Alliance Health CAP/C Coverage & Prior Auth Update | OpenPayer
ModifiedAlliance HealthPolicy 3K-1
Community Alternatives Program for Children (CAP/C)
Defines eligibility, covered services, provider requirements, documentation, and program operations for North Carolina Medicaid's CAP/C waiver program for children and beneficiaries under 21. Applies to providers, case management entities, and Medicaid beneficiaries seeking CAP/C participation in NC.
Policy Summary
PayerAlliance Health
PolicyCommunity Alternatives Program for Children (CAP/C)
Policy CodePolicy 3K-1
Change TypeAmendments and EVV/waiver alignment (multiple material updates)
Effective DateN/A
Next Review DateN/A
Key ActionObtain required prior approval and submit the Service Request Form with physician attestation, comprehensive multidisciplinary assessment, and an approved person-centered service plan before providing CAP/C services.
Added code T1004 for Pediatric Nurse Aide Respite and deleted codes/references to T2027 and G0154.
Numerous 05/01/2020 changes adding new waiver services, updated eligibility/medical fragility criteria, processes for EPSDT/LEA coordination, and many operational clarifications.
Added requirements for Electronic Visit Verification (EVV) compliance for affected provider types.
Policy was amended to align with the CAP/C 1915(c) HCBS approved waiver and to reflect end of COVID-19 PHE federal flexibilities with a retro-effective alignment.
Requirements for providers subject to the Electronic Visit Verification (EVV) federal mandate were added across multiple sections and attachments.
Service definitions and new services (e.g., Attendant Nurse Care, Coordinated Caregiving, Community Integration) were added or updated effective 03/01/2023.
Billing and provider claims guidance updated to reference NCTracks, National Coding Guidelines, and to list specific HCPCS/T codes used for CAP/C services.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.
100+
document pages/topics
NCapplicable state
16CAP/C services listed
AnnualLOC reassessment frequency
90 daysloss of contact noncoverage timeframe
05/01/2020revision history major update
Coverage and Medical Necessity Criteria
General and Medicaid Additional Coverage Criteria
Coverage and eligibility are defined in sections 3.0–3.3 with Medicaid-specific additional criteria in 3.2 and 3.3.
General Coverage Determination: Beneficiaries meeting general and specific CAP/C criteria (sections 3.0–3.3) are eligible for services; includes Medicaid additional criteria and level of care determinations.
See sections 3.1–3.3 for specifics.
Service-Specific Coverage
Specific CAP/C services are covered when program criteria and prior approval requirements are met.
Covered Services Examples: Assistive Technology; Attendant Nurse Care; CAP/C In-Home Aide; Case Management; Community Transition and Integration Services; Coordinated Caregiving; Financial Management; Home Accessibility and Adaptation; Goods and Services; Pediatric Nurse Aide; Respite; Specialized Medical Equipment; Training, Education and Consultative Services; Vehicle Modifications.
Full list in section 3.3 and Appendix B.
CAP/C Enrollment and Coverage Criteria
Covered when ALL of the following are met:
Enrollment & Medicaid: Beneficiary is enrolled in NC Medicaid; assigned a CAP/C waiver slot; approved for long-term care Medicaid in an eligible category prior to receipt of waiver services.
Verification each service; guardian signatures as required.
Age: Beneficiary is age 0 through 20 years.
Level of Care: Meets HCBS nursing facility level of care comparable to State Plan nursing facility LOC as determined by NC Medicaid, documented via LOC determination at enrollment and annually (or when condition changes).
LOC based on diagnoses, treatments, and non-age appropriate ADL deficits.
Service Need & Plan: Requires one or more CAP/C services coordinated by a CAP/C case manager, with a completed CAP assessment showing reasonable indication of need within 30 days, and an approved person-centered service plan identifying amount, duration, frequency and provider taxonomy.
Consumer-Directed Care Criteria
When electing consumer-direction, ALL of the following must be met:
Understanding & Training: Completion of mandatory self-assessment questionnaire and introductory consumer-direction training and orientation as evidence of understanding rights and responsibilities.
Refer to Appendix G.
Willing & Capable: Beneficiary or representative willing and emotionally capable to assume employer responsibilities (or selects a willing/capable representative) as evidenced by the self-assessment questionnaire.
Questionnaire must detail care needs, training needs, and emergency planning.
Level of Care Determination Criteria
HCBS Nursing Facility Level of Care is met when the beneficiary satisfies ONE of the following standalone criteria OR specified combinations of Category I and II conditions:
Standalone LOC indicators: Any one qualifying indicator such as need for RN/LPN supervision; intensive observation/assessment during acute episode; restorative nursing measures per plan; dialysis as maintenance; physician‑prescribed therapeutic diet; medication administration requiring licensed nurse; nasogastric/gastrostomy feedings requiring RN/LPN supervision; respiratory therapy (oxygen, nebulizer, suction, pulse oximetry); isolation when medically necessary; wound care for decubitus/open areas; rehabilitative services by licensed therapist.
See qualifying conditions list.
Category combination LOC: HCBS LOC may also be established by either (A) two or more conditions from Category I OR (B) one or more conditions from both Category I and Category II.
See Category I and II examples.
Category I examples: ancillary therapies supervision; chronic recurrent medical problems needing daily observation; blindness; injections requiring RN/LPN; diabetes with daily observation or frequent DKA/hypoglycemia; treatments requiring nursing direction; frequent falls; behavioral problems related to cognitive impairment or depressive disorders.
Attendant Nurse Care
Attendant Nurse Care coverage criteria — beneficiary must meet ALL of the following:
Attendant Nurse Care criteria: a) Life‑threatening medical condition with reasonably frequent acute exacerbations requiring frequent physician supervision; b) Needs frequent, ongoing, specialized medically necessary treatments and nursing interventions; c) Dependency on life‑sustaining medical technology (e.g., ventilator, endotracheal tube, G‑tube, oxygen therapy, cough assist, chest PT vest, suction) such that health cannot be maintained without it.
Meets definitions of substantial, complex, and continuous skilled nursing care.
In-Home Aide and Personal Assistance Services
In‑Home Aide and Personal Assistance coverage criteria — beneficiary must meet ALL of the following:
In‑Home Aide/Personal Assistance criteria: Provides assistance with or monitoring of a minimum of two limited to extensive ADLs during service hours; beneficiary is unable to perform tasks independently due to a medical condition documented on a validated comprehensive assessment and need relates directly to physical, social, environmental, and functional condition.
Services may be provided in home, community, workplace, or educational settings when appropriate.
Case Management
Case management coverage criteria:
Case Management: Services include assessing, person-centered care planning, referral/linkage, monitoring and follow‑up; case management activities must be performed at least monthly to maintain community integration and safeguard health, safety, and well‑being.monthly
CME retains required documentation and coordinates service authorizations.
