NC Medicaid Enhanced Mental Health and Substance Abuse Services
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Defines coverage, prior authorization, provider qualifications, documentation, and claims-related information for enhanced mental health and substance abuse services under NC Medicaid for beneficiaries enrolled in a Prepaid Health Plan (PHP). Affects providers delivering these services and PHP-enrolled beneficiaries.
Amended Date: January 1, 2026
Added LCMHC, LCMHCA, and CADC per NC Session Law; effective with related rule change
Revised telehealth/telephonic language and GT modifier guidance
Migrated several substance abuse services to standalone CCP policies (effective 01/01/2026)
Removed prior authorization/authorization language to comply with MHPAEA and CFR § 438.900
Added Tribal and IHS provider licensure exemptions
Policy Header and Core Summary
This policy defines coverage for NC Medicaid Enhanced Mental Health and Substance Abuse Services. Coverage is provided when the sections titled 'When the Procedure, Product, or Service Is Covered' and 'Specific Criteria Covered' are met, per the policy. Providers must follow the General Criteria Covered and any Specific Criteria Covered referenced in Subsection 3.1 and 3.2.
Eligibility and reimbursement require that the beneficiary be enrolled in NC Medicaid and that providers verify Medicaid eligibility each time a service is rendered. Services are covered only when they meet the general conditions (individualized, consistent with diagnosis, necessary and not primarily for convenience) and the specific medical necessity requirements described in the policy.
Service-level prerequisites include a written service order signed and dated by an authorized professional that is in place on or before the date of initial service; service orders are valid for one year. A Person-Centered Plan (PCP) must be in place at admission, relate billed services to PCP goals, and be reviewed/rewritten at least annually. Service notes must document required content (date, service name, contact type, purpose tied to PCP goals, interventions, duration, effectiveness/progress assessment, signature with credentials, and beneficiary identifiers).
Level-of-care details are provided in service-specific sections and Attachment D: Service Definitions; this excerpt contains headings and an index of levels (Inpatient, Residential, Partial Hospitalization, Intensive Outpatient, Outpatient) but does not include top-level admission or continued-stay criteria.
Select services named in the policy (for example, Mobile Crisis Management, Intensive In-Home Services, Multisystemic Therapy, Psychosocial Rehabilitation, Child and Adolescent Day Treatment, Partial Hospitalization, and Facility-Based Crisis) have their detailed level-of-care criteria and ordering requirements located in their individual service subsections or Attachment D.
Telehealth and telephonic delivery are referenced for some services; consult the service-specific sections and Policy 1-H for telehealth delivery rules and any related limitations.
Coverage and Medical Necessity Criteria
inv-03: Eligibility for reimbursement — Covered when ALL of the following are met:
Covered when ALL of the following are met:
Providers must confirm beneficiary eligibility each visit; beneficiary eligibility category restrictions may render them ineligible for some services.
inv-04: General Criteria Covered — Medicaid covers services when ALL of the following are met
Medicaid covers services when ALL of the following are met:
See Subsection 3.2 and Attachment D for service-specific definitions and medical necessity criteria.
inv-05: Specific Criteria Covered (Subsection 3.2)
Specific coverage requirements:
Definitions: (a) Preventive — anticipate development and preclude occurrence; (b) Diagnostic — examine symptoms to understand condition; (c) Therapeutic — treat or preserve health; (d) Rehabilitative — restore to normal or optimum health. Refer to Attachment D for service-specific medical necessity criteria. Medicaid Additional Criteria Covered: None Apply.
inv-06: Medical necessity and documentation prerequisites
Covered when ALL of the following are met (service-level medical necessity and planning requirements):
Even if beneficiary is retroactively eligible, providers cannot bill Medicaid without a valid service order.
If limited information at admission, document known information and update later; refer to Attachment B for PCP goal writing guidance.
Staff who provide the service are responsible for documentation; supervision and signature rules are detailed in Attachment D and related manuals.
North Carolina Medicaid and North Carolina Health Choice expressly do not reimburse for conversion therapy. Providers must not submit claims to Medicaid for services that meet the definition of conversion therapy; Medicaid reimbursement is prohibited regardless of setting or provider.
This non-reimbursement statement aligns with the policy's explicit exclusion language and billing guidance stating that conversion therapy is not a payable service under NC Medicaid.
