ModifiedBlue Cross Blue Shield - North CarolinaPolicy 2B-2

Geropsychiatric nursing facility units (geropsychiatric units)

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Defines coverage, eligibility, and requirements for Medicaid-covered geropsychiatric nursing facility units for beneficiaries with severe and persistent mental illness (SPMI) in North Carolina Medicaid.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyGeropsychiatric nursing facility units (geropsychiatric units)

Policy CodePolicy 2B-2

Change TypeAmendment — removal of continued stay criteriaAttachment A revenue code update

Effective DateJan 1, 2025

Last ReviewJan 1, 2025

Next Review Date

Key ActionVerify prior approval is obtained for all nursing facility admissions and confirm beneficiary meets Sections 2.0 and 3.0 before admission.

SourceLink

POLICY UPDATE CHANGES

Removed continued stay geropsychiatric unit criteria requirement to comply with Mental Health Parity and related federal regulations.

Removed certain revenue codes (100 and 183) from Attachment A.

65+primary intended beneficiary age

<=40admission GAF threshold

PASRR IIrequired PASRR confirmation

20max beds without CON

40initial staff training hrs

Coverage and Admission/Discharge Requirements

Initial Placement Criteria

To qualify for placement in a geropsychiatric nursing specialty unit, a beneficiary shall meet ALL of the following:

Admission criteria: a) Beneficiary has an SPMI as defined: (1) a major mental disorder diagnosable under DSM (examples: schizophrenia, bipolar disorder, major depression, schizoaffective disorder, schizophreniform disorders, psychotic disorder NOS); (2) prior to admission, Global Assessment of Functioning (GAF) score is 40 or lower.GAF <= 40

examples listed in policy

PASRR confirmation: b) Level of impairment is confirmed by a Level II PASRR evaluation (42 CFR 483.128) which confirms SPMI and may recommend additional supportive therapies (occupational, physical, recreational, creative expressive arts).PASRR Level II

Resource Regulatory Management Section ensures PASRR compliance

Hospitalization risk/history: c) Beneficiary is currently in a psychiatric hospital; or has had one or more past psychiatric hospitalizations; or is exhibiting behaviors that place them at risk of psychiatric hospitalization in a State, public, or private psychiatric hospital in North Carolina.

Chronic unsafe behaviors: d) Beneficiary exhibits chronic, unsafe behaviors that cannot be managed in a traditional nursing facility, including one or more of: elopement/wandering; combative or assaulting behaviors (physical or verbal); sexually inappropriate behaviors; self-endangering behaviors and medication noncompliance; or other challenging behaviors related to psychiatric illness.

Availability of alternatives: e) Alternative services to meet the beneficiary's behavioral health needs are not available or are not appropriate.

General Medical Necessity

Medicaid covers the procedure, product, or service when medically necessary and ALL of the following are met:

Medical necessity general: a) Service is individualized, specific, and consistent with symptoms or confirmed diagnosis and not in excess of beneficiary's needs; b) Service can be safely furnished, and no equally effective, more conservative or less costly treatment is available statewide; c) Service is not primarily for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.

Medicaid Additional Criteria Covered — Admission to geropsychiatric unit

Covered when ALL of the following are met for Medicaid beneficiaries (additional Medicaid-specific criteria):

Medicaid geropsychiatric admission requirements: Beneficiary meets nursing facility level of care and has SPMI diagnoses as defined (DSM major mental disorder examples: schizophrenia, bipolar disorder, major depression, schizoaffective disorder, schizophreniform, psychotic disorder NOS); GAF score <= 40 prior to admission; Level II PASRR confirms diagnosis and need; beneficiary currently in or has history of psychiatric hospitalization or is at risk for hospitalization in NC; beneficiary exhibits chronic unsafe behaviors not manageable in traditional nursing facility (e.g., elopement, combative/assaultive, sexually inappropriate, self-endangering, medication noncompliance, or other challenging behaviors); alternative services not available or not appropriate.

Discharge Criteria

Discharge from a geropsychiatric unit is allowed when ALL of the following are met:

Discharge conditions: a) Consistent absence of unsafe behaviors as defined in admission criteria while in a structured geropsychiatric unit; b) Anticipation that beneficiary will not exhibit unsafe behaviors if transitioned from the geropsychiatric unit, demonstrated by trial stays on a regular nursing unit without observed unsafe behaviors; plus consideration of medication stability, treatment compliance, appropriate living arrangements, and arranged aftercare with family or legal guardian involvement. Note: these criteria must be observed and monitored for at least three months.

