Facility-Based Crisis Service for Children and Adolescents
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Defines coverage, eligibility, clinical criteria, service components, and operational requirements for facility-based crisis services for Medicaid beneficiaries aged 6–17 in North Carolina.
Discharge planning language was updated to replace references to the Prepaid Inpatient Health Plan (PIHP) with 'health plan' and to add the member's benefit health plan.
Removed prior approval language and revised authorization/authorization-limitation language to comply with MHPAEA and 42 CFR § 438.900, removing references to initial authorizations and 45-day service limitation in a 12-month period.
Noted tribal and Indian Health Service provider exemptions and alternate reimbursement methodologies under federal law.
Replaced terminology 'mental retardation' with 'intellectual disability' and updated references from LME and PIHP to 'health plan'.
Clarified telehealth allowances for psychiatrist-provided components and billing guidance about GT modifier not being appended to HCPCS code when only some components are via telehealth.
Coverage and Medical Necessity Criteria
inv-01: General Criteria Covered
Covered when ALL of the following are met
chunk 16
inv-02: Specific Criteria Covered for Medicaid
Covered when ALL of the following specific Medicaid criteria are met
3.2.1.a; chunk 18
3.2.1.b; chunk 18
3.2.1.c (1-5); chunk 18
3.2.1.d-e; chunk 18
inv-04: Initial Admission Medical Necessity
Covered when ALL of the following are met for Medicaid beneficiaries:
Supports admission decision; chunks 18 and 31
inv-03: Continued Service Criteria
Continued service is covered when ANY of the following applies
3.2.2 a-e; chunk 19
inv-05: Continued Service
Continued stay is allowed when ANY of the following apply (or desired outcomes not achieved in service plan time-frame):
chunk 19
inv-06: Discharge Criteria
Discharge should occur when ONE of the following applies:
3.2.3.a; chunk 20
3.2.3.b; chunk 20
inv-07: General coverage criteria for Facility-Based Crisis Service
Covered when ALL of the following service-level requirements are met:
chunks 52 and 69
chunks 52, 53, 36
chunks 46 and 52
chunks 9, 52, 54
inv-08: Structural and Discharge Planning Requirements
Covered when ALL of the following structural and coordination requirements are met
chunk 69
chunks 54 and 52
Under the federal EPSDT provision (42 U.S.C. § 1396d(r)), services for Medicaid beneficiaries under age 21 must be covered when medically necessary to correct or ameliorate a condition. However, EPSDT does not obligate the State to pay for services that are unsafe, ineffective, experimental/investigational, or not medical in nature or not generally recognized as accepted medical practice. Service limitations in clinical coverage policies may be exceeded for beneficiaries under 21 when documentation demonstrates the service meets EPSDT medical necessity criteria.
Facility-Based Crisis Service is not covered by Medicaid when delivered to: (a) an inmate in a public correctional institution; (b) a beneficiary in a facility with more than 16 beds classified as an Institution for Mental Diseases (IMD); or (c) a child or adolescent who is stepping down from an inpatient level of care.
Any other service provided during the period between admission to and discharge from Facility-Based Crisis Service must be coordinated with the Facility-Based Crisis Service to ensure appropriate transition into the program and planning for discharge and aftercare.
North Carolina Medicaid will not reimburse for conversion therapy under this policy.
Services are not covered when the beneficiary fails to meet eligibility (Section 2.0) or the clinical criteria in Section 3.0, when the procedure duplicates another provider's service, or when the procedure/product/service is experimental, investigational, or part of a clinical trial.
Billing Codes, Units, and Modifiers
| S9484 HA | Facility-Based Crisis Service (HCPCS) with HA modifier indicating child/adolescent program; Telehealth Eligible = No |
Provider Responsibilities, Documentation, and Authorization
Prior approval still required for under-21
If the service requires prior approval, being under age 21 does NOT eliminate the prior approval requirement. Providers must follow NCTracks and the health plan's current authorization processes for EPSDT-related requests; see the NCTracks Provider Claims and Billing Assistance Guide and the NC Medicaid EPSDT provider page for details.
- NCTracks Provider Claims and Billing Assistance Guide: https://www.nctracks.nc.gov/content/public/providers/providermanuals.html
- EPSDT provider page: https://medicaid.ncdhhs.gov/
Prior Approval Not Required (for this service) — Authorization / Prior Approval Guidance
No prior approval is required for Facility‑Based Crisis Services for Children and Adolescents for Medicaid beneficiaries. However, follow the health plan's current authorization guidance and NC Medicaid processes for any services that do require authorization. Prior authorization language has been removed from earlier versions; providers must consult NC Medicaid and the member's health plan for up‑to‑date authorization rules.
