NC Medicaid Innovations: Telehealth & Remote Monitoring
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Medicaid Clinical Coverage Policy No. 8-P governs coverage, documentation, provider qualifications, and service-specific requirements for telehealth and related services under North Carolina Medicaid Innovations for beneficiaries enrolled in Prepaid Health Plans.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Coverage sections referenced
Document outlines sections for coverage criteria including general criteria, telehealth criteria, specific Medicaid criteria, and related attachments.
Table of contents references show where detailed criteria appear in the full policy
NC Innovations Waiver Coverage
Covered when ALL of the following are met
Refer to Clinical Coverage Policy 8E for ICF‑IID LOC and Attachment C for service definitions
Eligibility and EPSDT coverage criteria
Covered when ALL of the following are met
Section 2.1.1 General
Section 2.2.1 EPSDT
Section 2.3 Eligible Coverage Groups
Medicaid Additional Criteria Covered
Covered when ALL of the following are met
Subsection 3.2.2
General Criteria Covered
Covered when ALL of the following are met
Section 3.1 General Criteria Covered
Telehealth Services
Telehealth allowed when the following are met
Subsections 3.1.1 and 3.1.2
Administrative Coverage Criteria for NC Innovations Services
Covered when ALL of the following administrative and plan requirements are met
Sections 5.1 and 5.2.1
Section 5.2.2
Sections 5.3 and ISP excerpts
ISP development, implementation, revision, and responsibilities
Covered when the ISP is developed and maintained according to NC Innovations waiver rules and timelines; responsibilities are shared across team members as specified.
Section 1 Initial ISP (5.3.1) and 5.3.1 timing
Section 5.3.4 ISP Implementation and Monitoring
Section 2 Annual ISP
Sections on ISP Revisions and Interim Plans
Sections describing Care Coordinator duties
Section 5.3.3 and provider responsibilities
The Table of Contents for this policy includes a designated section titled "When the Procedure, Product, or Service Is Not Covered" and subordinate headings for General Criteria Not Covered and Specific Criteria Not Covered, indicating where exclusions would be documented in the full policy text.
Within the supplied excerpt there are no explicit statements listing coverage exclusions; the fragments primarily present documentation and service-topic headings (e.g., 7.2 General Documentation Requirements and 7.3 Service Specific Documentation) rather than specific "not covered" rules.
The material in these chunks does not contain detailed exclusion language. Instead, it references attachments and claims-related content (Attachment A) and shows where exclusion sections appear in the Table of Contents; no explicit exclusions are provided in the excerpt.
This fragment is limited to table-of-contents entries and cross-references to attachments (e.g., Attachments A–H) and section headings; it does not list explicit coverage exclusions. Where exclusions are to be defined, the document points readers to the 4.0 When the Procedure, Product, or Service Is Not Covered section and its subsections.
Although explicit clinical exclusions are not listed in the excerpt, administrative conditions that terminate or suspend services are enumerated (for example, hospitalization, admission to an ICF-IID or other institution, temporary absence from the area, service breaks, termination of Medicaid eligibility by DSS, and beneficiary death), which affect coverage continuity.
Services allowed under the waiver are limited to those identified in the policy and referenced attachments; specifically, services not listed in Attachment A (HCPCS/claims information) or not approved by CMS for the waiver are not authorized under the waiver framework described. The waiver targets only beneficiaries meeting the specified ICF‑IID level of care.
The policy explicitly states that no NC Innovations services are eligible to be provided through EPSDT, clarifying that EPSDT does not make Innovations waiver services available via EPSDT authorities.
EPSDT provisions do not obligate the state to provide services that are unsafe, ineffective, experimental or investigational, or not generally recognized as accepted medical practice. When EPSDT is implicated for beneficiaries under 21, documentation must demonstrate that the requested service is medically necessary to correct or ameliorate the condition; however, the excerpt reiterates that Innovations services are not provided through EPSDT.
The excerpt identifies specific coverage triggers for denial: services are not covered if the beneficiary fails to meet Section 2.0 eligibility or Section 3.0 criteria; if the procedure, product, or service duplicates another provider's service; or if it is experimental, investigational, or part of a clinical trial. The document also notes that for the specific and Medicaid-additional "Not Covered" subsections the policy lists "None Apply" in this excerpt.