Several substance abuse services previously listed in this policy were removed and migrated to standalone Clinical Coverage Policies (CCP). Examples include the Opioid Treatment Program, Ambulatory Withdrawal/Detoxification services, Substance Abuse Intensive Outpatient/Comprehensive Outpatient Treatment programs, and non-medical and medically monitored residential substance abuse services. These services are now maintained in separate CCP documents effective 01/01/2026 (see related CCP references).
The policy text and revision history reflect these removals: references to specific substance abuse service definitions and codes were deleted from this policy's Medicaid Service Summary, Attachment A (Claims-Related Information), and Attachment D (Service Definitions) and relocated to the designated standalone CCPs.
Consistent with the policy exclusions, North Carolina Medicaid shall not reimburse for conversion therapy. Providers are required to bill any liable third-party payers before submitting claims to Medicaid, but under no circumstances will Medicaid pay for conversion therapy services.
This prohibition is reiterated in the Reimbursement and Revision Information sections and is an explicit policy stance prohibiting coverage of conversion therapy.
Codes, Modifiers, Billing Units, Place of Service
| ICD-10-CM | International Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification |
| PCS | Procedural Coding System (PCS) |
| Billing Units | Billing Units (see Attachment A for unit definitions and reporting) |
| Place of Service | Place of Service codes (see Attachment A) |
| GT | Modifier to indicate service provided via interactive audio-visual telehealth communication (append to CPT/HCPCS) |
| KX | Modifier to indicate service provided via telephonic, audio-only communication (append to CPT/HCPCS) |
| HT | Modifier to indicate multidisciplinary team service (append to HCPCS) |
| HA | Modifier HA (used when billing H2012: Child and Adolescent Day Treatment) |
| Modifiers | Providers shall follow applicable modifier guidelines as detailed in Attachment A |
| Telehealth POS filing | Telehealth claims should be filed with the provider's usual place of service code(s) and not place of service 02 (Telehealth). |
| Billing Units | See Attachment A for billing unit definitions and reporting; providers using institutional claims shall bill applicable revenue codes. |
| Claim Type | See Attachment A: Claim Type guidance for appropriate claim filing |
| GT | Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio-visual communication (telehealth). |
| Telehealth place of service filing | Telehealth claims should be filed with the provider's usual place of service code(s) and not POS 02 (Telehealth). |
| KX | Modifier KX must be appended to the CPT or HCPCS code to indicate that a service has been provided via telephonic, audio-only communication. |
| CPT/HCPCS/UB-04 | Providers shall report the most specific billing code (CPT, HCPCS, or revenue code) that accurately and completely describes the procedure, product, or service and follow current editions in effect at time of service. |
| Unlisted CPT/HCPCS | Follow current CPT/HCPCS instructions for unlisted procedures and provide special report as required. |
| ICD-10-CM | Report ICD-10-CM and PCS to the highest level of specificity that supports medical necessity and use the current ICD-10 edition in effect at time of service. |
| H2011 | Mobile Crisis Management; 1 unit = 15 minutes; triage and screening telehealth eligible; use GT modifier for telehealth when applicable |
| No codes listed |
| H2022 | Intensive In-Home Services; 1 unit = 1 day; telehealth eligible = No |
| No codes listed |
| H2033 | Multisystemic Therapy; 1 unit = 15 minutes; telehealth eligible = No |
| No codes listed |
| H2017 | Psychosocial Rehabilitation; 1 unit = 15 minutes; telehealth eligible = No |
| No codes listed |
| H2012 | Child and Adolescent Day Treatment; bill with Modifier HA; 1 unit = 1 hour; telehealth = No |
| No codes listed |
| H0035 | Partial Hospitalization; 1 unit = 1 event; telehealth eligible = No |
| No codes listed |
| S9484 | Professional Treatment Services in Facility-Based Crisis Programs - Adult; 1 unit = 1 hour; telehealth eligible = No |
| No codes listed |
| GT | Append GT to indicate interactive audio-visual telehealth communication |
| KX | Append KX to indicate telephonic, audio-only communication |
| HT | Append HT to indicate multidisciplinary team service (more than one team member) |
| No codes listed |
Provider Obligations, Prior Approval, and Documentation
Prior Approval Required
Prior approval is required as described under the policy's Prior Approval and Utilization Management sections; providers must follow the prior approval process outlined in the policy before rendering services that require it.
Prior Approval for Child & Adolescent Day Treatment
Medicaid requires prior approval before rendering Child and Adolescent Day Treatment; the provider must obtain prior approval prior to providing these services.
