CurrentAlliance HealthPolicy 3A

Home Health Services

Defines coverage, clinical definitions, provider requirements, and prior authorization/administrative provisions for home health services (skilled nursing, specialized therapies, home health aide services, medical supplies) for beneficiaries under Alliance Health Medicaid in North Carolina.

Policy Summary

PayerAlliance Health

PolicyHome Health Services

Policy CodePolicy 3A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior approval requests via NCTracks for miscellaneous supply (T1999) or follow Attachment B procedures and include documentation that items are ordered and documented in the beneficiary's plan of care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4service types

48-hrinitial assessment

5 dayscomprehensive assessment

60 dayssupply reassess interval

$250/$1500T1999 threshold

EPSDT

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Coverage Criteria for Home Health Services

Medical necessity criteria (off-fee-schedule / over-limit supplies)

Medical Supply Items Not Listed On The Fee Schedule Or Exceeding The Miscellaneous Procedure Code Limits — Covered when ALL of the following are met:

ALL of the following

The general requirements and criteria set forth in clinical coverage policy 3A are met (see Section 3.0 General Criteria).
The item is ordered by a physician, physician assistant, or nurse practitioner and the order is documented in the beneficiary's plan of care (POC).
Physician order alone does not establish medical necessity; it authorizes provision but billing requires meeting Medicaid medical necessity criteria.
The item is medically necessary as part of the beneficiary's home health services and is reasonable for treatment of the beneficiary's illness or injury.
The item is for a therapeutic or diagnostic purpose for a specific beneficiary and is not a convenience or comfort item (examples: soaps, shampoos, lotions, skin conditioners, pantiliners or pads).
The item is not routinely furnished as part of beneficiary care (examples: alcohol wipes, applicators, lubricants, lemon-glycerin mouth swabs, thermometers, nonsterile gloves, thermometer covers). These routine items are considered agency overhead and cannot be billed separately.
The item is one that Medicaid considers a home health medical supply item. Items that are not considered home health medical supplies include drugs and biologicals, medical equipment (e.g., blood pressure cuffs, glucometers), orthotics and prosthetics, and nutritional supplements.
Need and appropriateness for the item are assessed and documented every 60 calendar days. If incontinence supplies are provided and the only service being rendered is physical or occupational therapy, the therapist may conduct the assessment for incontinence supplies.
Items needed in the provision of physical therapy, occupational therapy, speech-language therapy, skilled nursing, or home health aide services are eligible under the home health policy; medical supplies not needed for provision of these services are considered under Medical Equipment Clinical Coverage Policies.
The agency documents the item and the documentation supports the medical necessity and quantity of supplies for the beneficiary's need.
When the requested item is not on the home health fee schedule or exceeds miscellaneous procedure code limits, the provider may submit a completed Certificate of Medical Necessity/Prior Approval (CMN/PA) and supporting prior authorization documentation for a medical necessity review to NC Medicaid.
Requests for medical necessity review should be faxed to NC Medicaid at 919-715-9025 with a cover sheet to the attention of Home Health Services; do not submit these requests through NCTracks.
If approved, the provider will be notified with instructions for submitting claims; if denied, the provider and beneficiary will be notified and normal beneficiary appeal rights will apply. Providers will be notified if the item requested is covered by a different N.C. Medicaid policy area or waiver program.

Coding, Billing, and Timelines

Referenced coding dataCPT

CPT (general reference)

Home health fee schedule & miscellaneous supply codeHCPCS

HCPCS national codes per Home Health Services Fee Schedule	Home Health Services Fee Schedule contains national HCPCS codes; updates made periodically via NC Medicaid website.
miscellaneous supply procedure code	Used to bill medically necessary items not listed on the fee schedule, subject to PA and meeting Medicaid coverage criteria.

Miscellaneous / Non-fee-schedule supply codeHCPCS

Miscellaneous Supply Procedure Code

Used to bill medically necessary supplies not listed on the home health fee schedule; limited to $250 without PA and up to $1500 with PA per year.

Referenced revenue/code attachmentsmixed

Attachment A (c)-Revenue Codes

Chart referenced for limitations on skilled nursing visits and miscellaneous therapeutic items and supplies.