This extract does not include further explicit exclusion statements beyond the Table of Contents entries and cross-references; the policy structure indicates where exclusions would be located but the substantive exclusion text is not present in the provided chunks.
Temporary, one-time changes in an approved service do not require an ISP revision; for example, suspending Supported Employment for a two‑week vacation does not require a formal plan revision. The ISP revision rules and documentation topics are described in the documentation and ISP sections of the policy.
The Table of Contents references "Not Covered" sections and headings, but no explicit not medically necessary condition statements appear within the supplied text. The locations for such statements are shown, but the substantive language is absent from this excerpt.
No statements explicitly labeled "not medically necessary" are present in the provided fragments; the excerpt includes Table of Contents references and attachment placeholders but not the full "not medically necessary" determinations.
Coverage under the NC Innovations Waiver is limited to beneficiaries who meet the waiver's target group and ICF‑IID level of care requirements; beneficiaries who do not meet those criteria are not eligible for waiver services and therefore not covered under this policy.
The policy reiterates that services which are unsafe, ineffective, experimental or investigational, or not generally accepted medical practice are not required under EPSDT and are not considered medically necessary for coverage.
Procedures, products, or services that fail to meet the eligibility requirements in Section 2.0, do not satisfy the criteria in Section 3.0, duplicate services provided by another provider, or are experimental/investigational (including clinical trials) are not covered by Medicaid under this policy.
The excerpt does not specify additional categories of exclusion beyond those already described; the PIHP retains utilization management authority and may approve, reduce, or deny individual services consistent with the ISP and waiver requirements.
Attachment A — Codes and Billing Information
| ICD-10-CM/PCS | International Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) and Procedural Coding System (PCS) |
| Code(s) | Placeholder header in Attachment A for specific codes (not listed in this excerpt) |
| ICD-10-CM | International Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification |
| PCS | Procedural Coding System (PCS) |
| CODES | Placeholder — 'C. Code(s)' is listed in Attachment A but specific codes are not included in this excerpt |
| MODIFIERS | Placeholder — 'D. Modifiers' is listed in Attachment A but specific modifiers are not included in this excerpt |
| BILLING_UNITS | Placeholder — 'E. Billing Units' is listed in Attachment A but specific units are not included in this excerpt |
| PLACE_OF_SERVICE | Placeholder — 'F. Place of Service' is listed in Attachment A but specific POS guidance is not included in this excerpt |
| CO_PAYMENTS | Placeholder — 'G. Co-payments' is listed in Attachment A but specifics are not included in this excerpt |
| REIMBURSEMENT | Placeholder — 'H. Reimbursement' is listed in Attachment A but rate/fee schedule details are not included in this excerpt |
Prior Authorization, Documentation, and Provider Responsibilities
Follow prior approval process (Sections 5.0–5.2)
Prior approval is named in policy sections 5.0 and 5.2; providers must follow the prior approval process described in those sections when requesting NC Innovations services.
- Obtain prior approval before rendering NC Innovations services (Section 5.1).
- Submit the prior approval request and supporting health/other records to the DHHS Utilization Review Contractor (Section 5.2.1).
- NC Innovations services also require PIHP prior approval; the PIHP approves the ISP and may approve, reduce, or deny services (Section 5.2.2).
No separate prior authorization statements in excerpt
The provided excerpts do not contain any standalone 'prior authorization' statements beyond the referenced prior approval requirements; no additional prior authorization rules are specified in these chunks.
Prior authorization details not specified in excerpt
This excerpt does not specify detailed prior authorization rules for individual services; it lists documentation, ISP, and implementation sections but defers specific PA/coding details to attachments and PIHP processes.
- Attachment A and PIHP processes likely contain service-level authorization and coding details.
- Providers must still obtain prior approval as required in Sections 5.1–5.2 even though service-level PA text is not included here.
Refer to Attachment A for claims & coding guidance
Attachment A (Claims-Related Information) is referenced for coding and claims guidance; while this excerpt does not state PA requirements, providers should consult Attachment A for claim-type and code listings that affect authorization and claims.
- Attachment A includes Claim Type, ICD-10-CM/PCS, Code(s), Modifiers, Billing Units, Place of Service, Co-payments, and Reimbursement sections.
- Attachment A begins around page 37 in the full document and contains the claims-related details providers must follow.
