Prior approval required (submit PA + supporting records; physician referral required)

Prior approval is required before rendering State Plan Personal Care Services in in‑home settings; the amount is based on an independent assessment by the designated Comprehensive Independent Assessment Entity (CIAE). Providers must submit the prior approval request and supporting health records to the DHHS Utilization Review Contractor and obtain a physician referral (NC Medicaid-3051) as part of the prior authorization process.

• Prior approval required before rendering PCS (5.1).
• Prior approval amount determined by CIAE independent assessment (5.1, 5.4.c–d).
• Providers must submit prior approval request and all supporting records (5.2.1).
• Physician referral (NC Medicaid-3051) required for prior approval (5.2.2, 5.4.2).

Prior authorization referenced in TOC — provider certifications and requirements noted

The Table of Contents and provider qualifications sections reference prior authorization, provider certifications, and related provider requirements, but do not provide full prior authorization procedural details in this excerpt — providers must follow the policy sections indicated for complete certification and PA rules.

• Provider certifications and Provider Interface requirements are listed under Provider Qualifications (6.1.x).
• Reference to Prior Approval Requirements and EPSDT additional requirements are in the TOC (5.2.x).

Attachment A referenced for claims and prior authorization documentation

Claims and coding guidance is provided in Attachment A (Claims-Related Information); providers must follow Attachment A and NCTracks guidance for claims and coding when submitting authorization‑related or billing documentation.

• Attachment A contains claim type, ICD-10 and coding guidance (Attachment A).
• Claims must comply with NCTracks Provider Claims and Billing Assistance Guide and applicable coding/claiming guidance.

Prior authorization referenced but detailed rules not included in this excerpt

This excerpt references prior authorization sections but does not include full procedural prior authorization rules here; providers must refer to the cited prior approval subsections for the detailed PA process.

• Table of Contents lists Prior Approval and Prior Approval Requirements (5.1, 5.2).
• No complete PA procedural rules are contained in the provided chunks.

CIAE prior approval required — authorization based on independent assessment

Prior approval from the CIAE is required before rendering PCS; the CIAE conducts the independent assessment that determines qualifying ADLs, level of assistance, and the amount/scope of authorized PCS hours.

• CIAE designated by NC Medicaid conducts assessments and issues prior authorization (5.4.a, 5.4.c–d).
• Authorization amount is based on the independent assessment of ADL needs (5.1, 5.4.d).

Expedited/fast‑track provisional authorization — up to 60 billable hours

An expedited/fast‑track provisional authorization may pre‑authorize up to 60 billable PCS hours; provisional authorization must be followed by the standard face‑to‑face assessment and is adjusted to assessed need per policy timelines.

• Expedited/fast‑track process pre‑authorizes up to 60 billable PCS hours (5.4.4.d–f).
• Face‑to‑face assessment must be completed within 3–5 months and provisional authorizations are adjusted to assessed needs (5.4.4.d).
• Provisional authorization timeframes and Medicaid eligibility handling are specified (5.4.4.i–j).

Retroactive prior approval timing — 30‑day lookback for initial requests

Retroactive prior approval for initial requests may be effective to the request date if the Request for Independent Assessment form is received by the CIAE within 30 calendar days of that request date; if received after 30 days, authorization is effective the date CIAE received the form.

• Retroactive effective date applies when form received within 30 calendar days of request date (5.5).
• If form received >30 days after request date, effective date is CIAE receipt date (5.5).

Service plan must be entered and validated in Provider Interface before PA is granted

Prior approval for PCS hours or units will not be granted until the provider develops the on‑line PCS service plan and it is entered into and validated by the Provider Interface; reimbursement is limited to hours and services specified and scheduled in the validated PCS service plan.

• All CIAE referrals are transmitted via the Provider Interface and require a new online service plan (6.1.4.a–d).
• Service plan must be validated by the Provider Interface for consistency with the CIAE assessment (6.1.4.h).
• Providers reimbursed only for authorized hours/services specified in the validated plan; prior approval not granted until plan validated (6.1.4.o–p).

Annual CQI attestation — submit by Dec 31 and provide CQI records upon request

PCS provider organizations must submit an annual CQI attestation to NC Medicaid by December 31 each year confirming compliance with the organizational CQI program and must provide CQI documents upon request for reviews.

• Develop and update Quality Improvement Plan at least quarterly; conduct annual beneficiary PCS satisfaction survey (7.7.a–c).
• Submit annual attestation of CQI compliance by December 31 and provide CQI documentation upon request (7.7.e–f).

