Opioid Treatment Program (OTP) Service
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Defines coverage, eligibility, and service delivery requirements for Opioid Treatment Program services (including OTP facilities, mobile units, and medication units) for NC Medicaid beneficiaries. Applies to providers delivering outpatient treatment for opioid use disorder under NC Medicaid.
Added definitions for OTP Medication Unit and OTP Mobile Unit to align with Session Law 2023-65.
Changed 'treatment and service plan' language to 'person centered plan' and removed language referencing prior authorization.
Added medication units, mobile units and outpatient OTP emergency rule language to align with Session Law 2023-65.
Coverage, Eligibility, and Core Clinical Criteria
General Coverage / Eligibility
Covered when ALL of the following are met
Policy states Medicaid shall cover OTP for eligible beneficiaries
Minimum age for coverage
See Specific Criteria Covered for diagnosis and ASAM level requirements
Specific Criteria Covered
Covered when ALL of the following are met
Both (a) and (b) required for coverage.
Admission Criteria
Admission criteria (OTP specific)
CCA may incorporate a recent equivalent assessment from another clinician if substantially equivalent and current.
Continued Stay Criteria
Continued stay criteria
Details of the six-dimension assessment must be included in the record.
AND beneficiary must meet ONE of
- ONE of: 1) Has achieved current Person-Centered Plan (PCP) goals and additional goals are indicated as evidenced by documented symptoms; 2) Is making satisfactory progress toward meeting goals with documentation that continuation is effective; OR 3) Is making some progress but PCP interventions need modification to achieve greater gains.
Transition/Discharge Criteria
Transition and discharge criteria
Assessment details must be recorded in the service record.
AND beneficiary must meet ONE of
- ONE of: 1) Improved level of functioning with a transition plan to step down to a lower level of care (including coordinated transition to OBOT) and no medical expectation that symptoms persist without ongoing medication or medication change; 2) Achieved positive life outcomes with low potential for regression, no medical expectation that symptoms persist, and a transition plan in place to step down to a lower level of care (including OBOT) such that OTP service is no longer needed; OR 3) Beneficiary or legally responsible person requests discharge from OTP or other Medication Assisted Treatment.
Transition plans should include coordination to OBOT when medically necessary.
Covered OTP service elements
Covered when the OTP provides interdisciplinary, person-centered treatment including medication and counseling with required program elements:
PCP must address major lifestyle and recovery goals.
Daily, weekend and holiday dispensing hours must meet beneficiary needs.
Supervision plans and staff training must be documented.
Medication dose is reviewed as indicated until stability achieved.
Service coordination activities included.
At least one service from the bundled list must be provided within the weekly billing unit to bill the bundled rate; certain items may be billed separately as specified.
Eligibility restrictions: Providers must verify Medicaid enrollment for each beneficiary at every visit. A beneficiary’s eligibility category may impose service restrictions that render them ineligible for Opioid Treatment Program (OTP) services; verify enrollment and applicable eligibility rules before rendering or billing services.
Bundled-per-diem services and non-billable items: Services included in the OTP per diem must not be billed separately unless this policy explicitly indicates otherwise. The bundled rate includes programmatic items such as administrative/clinical supervision (indirect costs), and excludes separate billing for transportation, habilitation activities, recreational activities (unless tied to a planned social-skill intervention), childcare, academic instruction, interventions not in the Person-Centered Plan (PCP), services to family members not addressing the beneficiary’s needs, and room and board.
A beneficiary may receive Opioid Treatment Program services from only one provider organization at a time. Ensure coordination of care and appropriate transfers before initiating services with a different OTP provider to avoid duplicate billing or conflicts with program enrollment.
Non-bundled billable items: In addition to services included in the OTP bundled rate, providers may bill separately for certain items: evaluation and management (E/M) codes; diagnostic assessments or Comprehensive Clinical Assessments (CCA); laboratory testing except for pregnancy tests, TB tests, and drug toxicology which are included in the bundle; additional individual/group/family counseling beyond the bundled minimums (only when delivered by licensed professionals); and Peer Support Services. Follow Attachment A and coding guidance when reporting these services.
North Carolina Medicaid will not reimburse for conversion therapy. Providers must not bill Medicaid for any services identified as conversion therapy under this policy.
The policy contains a section titled 'When the Procedure, Product, or Service Is Not Covered' that lists specific Not Medically Necessary conditions. Providers should consult that section for the detailed exclusions and when a service is considered not medically necessary under this policy.
Services are not covered when the beneficiary does not meet the eligibility requirements in Section 2.0 or the clinical criteria in Section 3.0. Claims may also be denied when the service duplicates another provider’s service or is experimental, investigational, or part of a clinical trial. Additionally, failure to verify eligibility at the time of service can render the service ineligible for coverage.
Claims Codes, Billing Units, and Key Service Metrics
| No codes listed |
| Professional (CMS-1500/837P) | Claim Type |
| ICD-10-CM / PCS | Report to highest level of specificity; use current edition in effect at time of service |
| H0020 | Opioid Treatment Service; Billing Unit = 1 Unit = 1 week |
Provider Responsibilities, Billing Rules, and Documentation
Consult policy prior approval section
See policy for prior approval rules; consult the policy prior approval section and requirements for any services that may require authorization.