Attachment A contains codes and claim elements
Attachment A lists claim type and code subsections (Codes, Modifiers, Billing Units, Place of Service, Co-payments, Reimbursement) that may affect billing and authorization; providers must use Attachment A when preparing claims and may need it to determine prior-approval coding requirements.
- Use Attachment A's Code(s) and Modifiers sections when selecting billing codes.
- Follow Attachment A's Billing Units and Place of Service guidance for claims submission.
Consult Attachment A for coding and billing index
Attachment A enumerates claims-related subsections (Code(s), Modifiers, Billing Units, Place of Service) but this fragment does not include the specific billing rules — providers must consult Attachment A for exact coding and billing instructions.
Attachment A lists claim elements used to determine PA/billing
Attachment A includes claim-related subsections where billing and prior authorization code requirements would be specified; providers should reference Attachment A when determining whether specific services require additional authorization or billing modifiers.
Attachment A may indicate services requiring prior approval
Attachment A contains codes and billing guidance that may identify services requiring prior authorization; while the excerpt implies this, exact services and codes requiring PA are defined in Attachment A and PIHP processes.
- Attachment A sections A–H (Claim Type through Reimbursement) outline the billing elements providers must follow.
- Providers must consult Attachment A for code-level PA implications.
Attachment A defines claims-related requirements
Attachment A's Claims-Related Information (Claim Type, ICD-10-CM/PCS, Codes, Modifiers, Billing Units, Place of Service, Co-payments, Reimbursement) contains the billing and claims requirements providers must follow when submitting claims for NC Innovations services.
PIHP authorizes waiver services; see Attachment A for codes
Services allowed under the waiver are referenced to Attachment A (HCPCS/Code(s)); authorization for waiver services is managed through the PIHP (LME/MCO), so providers must coordinate with the PIHP for service authorization and coding.
- Refer to Attachment A for HCPCS codes applicable to waiver services.
- PIHP is responsible for approving the ISP and authorizing services.
Definitions section does not replace PA instructions
The Definitions and TOC pages in this excerpt do not specify prior authorization rules; providers must rely on Sections 5.0–5.2 and Attachment A/PIHP guidance for PA requirements.
EPSDT does not waive prior approval for <21
For beneficiaries under age 21, EPSDT does not remove the requirement to obtain prior approval if the service requires it; providers should follow NC Tracks and EPSDT guidance for additional instructions.
- If prior approval is required for a service, beneficiaries under 21 still require PA (Section on EPSDT and Prior Approval).
- See NC Tracks Provider Claims and Billing Assistance Guide and EPSDT provider page for more information.
Obtain prior approval before rendering NC Innovations services
Prior approval is required for NC Innovations services; providers must obtain prior approval before rendering services and submit required supporting records to the DHHS Utilization Review Contractor.
- Obtain prior approval before providing NC Innovations services (Section 5.1).
- Submit the prior approval request plus all supporting health/other records showing Subsection 3.2 criteria are met (Section 5.2.1).
PIHP approval of ISP is required; PIHP may alter service authorization
Prior approval must be obtained and the PIHP must approve the ISP; the PIHP may approve, reduce, or deny individual services and an approved ISP is required at least annually for continued participation.
- PIHP approval of the ISP is required for service authorization (Section 5.2.2).
- Beneficiaries must have an approved plan at least annually to continue waiver participation.
Complete Level of Care before ISP; submit ISP to PIHP within 60 days
Initial Level of Care determination must be completed before beginning the ISP; the completed ISP and required documentation must be received by the PIHP no later than 60 calendar days after Level of Care approval or a new Level of Care determination is required.
- Complete Level of Care determination prior to ISP development.
- Care Coordinator must send completed ISP and documentation to PIHP within 60 days of Level of Care approval; failure requires restarting Level of Care process.
No step therapy rules in this excerpt
No step therapy rules or step therapy processes are present in these excerpts; the policy does not define step therapy requirements in the provided chunks.
Step therapy not present in provided text
No step therapy requirements are specified in these chunks; providers should not assume step therapy applies unless stated elsewhere in the full policy or attachments.
Step therapy not included in excerpt — consult full policy
No step therapy information is present in the provided excerpts; check the full policy or Attachment A if step-based authorization applies to specific codes/services.
PIHP may approve, reduce, or deny services (utilization decisions)
PIHP utilization management may approve, reduce, or deny individual services as part of its review of ISPs and authorizations; beneficiaries affected by denials retain appeal rights.