Care Advisor
Care Advisor coverage criteria:
Care Advisor: Provides advisement to the employer of record to access needed medical, social, educational and other services; empowers the beneficiary to define and direct personal assistance needs and supports the beneficiary under their guidance rather than directing services.
Functions under the guidance of the beneficiary or responsible party.
Community Transition
Community Transition coverage criteria:
Community Transition: Covers initial setup expenses for a prospective CAP/C beneficiary transitioning from an institution to community setting for up to one year to establish basic living arrangements; expenditures must be necessary and documented.1 year
Used to establish basic living arrangement during transition.
Community Integration
Community Integration coverage criteria:
Community Integration: Covers services for active beneficiaries who are in jeopardy of losing community placement due to tenancy‑related issues; services must be documented in the person‑centered service plan.
Provided to preserve community placement.
Coordinated Caregiving
Coordinated Caregiving coverage criteria:
Coordinated Caregiving: Supportive services to assist with acquisition, retention, or improvement of skills for community living including adaptive skill development, ADL/IADL assistance, linkage to resources, protective oversight and supervision to promote independence and community integration.
Includes caregiver coaching and competency validation per provider requirements.
Financial Management
Financial Management coverage criteria:
Financial Management: Provides financial assistance, education, training, and fiscal administration to beneficiaries directing their care to ensure consumer‑directed funds are managed and used to employ and pay for personal assistance as outlined in the service plan.
Provider must be approved as a fiscal intermediary and meet experience requirements.
Covered CAP/C Services
Medicaid covers CAP/C services when services are identified in the person-centered service plan and meet eligibility and medical necessity requirements.
General service coverage: Services must be identified in the person-centered service plan and be necessary to improve independence, safety, integration, or to prevent institutionalization; items not available through waiver or State Plan may be covered when beneficiary lacks funds or other sources.
Applies across listed services.
Examples of covered services: Includes coordinated caregiving, financial management, home accessibility/adaptations, individual‑directed goods and services, nutritional services (physician‑ordered supplements/OTC when not State Plan), one‑time pest eradication when in own home, participant goods/services, non‑medical transportation, Pediatric Nurse Aide Services, institutional and in‑home respite (combined limit 30 days/720 hours per fiscal year), specialized medical equipment (adaptive car seat, vehicular vest, adaptive tricycle), training/education, and vehicle modifications (vehicle owned prior to modification).
Each item described in document.
Pediatric Nurse Aide specific criteria: Beneficiary must be unable to perform any two of seven ADLs due to a medical condition documented on a validated assessment; at least one ADL must be within Nurse Aide II scope; services are hands‑on and may be delivered in community/home/workplace/educational settings when not LEA responsibility.
Eligibility, Assessment, and Service Plan Criteria
Covered when ALL of the following administrative and clinical requirements are met:
Prior Approval and Documentation: Prior approval is required; provider must submit SRF with Physician Attestation, multidisciplinary comprehensive assessment, and signed person‑centered service plan for approval; required supporting health records must be included.SRF <=45 days
SRF must be completed within 45 calendar‑days; incomplete SRFs voided.
Assessment timing and conduct: Comprehensive multidisciplinary assessment completed by a NC‑licensed nurse with multidisciplinary input must be completed within designated timeframe but no later than 30 calendar‑days of assignment.<=30 days
Telephonic initial assessment allowed with follow‑up face‑to‑face per policy when necessary.
Person-centered service plan: Draft person‑centered service plan identifying CAP/C and State Plan services (type, amount, frequency, duration) must be submitted no later than 30 calendar‑days after approved comprehensive assessment; plan must be approved and contain goals, outcomes, provider taxonomy and cost summary.
Initial and Annual Service Plan Criteria
Covered when ALL of the following are met
Service plan initiation and timing: Person‑centered service plan must be initiated after completion of the multidisciplinary comprehensive assessment and be in draft form no later than 30 calendar‑days after the completed assessment; effective date is first day of next eligible month or after Medicaid eligibility is established.30 days
Service plan expires 13 months after effective date unless otherwise determined.
Content of person-centered service plan: Plan must summarize assessment, list person‑centered goals/objectives, identify outcomes, list all approved CAP/C and non‑CAP/C services, medical supplies, DME with provider name, amount, frequency, duration, and cost totals to ensure within established cost limit.
Used to evaluate annual cost of care needs.
Approval and signatures: Participation is approved when beneficiary or legal representative signs Freedom of Choice and the person‑centered service plan; missing required signatures on initial or annual plans within 30 days leads to ineligibility or disenrollment.
Service Plan Revision Criteria
Revisions required when ANY of the following occur
Revision triggers: Service plan revision required when a CAP/C, Medicaid State Plan, 1915(b) or Medicare service is added, reduced, increased, deleted, or when there are changes in type, scope, amount, duration, or frequency of a CAP/C service.
Changes must be submitted in CAP Business System within 30 calendar‑days and approved within 10 calendar‑days.
Retroactive approval for urgent needs: Service plan revisions (excluding goods/services, training/education/consultative services, home/vehicle modifications and assistive technology) may be approved retroactively up to 30 calendar days when an urgent need risks community placement; service cannot be procured prior to first day of retroactive period.30 days
Excluded items may be considered for urgent approval based on need.
Revision processing timeframe: Changes to the service plan must be submitted in the CAP Business System within 30 calendar days of the request and approved within no more than ten (10) calendar days of the entered revision.
Assistive Technology and Modifications Criteria
Required documentation and conditions for approval
Multidisciplinary recommendation and cost: Request must include MDT or appropriate professional recommendation identifying need and cost, including shipping and itemized costs; NC Medicaid may require multiple quotes based on region.
Professional recommendation and cost estimates required.
Training and safety/back-up plan: A training plan for beneficiary/family on equipment use must be documented as completed and, when applicable, a safety back‑up plan with designated responsible party, backup procedures, and response timeframe is required.
Documentation signed by beneficiary or responsible party upon receipt/installation.
Adaptive car seat specific criteria: Adaptive car seat requests require documented chronic health condition requiring positioning, seat‑to‑crown measurements, rationale why seatbelt/convertible/booster cannot be used for beneficiaries >=30 lbs, and certification/quotes.>=30 pounds referenced
CME and Case Manager Qualifications, Training, and Activity Requirements
Entities and personnel must meet ALL of the following to be appointed and to provide CAP/C case management:
CME organizational qualifications: CME shall be an organization with five or more years of direct case management experience in HCBS; must enroll as Medicaid provider; NC Medicaid may provide one year technical assistance if <5 years; must demonstrate capacity to coordinate and manage CAP/C beneficiaries.5 years or 1 year technical assistance
Evidence of fiscal soundness (access to >= $60,000) and IT capability required.