3.2.1 Specific criteria covered by Medicaid: None Apply.

Services are not covered when any of the following apply: the beneficiary does not meet the eligibility requirements in Section 2.0; the beneficiary does not meet the coverage criteria in Section 3.0; the service duplicates another provider’s procedure, product, or service; or the procedure, product, or service is experimental, investigational, or part of a clinical trial. Additionally, there are no further Medicaid‑specific "not covered" criteria identified in this policy.

The policy was revised effective 01/01/2025 to conform with federal parity and regulatory requirements. As part of that revision the prior requirement specifying continued stay geropsychiatric unit criteria was removed; continued‑stay criteria for geropsychiatric units are no longer required under this policy revision.

Medicaid beneficiaries residing in a nursing facility are exempt from co‑payments for the following items per the Medicaid State Plan: 1. Facility room and board; 2. Any services rendered by practitioners at the facility or at another location; and 3. Prescription drugs. Providers should refer to the Medicaid State Plan and the NC Medicaid website for schedules and additional guidance.

Treatment and services are not covered if the beneficiary fails to meet the eligibility requirements in Section 2.0 or the covered‑service criteria in Section 3.0. Claims may also be denied when services duplicate another provider’s service or are experimental/investigational, consistent with the policy’s general noncoverage provisions.

Facility Level of Care Definitions and Eligibility

Services, Therapies, and Multidisciplinary Care

Supportive/rehabilitative therapies

Supportive/rehabilitative therapies: PASRR Level II may recommend supportive therapies such as occupational, physical, recreational, and creative expressive arts as part of the geropsychiatric service package.

Multidisciplinary geropsychiatric services

Service components: Enhanced nursing services; psychiatric services for symptom and medication management; psychological services for behavior management plans and staff training; social work services for coordination; licensed psychiatric nursing supervision; programming focused on maintaining psychosocial and recreational skills.

Facility-based behavioral health services

Staff training requirements: All nursing staff (RNs, LPNs, CNAs) must complete at least 40 initial hours of behavioral health management training and a minimum of 20 hours annually thereafter covering topics such as assessment of mental status, documentation of behaviors, crisis prevention/intervention, psychotropic medications and side effects, elopement precautions, and training for staff self‑protection.

Staffing, Training, and Facility Establishment Requirements

Beneficiary safety staffing ratios

Facility must maintain staffing to ensure beneficiary safety as a coverage requirement:

Shift staffing ratios: First shift: 1 CNA per 3 beneficiaries, 1 LPN per 12 beneficiaries, and 4 hours RN coverage; Second shift: 1 CNA per 3 beneficiaries, 1 LPN per 12 beneficiaries, and 4 hours RN coverage; Third shift: 1 CNA per 7 beneficiaries and 1 LPN per 20 beneficiaries; per 20 beneficiaries also require 0.2 FTE psychiatrist; 0.2 FTE licensed psychologist; 0.5 FTE social services assistant; and 0.5 FTE LCSW.

Enhanced staffing FTE requirements

Minimum enhanced staffing for a 20-bed geropsychiatric specialty unit:

Enhanced staffing: 10 FTE nursing staff (RN, LPN, CNA); 0.2 FTE psychiatrist; 0.2 FTE licensed psychologist; 0.5 FTE Licensed Clinical Social Worker (LCSW); 0.5 FTE social work assistant (BSW or related with 1 year experience). The psychiatrist and psychologist participate in ongoing treatment, assessment, and treatment planning. Nursing staff must be facility employees; other roles may be contracted.

Establishing geropsychiatric units

Options for establishing units (coverage/approval implications):

Unit establishment options: Option A: convert up to 20 currently certified nursing beds to create a geropsychiatric unit with documentation that displaced beneficiaries meet criteria and a transition plan; Option B: expand by converting non‑certified beds or developing new certified beds which requires Certificate of Need (CON) approval prior to final approval and compliance with CON requirements.

