2021, and must capture the six validation components (chunk 255).
- Providers must register with the state's EVV solution or procure a compliant alternate and maintain beneficiary and staff EVV notification/training documentation (chunk 254).
No Step Therapy Requirements in This Excerpt
No step therapy or step‑therapy-like requirements are present in the provided chunks; the policy contains no step therapy information in these sections.
Respite Services Are Subject to EVV
Respite services (institutional and in‑home) are subject to EVV requirements per Section 12006 (1903(l)) of the 21st Century Cures Act; providers must comply with EVV rules when delivering personal care–type respite services.
- Combined institutional and in‑home respite must not exceed 30 calendar days or 720 hours per fiscal year (chunk 121).
- Respite providers must comply with EVV statutory requirements (chunk 121) and EVV policy requirements (chunk 254).
Obtain EVV Confirmation to Ensure Claim Adjudication
Providers subject to EVV must obtain EVV confirmation for personal care–type services to ensure adjudication of claims for those services.
Bill Only Within Your Medicaid‑Authorized Scope and Enrollment
Providers may only bill for procedures, products, and services within the scope of their clinical practice and who meet Medicaid participation and enrollment requirements (current signed DHHS Provider Administrative Participation Agreement required).
- Provider must meet Medicaid qualifications and have a current signed DHHS participation agreement (chunk 166).
- Billing limited to services within the scope of the provider's clinical practice (chunk 166).
Follow Billing and Invoicing Rules; Retain Supplier Invoices/Receipts
Billing must follow specified rules: bill cost/invoice amounts for equipment, supplies, home modifications, community transition items; bill customary charges or Medicaid nursing facility rates for respite and other services per Attachment A/Appendix B; retain supplier invoices/receipts.
- Specialized medical equipment: bill cost as invoiced by supplier and comply with Subsection 5.7 (chunk 211).
- Institutional respite: bill Medicaid nursing facility rate for the catchment area (chunk 212).
- Community Transition and goods/services: bill cost per supplier invoice and retain receipts (chunk 212; chunk 196).
Avoid Dual‑Role Conflicts — CME Must Not Also Provide Direct Services (Except With Approval)
Conflict‑of‑interest protections prohibit a case management entity from both developing the person‑centered service plan and rendering approved direct CAP/C services for the same beneficiary except in limited rural circumstances when state grants dual‑role approval with safeguards.
- When dual‑role approval is granted, safeguards must separate monitoring and service functions and include independent quality reviews (chunk 247).
Telephony and Automated Systems Allowed for Documentation per NC Medicaid Guidance
Providers may utilize telephony and other automated systems to document CAP/C service provision in accordance with NC Medicaid telephony/telehealth and CAP/C electronic engagement guidance.
Submit Required Documentation for CAP/C Participation and Reimbursement
CAP/C Service Requests and Required Documentation sections list minimum documents required for participation approval and reimbursement; providers and CMEs must submit required forms and supporting health records for approval and claims.
- Initial required documents include SRF, signed consents, participants' rights, freedom of choice, service plan, and comprehensive multidisciplinary assessment (chunk 143).
- Change‑in‑status and annual documentation requirements are specified and include physician orders, nurse notes, and summaries for PNA/IHA services over 90 days when applicable (chunk 144).
Complete Nurse‑Led Multidisciplinary Assessment to Establish LOC and Eligibility
An initial and annual comprehensive multidisciplinary assessment must be completed by a licensed nurse (with MDT input) to determine medical/functional needs and HCBS LOC; failure to complete required nurse/social worker assessment per Appendix F precludes CAP/C participation.
- Assessment identifies reasonable indication of need and supports LOC determination (chunks 92, 145).
- Lack of required assessment is a specific noncoverage trigger (chunk 127).
Document EVV Notifications and Staff Training
Providers must document that beneficiaries were informed of EVV requirements and must complete required EVV trainings; agencies must maintain written beneficiary notification and initial/at least annual staff training records.
