Opioid Treatment Program Service
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Defines coverage, eligibility, and program requirements for outpatient OTP services (methadone, buprenorphine, naltrexone, and other FDA‑approved medications) for North Carolina Medicaid beneficiaries. Applies to OTP facilities, mobile units, and medication units and to providers billing Medicaid.
Added definitions for OTP Medication Unit and OTP Mobile Unit to align with Session Law 2023-65.
Added OTP mobile unit and OTP medication unit as a place of service to align with Session Law 2023-65.
Removed reference to treatment and service plan, changed to person centered plan.
Removed language referencing prior authorization and utilization management.
Coverage and Medical Necessity Criteria
General Coverage Criteria
Covered when ALL of the following are met
General applies to all Medicaid policies.
See EPSDT exceptions for beneficiaries under 21 years of age.
See place-of-service definitions.
Medications and therapies provided per program requirements.
Specific coverage criteria
Covered when ALL of the following are met
ASAM OTP level required for admission.
Admission Criteria
Admission criteria (special rules for OTP admissions)
Program physician may bill E/M separately for admission evaluation and physical exam.
Continued Stay Criteria
Continued stay covered when documentation shows ongoing need using ASAM dimensions and one of individualized progress conditions
Details of assessment in each dimension are required.
Any one of the three conditions satisfies this element.
Any one condition suffices to continue services.
Transition and Discharge Criteria
Transfer or discharge covered when ASAM documentation supports step-down or discharge
Any one condition suffices for discharge or transfer.
General Coverage Criteria
General medical necessity
OTP operational and medical necessity criteria
Covered when program and documentation requirements are met:
Service order demonstrates medical necessity and must be reviewed at least annually.
Staff who provide services are responsible for accurate documentation.
Providers operating OTPs must meet licensing and federal OTP standards.
Continuous availability means immediate phone access and ability to arrive on site within one hour as needed.
Staff responsibilities include assessment, PCP development, monitoring, and documentation.
Covered Services — OTP
Covered when ALL of the following program, assessment, and service criteria are met
Daily, weekend and holiday dispensing hours must meet beneficiary needs.
PCP developed collaboratively and updated regularly.
A minimum number of counseling sessions is included within the bundled rate.
Additional specified services may be billed separately.
Services that are unsafe, ineffective, experimental, investigational, or not generally recognized as accepted medical practice are excluded from coverage. This exclusion applies even under EPSDT; EPSDT does not require coverage for services that meet these criteria.
The policy lists specific non‑covered items for OTP services. Any services included in the OTP per diem may not be billed separately unless the clinical coverage policy explicitly permits it. Additionally, transportation, habilitation activities, recreational activities (unless tied to a specific planned social‑skills intervention in the PCP), clinical/administrative supervision (part of the indirect rate), childcare, academic instruction substitutes, services not rendered, family services not directly related to the beneficiary's PCP, and room and board are not covered.
Service orders must be valid and contemporaneous. Backdating of a service order is not allowed; each service order must be signed and dated and must be in place prior to or on the first day the service is initially provided. A backdated or absent service order does not validate billing.
The OTP weekly bundled rate requires that at least one service included in the Program Bundled Rates be provided to the beneficiary within the weekly service payment unit in order to bill the bundled rate. Services outside the bundled minimums may only be billed separately as specified by the policy; additional eligible counseling by licensed clinicians may be billed separately beyond the bundled minimums when allowed.
North Carolina Medicaid explicitly disallows payment for conversion therapy; such services will not be reimbursed.
Services are not covered when the beneficiary fails to meet required eligibility or clinical criteria. Specifically, Medicaid will not cover services when the beneficiary does not meet the eligibility requirements in Section 2.0 or the coverage criteria in Section 3.0, or when the service duplicates another provider's services. Also, services that are experimental, investigational, or part of a clinical trial are not covered.
Billing Codes and Units
| H0020 | Weekly OTP service (Billing Unit = 1 week) |
Provider Requirements, Documentation, and Billing Rules
Prior Approval Requirement
If OTP services require prior approval per this policy, beneficiaries under 21 still require prior approval; EPSDT does not waive prior approval. See NCTracks Provider Claims and Billing Assistance Guide and the EPSDT provider page for additional information.
- If a service requires prior approval, EPSDT does not eliminate that requirement.
- Refer to NCTracks Provider Claims and Billing Assistance Guide: https://www.nctracks.nc.gov/content/public/providers/providermanuals.html
- Refer to EPSDT provider page: https://medicaid.ncdhhs.gov/
Prior approval not required
Medicaid shall not require prior approval for Opioid Treatment Program Services.
Service order (authorization) requirement
A signed service order by an authorized clinician (physician, physician assistant, or nurse practitioner) is required to demonstrate medical necessity. Service orders are valid for 12 months, must be signed and dated by the authorizing professional, cannot be backdated, and must be in place prior to or on the first day the service is initially provided.