Retroactive PA window — PASRR timing may permit up to 30‑day retroactive effective date

Retroactive prior approval may be effective up to 30 days prior when PASRR requirements are met; if PASRR is not completed or effective within 30 days of referral submission, retroactive approvals do not apply for beneficiaries seeking admission to Adult Care Homes.

• Retroactive prior approval tied to PASRR effective date when within 30 days of Physician Referral submission (History and 5.5).
• If PASRR effective date not within 30 days of referral submission, referral is invalid and retroactive approval does not apply (History 5.5/5.4 notes).

Expanded hours (>standard limits) require physician attestation + qualifying criteria; absolute maximum applies

Hours may exceed standard monthly limits only with a physician attestation and qualifying criteria per Session Law 2013‑306; even with expansions the total authorized hours may not exceed the absolute maximum stated by the State Plan.

• Expanded hours require physician attestation and qualifying dementia/safety criteria per Session Law 2013‑306 (Daily Minutes/History).
• Absolute cap on monthly authorized hours applies (e.g., no more than 130 hours/month per policy) (chunk 203).

Referral Screening ID required — authorization cannot precede effective Referral Screening ID

A valid Referral Screening ID is required for PCS authorization when applicable; PCS authorization may not precede the Referral Screening ID effective date and referrals older than the allowed timeframe are invalid.

• PCS authorization cannot precede the effective Referral Screening ID date (History/5.4 notes).
• If Referral Screening ID effective date is not within 30 calendar days of Physician Referral submission, the Physician Referral is invalid and a new referral is required (182).

Authorization based on standardized assessment and Daily Minutes table (sum daily minutes; apply minimums/adjustments)

Prior authorization of PCS time is determined by summing the daily minutes from the Daily Minutes table for each day of unmet ADL need and applying minimums and allowable percentage increases per the policy; requests exceeding standard monthly caps require physician attestation and assessment verification.

• Time authorized equals sum of daily minutes for each unmet ADL per the Daily Minutes table (Appendix A: Service Level Determinations).
• If computed total <60 minutes/day, increase to minimum 60 minutes/day (202).
• Additional time up to combined caps may be authorized for exacerbating or environmental conditions and Session Law expansions require physician attestation and CIAE verification (202–203).

Develop new validated online service plan for each CIAE referral addressing all unmet needs

Providers must develop and submit a new on‑line PCS service plan for each CIAE referral based on the CIAE independent assessment results; the plan must address each unmet ADL/IADL/special assistance or delegated medical monitoring task and reflect assessment frequencies and scheduling.

• Each CIAE referral requires a new PCS service plan developed by the provider organization (6.1.4.d).
• Service plan must address each unmet ADL, IADL, special assistance, or delegated medical monitoring task identified in the assessment (6.1.4.e–f).

Aide documentation and service plan recordkeeping — document tasks, dates, aide identity, and deviations

Providers must maintain aide documentation demonstrating that all aide tasks listed in the validated online PCS service plan were performed at the indicated frequency and on the documented days; documentation must include date of service, aide tasks provided, the aide identity, and any deviations with date and reason.

• Document aide services with date, tasks provided, and aide identity (6.1.5.b).
• Document all deviations from the service plan including date and reason (6.1.5.c).
• Provider Interface option may be used or provider worksheets that mirror the validated online plan (6.1.5.d).

Assessment tools, service plans, and required forms are referenced — use NC Medicaid standardized tools/forms

The Table of Contents and Appendix A reference assessment tools, service plans, and forms; providers must follow the assessment tool and forms specified in policy (e.g., NC Medicaid-3051 referral and the standardized functional assessment approved by NC Medicaid).

• Assessment tools, service plans, and forms are referenced in the TOC (7.2, 6.1.4, 6.1.5).
• Providers must use the standardized functional assessment provided or approved by NC Medicaid (Appendix A).
• Referring clinicians must complete the NC Medicaid-3051 PCS Request for Independent Assessment attestation form (5.4.2; 5.4.3.g).

Claims and coding documentation — follow Attachment A and NCTracks guidance

Attachment A and policy sections require providers to follow claims and coding guidance; providers shall report ICD‑10 codes to the highest level of specificity and comply with NCTracks and Medicaid billing guides when submitting claims for PCS.

• Report ICD‑10‑CM and PCS codes to the highest level of specificity supporting medical necessity (Attachment A).
• Claims must comply with NCTracks Provider Claims and Billing Assistance Guide and applicable Medicaid bulletins/fee schedules (Attachment A).

Required documentation for prior approval and EPSDT — submit PA request + supporting records

Providers must submit the prior approval request and all health records and supporting documentation that demonstrate meeting specific criteria; for EPSDT exceptions, include work/school verification, Exceptional Children's verification, clinician documentation, or other independent records as applicable.