Provider and facility eligibility

Provider and facility eligibility and requirements for billing:

Provider billing eligibility: Provider must meet Medicaid participation qualifications, have a signed DHHS Provider Administrative Participation Agreement, and bill only for services within scope of licensing; facility must be certified (42 CFR 483), meet DHSR nursing facility requirements, provide a therapeutic environment with enhanced trained staff, and be monitored by the Program Accountability Team for training and compliance.

inv-19: Staff training hours — Initial >= 40 hours; Annual >= 20 hours

Initial staff trainingMinimum 40 hours of initial behavioral health management training for all nursing staff (RNs, LPNs, CNAs).

Annual refresher trainingMinimum 20 hours of behavioral health management training annually after initial training.

Applicable staffTraining required for all nursing staff assigned to geropsychiatric unit (RNs, LPNs, CNAs).

Curriculum oversightTraining calendar and schedule planned by Staff Development Coordinator with DMH approval and follows MH/DD/SAS guidelines.

Training topics examplesIncludes assessment of mental status, documentation of behaviors, crisis prevention/intervention, psychotropic medication side effects, elopement precautions, and working with aggressive/sexual behaviors.

inv-39: Geropsychiatric unit — definition: nursing facility units providing skilled nursing services and enhanced supervision for geriatric beneficiaries

DefinitionNursing facility units providing skilled nursing services and enhanced supervision for geriatric beneficiaries with long-term psychiatric and behavioral health needs (geropsychiatric units).

PurposeProvide skilled nursing care plus enhanced behavioral supervision and management for beneficiaries with SPMI whose behaviors are beyond management capacity of traditional skilled nursing facilities.

PopulationGeriatric beneficiaries diagnosed with severe and persistent mental illness who exhibit chronic, unsafe or challenging behaviors.

Related requirementsAdmissions require meeting nursing facility level of care and PASRR Level II confirmation of SPMI per policy.

Billing, Codes, and Claim Types

Claim Typemixed

Institutional (UB-04/837I)

Claim type for institutional providers

Unlisted Procedure or Service CodesCPT | HCPCS

CPT unlisted	Use CPT unlisted procedure code with special report per CPT instructions
HCPCS unlisted	Use HCPCS unlisted code with special report per HCPCS instructions

Removed Revenue CodesRevenueNot Covered

Revenue codes 100, 183

Revenue codes removed from Attachment A

inv-17: Global Assessment of Functioning (GAF) — <= 40

ThresholdGlobal Assessment of Functioning (GAF) score of 40 or lower prior to admission.

UseGAF used as part of admission criteria to confirm level of impairment for geropsychiatric unit placement.

DocumentationGAF score must be recorded prior to admission as part of eligibility assessment.

inv-18: GAF score — <= 40

Admission cutoffGAF score of 40 or lower (<= 40) is required prior to admission to a geropsychiatric nursing specialty unit.

ContextGAF threshold is listed under Specific Criteria Covered for Medicaid beneficiaries seeking placement.

Relation to SPMIGAF <= 40 is used alongside DSM-based SPMI diagnoses and PASRR Level II confirmation to determine eligibility.

Documentation, Prior Approval, and Billing Requirements

Prior Authorization

Prior approval remains required for EPSDT cases

If the service requires prior approval, prior approval still applies for beneficiaries under age 21; providers must consult NCTracks and EPSDT guidance for prior approval procedures.

EPSDT does not eliminate prior approval requirements when a service requires prior approval; follow NCTracks Provider Claims and Billing Assistance Guide and EPSDT provider page for procedures.

Prior Authorization

Prior approval required for nursing facility admission

Prior approval is required for all admissions to a nursing facility; providers must confirm the beneficiary meets Section 2.0 eligibility and Section 3.0 coverage criteria before seeking Medicaid reimbursement.

Confirm beneficiary meets eligibility requirements in Section 2.0 and coverage/medical necessity in Section 3.0 prior to admission.

Prior Authorization

Prior Authorization / Policy revision impacts

Policy revisions and Attachment A note removal of certain revenue codes and removal of continued-stay criteria; providers should refer to NC Medicaid guidance for any impacts on prior authorization or billing.

02/01/2023 revision removed revenue codes 100 and 183 from Attachment A; 01/01/2025 revision removed continued stay criteria to comply with federal parity/regulations.
Check NC Medicaid guidance and Attachment A for updated claim-type and code instructions that may affect authorization or billing processes.