Mandated CME capabilities: Must have resource connections, pediatric/medical complexity experience, policies aligning with laws, ability to provide case management by social worker and nurse, physical location, fiscal soundness, appropriate staff‑to‑participant ratio, and confirm rendering of services within 5 calendar days of service authorization.$60,000 cash flow
CME must retain required records and meet monitoring responsibilities.
Provider and CME qualification and operational criteria
Providers must meet the following qualifications and operational requirements to be authorized to provide CAP/C services:
General provider requirements: Medicaid providers must be approved by NC Medicaid through managed change request, complete CAP/C overview and orientation training before rendering services and annually, and attest to policies ensuring nonuse of restraints and seclusions.
Provider enrollment and taxonomy requirements apply for equipment and home modifications.
Service‑specific provider requirements: Providers for community transition/integration, home accessibility/modifications, institutional and in‑home respite, in‑home care aide, pediatric nurse aide, specialized medical equipment, financial management, and coordinated caregiving must meet service‑specific licensure, experience and documentation requirements (e.g., receipts/invoices, enrolled Medicaid provider with approved taxonomies, licensed homecare agencies, three years HCBS experience for coordinated caregiving, fiscal intermediary status for financial management).
See individual service subsections for details.
Live‑in and familial employment conditions: A spouse, parent, child, or sibling may be employed only if they meet age (18+), qualifications or deemed competency by supervising professional, meet live‑in caregiver requirements, and employment does not interfere with care; EVV rules apply where applicable.
Eligibility and Safety Criteria
Participation is allowed when the following monitoring and safety requirements are met; failure to meet or mitigate listed safety conditions may lead to denial or disenrollment.
Monitoring and Documentation Requirements: CME and providers must conduct monthly contacts, multidisciplinary team meetings monthly/quarterly based on risk, monthly or quarterly contact visits, maintain service records and complete service notes within 72 hours, and perform quarterly respite reviews.service notes <=72 hours
Electronic monitoring limited within quarterly schedule.
Live‑in Caregiver Requirements: Live‑in caregiver must be at least 18 years old, in good health, pass criminal background and health care registry checks, demonstrate competency for authorized activities, and receive a minimum of 8 hours annual training; provider must document shared residence with two proofs and reverify every six months starting June 1.8 hours training
Competency validation per Subsection 6.6.9 and 7.3.
Participation and Disenrollment Criteria
CAP/C participation is permitted when the beneficiary's health, safety, and well-being can be maintained or mitigated through the program's requirements and agreements. Disenrollment occurs when criteria below are met.
Participation maintenance: CAP/C beneficiary must have a current service plan, an emergency/disaster plan reviewed at least quarterly, and active engagement with CME; CMEs must monitor hospitalizations and absences, report critical incidents within 72 hours, and implement IRAs when appropriate.
CME coordinates discharge planning for hospitalizations <=30 days and suspends non‑case management services.
Disenrollment triggers: Disenrollment occurs when any of the following apply: Medicaid eligibility terminated; physician determines nursing facility level no longer appropriate; annual assessment shows needs not meeting LOC; DSS removes CAP/C evidence code; inability to contact beneficiary/primary caregiver for >90 days after attempts; failure to use CAP/C services for 90 consecutive days; health/safety risks cannot be mitigated via IRA; beneficiary or caregiver refuses to participate in or sign service plan; repeated program noncompliance (three occurrences) or single serious violation threatening health/welfare.90 days/contact; 90 consecutive days nonuse
See Subsection 7.16 for details and due process.
Critical Incident Management
All critical incidents must be reported and managed according to level-based procedures.
Critical incident reporting: CMEs must report all critical incidents within 72 hours of awareness in the CAP Business System; Level II incidents require a root cause analysis with listed follow‑up steps including contacting reporter and providers, home visit, trend review, outreach to agencies, and implementation follow‑up.72 hours
Level definitions and reporting steps listed in policy.
Administrative Coverage Criteria
Covered when ALL of the following administrative/program requirements are met:
Service plan requirements: Service plans must address all assessed needs and person‑centered goals, list type, scope, amount, duration and frequency, be updated at CAP/C effective date or when warranted, and services delivered according to the service plan.
Beneficiary has choice between CAP/C and institutional care and among providers.
Qualified provider verification: State verifies providers initially and continually meet required licensure and certification standards and monitors non‑licensed providers; training and oversight per state requirements and waiver must be documented.
Provider enrollment and taxonomy requirements apply for certain services.
Conflict of Interest Safeguards for Dual-role CMEs
When a Case Management Entity (CME) is approved to act in a dual role (case management and direct service), the following safeguards must be in place:
Conflict of interest disclosures: CME, coordinated caregiver and financial management providers must review potential conflict of interest information with beneficiary; HCBS provider shall review potential or perceived conflicts with the beneficiary and beneficiary must agree that service plan meets needs.
Disclosure and beneficiary agreement requirements.
Administrative separation: Monitoring staff and service rendering staff must be separate personnel or units within the CME; CME must perform independent quarterly quality reviews of beneficiary files and routinely assess HCBS provider network and free choice.
Safeguards for dual‑role CME.
State monitoring: Long‑Term Services and Supports Section identifies and approves dual‑role CMEs in advance and monitors through claims, service plan revisions, monthly and quarterly visit summaries, incident reports and annual surveys.
State oversight when dual role approved.
HCBS Setting and Residential Requirements
Home and community-based settings must meet the following characteristics and conditions:
General HCBS setting characteristics: Settings must be integrated in the community, provide access to employment and community life, allow selection among nondisability specific settings, protect privacy, dignity and freedom from coercion, optimize autonomy and allow choice of services and providers.
General characteristics aligned with HCBS requirements.
Residential protections: Residential settings must provide eviction protections per landlord‑tenant law, privacy in sleeping/living units, freedom to control schedules and access to food, allow visitors at any time, and be physically accessible; any modifications must be supported by assessed need and justified in the person‑centered service plan.
See NC DHHS HCBS Transition Plan for additional information.
Coverage-related revisions (summary)
Revisions that affect coverage criteria and program eligibility were made on 05/01/2020 and earlier; they include changes to medical fragility criteria, level of care, priority consideration, and service definitions.
Revision summary: Multiple sections were updated to align eligibility, medical fragility, and LOC criteria with waiver guidelines, add new services, and clarify operational processes including SRF workflow and service request timelines; see referenced revision history for details.
See full policy sections and attachments for exact changes.