Prior Approval CodesCPTCovered

T1999

Miscellaneous Supply Procedure Code (prior approval and limits; submit PA via NCTracks)

THERAPIESRevenueCovered

420	Physical therapy (1 visit)
424	Physical therapy evaluation (1 visit)
430	Occupational therapy (1 visit)
434	Occupational therapy evaluation (1 visit)
440	Speech-language pathology services (1 visit)
444	Speech-language pathology evaluation (1 visit)

SKILLED NURSING VISITSRevenueCovered

550	Skilled nursing: Initial assessment/re-assessment (1 visit)
551	Skilled nursing: Treatment, teaching/training, observation/evaluation (1 visit)
559	Skilled nursing: For a dually eligible beneficiary when the visit does not meet Medicare criteria (1 visit)
580	Skilled nursing: venipuncture (1 visit)
581	Skilled nursing: Pre-filling insulin syringes/Medi-Planners (1 visit)
589	Skilled nursing: Supply only visit; no other skilled service provided (1 visit)

HOME HEALTH AIDERevenueCovered

570	Home Health Aide (1 visit)

Medical supplies revenue codeRevenueCovered

270	Home health medical supplies (use with applicable HCPCS)

Unlisted/MiscellaneousHCPCSCovered

T1999

Miscellaneous Supply Procedure Code (misc billing limits and PA rules apply)

Fee schedule / HCPCS procedure code reportingmixed

Procedure (CPT or HCPCS)

Indicate procedure code; state if there is no HCPCS code for the item

inv-40: Initial assessment timeframe — within 48 hours of referral or return to service location

TimingInitial RN assessment must be completed within 48 hours of referral or within 48 hours of the patient's return to the service location.

Responsible clinicianRegistered Nurse (RN) completes the initial assessment; RN supervises LPN if LPN performs services.

PurposeDetermine immediate care and support needs to plan and deliver appropriate home health services.

inv-41: Comprehensive assessment timeframe — no later than 5 calendar days after start of care

Provider Responsibilities, Prior Authorization, and Documentation

Prior Authorization

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

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.

Background and Scope

Home health services provide skilled nursing, specialized therapies (physical therapy, occupational therapy, speech-language pathology), home health aide services, and related medical supplies in community settings where normal life activities occur. Coverage requires services to be ordered by an authorized clinician and documented in the beneficiary’s plan of care (POC), be medically necessary and reasonable for treatment, be furnished by appropriately licensed personnel, and comply with assessment and documentation timelines (for example, initial RN assessment within 48 hours and comprehensive assessment within 5 calendar days). Medical supplies must be assessed for need every 60 calendar days and meet the policy’s medical necessity criteria to be covered.

Key Definitions

inv-80: Skilled Nursing — definition and scope

DefinitionSkilled Nursing consists of assessment, judgment, intervention, and evaluation by an RN (or LPN under RN supervision) in accordance with the plan of care.

Scope of servicesIncludes assessing, caring, counseling, teaching, referring, implementing prescribed treatment, monitoring during convalescence and rehabilitation, and supervising delegated tasks.

Assessment responsibilityRN completes the initial assessment within 48 hours and comprehensive assessment within 5 calendar days; RN supervises LPNs and ensures POC compliance.

inv-81: Specialized Therapies — PT/OT/SLP definitions and provider requirements

Included disciplinesSpecialized therapies include Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP).

Provider qualifications

Policy Summary

PayerAlliance Health

PolicyHome Health Services

Policy CodePolicy 3A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

DeadlineComprehensive assessment must be completed no later than 5 calendar days after the start of care.

Responsible clinicianRN completes the comprehensive assessment unless specialized therapy is the only ordered service, in which case the appropriate therapy professional completes it per 42 CFR 484.55.

Relation to initial assessmentComprehensive assessment is patient-specific and must be timely based on patient needs following the initial assessment.

inv-42: Medical supply reassessment interval — every 60 calendar days

IntervalMedical supply needs and appropriateness must be assessed every 60 calendar days.

Who may assessAssessment performed by agency clinician; when only PT/OT are providing incontinence supplies, therapist may perform the assessment.