Prior Authorization

Prior authorization statements

No additional standalone prior authorization statements beyond admission prior approval are specified in these sections.

Prior approval is explicitly required for admissions (see 5.1); no other separate prior authorization requirements are stated in the cited Attachment A/Unlisted Procedure sections.

Step Therapy

Conservative therapy consideration

Services must be individualized, consistent with the beneficiary's confirmed diagnosis, not in excess of needs, and provided only when no equally effective, more conservative, or less costly statewide option exists.

Apply conservative therapy consideration: confirm no equally effective, more conservative, or less costly treatment is available statewide before approving this level of service.

Note

PASRR Level II confirmation required for admissions

Admissions require PASRR Level II confirmation of SPMI and nursing facility level of care; the prior-approval and PASRR processes apply to determine placement—no other step-therapy sequence is specified in this segment.

Ensure PASRR Level II confirms SPMI per 42 CFR 483.128 before admission.
After Level II evaluation, Annual Resident Review (ARR) is not required but PASRR Level II documentation and MDS evaluations must be maintained.

Billing Rule

Unlisted procedure or service reporting

If no specific CPT or HCPCS code exists for a provided service, report the service using the appropriate unlisted procedure or service code and follow CPT/HCPCS special report instructions.

Use unlisted CPT or HCPCS code only when no specific code exists and include the required special report per coding guidelines.

Documentation Required

EPSDT documentation and prior approval

For beneficiaries under 21, providers must document how the requested service meets EPSDT criteria to correct or ameliorate a condition; prior approval requirements still apply when the service requires prior approval.

Document how the service meets EPSDT criteria (correct, ameliorate, prevent worsening, or prevent additional health problems).
If prior approval is required for the service, EPSDT does not waive the prior approval requirement—follow NCTracks guidance.

Note

Documentation Required

Report ICD-10 codes to highest specificity

Report ICD-10-CM and PCS to the highest level of specificity that supports medical necessity and use the current ICD-10 edition in effect at the time of service.

Use the applicable ICD-10 edition and report codes to the most specific level that documents medical necessity.

Billing Rule

Use most specific procedure/revenue codes

Report the most specific CPT, HCPCS, or UB-04 revenue code that accurately and completely describes the service; use an appropriate unlisted code with special report only if no specific code exists.

Refer to current CPT, HCPCS, and UB-04 Data Specifications Manual editions for code selection.
Use unlisted procedure codes only when no specific code exists and include required documentation.

Documentation Required

Verify beneficiary eligibility for each service

Providers must verify beneficiary eligibility each time a service is rendered; eligibility category restrictions may render a beneficiary ineligible for this service.

Confirm Medicaid enrollment and any service restrictions before providing or billing for services.

Denial Risk

Denial risk if eligibility or coverage criteria are not met

Claims may be denied when the beneficiary does not meet Section 2.0 eligibility requirements or Section 3.0 coverage criteria, when the service duplicates another provider's service, or when it is experimental/investigational.

Confirm eligibility and coverage criteria prior to billing to avoid denials for not meeting Sections 2.0/3.0, duplication, or experimental status.

Billing Rule

Bill using Institutional (UB-04/837I) format

Failure to bill according to Institutional (UB-04/837I) and National Uniform Billing Guidelines may trigger claim denials; bill using the Institutional claim type unless otherwise directed.

Submit Institutional claims per UB-04/837I and National Uniform Billing Guidelines; ensure compliance with National Coding Guidelines.

Billing Rule

Bill usual and customary charges

Providers shall bill their usual and customary charges; billing that does not follow usual and customary charges may risk reimbursement issues.

Refer to NC Medicaid for schedule of rates and ensure billed charges reflect usual and customary amounts.

Note

Refer to Medicaid State Plan for co-pay and rate rules

For Medicaid-specific co-payment and rate details, refer to the Medicaid State Plan and NC Medicaid website; beneficiaries of a nursing facility are exempt from co-payments for facility room and board, practitioner services, and prescription drugs.

Check the Medicaid State Plan and NC Medicaid site for schedules of rates and co-payment guidance.
Nursing facility beneficiaries are exempt from co-payments for room and board, practitioner services, and prescriptions.

Billing Rule

Use specific codes or provide required special reports for unlisted codes

Claims/billing may be denied if ICD/CPT/UB codes are not the most specific or if unlisted procedures lack the required special report; use appropriate unlisted codes and include special reports when necessary.

