Prior Approval Required Where Specified

Providers must obtain prior approval where specified in this policy before furnishing services or supplies. Prior approval (PA) is required for items and services identified in Subsection 5.1 and elsewhere in this policy. PA is granted based on medical necessity and does not guarantee payment or beneficiary eligibility on the date of service. Providers must follow the submission methods and documentation instructions in Subsections 5.1, 5.2, and Attachment B.

• Prior approval is required where specified in policy subsections (see Subsection 5.1).
• PA decisions are based on medical necessity only and do not guarantee payment or eligibility.

Prior authorization required for non‑fee‑schedule supplies

Medical supplies not listed on the Home Health Fee Schedule require prior authorization for medical necessity review before billing. For beneficiaries under age 21 request an EPSDT review using NCTracks. For beneficiaries age 21 and older follow the procedure in Attachment B or submit as directed in Subsection 5.2.2.

• Non‑fee‑schedule items: submit PA for medical necessity review.
• EPSDT: use NCTracks for beneficiaries under 21.
• Adults: follow Attachment B instructions for submission.

Prior approval for non‑fee‑schedule supplies (T1999 guidance)

Items not on the fee schedule may be billed using the miscellaneous supply procedure code (T1999) only when the item meets medical necessity criteria and prior authorization rules are followed. Total miscellaneous billing up to $250 per patient per year may be billed without prior approval; prior approval is required when total miscellaneous billing for a beneficiary exceeds $250. The total maximum miscellaneous billing limit is $1,500 per beneficiary per year.

• T1999 may be used for items not on the fee schedule when criteria are met.
• Up to $250 per patient/year in miscellaneous billing does not require prior approval.
• Prior approval is required when total miscellaneous billing exceeds $250; maximum allowed is $1,500 per beneficiary/year.

Prior approval for specialized therapies

Specialized therapy treatment visits are limited to the type, amount, frequency, and duration ordered by the physician and documented in the POC. Specialized therapies are subject to the limits, requirements, and prior approval processes described in Subsection 5.1 and clinical coverage policy 10A, Outpatient Specialized Therapies.

• Specialized therapies require physician order and POC documentation.
• Subject to prior approval per Subsection 5.1 and clinical coverage policy 10A.

T1999 prior approval via NCTracks

Prior approval requests for T1999 (miscellaneous supply procedure code) must be submitted via the secure NCTracks Provider portal. T1999 PA requests cannot be submitted by fax, email, postal service, or by phone.

• Submit T1999 prior approval requests through NCTracks only.
• Paper submissions (fax, email, mail, phone) are not accepted for T1999 PA.

Prior approval for miscellaneous supplies (T1999)

Prior approval is required for miscellaneous supply billing totals greater than $250 per patient per year. Providers must submit a Certificate of Medical Necessity/Prior Approval (CMN/PA) and supporting documentation when the provider determines the criteria are met. If the request is for adults and not submitted via NCTracks per Attachment B, follow the fax or mail instructions in the policy for medical necessity review.

• Total miscellaneous billing > $250/year requires PA.
• Submit completed CMN/PA and supporting documentation for review.
• Adults: follow Attachment B procedures or fax/mail instructions when applicable.

Prior authorization required for off‑fee‑schedule or over‑limit supplies

Prior authorization (medical necessity) review is required for any supplies not on the fee schedule or supplies that exceed the miscellaneous procedure code limits. Submit a completed CMN/PA with supportive documentation to NC Medicaid as directed; some requests for adults require submission outside NCTracks per policy instructions.

• Submit CMN/PA and supporting records for medical necessity review.
• Some off‑fee‑schedule adult requests are submitted by fax to NC Medicaid (fax 919-715-9025) per instructions; do not submit these through NCTracks unless directed.
• If approved, provider will be notified with claim submission instructions; if denied, provider and beneficiary will be notified with appeal rights.

Billing prohibited for routine agency overhead items

Items that are routinely furnished as part of beneficiary care and considered agency overhead (for example: alcohol wipes, applicators, lubricants, lemon-glycerin mouth swabs, thermometers, nonsterile gloves for staff) are not reimbursable as separate billable items and must not be billed to Medicaid.

• Routine agency overhead items are non‑billable.
• Nonsterile gloves for staff are overhead; gloves for beneficiary/caregiver may be billed only if medical necessity is documented.

Claims may be denied if beneficiary does not meet requirements

Claims may be denied when the beneficiary does not meet eligibility requirements, does not meet the policy criteria in Section 3.0, when the service duplicates another provider's service, or when required documentation is missing. Providers should verify beneficiary eligibility and ensure services are ordered, documented in the POC, and supported by clinical records.

• Denied when beneficiary fails eligibility or policy criteria.
• Denied when service duplicates another provider.
• Denied when documentation does not support services provided.

Post‑payment validation reviews

Medicaid will conduct post‑payment validation reviews using statistically valid random samples from paid claims to monitor utilization, quality, and appropriateness. Overpayments will be determined using monthly paid claims data. Providers will receive written notice of findings, the overpayment amount, and appeal rights.

• Post‑payment reviews use statistically valid random sampling of paid claims.
• Overpayment determinations are based on monthly paid claims data and will be communicated in writing with appeal instructions.

Post‑payment overpayment determinations

Findings from post‑payment reviews may result in overpayment determinations and recovery actions. Providers are responsible for responding to written notices and following the appeals and corrective action processes described by NC Medicaid's Program Integrity Section.

• Overpayment findings will state basis, amount, and appeal rights.
• Providers must participate in corrective action and overpayment recovery processes when required.