Coverage conditions and EVV requirements
Covered when services are provided within approved CAP/C service authorization and program eligibility
Basic CAP/C coverage conditions: Services must be provided in an amount, duration, and scope consistent with the beneficiary's medical needs and according to the service authorization; amount of service cannot exceed approved CAP/C service plan; provider must be an approved CAP/C provider and beneficiary must be eligible for CAP/C.
Claims submitted through NCTracks or as specified for assessment/SRF link payments.
EVV validation requirement: For providers subject to EVV, claims for qualifying in‑home services must capture and verify seven core EVV components (date, location, provider, type, recipient, start time, end time); qualifying service codes are listed in Attachment A/fee schedule.7 components
Paid live‑in caregiver may bypass EVV edits with attestation (POS 99).
Paid live-in caregiver exception: Paid live‑in caregiver claims may bypass EVV edits using POS 99 if provider attests using Paid Live‑in Caregiver Attestation Form that caregiver meets live‑in status definition.
Attendant Nurse Care — Medical Necessity
Covered when ALL of the following are met
Attendant nurse care qualifying criteria: 1) Life‑threatening medical condition with frequent acute exacerbations requiring frequent physician supervision; 2) Needs frequent, ongoing, specialized medically necessary treatments and nursing interventions; 3) Dependency on life‑sustaining medical technology such that health could not be maintained without it (examples: ventilator, endotracheal tube, G‑tube, oxygen therapy, cough assist, chest PT vest, suction); 4) Needs meet definitions of substantial, complex, and continuous nursing care as defined (substantial = interrelated nursing assessments; complex = scheduled hands‑on interventions; continuous = interventions at least every 2–3 hours).every 2–3 hours for continuous
Service provided by RN or LPN (under RN supervision) with required credentials and background checks; available only for waiver participants in consumer‑directed care per policy.
Case Management — Inclusion Criteria
Covered when ALL of the following are met
Case management (CME) coverage criteria: 1) Multidisciplinary assessment identifies need for case management to maintain community placement or address lack of informal supports; 2) Case management is listed in the service plan monthly if participant is at risk of institutionalization; 3) Beneficiary selects an approved case management provider; 4) CME retains required documentation and coordinates service authorizations; 5) Service utilization limitations follow published fee schedule and CAP/C beneficiaries shall not receive additional Medicaid‑reimbursed case management services concurrently.monthly
Requests for additional case management time may be approved for disaster or crisis situations per fee schedule guidance.
CAP/C In-Home Aide congregate care (EVV qualifying)
S9122TG
CAP/C Pediatric nurse aide congregate care (EVV qualifying)
Attachment A — HCPCS / Procedure changes (historical)mixed
T1004
Added for Pediatric Nurse Aide Respite (historic change)
T2027
Personal Care Assistance Services added/retained
S9122TF
S9122 TF added as congregate care code
S9122TG
S9122 TG added as congregate care code
High-level Billing Guidancemixed
POS
Use most specific POS; live-in caregiver may use POS 99 with Paid Live-in Caregiver Attestation to bypass EVV edits
Billing Units
Refer to Billing Units section for units and place of service-specific guidance
Unlisted Codes
When no specific CPT/HCPCS exists, use appropriate unlisted procedure code as directed
Attachment A — Full HCPCS list (selected)HCPCS
S5125
CAP/C In-home aide services
S5150
CAP/C In-home respite care
S5165
CAP/C related service
S5111
CAP/C service S5111
S9122TF
CAP/C In-Home Aide congregate care (S9122 TF)
S9122TG
CAP/C Pediatric nurse aide congregate care (S9122 TG)
H0045
Behavioral health prevention service (as listed)
T1004
CAP/C Pediatric nurse respite services
T1019
CAP/C Pediatric nurse aide
T2027
Personal Care Assistance Services
1–10 of 14
1/2
Qualifying CAP/C EVV service codesHCPCSCovered
S5125
CAP/C In-home aide services
S5150
CAP/C In-home respite care
T1004
CAP/C Pediatric nurse respite services
T1019
CAP/C Pediatric nurse aide
T2027
Personal Care Assistance Services
S9122TF
CAP/C In-Home Aide congregate care (qualifies for EVV)
S9122TG
CAP/C Pediatric nurse aide congregate care (qualifies for EVV)
Billing Units / Place of Service — reference
Billing Units / Place of ServiceRefer to Subsection 6.4 and the Billing Units section for exact billing unit definitions and Place of Service mapping.
Medical condition duration
Medical condition duration> 12 calendar months
SRF and assessment time limits
SRF and assessment time limitsSRF must be completed within 45 calendar-days or will be voided; initial comprehensive assessment must be completed within 30 calendar-days of referral.
Individual Risk Agreement duration
Prior Authorization, Documentation, EVV, and Operational Steps for Providers
Prior Authorization
Prior Authorization, Service Authorization, Documentation, EVV, Transfers, and Denial/Disenrollment Risks
Prior approval is required before rendering CAP/C services. Providers must obtain prior approval (service authorization) for CAP/C participation and for individual CAP/C services; failure to obtain required prior approval may result in claim denial or referral to Program Integrity.
Providers must verify each Medicaid beneficiary's eligibility at every service encounter; services provided to ineligible or sanctioned beneficiaries are not payable.
Even for beneficiaries under 21 (EPSDT), prior approval requirements still apply — follow NCTracks guidance for EPSDT and prior approval workflows.
The Case Management Entity (CME) shall submit person-centered service plans and required documentation (SRF, multidisciplinary assessment, signed service plan) to the DHHS designated contractor no later than the required timeframe; NC Medicaid or its designee will review and approve (PA or denial) and transmit electronic prior approval to NCTracks.
Service authorizations act as the prior approval mechanism: the CME shall authorize selected providers via service authorizations that detail the authorization period, specific services, tasks, amount, duration, frequency, and provider. Authorized providers must accept or reject the service authorization within three business days and confirm receipt and acceptance within 72 hours of submission.
Service authorizations expire 13 consecutive months from the effective date of the initially approved service plan unless otherwise extended; under special circumstances an extension and prior approval segment may be transmitted.
Program Background and Scope
The Community Alternatives Program for Children (CAP/C) is North Carolina Medicaid's 1915(c) Home and Community‑Based Services waiver that provides a cost‑effective alternative to institutional care for medically fragile and medically complex children (age 0–20). CAP/C funds an array of home‑ and community‑based services — including assistive technology, in‑home aides, pediatric nurse aide, attendant nurse care, case management, respite, home and vehicle modifications, and consumer‑directed supports — so that beneficiaries who meet the HCBS nursing facility level of care (LOC) can remain safely in the community rather than be institutionalized [[20],[22]].
