CurrentAlliance HealthPolicy 1M-6

Maternal care skilled nurse home visits

Policy governs coverage of skilled nurse home visits for pregnant Medicaid beneficiaries in North Carolina who have one or more specified high-risk medical conditions and are referred by their prenatal care clinician.

Policy Summary

PayerAlliance Health

PolicyMaternal care skilled nurse home visits

Policy CodePolicy 1M-6

Change TypeNo material change

Effective Date

Next Review Date

Key ActionVerify Medicaid eligibility at each visit and document medical necessity and required visit elements in the client record.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicaid (NC)program governed

2visits per month allowed

RNrequired provider skill level

Referral requiredreferral requirement

Under-21 exceptionEPSDT provision

Coverage Criteria for Maternal Care Skilled Nurse Home Visits

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Covered when ALL criteria are met

Covered when ALL of the following are met:

ALL of the following

Beneficiary is enrolled in NC Medicaid and eligibility is verified at time of service (Section 2.1.1 General).
Providers must verify eligibility each visit.
Service is medically necessary per general Medicaid criteria: individualized, specific, consistent with symptoms or confirmed diagnosis, not in excess of needs; safely furnished with no equally effective, more conservative or less costly statewide option; and not primarily for convenience (Section 3.1 General Criteria Covered).
Beneficiary has one or more high-risk medical conditions or diagnoses: preterm labor; hypertension; pre-eclampsia; diabetes; suspected fetal growth retardation; multiple pregnancy; renal disease; HIV infection/AIDS; perinatal substance abuse; or other high-risk medical conditions (Section 3.2.2 Medicaid Additional Criteria Covered).
Beneficiary has been referred by their prenatal care physician or physician extender (certified nurse midwife, nurse practitioner, physician assistant).
Referral from prenatal care provider is required.

Covered Services — service and provider requirements

Covered Services — ALL of the following are met (service-level requirements and provider qualifications):

ALL of the following

The service is a one-on-one, face-to-face maternal care skilled nurse home visit conducted in the client's home.
Place of service must be the beneficiary's home.
Visit components are performed: pre-visit preparation (review prenatal and related records), home visit, assessment of high-risk condition(s), treatment in the home as outlined in the referral, referrals/documentation, referrals to Pregnancy Care Manager, WIC, and other providers as needed, written findings sent to the medical provider, and RN–Pregnancy Care Manager consultation when applicable.
All listed components must be included in the visit.
No prior approval is required for maternal care skilled nursing home visits (Section 5.1 Prior Approval).
Provider eligibility: providers must meet Medicaid participation qualifications, have a current signed DHHS Provider Administrative Participation Agreement, and bill only within scope of clinical practice (Section 6.0).

Standard coverage and billing conditions

Standard coverage — service and billing conditions (limits, place of service, billing frequency):

ALL of the following

Billing units: up to two visits per month are covered (Billing Units).
Place of service: beneficiary's home only (Place of Service).
A maternal care skilled nurse home visit must be billed per date of service (billing frequency).
Reimbursement: providers shall bill usual and customary charges; refer to the Medicaid schedule of rates. Claims for additional units beyond two visits per month will be considered for reimbursement through the adjustment process only when coverage conditions are met and documentation supports medical necessity.
Pregnancy Care Management and Care Coordination for Children providers must follow applicable PMPM reimbursement guidelines (note).

Medicaid shall not cover the procedure, product, or service when the beneficiary does not meet eligibility requirements in Section 2.0, does not meet the criteria in Section 3.0, the service duplicates another provider's service, or the service is experimental, investigational, or part of a clinical trial (General Not Covered).

None Apply.

Claims for additional units beyond two visits per month will be considered through the claims adjustment process only when the conditions of coverage are met and documentation supports medical necessity. Providers must retain and submit documentation (including referral, treatment plan, and visit notes) to justify additional visits for review.