- Prior approval must be obtained before rendering Child and Adolescent Day Treatment.
Submit Prior Approval & Supporting Records to DHHS Contractor
Providers must submit the prior approval request plus all health records and supporting documentation showing the beneficiary meets the specific criteria in Subsection 3.2 to the DHHS Utilization Review Contractor.
- Submit the prior approval request to the DHHS Utilization Review Contractor.
- Include all health records and any other records that support the beneficiary meets Subsection 3.2 criteria.
Review Service Migrations and UM Updates
Several services were migrated to standalone policies and utilization management statements were updated; providers must consult the revised service-specific utilization management and authorization requirements in the updated/standalone policies.
- Diagnostic Assessment and other services moved to separate CCP policies; check those policies for current UM/authorization rules.
- Utilization management is performed by NC Medicaid's designated contractor or the LME‑MCO (see Attachment D for service-specific requirements).
Authorization Language Removed for MHPAEA/CFR §438.900 Compliance
Language referencing prior approvals, initial authorizations, reauthorizations, concurrent authorization, and similar authorization language was removed from multiple services to comply with MHPAEA and 42 CFR §438.900; providers should note these authorization-language changes in the policy.
- Authorization-related wording removed from listed services to align with MHPAEA / CFR §438.900.
Non‑Reimbursable Services & Coordination of Benefits
North Carolina Medicaid will not reimburse for conversion therapy; providers must bill other third‑party payers (including Medicare) before submitting a claim to Medicaid when applicable.
- Do not bill Medicaid for conversion therapy—Medicaid will not reimburse.
- Bill all other third‑party payers, including Medicare, prior to submitting Medicaid claims.
Report Appropriate Procedure Codes and Billing Units
Providers shall report the appropriate procedure code(s) that determine billing units and follow current CPT/HCPCS/UB‑04 specifications when selecting codes.
- Report the procedure code(s) that determine the billing unit(s).
- Follow current CPT, HCPCS, and UB‑04 specifications when selecting codes.
Incomplete Prior Approval Submissions Risk Denial
Failure to submit the required prior approval request and supporting health records that demonstrate the beneficiary meets the Subsection 3.2 criteria may result in denial of the request or payment.
- Include all supporting health records with the prior approval request to avoid denial.
- Requests lacking required documentation may be denied.
Verify Medicaid Eligibility at Each Visit
Providers must verify each beneficiary's Medicaid eligibility at each service encounter; services may be denied if the beneficiary is not enrolled or has eligibility-based service restrictions.
- Verify Medicaid eligibility each time a service is rendered.
- Be aware that eligibility category restrictions may make a beneficiary ineligible for a service.
Include Required Content and Signature in Service Notes
Service notes must document the nature and course of treatment and include required fields; the staff member who provided the service must sign the entry with credentials or job title.
- Document date, service name, contact type, place when required, purpose related to PCP goals, intervention description, duration, assessment of effectiveness/progress, signature with credentials/job title, and beneficiary identifiers.
- The staff person who provides the service must sign the written entry; QP countersignature is not required for non‑QP staff notes.
Maintain Supervision Documentation for APs & Paraprofessionals
Documentation must support the supervision provided to Associate Professionals and Paraprofessionals; individualized supervision plans must be created at hire and reviewed annually and kept on file.
- Maintain documentation to support supervision for APs and Paraprofessionals.
- Create an individualized supervision plan at hire and review it annually.
Align Documentation with Attachments and DMHDDSAS Guidance
All documentation must be consistent with this policy, Attachment D service definitions, and the DMHDDSAS Records Management and Documentation Manual; service‑specific frequency and format requirements are found in the service definitions.
- Ensure documentation aligns with Attachment D service definitions and DMHDDSAS guidance.
- Follow service‑specific documentation frequency/format requirements in Attachment D.
Authorizations & UM Affect Payment
Failure to obtain required authorizations or to meet utilization management requirements described in the policy and attachments may affect payment or result in denial.
- Follow prior approval and utilization management processes described in the policy to avoid payment impacts.
Ensure Claims Comply with NCTracks & Medicaid Guidance
Claims must comply with the NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, NC Medicaid clinical coverage policies and other referenced documents; noncompliance may trigger denial.
- Follow NCTracks guides, Medicaid bulletins, fee schedules, and clinical coverage policies when submitting claims.
Report ICD‑10 Codes to Highest Specificity
Providers must report ICD-10-CM and PCS diagnosis codes to the highest level of specificity that supports medical necessity and use the current ICD‑10 edition in effect at the time of service to reduce risk of denial.