Participation requires prior clinical and administrative approvals: a documented determination that the child meets the CAP/C LOC and medically fragile criteria, a completed Service Request Form (SRF) and comprehensive multidisciplinary assessment, and an approved person‑centered service plan that lists the type, amount, frequency and duration of approved CAP/C and non‑CAP/C services [[33],[77],[90],[91]]. Providers and Case Management Entities (CMEs) must follow NC Medicaid enrollment, documentation, and service‑authorization procedures and comply with program safeguards such as emergency/back‑up planning, critical incident reporting, and monitoring to protect beneficiary health and welfare [[75],[85],[164]].
CAP/C operates as a targeted, limited‑slot waiver: beneficiaries must be Medicaid‑eligible for long‑term care, assigned a CAP/C slot, and demonstrated to need services that mitigate institutionalization. The program supports three delivery options — provider‑led, consumer‑directed, and coordinated caregiving — and is administered through designated entities (CIAE/CME) that coordinate assessment, authorization, and oversight to ensure services are delivered in accordance with the approved plan of care [[20],[24],[22],[109]].
Key Terms and Service Definitions
inv-136: CAP/C service definitions reference appendices (SRF and definitions in Appendix A/B)
Appendices referencedCAP/C Service Request Form and detailed service definitions/requirements are provided in Appendix A and Appendix B (see Table of Contents and H.1 attachments).
SRF locationService Request Form (SRF) is listed in Appendix A and is required to establish medical fragility and LOC.
Definitions locationService definitions and requirements (including EVV and code lists) are in Appendix B and attachments (see H.1 and Appendices).
inv-137: Medically fragile (initial criteria)
Definition (initial criteria)Medically fragile: primary chronic physical medical condition lasting or expected to last more than 12 calendar months and meeting the other specified treatment/hospitalization and assistance criteria.
Three-part criteria
Policy Changes and Revision Log
2024-11-15major_revisionLatest
Policy amended to align with CAP/C 1915(c) HCBS approved waiver (effective 03/01/2023) with additions including attendant nurse care, community integration, coordinated caregiving, and removal of participant goods and services; multiple sections and attachments revised.
2020-05-01major_consolidated_update
Extensive operational and programmatic updates across sections and attachments: added new waiver services, revised medical fragility and LOC criteria, clarified EPSDT/LEA coordination, updated assessment and service plan timelines and business processes.
Policy Summary
PayerAlliance Health
PolicyCommunity Alternatives Program for Children (CAP/C)
Policy CodePolicy 3K-1
Change TypeAmendments and EVV/waiver alignment (multiple material updates)
Effective DateN/A
Next Review DateN/A
Key ActionObtain required prior approval and submit the Service Request Form with physician attestation, comprehensive multidisciplinary assessment, and an approved person-centered service plan before providing CAP/C services.
Short-term enrollments allowed for installations to be completed within 3 months.
Safety & Supports: Able to maintain health, safety, and well‑being at residence with formal and informal supports; has an emergency back-up/disaster plan; primary physician coordination documented.
Emergency/disaster plan required during plan development or within 30 days and updated quarterly.
Category II examples: need for teaching/counseling related to disease/medication; adaptive programs (retraining, e.g., bowel/bladder training); psychosocial factors to consider (acute psychological symptoms, age, length of stay, caregiver status, social supports, transfer effects).
2 of 7 ADLs
Chunk 62.
Respite limits and EVV: Combined institutional and in‑home respite must not exceed 30 calendar days or 720 hours per fiscal year; respite services are subject to EVV requirements per 21st Century Cures Act.30 days or 720 hours
Chunk 64.
Vehicle ownership for modifications: Vehicle modifications covered only if vehicle is owned by beneficiary or primary caregiver prior to modification and specified in the service plan.ownership prior to modification
Chunk 67.
<=30 days
Effective date is first day of next eligible month or after Medicaid eligibility established.
Documentation for participation: Initial, annual, and change‑in‑status documentation (contact info, consents, signed rights forms, service plan, comprehensive assessment, physician orders, training/competency documentation for consumer direction, and other specified documents) must be present for CAP/C participation approval.
See Subsection 5.3.2 for full lists.
30 days
Refer to assessment and plan denial procedures.
CNR timing and content: Continued Need Review (CNR) assessment must be completed at least every 12 months and include a comprehensive multidisciplinary assessment identifying LOC and an approved person‑centered service plan.12 months
Annual service plan must be approved by first day of month following CNR month.
30 days/10 days
Documenting change of provider requires signed beneficiary consent and Freedom of Choice form.
Cap/C beneficiary medical justification required.
Vehicle modification specialist recommendation: Vehicle modification requires recommendation by PT/OT specializing in vehicle modification or rehabilitation engineer, rationale, beneficiary ability to manipulate modifications, pre‑driving assessment if driving, vehicle condition and insurance documentation, and safety/code compliance.
Used lifts value assessment required if purchasing used vehicle with lift.
Case manager minimal qualifications:
Case manager must meet one of: BS in social work +1 year related experience + NC Medicaid training within 90 days; BS in human services +2 years related experience + training; BS non‑human services +2 years + training; or RN with NC license + 1 year case management experience + training. Apprentices allowed with supervision.
90 days training
Training curriculum specified; annual continuing education requirements apply.
Case manager continuing education: Case manager or care advisor must complete 9 contact hours of continuing education per calendar year including mandatory topics (person‑centered training, legislation, PI/abuse/neglect) and complete NC Medicaid program‑specific modules annually.9 hours/year
See required training list.
Case management activity frequency: Case management activity must be performed at least monthly and a multidisciplinary case management assessment must be performed quarterly; monitoring and follow‑up include announced and unannounced visits as needed.monthly/quarterly
CME responsibilities include documentation retention and incident reporting within 72 hours.
Assessment content and frequency: Initial and annual comprehensive assessments must address medical, functional, psychosocial, behavioral, financial, social, cultural, environmental, legal, vocational, educational and other areas; consult providers and supports and reassess per monitoring intervals.
Integrate other current assessments.
18+
Live‑in caregiver documentation and periodic reverification required.
CME responsibilities and competency validation: CME must develop referral procedures, educate caregivers, obtain medical documentation, complete assessments, authorize services, ensure provider qualifications, complete critical incident reports within 72 hours, and ensure competency validation and documentation (electronic caregiver notes, medication records, training/coaching, multidisciplinary meeting records).72 hours incident reporting
Provider agencies must assure caregiver competency for authorized tasks.
Health, Safety, and Well‑being Exclusion Conditions:
Enrollment/participation may be denied when beneficiary's needs cannot be mitigated including inability of responsible party to devise/execute safety plan; lack of willing/capable 24‑hour caregiver; unsafe primary residence (hazardous utilities, lack of refrigeration, plumbing hazards, electrical/fire risks); presence of unlawful activity or pest infestation/hoarding; threatening/abusive behavior; dangerous behaviors (suicide attempts, injurious behavior, sexualized behavior, destruction); caregiver refusal to follow service plan or IRA; beneficiary choosing to remain in abusive/neglectful environment as evidenced by CPS assessment.