• Submit prior approval request and all health records supporting Subsection 3.2.2 criteria (5.2.1).
• For EPSDT exceptions, submit specified supporting documents before PCS is rendered (5.2.3.a–e).

Physician attestation and referral form (NC Medicaid‑3051) required and must be signed/dated with current diagnosis coding

The referring clinician must complete and submit the NC Medicaid-3051 PCS Request for Independent Assessment for Personal Care Services Attestation for Medical Need form, providing physician authorization for CIAE assessment, diagnoses with current diagnosis codes, and a signed/dated attestation of medical necessity.

• Referring clinician completes NC Medicaid-3051 form and submits to CIAE via secure fax or mail (5.4.2; 5.4.3.g).
• Form must include authorization for CIAE assessment, diagnoses and diagnosis codes, and signed/dated attestation of medical necessity (5.4.3.g.1–4).

Assessment must document ADL tasks, diagnoses, exacerbating conditions, and self‑performance ratings

The standardized assessment must document defined tasks for each qualifying ADL, causative diagnoses, exacerbating conditions/symptoms that affect ADLs, and a rating of the beneficiary's self‑performance capacity for each ADL; the assessor must review findings with family/caregivers present and obtain verbal consent for their participation.

• Assessment must define tasks for each qualifying ADL and document diagnoses and exacerbating conditions (5.4.9.a–c; Appendix A items 4 and 12).
• Assessment must include a rating of self‑performance for each ADL and review with family/caregivers present with verbal consent (5.4.9 and 5.4.9 notes).
• Appendix A lists required assessment elements including tasks, medications, supports, assistive devices, unmet days/week, assessor ratings, and next reassessment date (Appendix A).

Assessment documentation elements — Appendix A required elements

Assessment documentation must include beneficiary identification, referral summary, diagnoses and codes, medications and medication self‑management evaluation, assistive devices, task needs and days/week of unmet need, assessor ratings, environmental/safety evaluation, preferred provider, and next reassessment date as specified in Appendix A.

• Appendix A lists 16+ assessment elements including identification, diagnoses/codes, medication evaluation, supports, assistive devices, task needs, assessor ratings, environmental safety, preferred provider, and next reassessment date (Appendix A).

Do not bill for PCS provided by individuals with excluded convictions or substantiated NC Health Care Registry allegations

Providers shall not bill for PCS services provided by individuals with specified criminal convictions or substantiated NC Health Care Registry allegations; provider organizations must ensure staff pass required criminal background checks per policy.

• Prohibited convictions and substantiated registry allegations are listed; providers must ensure compliance with criminal background check requirements (6.0).
• Providers may not bill for services rendered by excluded individuals (6.0).

Cooperate with NC Medicaid compliance reviews — non‑cooperation risks audits, overpayment recovery, sanctions

Failure to cooperate with or fully participate in desktop and on‑site quality, compliance, prepayment, or post‑payment audits may result in corrective actions, overpayment recovery, or sanctions by NC Medicaid Program Integrity.

• PCS Provider Organizations must cooperate with NC Medicaid compliance reviews and meet corrective action and overpayment/sanction requirements (7.6.a–b).
• Maintain clinical and billing records to facilitate regulatory reviews and post‑payment audits (7.6.c).

No explicit denial triggers present in this TOC excerpt — consult full sections for specifics

This excerpt lists headers for compliance, EVV, audits and related topics but does not present explicit denial triggers in these table‑of‑contents chunks; providers must consult the full sections for specific denial triggers.

• TOC includes sections 7.1–7.10 covering compliance, assessment tools, EVV, audits, and supervision (TOC).
• No detailed denial trigger language appears in the provided TOC chunks.

Triggers for denial — inability to schedule assessment, lack of PA, missed reassessment timelines

Services will be denied if the CIAE is unable to schedule an assessment, prior approval is not obtained before services are provided, or reassessment requirements are not met (e.g., reassessment not completed within 30 days of prior authorization end date when beneficiary refused or did not attend).

• If CIAE unable to schedule an assessment when contacting the beneficiary, services will be denied (5.4.g).
• PCS provided prior to effective date or after end date of prior authorization is not covered (4.2.1.g).
• Reassessment not completed within 30 calendar days of prior authorization end date due to beneficiary refusal/nonattendance is a basis for not covering services (4.2.1.c).

Referral recency — beneficiary must have practitioner visit within preceding 90 days

If the beneficiary has not been seen by their practitioner within the preceding 90 calendar days, the Physician Referral will not be processed and the beneficiary must schedule a visit to request a referral for PCS assessment.