- PIHP may modify service authorizations during utilization management.
- Care Coordinator must inform beneficiaries of fair hearing and grievance rights when ISP decisions deny services.
Use interim plan for immediate needs; update to full ISP within 60 days
Interim plans may be used to begin services immediately in emergency situations but must be updated to a full ISP within 60 calendar days; interim plans contain mandatory ISP components though with less detail.
- Interim plan allows services to start immediately (e.g., emergency reserve capacity) and must be updated within 60 days.
- Interim plan contains mandatory ISP components but may lack full detail until updated.
Maintain general and service-specific documentation (Sections 7.2–7.3)
General documentation requirements (Section 7.2) and service-specific documentation (Section 7.3) are listed and must be followed; providers must maintain service notes, service grids, signatures, frequency documentation, corrections, and short-range goals/task analyses.
- Maintain Service Note, Service Grid, and required Signatures (7.2.1–7.2.3).
- Document Frequency of Service, Corrections in Service Record, and Short-Range Goals/Task Analysis (7.2.4–7.2.6).
- Follow service-specific documentation requirements for each service in Sections 7.3.1–7.3.12.
Follow enumerated documentation topics (Sections 7.2.5–7.3.12)
Sections 7.2.5–7.2.6 and 7.3.1–7.3.12 enumerate required documentation topics, including corrections in the service record, short-range goals/task analysis/strategies, and service-specific documentation for listed services; providers must comply with those sections.
- Service-specific documentation sections include Assistive Technology, Community Navigator, Crisis Services, Home Modifications, Individual Directed Goods, Natural Supports Education, Respite, Specialized Consultation, Supported Employment, and Vehicle Adaptation.
- Providers must follow documentation and retention rules in Sections 7.4–7.6.
Adhere to records administration and retention (Sections 7.4–7.6)
Sections 7.4–7.6 reference general records administration, how long records must be kept, and Individual and Family Directed Services documentation; providers must maintain records per those sections.
- Follow General Records Administration and Availability of Records (7.4).
- Comply with retention timelines in How Long Records Must Be Kept (7.5).
- Maintain documentation required for Individual and Family Directed Services (7.6).
Submit supporting records with prior approval request to DHHS UR Contractor
Providers must submit the prior approval request and all health records and other records that support the beneficiary has met the specific criteria in Subsection 3.2 to the DHHS Utilization Review Contractor as part of the PA process.
- Include all supporting health records and documentation demonstrating Subsection 3.2 criteria are met with the PA submission.
Ensure ISP signatures and timely submission to PIHP
All initial and annual ISPs require authorized signatures and must be signed and dated by providers delivering services per the ISP; the Care Coordinator must send the completed ISP and required documentation to the PIHP for receipt within 60 calendar days after Level of Care approval.
- Ensure ISPs are signed and dated by providers listed as delivering services.
- Care Coordinator must submit ISP to PIHP within 60 days of Level of Care approval to avoid reinitiation of Level of Care.
Verify Medicaid eligibility at each service delivery
Failure to verify Medicaid eligibility at each service encounter can trigger claim denials; providers must verify beneficiary eligibility each time a service is rendered.
- Verify beneficiary enrollment in NC Medicaid prior to service delivery.
- Document eligibility verification in the service record as required.
Avoid providing services that trigger noncoverage (Sections 2.0/3.0/4.0)
Services are not covered when the beneficiary does not meet Section 2.0 eligibility or Section 3.0 criteria, duplicates another provider's service, or is experimental/investigational; providing services in these conditions risks denial.
- Confirm beneficiary meets eligibility (Section 2.0) and policy criteria (Section 3.0) before providing services.
- Do not bill for services that duplicate other providers' services or are investigational.
Timely ISP submission required or Level of Care process restarts
If the ISP is not received by the PIHP within 60 calendar days after Level of Care approval, a new PIHP Level of Care Eligibility Determination Form must be completed and the approval process reinitiated; providers should track and meet the 60-day submission timeline.
- Care Coordinator must ensure ISP and documentation are received by PIHP within 60 days of Level of Care approval.
- Failure to meet the timeline requires restarting Level of Care determination.
Policy Background and Scope
The table of contents and section headings in this fragment do not provide explicit additional exclusion items; where exclusions apply they are referenced to the 'When Not Covered' sections and attachments not included in the excerpt.
Defined Terms and Attachments
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