See Section 7.10 for full list.
IRA Use and Disenrollment: An Individual Risk Agreement may be implemented for up to 90 days to attempt mitigation; after 90 days reevaluation required; failure to remediate risk may result in disenrollment and serious violations may lead to immediate disenrollment.90 days
Appendix E contains IRA tool and procedures.
Refer to Appendix F for live‑in requirements.
Assessment-only and SRF linking payments: Payment for SRF linking or 'assessment only' claims payable when SRF is approved and assessment documented per policy; assessment‑only max 6 hours, SRF link max 2 hours; these are paid via paper claim with cover letter.max hours: 2 or 6
See reimbursement subsection H.1 for claim submission details.
Individual Risk Agreement duration
90 days
Hospitalization/service suspension thresholds
Hospitalization/service suspension thresholds<=30 days: suspend services except case management; >30 days: may affect Medicaid eligibility and CAP/C disenrollment processes.
EVV core components
EVV core componentsDate of Service; Location of service delivery; Individual providing service; Type of services performed; Individual receiving service; Time service begins; Time service ends.
Continuous nursing assessment frequency
Continuous nursing assessment frequencyEvery 2–3 hours for 'continuous' nursing definition
Providers subject to EVV must obtain EVV confirmation for personal care-type services when applicable; EVV capture of the seven core components is required for adjudication of in-home services.
For assistive technology, home modifications, vehicle modifications, goods and services and similar requests, the CME must obtain required documentation (MDT recommendation, physician attestation/order, itemized cost/quotes as required, training plan, supplier invoice/receipt, signed agreement regarding disenrollment when applicable) prior to approval and implementation.
If a beneficiary is hospitalized for 30 calendar-days or less, the CME shall suspend all CAP/C services except case management, notify discharge planners and county DSS, monitor progress, determine post-discharge needs, alert providers when to resume care, and revise the service plan as appropriate. Nursing facility admissions follow specific suspension and re-entry rules.
Providers shall use the Service Request Form (SRF) workflow for CAP/C participation and assessment requests; an approved SRF and completed assessment documented and certified by assessors are prerequisites to billing certain claim types.
Failure to complete an initial level-of-care assessment or required documentation, an incomplete/denied SRF, inability to establish contact for >90 calendar-days despite attempts, inactive Medicaid eligibility, sanctions, or repeated noncompliance may lead to denial of participation or disenrollment.
Transfers: when transferring a beneficiary between counties or providers, CMEs must coordinate transition planning, transfer electronic records, arrange a home visit by the receiving CME within five business days of arrival, and plan services to start on the transfer date to avoid gaps and potential disenrollment.
Background checks and licensure: providers must attest that hired workers/nurses/live-in caregivers have required criminal history and health care registry checks and meet licensure/registry requirements (e.g., Nurse Aide Registry, homecare agency licensure) prior to service delivery.
Providers must document services contemporaneously: service notes completed within 72 hours (or documented as late entry with reason) and include purpose, beneficiary name, date/duration, goals, progress, recommendations, and signer. CMEs and providers must retain SRF, assessments, service plans, authorizations, monthly contacts, quarterly visits, incident reports, claims, and related correspondence per record retention rules.
EVV documentation: providers must document beneficiary notification of EVV in each file, maintain staff EVV training records, register with the State EVV solution or an approved alternate, and capture the seven required EVV data elements (type of service, beneficiary, date, location, staff, time begin/end). Failure to capture/verify required EVV components may result in claim denial.
Coding and claims: report ICD-10-CM/PCS and CPT/HCPCS/UB-04 codes to the highest level of specificity that supports medical necessity; bill only for valid CAP/C procedures and for beneficiaries eligible for CAP/C. Date-of-service must be the actual date the service was provided. For assessment-only or SRF-linked payments follow paper claim rules and include required cover letter info.
Use of Individual Risk Agreement (IRA) is permitted temporarily (up to 90 days) to attempt mitigation of identified health, safety, or environmental risks; repeated failed mitigation or unremediated risks can lead to disenrollment.
Restrictions: services not on the approved service plan, services not medically necessary, unauthorized services, or services not adhering to service authorization are subject to denial, recoupment and Program Integrity referral.
PDN to attendant nurse care transitions require PDN provider agency to notify the assigned waiver case manager and collaboratively develop a transition plan and submit requests to adjust approved hours or end-date prior approvals consistent with the transition plan.
Requires (A) condition duration >12 months, (B) medically necessary ongoing specialized treatment or specified exacerbation/hospitalization history, and (C) need for life-sustaining device, hands-on assistance, or non-age-appropriate assistance to prevent deterioration.
Role in enrollmentMeeting medically fragile criteria is required for initial participation in CAP/C and must be documented via the SRF and assessment.
inv-138: HCBS Nursing Facility Level of Care (LOC) definition
LOC definitionHCBS Nursing Facility Level of Care (LOC): beneficiary's conditions, diagnoses, treatments and ADL deficits meet or exceed Medicaid State Plan nursing facility LOC criteria.
Determination timingLOC determination must be completed at initial enrollment and annually during the Continued Need Review using the comprehensive assessment.
Reassessment triggerChanges to condition that may affect LOC may prompt a reassessment using the SRF.
inv-139: Attendant Nurse Care definition — hands-on complex continuous skilled nursing during service hours
Core definitionAttendant Nurse Care: hands-on provision of substantial, complex, and continuous skilled nursing care during service hours for beneficiaries meeting qualifying acuity and technology dependence criteria.
Qualifying criteriaLife‑threatening condition with frequent exacerbations requiring physician supervision; frequent, ongoing specialized treatments; dependency on life‑sustaining medical technology (e.g., ventilator, G-tube, oxygen, suction).
Provider type & requirementsProvided by licensed RN or LPN (under RN supervision); must meet registry/background checks, Board of Nursing standing, and BLS certification.
inv-140: Coordinated Caregiving definition
DefinitionCoordinated Caregiving: supportive in-home services assisting acquisition, retention, or improvement of skills for community living including adaptive skill development, ADL/IADL assistance, linkage to local resources, protective oversight and supervision.
PurposeIntended to promote beneficiary independence and integrate the beneficiary into family and community activities.
Provider requirementsProviders must be an NC Medicaid provider (Atypical or licensed) with three years of HCBS experience and implement/manage person-centered service plans.
inv-141: Pediatric Nurse Aide Services — hands-on assistance with ADLs and Nurse Aide II scope requirements
Service definitionPediatric Nurse Aide Services: hands-on assistance with at least two ADLs, one of which must be within Nurse Aide II scope, for beneficiaries unable to perform two of seven ADLs due to medical condition per validated assessment.