Coding, Claim Types, and Limits

Claim Typemixed

Professional (CMS-1500/837P transaction)

Claim type for provider billing

ICD-10-CM Codes (as listed)ICD-10

O09.01	listed in ICD-10 section
O09.02	listed in ICD-10 section
O09.03	listed in ICD-10 section
O09.11	listed in ICD-10 section
O09.12	listed in ICD-10 section
O09.13	listed in ICD-10 section
O09.211	listed in ICD-10 section
O09.212	listed in ICD-10 section
O09.213	listed in ICD-10 section
O09.291	listed in ICD-10 section

1–10 of 37

1/4

ICD-10-CM CodesICD-10

O09.01	ICD-10-CM Code
O09.41	ICD-10-CM Code
O09.891	ICD-10-CM Code
O09.02	ICD-10-CM Code
O09.42	ICD-10-CM Code
O09.892	ICD-10-CM Code
O09.03	ICD-10-CM Code
O09.43	ICD-10-CM Code
O09.893	ICD-10-CM Code
O09.11	ICD-10-CM Code

1–10 of 43

1/5

Procedure Coding Guidancemixed

CPT (unspecified)	Use most specific CPT code; if none exists use appropriate unlisted CPT code per CPT instructions
HCPCS (unspecified)	Use most specific HCPCS code; if none exists use appropriate unlisted HCPCS code per HCPCS instructions

inv-12: Monthly visit limit — 2 visits per month

Monthly visit limit2 visits per month

Billing unit basisBilled per date of service

Additional units policyClaims for additional units beyond two visits per month are considered only through the adjustment process with documentation of medical necessity

Provider Actions, Documentation, and Authorization

Prior Authorization

Prior Authorization Required / Exception for Maternal Care

Prior approval is required when indicated by the policy; EPSDT (beneficiaries under 21) does not remove prior approval requirements. Maternal care skilled nursing home visits are an exception: Medicaid shall not require prior approval for maternal care skilled nursing home visits.

EPSDT: beneficiary under 21 still subject to prior approval when the service requires it.
NCTracks and EPSDT provider resources: https://www.nctracks.nc.gov/content/public/providers/providermanuals.html and https://medicaid.ncdhhs.gov/

Prior Authorization

Prior Authorization / Additional Units

Claims for more than two maternal care skilled nurse home visits per month require prior authorization via the adjustment process with documentation demonstrating medical necessity; additional units will be considered only when coverage conditions are met and medical necessity is documented.

Reimbursement limit: up to two visits per month without adjustment.
Additional units: submit adjustment request with supporting medical necessity documentation.

Denial Risk

Denial Triggers for Insufficient Visit or Documentation

A maternal care skilled nurse home visit must be a one-on-one, face-to-face RN visit in the client's home and include required components; failure to perform a one-on-one RN visit or to document required elements may result in denial.

Denial triggers include: not meeting Section 2.0/3.0 eligibility or medical necessity criteria, duplicative services, or experimental services.
Specific denial risk: absence of a documented one-on-one RN home visit or missing required visit components.

Documentation Required

Documentation and Eligibility Verification

Verify Medicaid eligibility at each visit and document medical necessity per EPSDT when applicable. Maintain complete clinical records showing how the service meets EPSDT criteria for beneficiaries under 21.

Verify eligibility each time a service is rendered.
When beneficiary is under 21, document how the service corrects, ameliorates, or prevents worsening of a condition per EPSDT.

Billing Rule

Coding and Special Report Documentation

Report the most specific CPT/HCPCS code that accurately describes the service. If no specific code exists, use the appropriate unlisted code and include the required special report per CPT/HCPCS instructions.

Use Current Procedural Terminology (CPT), HCPCS, and UB-04 revenue codes in effect at time of service.
For unlisted procedures, follow CPT/HCPCS Instructions for Use and include a special report as required.

Documentation Required

Medical Necessity Documentation for Additional Units

Medical necessity documentation must support reimbursement for any additional units beyond the standard two visits per month; include clinical rationale, relevant assessments, treatment plan, referrals, and consultation notes as applicable.

Include assessment of high-risk conditions and treatment provided in the home tied to the referral.
Provide documentation of consultations (RN and Pregnancy Care Manager) and referrals made.
Attach plan of treatment/outcome and clinician signatures.

Documentation Required

Required Documentation Minimums

Ensure client records include beneficiary identifiers, MID, dates of service, referral, plan of treatment and outcome, name and title of the person performing the service, and written findings sent to the medical provider.

Minimum required documentation: beneficiary name, DOB, MID, dates of service.
Clinical documentation: referral from prenatal care provider, plan of treatment/care and outcomes, RN documentation, and signatures.
Operational documentation: referrals made (e.g., Pregnancy Care Manager, WIC) and written findings sent to the medical provider.

OpenPayer

Maternal care skilled nurse home visits

Coverage Criteria for Maternal Care Skilled Nurse Home Visits

Coding, Claim Types, and Limits

Provider Actions, Documentation, and Authorization

Background

Definitions