Billing items that are routine agency overhead or not home health supplies

Providers must not bill Medicaid for items that are routine agency overhead or not considered home health medical supplies (e.g., drugs/biologicals, durable medical equipment like blood pressure cuffs, orthotics/prosthetics, nutritional supplements). Only items that meet the Home Health supply definition and are ordered, documented, and medically necessary may be billed.

• Do not bill for drugs, biologicals, DME, orthotics/prosthetics, or routine overhead as home health supplies.
• Ensure each billed supply meets the definition of a home health medical supply and is supported in the POC.

Exceeding the $250 per patient/year miscellaneous billing without PA risks denial

Exceeding the $250 total miscellaneous billing threshold per patient per year without prior approval risks claim denial. Providers must request prior approval when anticipated miscellaneous billing for a beneficiary will exceed $250 in a year.

• $250 per patient/year miscellaneous billing threshold without PA.
• Prior approval required when totals exceed $250; do not exceed the $1,500 per beneficiary/year maximum.

PA requests may be denied if documentation does not support medical necessity

Prior approval requests may be denied if documentation does not support medical necessity or quantity of supplies. If denied, the provider and beneficiary will be notified and standard beneficiary appeal rights will apply.

• PA may be denied if documentation is insufficient to support medical necessity.
• Denials trigger notification to provider and beneficiary and allow for appeals.

Assessment and Plan of Care (POC) documentation requirements

Providers must complete timely assessments and document the Plan of Care (POC). An RN must complete the initial assessment within 48 hours of referral or return to service location and the comprehensive assessment no later than 5 calendar days after start of care (unless a specialized therapist is the only service ordered, in which case that therapist completes assessments per 42 CFR 484.55). The POC must be authorized by the physician (CMS‑485) and recertified every 60 calendar days if services continue.

• Initial RN assessment within 48 hours of referral or return to service location.
• Comprehensive assessment completed by RN within 5 calendar days of start of care (unless specialized therapy only).
• POC must be signed (CMS‑485) by ordering physician and recertified every 60 calendar days.

Services and medical supplies must be ordered and documented in the POC

All services and medical supplies must be ordered by an authorized practitioner and documented in the beneficiary's POC. Documentation must support medical necessity, quantity, frequency, and duration, and be available for review. Supplies must be assessed at least every 60 calendar days.

• Services and supplies must be ordered by physician, PA, or NP and included in the POC.
• Documentation must support medical necessity, quantity, frequency, and duration.
• Supply need/appropriateness must be reassessed every 60 days.

Required documentation and POC content

Retain agency documentation that supports medical necessity and quantity of supplies and include all supporting health records with PA requests. The POC must include diagnoses, ordered services/supplies, frequency/duration, goals, and other required elements per 42 CFR 484.60. For skilled nursing or therapy, the POC must include discipline‑specific goals and visit content.

• Keep documentation supporting supply medical necessity and quantities; include health records with PA submission.
• POC components per 42 CFR 484.60 must be present (diagnoses, services, frequency, goals, etc.).
• Skilled nursing/therapy POC must include defined goals, content, duration, and visit purpose (evaluation vs treatment).

Medical record and documentation requirements

Clinical or progress notes must document the nature and extent of services, include the employee's signature with credential, date/time, beneficiary identification, a copy of the signed CMS‑485 or similar POC, and physician certification of face‑to‑face encounter when required. Records must be retained in an accessible location for six years after discharge and made available for audits.

• Each clinical/progress note must describe the service, include staff signature/credential, date/time, and beneficiary ID.
• Include signed CMS‑485 and face‑to‑face certification when applicable.
• Retain clinical records for 6 years after discharge and make available for review.

EVV beneficiary and staff documentation

Providers must maintain written documentation that beneficiaries were informed of EVV requirements and must document initial and at least annual staff training on the EVV system. Documentation that beneficiaries were informed must be retained in each beneficiary's file.

• Written documentation that beneficiaries were informed of EVV must be retained in beneficiary file.
• Providers must document staff initial and at least annual EVV training in each employee's file.

Providers must document physician orders and include them in the POC

Physician orders must be documented and included in the POC. All orders, including verbal orders, must include date and time and be recorded in the POC; verbal orders must be transcribed and signed by the physician in accordance with regulatory requirements.

• Physician orders (written or verbal) must be recorded in the POC with date/time.
• Verbal orders must be transcribed and signed by the physician per 10A NCAC 13J and 42 CFR 484.2.
• POC must include all patient care orders and be signed by the physician (CMS‑485).

Provider must document that general Home Health requirements are met

Providers must document that general home health requirements are met: services are medically necessary, ordered by an authorized practitioner, included in the POC, and supported by clinical records. The scope, duration, and date of service must be documented to support billing.

• Services billed must be ordered, in the POC, medically necessary, and supported in clinical notes.
• Document scope, duration, and date of service to support claims.
• Use most specific CPT/HCPCS/ICD‑10 codes that support medical necessity.

Form requests should state whether an existing HCPCS code covers the item and include required details

Form submissions (e.g., DMA 3400 / CMN) should clearly state whether an existing HCPCS code covers the item, include diagnostic indication(s), duration/frequency of use, estimated charges and costs, manufacturer, and supporting evidence. Include attachments such as supporting research, verification of other coverage, and cost estimates as directed on the form.

• Form should state if an existing HCPCS code can cover the item.
• Include diagnostic indication(s), duration/frequency, estimated charges and actual cost/source.
• Attach supporting data, verification of other coverage, and manufacturer information as available.