SettingsServices provided in home, community, workplace, or educational settings (when not LEA responsibility) and are extensive hands-on assistance rather than cueing or setup.
Billing codes/examplesAssociated CAP/C codes include T1019, T1004 (pediatric nurse respite), and related HCPCS listed in Attachment A for pediatric nurse aide services.
inv-142: Service Request Form (SRF) — SRF timing and voiding rules
SRF timingSRF must be completed within no more than 45 calendar-days of initiation; incomplete SRFs after 45 days will be voided and no slot is reserved.
PurposeSRF establishes medical fragility and level of care and initiates eligibility determination for CAP/C services.
Related submissionSRF must include Physician Attestation and be submitted by the CIAE or CME into the CAP Business System per workflow.
inv-143: Multidisciplinary comprehensive needs assessment — assessment roles and content
Assessors and teamComprehensive multidisciplinary assessment completed by a North Carolina-licensed nurse with consultation from a multidisciplinary team including at minimum a social worker and others as needed.
Assessment contentCovers medical, physical, functional, psychosocial, medication, skin, neurological and other modules to determine acuity and service needs.
Face-to-face vs telephonicInitial telephonic assessment allowed with beneficiary agreement; if telephonic assessment could lead to denial/reduction/termination, face-to-face must occur within 5 business days; otherwise face-to-face within 2–3 months.
inv-144: Continued Need Review (CNR) — periodic review at least every 12 months
Review frequencyContinued Need Review (CNR) must be completed at least every 12 consecutive months to determine ongoing need for CAP/C participation.
CNR componentsCNR includes a completed multidisciplinary comprehensive assessment that verifies LOC and an approved person-centered service plan.
Timing guidanceCNR must be completed in the month of the CAP/C effective month; begin tasks 60–90 days in advance as prompted by CAP Business System.
inv-145: Person-centered service plan — definition and required elements
DefinitionPerson-centered service plan: a plan developed after the comprehensive assessment documenting goals, objectives, approved CAP/C and non-CAP/C services (type, amount, frequency, duration), authorized providers, and monitoring priorities.
Required elementsMust summarize assessment, list person-centered goals/objectives, identify outcomes, list all approved services/DME with provider name, amount, frequency, duration, and cost totals.
Timing & signaturesDraft service plan must be ready within 30 calendar-days of completed assessment; beneficiary or legal rep signs Freedom of Choice and service plan for participation approval.
inv-146: CIAE — Comprehensive Independent Assessment Entity role
Role summaryComprehensive Independent Assessment Entity (CIAE): entity awarded by NC Medicaid to perform waiver eligibility decisions, conduct multidisciplinary assessments, process referrals, obtain consents, and complete critical incident reports within 72 hours.
Operational dutiesActs as front-door for waiver inquiries, coordinates with CME, obtains documentation for SRF, and distributes notifications via CAP Business System.
Compliance responsibilitiesMust follow NC Medicaid guidelines for application, provider enrollment, prior authorization, utilization management, QA, and audits.
inv-147: CME — Case Management Entity role
Role summaryCase Management Entity (CME): local organization appointed by NC Medicaid to provide day-to-day oversight, case management and coordination for CAP/C beneficiaries; local entry point for enrollment and management.
Key responsibilitiesDevelop referral procedures, educate caregivers, process referrals, obtain medical documentation, perform initial/annual assessments, authorize services, ensure monitoring and QA, complete critical incident reports within 72 hours, and address grievances within five business days.
Qualification overviewMust enroll as Medicaid provider, have experience and fiscal soundness, meet staffing and IT requirements, and confirm rendering services within five calendar days of service authorization.
inv-148: CME local entry point responsibilities and referral duties
Local entry point dutiesCME is the local entry point responsible for referrals, education, processing referrals, obtaining medical documentation, completing assessments, case management, authorizations and quality and risk mitigation activities.
Referral & enrollment actionsProcess referrals for CAP/C enrollment consideration and assist applicants in obtaining documentation to confirm need for services.
Monitoring & incident dutiesComplete critical incident reports within 72 hours and address complaints within five business days; ensure service limits and monitoring details are included in service plan.
inv-149: Coordinated Caregiving Provider requirements and experience threshold
Minimum experienceCoordinated Caregiving Provider must have at least three (3) years' HCBS experience delivering services to individuals with disabilities.
Provider enrollmentMust be enrolled as an NC Medicaid provider (Atypical or licensed) and develop/implement person-centered service plans and caregiver supports.
Service responsibilitiesProvide ongoing management/support of the person-centered service plan, conduct competency validation and provide at least 8 hours annual training to live-in caregivers as applicable.
inv-150: Individual Risk Agreement — definition and purpose
Definition & purposeIndividual Risk Agreement (IRA): documented agreement outlining risks/benefits of a course of action, responsibilities, and accountability to permit temporary mitigation of identified risks while attempting remediation.
Use caseUsed when assessment identifies concerns (home environment, lack of staffing, safety issues) to allow short-term CAP/C participation while mitigation occurs.
Time-limited mitigationIRA standard timeframe is 90 days after which reevaluation is required; failure to remediate may lead to disenrollment.
inv-151: Live-in caregiver — definition and minimal requirements
DefinitionLive-in caregiver: paid caregiver who shares the same address as the CAP/C participant and meets age (>=18), health, background checks and competency/training requirements.
Documentation requirementsProvider must document shared residence with two proofs (one photo ID and one utility/lease/school form, etc.) starting June 1 and reverify every six months.
Training requirementProvider must ensure live-in caregiver receives minimum of 8 hours annual training reflecting beneficiary and caregiver assessed needs.
inv-152: Individual Risk Agreement (IRA) details and durations
IRA detailsIRA documents risks/benefits, responsibilities, and accountability; permits beneficiary or surrogate to accept risk and outlines mitigation strategies.
DurationStandard IRA timeframe is 90 days; reevaluation required at 90 days and additional IRA may be implemented if needed.
Outcome on failureFailure to remediate risks per IRA may result in disenrollment; serious violations can lead to immediate disenrollment.
inv-153: Critical Incident Levels — Level I and higher incident definitions
Level I incidentsAccident or injury needing medical care beyond first aid, unscheduled hospitalizations, ER visits not resulting in admission, inpatient psychiatric hospitalization, death by natural causes, failure to take medication as ordered.
Level II incidentsCPS/APS referrals, unexplained injuries, unexpected/unusual death, restraints/seclusions, misappropriation of funds, falls resulting in hospitalization or death, traumatic injury, treatment/medication errors causing injury, missing person, homicide/suicide, pandemics, 3 consecutive missed in-home visits, media events.