• Referral not processed if physician encounter >90 days prior (5.4.2.d).
• Beneficiary instructed to schedule an office visit to obtain a referral (5.4.2.d).

Referral must document diagnosis impacts ADLs — otherwise referral not processed

If the practitioner indicates the medical diagnosis listed on the PCS referral does not impact the beneficiary's activities of daily living (ADLs), the referral will not be processed.

• Physician must document that diagnosis impacts ADLs; if not, request is not processed (5.4.2.e).

Assessment scheduling nonresponse — failure to respond to IAE scheduling contact may lead to denial

Failure to respond when contacted by the designated IAE to schedule an assessment will result in denial of services.

• Beneficiary must respond promptly to IAE scheduling contact; inability to schedule can lead to denial (5.4.g).

Referral Screening ID timing — authorization cannot precede effective Referral Screening ID; referral invalid if dates misaligned

PCS authorization may not begin before the effective date of the beneficiary's Referral Screening ID; if the effective Referral Screening ID date is not within 30 calendar days of the Physician Referral submission, the Physician Referral is invalid and a new referral is required.

• Authorization cannot precede Referral Screening ID effective date and Referral is invalid if dates do not align within 30 days (182).

Assessment tool requirement — use NC Medicaid standardized functional assessment and document required elements

All PCS assessments must be conducted using the standardized functional assessment tool provided or approved by NC Medicaid and must document the required assessment elements listed in Appendix A.

• Standardized functional assessment is required and must include the listed components (Appendix A; 5.4.9).
• Assessment must document task needs, days/week of unmet need, medications, supports, assistive devices, assessor ratings, environmental safety, and next reassessment date (Appendix A items 1–17).

Recordkeeping and supervisory visit documentation — keep records accessible and document RN supervisory visits every 90 days

Providers must maintain clinical records and billing documentation in an accessible location to facilitate regulatory reviews and post‑payment audits; RN supervisory visits and associated documentation must be performed and recorded every 90 calendar days (with allowed grace period) per policy.

• Maintain all clinical and billing records accessible for audits and reviews (7.6.c).
• RN Supervisor must conduct supervisory visits every 90 calendar days and document visit components including date, arrival/departure times, purpose, findings, and signature (7.10.b.9).

Signed, dated PCS referral with current ICD coding required (NC Medicaid‑3051)

A signed and dated PCS referral containing the current ICD diagnosis code is required; the referring clinician must complete and submit the NC Medicaid‑3051 referral form to the CIAE.

• PCS referral must be signed and dated and include current diagnosis coding (5.4.3 g4; History 5.4.3).
• Use NC Medicaid‑3051 PCS Request for Independent Assessment form for referral and attestation (5.4.2, 5.4.3).

Service plan timelines — validate plan within 7 business days; obtain/upload consent within 14 business days

Providers must ensure the validated online PCS service plan reflects the CIAE assessment task‑by‑task and that beneficiary written consent is obtained and uploaded within specified timelines (develop/validate plan within 7 business days; obtain and upload signature within 14 business days).

• Develop and validate the PCS service plan within seven business days of accepting the CIAE referral (6.1.4.i).
• Obtain written consent signature and upload into the Provider Interface within 14 business days of validated service plan (6.1.4.j).
• Make a copy of the validated service plan available to the beneficiary within three business days of verbal request (6.1.4.k).

Service plan and aide documentation requirements — document tasks, deviations, and ensure signed logs

Providers must document aide tasks showing performance at the frequency and days indicated on the validated service plan; any deviations must be recorded with date and reason, and task logs must be signed weekly by aide and beneficiary.

• Document aide tasks per service plan frequency and days; include date, tasks, and aide identity (6.1.5.a–b).
• Document deviations from service plan with date and reason (6.1.5.c).
• RN Supervisor reviews and validates aide service records and ensures logs are signed weekly by aide and beneficiary (7.10.b.8–9).

Online Provider Interface required — submit and validate PCS service plan; documentation must match validated plan

Providers must use the Provider Interface to develop and submit the online PCS service plan; documentation of services provided must match the validated online service plan task by task.

• All CIAE referrals are transmitted through the Provider Interface and service plans must be developed there (6.1.4.a–c).
• Documentation must reflect services provided as scheduled in the online service plan task by task (6.1.4.f; Provider Interface requirements).

No step therapy information present in this extract

No step therapy information is provided in this excerpt; step therapy is not applicable in the supplied chunks.

• The provided text contains no step therapy rules or requirements.