Ensure unlisted procedure codes include the special report per CPT/HCPCS guidance to avoid denials.
Use the UB-04 Data Specifications Manual for revenue code accuracy.

Note

Key Terms and Abbreviations

inv-40: SPMI — Severe and persistent mental illness definition (examples listed)

DefinitionSevere and persistent mental illness (SPMI) refers to major mental disorders diagnosable under the DSM, used to determine eligibility for geropsychiatric placement.

Examples listedSchizophrenia; bipolar disorder; major depression; schizoaffective disorder; schizophreniform disorders; psychotic disorder NOS.

Role in coverageOnly Medicaid beneficiaries with nursing facility level of care and SPMI diagnoses are eligible for geropsychiatric unit services.

inv-41: SPMI — Severe and persistent mental illness (examples listed include schizophrenia, bipolar...)

Included diagnosesSchizophrenia; bipolar disorder; major depression; schizoaffective disorder; schizophreniform disorders; psychotic disorder NOS (examples listed in policy).

Diagnostic basisSPMI defined as major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Admission linkageSPMI diagnosis must be confirmed by PASRR Level II evaluation for admission to geropsychiatric units.

inv-42: GAF score — Global Assessment of Functioning (GAF) score threshold for admission: GAF score of 40 or lower prior to admission

Admission thresholdGAF score of 40 or lower prior to admission (GAF <= 40).

PurposeUsed to demonstrate level of impairment when combined with SPMI diagnosis and PASRR Level II confirmation.

Placement requirementGAF <= 40 is explicitly required as part of the initial placement criteria for geropsychiatric nursing specialty units.

inv-43: Behavioral health management training — Staff training requirements

Initial training requirementAll nursing staff (RNs, LPNs, CNAs) must complete no fewer than 40 initial hours of staff training on behavioral health management for challenging behaviors.

Annual requirementAt least 20 hours of behavioral health management training annually thereafter.

Training governanceStaff training calendar and schedule are planned by the Staff Development Coordinator with DMH approval and follow MH/DD/SAS guidelines.

Scope of trainingCovers recognition of mental illness symptoms, crisis prevention/intervention, psychotropic medication side effects, elopement precautions, and working with aggressive/sexual behaviors.

inv-39: Geropsychiatric unit — nursing facility units providing skilled nursing services and enhanced supervision for geriatric beneficiaries with SPMI

DefinitionGeropsychiatric unit: nursing facility unit providing skilled nursing services and enhanced supervision for geriatric beneficiaries with SPMI who exhibit challenging behaviors not manageable in traditional nursing facilities.

Admission requirementsAdmission requires nursing facility level of care, SPMI diagnosis, GAF <= 40, and PASRR Level II confirmation of SPMI and need.

Staffing/trainingUnits must have enhanced trained staff; all nursing staff must complete required behavioral health management training (40 initial hours; 20 hours annually).

Service componentsProvides both long-term psychiatric nursing care and enhanced behavioral supervision/management to maintain safety and skills.

Policy Background and Scope

Geropsychiatric units provide skilled nursing and enhanced behavioral supervision for geriatric beneficiaries with severe and persistent mental illness (SPMI) who exhibit chronic, unsafe, or challenging behaviors that cannot be managed in a traditional nursing facility. Services combine long‑term psychiatric nursing care, enhanced staffing and behavioral management, and multidisciplinary supports; policy revisions note alignment with federal mental health parity requirements and related regulatory standards.

Policy Changes and Effective Dates

2025-01-01amendmentLatest

Amendment effective 01/01/2025 removed the continued-stay geropsychiatric unit criteria to comply with the Mental Health Parity and Addiction Equity Act and 42 CFR §438.900.

2023-02-01coding_update

Attachment A revised on 02/01/2023 to remove revenue codes 100 and 183 from the policy's Attachment A.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyGeropsychiatric nursing facility units (geropsychiatric units)

Policy CodePolicy 2B-2

Change TypeAmendment — removal of continued stay criteriaAttachment A revenue code update

Effective DateJan 1, 2025

Last ReviewJan 1, 2025

Next Review Date

Key ActionVerify prior approval is obtained for all nursing facility admissions and confirm beneficiary meets Sections 2.0 and 3.0 before admission.

SourceLink

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