- Follow current NC Medicaid and health plan authorization procedures for any services that require authorization
Eligibility verification
Providers must verify each Medicaid beneficiary's eligibility at each encounter. Eligibility verification should be completed prior to furnishing services because the beneficiary's enrollment category may impose service restrictions that affect coverage.
- Verify Medicaid eligibility at each date of service
- Confirm service restrictions tied to beneficiary's eligibility category
General Non‑Coverage Triggers
Services are not covered when the beneficiary does not meet Section 2.0 eligibility, does not meet Section 3.0 clinical criteria, the service duplicates another provider's billed service, or the service is experimental/investigational or part of a clinical trial.
- Not covered if beneficiary fails eligibility in Section 2.0
- Not covered if clinical criteria in Section 3.0 are not met
- Not covered if duplicate of another provider's service
- Not covered if experimental, investigational, or part of a clinical trial
Specific Non‑Coverage Populations
Per federal regulation, Facility‑Based Crisis Service is not covered for: inmates in public correctional institutions; beneficiaries in facilities with >16 beds classified as IMDs; or children/adolescents stepping down from an inpatient level of care.
- Inmates in public correctional institutions — not covered
- Facility with >16 beds classified as an Institution for Mental Diseases (IMD) — not covered
- Child/adolescent stepping down from an inpatient level of care — not covered
Billing eligibility and credentialing
Providers must be enrolled and credentialed with NC Medicaid, have a current signed DHHS Provider Administrative Participation Agreement, meet applicable provider qualification and licensing requirements, and bill only for services within their licensed scope of practice.
- Meet Medicaid enrollment and credentialing requirements
- Maintain a current, signed DHHS Provider Administrative Participation Agreement
- Bill only for services within the scope of clinical licensure
- Achieve national accreditation within one year of enrollment (per policy requirements)
Required Clinical and Administrative Documentation
Clinical and administrative documentation must support medical necessity and the provision of services. Documentation must include a full service note per nursing shift and a full service note per intervention per date of service, dated and signed by the provider, and must document progress relative to the treatment and discharge plans.
- Each full service note must include beneficiary name, Medicaid ID, service provided, date of service, type of contact, purpose, intervention description, time spent, effectiveness, signature and credentials
- Full service note per nursing shift and per intervention per date of service
Required documentation and forms
The service record must include and provide copies of the treatment plan, discharge plan, after‑care plan, crisis plan, required assessments, and the LME Consumer Admission and Discharge Form for Medicaid beneficiaries. Psychiatric, psychological, comprehensive clinical, and nursing assessments must be documented in the service record no later than 24 hours from the time the assessment was conducted.
- Treatment plan (goals, objectives, interventions, responsible individual)
- Discharge plan (responsible person, first follow‑up appointment date/time/location, diagnosis, discharge medications, living and educational/vocational arrangements)
- After‑care plan with provider names and contact information, and PCP follow‑up where indicated
- Crisis plan developed with beneficiary and legally responsible person
- LME Consumer Admission and Discharge Form submitted for Medicaid beneficiaries
- Psychiatric, psychological, comprehensive clinical, and nursing assessments documented within 24 hours
Compliance with NCTracks, billing guides, and policies
Providers shall comply with the NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, NC Medicaid clinical coverage policies, and other relevant documents for coverage and reimbursement. Federally recognized tribal and Indian Health Service providers may be exempt from some requirements per federal law.
- Follow NCTracks Provider Claims and Billing Assistance Guide and Medicaid bulletins
- Adhere to NC Medicaid clinical coverage policies and fee schedules
- Note federal exemptions applicable to tribal and IHS providers
Requirement to Rule Out Less Intensive Alternatives
Providers must demonstrate that no equally effective, more conservative, or less costly treatment is available statewide and must rule out less intensive alternative interventions based on current North Carolina community practice standards before providing Facility‑Based Crisis Services.
- Document that no equally effective, more conservative, or less costly statewide alternative is available
- Rule out less intensive alternatives per community practice standards (e.g., AACAP, APA, ASAM)
Level-of-Care and Admission Standards
Permitted Interventions and Clinical Services
inv-46: Multidisciplinary crisis assessment and short-term therapeutic interventions
chunk 9
inv-47: Crisis stabilization interventions (multimodal)
chunk 34
inv-48: Detox initiation and referral
chunk 53
Service Setting, Bed Limits, and Billing Unit Rules
Background and Scope
Facility-Based Crisis Service is an intensive, short-term, medically supervised 24-hour residential service (available 24/7/365) intended as an alternative to hospitalization for children and adolescents. It provides crisis stabilization, multidisciplinary assessment, therapeutic interventions, and discharge planning in facilities limited to 16 beds or less and supervised by psychiatric medical direction.
Key Definitions
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