Reporting timeframeCMEs must report all critical incidents within 72 hours of awareness; Level II incidents require root cause analysis and follow-up steps.
Summary of revisions (May 2020 & later)Multiple definitions were revised/added (Medical Fragility, Portable Generator, Respite, Pediatric Nurse Aide, ADLs, Independent Assessment, etc.) and service definitions updated; EVV and other operational requirements were added or clarified.
Effective updatesSeveral updates effective 05/01/2020 and later (including 03/01/2023 and 11/15/2024) expanded service definitions and operational guidance.
Appendix changesAppendices A, B, F, G were updated to add definitions, new services, SRF workflow, and consumer-direction materials.
inv-155: New/updated CAP/C service definitions added or revised (Mar 2023 effective items)
New/updated servicesAttendant Nurse Care, Coordinated Caregiving, Community Integration, Pediatric Nurse Aide and other CAP/C service definitions were added or revised (notably effective 03/01/2023 with document updates through 11/15/2024).
Operational impactAdded service definitions include attendant nurse care specific qualifying criteria, continuous/substantial/complex clarifications, and EVV-related code listings for qualifying services.
Reference locationsSee Appendix B and H.1 CAP/C Claim Reimbursement attachments for full definitions and related coding guidance.
inv-156: EVV core components definition
EVV core components (definition)Electronic Visit Verification (EVV) core components required for in-home visits: date; location; individual providing service; type of service; individual receiving service; start time; end time.
Legal basisRequired under the 21st Century Cures Act for providers subject to EVV.
Related billing guidanceQualifying CAP/C codes subject to EVV validation are listed in H.1; live-in caregiver attestation may allow bypass of EVV edits for certain claims.
inv-157: Attendant Nurse Care definition (detailed) — substantial/complex/continuous criteria
Detailed definitionAttendant Nurse Care provides substantial, complex, and continuous skilled nursing care needs during service hours for waiver participants whose acuity typically requires hospital or skilled nursing oversight.
'Substantial' meaningNeed for interrelated nursing assessments and interventions; tasks not requiring nurse assessment/judgment are not substantial.
'Complex' meaningScheduled, hands-on nursing interventions; observation-only tasks are not considered complex skilled nursing.
inv-158: 'Substantial' definition for nursing need
'Substantial' for nursing needRequires interrelated nursing assessments and interventions; interventions not requiring a licensed nurse's assessment/judgment are not substantial.
ImplicationUsed to determine qualification for Attendant Nurse Care versus lesser nursing supports or home health services.
SourceDefinition provided in Attendant Nurse Care service description and Appendix.
inv-159: 'Complex' definition for nursing need
'Complex' for nursing needScheduled, hands-on nursing interventions; observation-only interventions are not complex skilled nursing.
ImplicationDistinguishes tasks requiring active skilled nursing from observation or routine assistance.
RelationUsed with 'substantial' and 'continuous' to assess Attendant Nurse Care eligibility.
inv-160: 'Continuous' definition for nursing need — nursing assessments every 2–3 hours
'Continuous' for nursing needContinuous means nursing assessments requiring interventions performed at least every two (2) or three (3) hours during the coverage period of this service.
ApplicationA qualifying attribute for Attendant Nurse Care and used to define service frequency and staffing needs.
DocumentationTasks, amount, frequency, and duration of skilled care must be clearly outlined in Skilled Declaration Form and CAP Skilled Level of Care Plan.
inv-161: Case Management / Care Advisor — roles and differences
Role distinctionCase Management (CME) directs and manages CAP/C beneficiaries' care; Case Manager provides services for provider-led care; Care Advisor provides specialized advisement and empowerment for consumer-directed care.
CME responsibilitiesIncludes assessing, care planning, referral/linkage, monitoring and follow-up, retention of records, authorizations, and quality assurance activities.
Care Advisor functionSupports and empowers the employer of record (participant) in consumer-directed models rather than directing care; focuses on coaching and enabling participant choices.
2017-03-01waiver_renewal_approval
CMS approval of waiver renewal noted; eligibility, LOC, and service descriptions updated to reflect 1915(c) HCBS waiver assurances.
2015-10-01administrative_template_update
Updated policy template language and added ICD-10 codes where applicable for federal compliance (10/01/2015).
2012-01-01coding_and_operational_changes
Multiple January 1, 2012 updates including addition of code T1004 for Pediatric Nurse Aide Respite and deletion of T2027 and G0154; clarifications on respite hours, assessor requirements, and other operational items.
2012-01-01code_changes
Added HCPCS code T1004 (Pediatric Nurse Aide Respite) and removed codes/references to T2027 and G0154 in Attachment A; other Attachment A table updates noted.
2021-07-01attachment_updates
Attachment A HCPCS code table updated to include EVV-related guidance and revised code listings consistent with federal EVV mandate requirements.
2024-11-15attachment_updatesLatest
Attachment A and appendices revised as part of comprehensive policy amendments aligning CAP/C services and codes with 1915(c) waiver updates effective 03/01/2023.
2024-11-15claim_icd_template_updatesLatest
Policy language updated to clarify assessment completion date, Medicaid LTC date, and evidence of medical need; ICD-10 coding and billing guidance refreshed as part of the comprehensive amendment aligning with waiver changes.
2020-05-01claims_workflow_change
Prior approval workflow replaced by CAP Business System service request form with specified timelines (no more than 45 calendar days from initiation); SRF and assessment linking clarified for claims processing.
2012-01-01claims_coding_change
Operational clarifications including that waiver incontinence supplies may not be sole waiver service besides case management and other claims-related assessor clarifications applied; inpatient/exceptions and claim instructions updated.
2020-05-01major_consolidated_update
Major consolidated update effective 05/01/2020 adding new waiver services, updating medical fragility and level-of-care criteria, changing business processes (including CAP Business System adoption), and clarifying assessment, service plan, transfer, and documentation requirements.
2021-07-01EVV_additionLatest
Added requirements and provider obligations related to Electronic Visit Verification (EVV) including telephony options, EVV components, updates to Attachment A, and EVV provisions across appendices and sections (posted 07/01/2021; some provisions retroactive to 01/01/2021).
Amendments effective 11/15/2024 to align the policy with the CAP/C 1915(c) HCBS approved waiver (effective 03/01/2023) and to reflect the end of COVID-19 public health emergency flexibilities with retroactive alignment to 11/11/2023 for many service provisions.
2023-04-01administrative_update
Policy posted 04/15/2023 with an effective date of 04/01/2023 to reflect North Carolina Health Choice Program move to Medicaid and related template updates.