- Service order must be completed by MD, PA, or NP per scope of practice.
- Service order validity: 12 months; must be renewed at least annually.
- Backdating of service orders is not allowed.
- A valid service order must be present before billing, even if beneficiary later becomes retroactively eligible.
Prior Authorization
No prior authorization requirements are specified for OTP services in this policy; references to prior authorization and utilization management were removed.
- Section 5.1 states Medicaid shall not require prior approval for OTP services.
- Policy history removed prior authorization and utilization management language.
Eligibility verification
Providers must verify each Medicaid beneficiary's eligibility at each service encounter. Failure to verify eligibility may result in denial or nonpayment.
- Verify Medicaid eligibility each time a service is rendered.
- Federally recognized tribal and IHS providers may have alternate rules under federal law.
General denial triggers
Claims may be denied when the beneficiary does not meet eligibility requirements in Section 2.0, does not meet criteria in Section 3.0, the service duplicates another provider's service, or the procedure/product/service is experimental/investigational or part of a clinical trial.
- Denial triggers include: ineligibility per Section 2.0; failure to meet clinical criteria in Section 3.0; duplicate services; experimental/investigational services or clinical trial participation.
Service order requirement
Billing Medicaid without a valid service order in place prior to or on the first day of service (including backdated orders) will result in denial.
- A service order must be signed and dated and indicate the date the service was ordered.
- Providers cannot bill Medicaid without a valid service order even if beneficiary is retroactively eligible.
At least one service included in the Program Bundled Rates must be provided
At least one service included in the Program Bundled Rates must be provided to the beneficiary within the weekly service payment unit to bill the bundled rate.
- Providers may bill bundled weekly rate only if at least one bundled service is delivered within that weekly payment unit.
- Providers may provide and bill for more than one week of take-home doses to meet beneficiary need.
Program director shall maintain documentation
The program director shall maintain documentation of supervision and training activities and ensure staff meet training and competency requirements.
- Program director responsible for oversight, supervision documentation, and ensuring required staff training within specified timelines.
- Training topics include crisis response, opioid antagonist administration, harm reduction, PCP instructional elements, ASAM Criteria, motivational interviewing, co-occurring treatment, and trauma-informed care.
Billing Guidance
Providers shall bill their usual and customary charges. For a schedule of rates and claims/billing processes, follow the NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, and clinical coverage policies. North Carolina Medicaid will not reimburse for conversion therapy.
- Bill usual and customary charges; refer to NCTracks and Medicaid fee schedules for rates and billing guidance.
- NC Medicaid will not reimburse for conversion therapy.
- Federally recognized tribal and IHS providers may be exempt from some items per federal law.
Step considerations for continued stay
Continuation of OTP services must be justified by documentation of the beneficiary's current status using the six ASAM dimensions, with evidence of progress toward PCP goals or risk of regression; no forced step-down is required without documentation supporting appropriateness of a step-down.
- Continued stay requires detailed ASAM six-dimension assessment and justification.
- Acceptable reasons to continue include: achievement of PCP goals needing further work; satisfactory progress with documented effectiveness; or need to modify interventions to achieve greater gains.
- Service must be maintained when regression is likely based on documented history, chronic DSM-5 diagnosis requiring ongoing management, or lack of a medically appropriate step-down.
Clinical supervision and medication induction/monitoring requirements
Medical and clinical staff must be available at least five days per week. Medical staff are required to perform appropriate methadone and buprenorphine inductions and monitor dosing until the beneficiary is stable; an on-call clinician must be continuously available when supervising staff are off site.
- Clinical staff available five days/week to provide counseling (in-person or telehealth).
- Medical provider staff available five days/week to provide inductions and beneficiary care.
- In-clinic dosing available at least six days/week for beneficiaries in induction or unstable for take-homes.
- On-call RN/physician/NP/PA must be immediately available by phone and able to arrive within one hour when supervising staff are not on site.
Step Therapy
No step therapy requirements are specified in this policy excerpt.
Program Background and Scope
An Opioid Treatment Program (OTP) is an organized outpatient service for the treatment of opioid use disorder using FDA‑approved medications such as methadone, buprenorphine formulations, and naltrexone. OTP services are delivered by an interdisciplinary team and include medication management, person‑centered recovery planning, SUD‑focused therapies, case coordination, health education, and monitoring (including drug testing). Services may be provided in OTP facilities, OTP mobile units, or OTP medication units.
Key Definitions
Level-of-Care and Service Setting Criteria
Permitted Treatment Modalities
Medication-Assisted Treatment (MAT)
Medication provided within OTP clinical context.
Medication Assisted Treatment (OTP)
Medication-assisted treatment (methadone, buprenorphine)
Medications address physiological aspects; therapy addresses psychosocial aspects.
Medication Assisted Treatment (methadone, buprenorphine)
Medication cost included in bundled rate.
Service Frequency, Availability, and Visit Limits
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