- Provider agencies must have written beneficiary notification in each beneficiary's file and maintain staff EVV training documentation (chunk 254).
Maintain Complete Service Records and Supporting Documentation in CAP Business System
Providers and CMEs must maintain service records in the CAP Business System, including referrals, all assessments, service plans, authorizations, case notes, monitoring notes, invoices, critical incidents, grievances/complaints, and copies of claims; documentation must be available for review.
- Service notes must be completed within 72 hours, include purpose, date/duration, goals, progress, recommendations, and signature (chunk 213).
- Supplier invoices/receipts must be retained for purchases reimbursed (chunk 196; chunk 219).
Require Vendor Receipts/Invoices for Reimbursement; CME May Submit MMIS Claims for Modifications
Vendors must provide a receipt or invoice for each purchase for reimbursement; for home modifications the CME may be listed as the provider to submit MMIS claims and must retain invoices identifying completion of the modification.
Authorize In‑Home Respite via Case Manager and Document Service Record
Case management authorization is required for in‑home respite services and the service record must document authorization details; CME is responsible for monitoring respite hours to avoid exceeding fiscal‑year caps.
- Combined institutional and in‑home respite limit: 30 calendar days or 720 hours per fiscal year (chunk 121).
- Respite documentation must include beneficiary name, Medicaid ID, type, date, location, duration, tasks, and signed service note (chunk 220).
Obtain Authorized Signature on Service Plan Within 30 Days or Risk Disenrollment
If an initial or annual person‑centered service plan is not submitted with an authorized signature within 30 calendar days, the applicant/beneficiary becomes ineligible or subject to disenrollment; NC Medicaid will disenroll when signature cannot be obtained.
- CME must obtain authorized signature within 30 calendar days of plan effective date to retain eligibility (chunk 152).
Verify Medicaid Eligibility at Each Service Encounter
Providers must verify each Medicaid beneficiary's eligibility every time a service is rendered.
Denial Triggers: Eligibility, Missing Assessments, SRF, Duplicate or Experimental Services, or Loss of Contact
Coverage may be denied or services not covered when eligibility or criteria in Sections 2.0 or 3.0 are not met; when services duplicate another provider; when services are experimental; when required assessments/recertifications (e.g., SRF, annual assessment) are not completed within required timeframes; or when contact with beneficiary cannot be established for >90 days.
- SRF incomplete after 45 days will be voided (chunk 134).
- Beneficiary contact not established for >90 calendar‑days after >2 verbal and >2 written attempts may lead to noncoverage/disenrollment (chunk 128).
Budget Neutrality Exceedance Triggers Cost Utilization and Adjustment Plans
If average per‑capita waiver costs exceed 110% of institutional per‑capita costs, NC Medicaid initiates a 90‑day cost utilization plan and may implement cost adjustment plans and monitor individual beneficiary utilization until cost neutrality is restored.
- NC Medicaid develops a 90‑calendar‑day cost utilization plan and may implement additional 90‑day cost adjustment plan; continued monitoring follows if thresholds persist (chunk 165).
Maintain Required Documentation or Risk Denial/Recoupment
Failure to maintain required documentation (e.g., proof of live‑in caregiver address, service records, billing documentation, supplier invoices) or to follow service authorizations and billing rules risks denial of reimbursement, recoupment, or program integrity referral.
- Paid live‑in caregiver address verification requires two supporting documents, one a photo ID, and must be confirmed beginning June 1 and every six months (chunk 211).
- Service notes due within 72 hours; late entries require notation and must be supported (chunk 213).
- Services not documented on the service plan or not authorized may be referred to Program Integrity for evaluation and recoupment (chunk 252).
Program Background and Purpose
Background: The CAP/C waiver provides home and community-based services to medically fragile and medically complex children to avoid institutionalization. It supplements formal and informal supports when those supports cannot meet assessed medical, psychosocial, or functional needs, and is administered under federal HCBS waiver authority.
Key Definitions and Terms
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.