Scheduling toleranceA five-calendar-day window is allowed for the sixty-calendar-day assessment (55–60 day range) to accommodate scheduling.

inv-43: Miscellaneous supply billing limits — $250 without prior approval; >$250 up to $1500 requires prior approval

Without prior approvalTotal miscellaneous supply billing up to $250 per beneficiary per year may be billed without prior approval.

With prior approvalMiscellaneous supply billing greater than $250 up to a maximum of $1,500 per beneficiary per year requires prior approval (manual review via Attachment B/NC Medicaid).

Procedure codeUse the Miscellaneous Supply Procedure Code (e.g., T1999) per guidance when item not on fee schedule; PA processes apply.

inv-44: Visit limits — Skilled nursing: 75 visits/year; Home health aide: 100 visits/year

Skilled nursing annual limitSkilled nursing visits are limited to a maximum of 75 total visits per year per beneficiary.

Home health aide annual limitHome health aide services are limited to a maximum of 100 total visits per year per beneficiary.

Part-time/intermittent definitionServices are provided part-time or intermittent: less than 8 hours per day and 28 or fewer hours per week (may be increased to 35 hours/week case-by-case).

inv-45: Record retention — Clinical records must be retained for 6 years after discharge

Retention periodClinical records must be retained for 6 years after the discharge of the patient.

Location and accessibilityRecords must be maintained at the home health provider's office and be accessible for regulatory review and NC Medicaid requests.

Scope of recordsProviders must provide all financial and medical records and other documents for beneficiaries billed to NC Medicaid upon request.

inv-46: Miscellaneous billing limit (T1999) — $250 per patient per year without prior approval; $1500 maximum per beneficiary per year

No-PA allowanceT1999 miscellaneous billing limit of $250 per patient per year may be billed without prior approval.

Maximum with PATotal maximum miscellaneous billing limit is $1,500 per beneficiary per year with prior approval.

PA requirementPrior approval required for totals exceeding $250 per year and for items not listed on the fee schedule; submit CMN/PA per policy instructions (fax or NCTracks as specified).

inv-47: Assessment interval — Assess need and appropriateness every 60 calendar days

IntervalAssess medical supply need and appropriateness every 60 calendar days.

DocumentationAgency must document medical necessity and quantity of supplies to support billing and prior authorization submissions.

Therapist assessment noteWhen incontinence supplies are provided and only PT/OT services are rendered, the therapist may conduct the assessment.

inv-48: Assessment interval — every 60 calendar days

IntervalSupply need and appropriateness must be reassessed every 60 calendar days.

PurposeReassessment documents continued medical necessity for supplies and supports claims and PA requests.

RecordkeepingRetain assessment documentation in beneficiary's medical records to justify continued coverage and quantity.

EPSDT: use NCTracks for beneficiaries under 21.

Adults: follow Attachment B instructions for submission.

Prior Authorization

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 Authorization

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.

Prior Authorization

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 Authorization

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

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 Rule

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.

Denial Risk

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.

Denial Risk

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.

Denial Risk

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 Rule

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.

Denial Risk

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.

Denial Risk

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.

Documentation Required

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.

Documentation Required

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.

Documentation Required

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).

Documentation Required

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.

Documentation Required

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.

Documentation Required

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).

Documentation Required

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.

Documentation Required

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.

Therapies must be provided by licensed professionals (PT, OT, SLP) or licensed assistants (PTA, OTA, SLPA) under direct supervision of the licensed therapist.

Clinical criteriaMedical necessity and treatment criteria for specialized therapies follow Clinical Coverage Policy 10A (Outpatient Specialized Therapies).

inv-82: Home Health Aide Services — definition and supervision requirements

DefinitionHome health aide services are hands-on paraprofessional services provided by a Nurse Aide I or II under RN supervision and in accordance with the plan of care.

Typical tasksAssist with ADLs (bathing, grooming, eating, transferring), help with self-administered medications not requiring a licensed nurse, light household tasks, and simple delegated health-related tasks.