- Report ICD‑10‑CM/PCS to the highest level of specificity that supports medical necessity.
- Use the current ICD‑10 edition in effect at the time of service.
Listed Behavioral Health Services and Modalities
inv-144: behavioral_health_services
Top-level reference listing behavioral health modalities and pointing to service definitions and attachment sections for details.
See Attachment D for each service's detailed definition and medical necessity criteria.
inv-145: Mobile Crisis Management
Attachment D and Attachment A contain full service criteria and coding guidance; H2011 triage and screening telehealth eligibility indicated in Attachment A.
inv-146: Intensive In-Home Services
Attachment D includes service-specific medical necessity and staffing/order requirements; Attachment A indicates H2022 billing unit = 1 day and telehealth eligible = No.
inv-151: Multisystemic Therapy (MST)
Attachment D contains MST medical necessity details; HCPCS H2033 billing unit = 15 minutes (see Attachment A/Coding).
inv-152: Partial Hospitalization
Attachment D and Attachment A contain full clinical and billing rules for Partial Hospitalization.
inv-153: Facility-Based Crisis Professional Treatment Services
Attachment D provides clinical criteria; Attachment A lists billing unit and telehealth eligibility.
inv-156: Telehealth/Telephonic Services
See Attachment A for telehealth modifier (GT) and POS filing instructions; follow Policy 1-H for telehealth requirements.
inv-157: service-specific ordering requirements
Service orders may be written by MD, DO, Licensed Psychologist, NP, or PA; backdating is not allowed.
Short-range PCP goals may not exceed 12 months from the Date of Plan.
inv-158: Telehealth, Service reassignments
See revision history and Attachment A for exact modifier instructions and migrated service references.
inv-159: Medicaid-coded behavioral health services (list)
Grouped reference to service-specific billing/coding details for listed modalities.
Refer to Attachment A and each service section for telehealth eligibility, modifier requirements, and billing unit details.
Visit Limits, Age Ranges, and Eligibility Exceptions
Definitions and Attachments
Background, Scope, and Notices
Background: This document is the NC Medicaid Enhanced Mental Health and Substance Abuse Services clinical coverage policy (Clinical Coverage Policy No: 8A). It applies to beneficiaries enrolled in NC Medicaid and describes coverage, prior approval, provider qualifications, documentation, and claims-related information for enhanced mental health and substance abuse services.
The policy covers multiple behavioral health services and references attachments (A–D) and related coverage policies; information in Sections 1.0–8.0 of this policy supersedes attachment information where noted.
Providers must consult related coverage policies for any service-specific prior authorization or criteria. Relevant cross-referenced policies include: 8A-1, 8A-5, 8A-7, 8A-11, 8B, 8C, 8D-1, 8D-2, 1-H, and the CCP policies implementing standalone substance-abuse services (e.g., CCP 8A-7, CCP 8A-9, CCP 8A-11, CCP 8A-12, CCP 8A-13, CCP 8D-5, CCP 8D-6).
Telehealth and telephonic filing and modifier guidance were updated across attachments: the policy added telehealth language and clarified modifier use (for example, adding GT modifier guidance for interactive audio-visual telehealth and instructing that telehealth claims be filed with the provider's usual place of service rather than POS 02). Revisions also removed some telephonic KX modifier language and updated telehealth eligibility for specific service components; consult Attachment A and Policy 1-H for complete telehealth and place-of-service instructions.
Revision History and Policy Changes
Policy amended effective January 1, 2026 (Amended Date listed in policy header).
References to multiple substance-abuse services were removed because those services were migrated to standalone CCP policies (effective 01/01/2026).
Language referencing prior approval/authorizations, reauthorizations, concurrent authorization, utilization management and unmanaged units/visits was removed to comply with MHPAEA and 42 C.F.R. §438.900.
Added Tribal Licensure Standards and note that Federally recognized Tribes or IHS providers may be exempt from certain provider credentialing requirements under federal law.
Telehealth language and attachments revised: GT modifier guidance added and telehealth filing with usual place of service clarified; 'face-to-face' replaced with 'in-person' in service definitions.
Amended Date: January 1, 2026. This amendment includes material changes: migration of multiple substance abuse services to standalone CCP policies with an effective date of 01/01/2026, updates to licensure titles and additions (e.g., LCMHC and CADC), and telehealth/modifier guidance updates across attachments.
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