SupervisionProvided under RN supervision and must follow federal Conditions of Participation (42 CFR 484.80); may be provided without other skilled services but requires skilled nursing supervision as indicated.

inv-83: Home health aide services — hands-on paraprofessional services description

Nature of servicesHands-on paraprofessional assistance by NA I or NA II to support beneficiary care and activities of daily living as specified in the plan of care.

ScopeIncludes assisting with personal care, simple delegated tasks, monitoring and reporting changes in condition to supervising clinician.

Regulatory referenceServices provided in accordance with federal CoP 42 CFR 484.80 and documented in beneficiary's POC.

inv-84: In advance — tasks staff must complete prior to hands-on care

Definition'In advance' refers to tasks that Home Health Provider staff must complete prior to performing any hands-on care or patient education.

ExamplesPre-visit preparations such as reviewing orders, verifying POC, gathering supplies, and completing required documentation before care delivery.

inv-85: Verbal order — definition and documentation requirement

DefinitionA verbal order is a physician order spoken to appropriate personnel and later put in writing to document or establish/revise the plan of care.

Documentation requirementVerbal orders must be transcribed, signed, and incorporated into the beneficiary's plan of care as required by policy and physician authorization rules.

inv-86: Medical supplies (home health) — definition: consumable nondurable supplies used for medical purposes

DefinitionMedical supplies are consumable nondurable supplies that are usually disposable, not reusable by multiple beneficiaries, primarily used for medical purposes, not useful in absence of illness/injury, and ordered/prescribed by a physician.

Classification stepsPolicy requires determination that item meets medical supply definition, meets medical necessity criteria, and documentation of reason if not on fee schedule.

ExclusionsItems such as drugs/biologics, medical equipment (e.g., BP cuffs, glucometers), orthotics/prosthetics, and nutritional supplements are not considered home health medical supplies.

inv-87: Visit — definition: personal contact by agency employee for home health services

DefinitionA visit is personal contact with a beneficiary by an employee or contracted employee of a certified home health agency for providing home health services; it begins when service is initiated and ends when delivery is completed.

Multiple services in one visitIf multiple services can be performed during the same visit, they shall be completed in that single visit.

Billing unitEach visit corresponds to the applicable billing code unit (one visit per code).

inv-88: Part-time or intermittent — weekly and daily hour limits and case-by-case adjustments

Daily/weekly limitsPart-time or intermittent defined as combined skilled nursing or home health aide services totaling less than 8 hours per day and 28 or fewer hours each week.

Case-by-case adjustmentWeekly total may be increased to up to 35 hours per week on a case-by-case basis based on need for care.

Relation to visit limitsServices defined as part-time/intermittent are subject to per-visit and annual limits (e.g., skilled nursing 75/year; aide 100/year).

inv-89: Children — Medicaid beneficiaries under 21 for concurrent care

DefinitionChildren means Medicaid beneficiaries under 21 years of age for purposes of concurrent care and EPSDT considerations.

Concurrent care noteChildren may receive hospice concurrent care without waiving rights to curative treatment; policy references Social Security Act sections and ACA provisions.

inv-90: Home health medical supply item — Medicaid definition and exclusions

DefinitionA home health medical supply item is an item considered by Medicaid to be a home health medical supply (excluding drugs, biologics, medical equipment, orthotics, prosthetics, and nutritional supplements) and used for therapeutic or diagnostic purpose.

Coverage conditionsMust be ordered by an authorized clinician, documented in the POC, medically necessary for the beneficiary, and not a routine agency overhead item.

DocumentationAgency must document medical necessity and quantity; items not on fee schedule require justification and PA submission per policy.

inv-91: Home health medical supply item — additional definition detail and documentation expectations

Clinical requirementsItem must be medically necessary for home health services, ordered by physician/PA/NP, documented in the POC, and for therapeutic/diagnostic purpose for a specific beneficiary.

Exclusions and overheadRoutine minor supplies (alcohol wipes, applicators, nonsterile gloves, thermometers) are agency overhead and not billable separately; drugs, DME, orthotics/prosthetics, and nutritional supplements are excluded from the home health medical supply category.

Prior authorizationIf criteria met but item not on fee schedule or exceeds T1999 limits, provider may submit completed CMN/PA and supporting documentation to NC Medicaid for medical necessity review; follow submission instructions in policy.