No prior approval required for OTP
Medicaid does not require prior approval for Opioid Treatment Program services.
No prior approval requirements apply
There are no general or specific prior approval requirements that apply to OTP services under this policy.
Prior authorization language removed — follow NCTracks
Policy language referencing prior authorization was removed from Subsection 4.2.1 and Section 5.0; providers should follow NCTracks and current billing guidance for any applicable authorization requirements.
Use H0020 — bill by 1-week unit
Report H0020 as the OTP weekly service code with a billing unit of 1 week; report the most specific codes required by current code sets.
Use FDA‑approved OTP medications (no step sequence specified)
Policy lists FDA‑approved medications (methadone, buprenorphine formulations, naltrexone) as treatment options; the policy does not specify a step-therapy sequence.
Provide individualized, conservative‑care–considered services
Services must be individualized, specific, consistent with the beneficiary's symptoms/diagnosis, and provided only when no equally effective, more conservative, or less costly statewide alternative exists.
No utilization management restrictions
The policy states that no utilization management restrictions apply to OTP services.
Know bundled services vs separately billable items
The OTP bundled per‑diem includes specific activities; certain items (E/M, diagnostic/CCA, most lab testing, additional counseling beyond minimums, Peer Support Services) may be billed separately as listed in the policy.
- Bundled activities include medical plan management, PCP, minimum counseling sessions, nursing/administering medication, medication cost, drug testing, pregnancy/TB tests, psychoeducation, and service coordination.
- Separately billable items include E/M codes, diagnostic or comprehensive clinical assessments, laboratory testing (excluding pregnancy/TB/drug toxicology), additional licensed counseling beyond bundled minimums, and Peer Support Services.
Billable for multi‑week take‑home dosing when indicated
Providers may bill for more than one week of take‑home doses when clinically indicated.
Follow documentation and claims attachments for billing
Follow the policy's Documentation Requirements section and Attachment A for claims-related information (codes, modifiers, billing units, place of service, reimbursements) when billing.
Complete required admission documentation and CCA/DA within 10 days
At admission, complete an initial abbreviated assessment, physical exam, and service order by a physician or approved medical provider; a licensed professional must complete a CCA or DA within 10 calendar days and include diagnostic information in the Person‑Centered Plan.
- Initial assessment must document presenting problem, needs/strengths, provisional/admitting diagnosis (established within 30 days), pertinent histories, and appropriate evaluations.
- CCA/DA must be completed within 10 calendar days and relevant diagnostic information must be in the PCP.
Document six‑dimension ASAM status for continued stay
For continued stay, document the beneficiary's current status across all six ASAM dimensions and justify the continued need for services in the record.
- Provide justification based on current level of functioning in each ASAM dimension.
- Document meeting one of the required progress-based conditions or rationale for maintenance to prevent regression.
Record ASAM‑based documentation and transition/discharge plan
For transition or discharge, document current status across the six ASAM dimensions and indicate one of the specified discharge/transition conditions, including a coordinated transition plan to OBOT when medically necessary.
- Include a transition plan to step down to a lower level of care or OBOT when indicated.
- Record justification for discharge based on improved functioning, stable recovery with low regression risk, or beneficiary request.
Meet DHHS documentation and MAR standards
Service notes must meet DHHS Records Management and Documentation Manual requirements; medication administration records (MAR/eMAR) must meet 10A NCAC 27G .0209(c)(4).
Keep supervision and training records in personnel files
Maintain supervision plans and staff training documentation in each staff member's personnel file; the program director shall document supervision and training activities.
- LCAS must facilitate weekly supervision (in‑person or interactive virtual) and document supervision.
- Initial and ongoing training requirements must be met and documented; program director maintains records.
Use most specific, current edition codes
Report ICD‑10‑CM/PCS and CPT/HCPCS codes to the highest level of specificity in effect at the time of service and use current codebook editions.
Verify Medicaid eligibility at each service
Verify that the beneficiary is enrolled in NC Medicaid and confirm eligibility each time a service is rendered; failure to verify enrollment may render the service ineligible for coverage.
Denial triggers: eligibility, criteria, duplication, experimental
Claims may be denied if the beneficiary does not meet eligibility (Section 2.0) or clinical criteria (Section 3.0), if the service duplicates another provider's service, or if the service is experimental/investigational or part of a clinical trial.
Obtain valid service order before first service date (no backdating)
A signed and dated service order must be in place prior to or on the first day the service is initially provided; backdating of service orders is not allowed and providers cannot bill without a valid service order.
Comply with NCTracks and billing guidance for claims
Follow NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, and the policy's Attachment A; noncompliance may trigger claim denials.
Use correct, specific billing codes (e.g., H0020 weekly)
Report the most specific billing code (for example H0020) to reflect the weekly billing unit; failure to use the correct and specific code may lead to claim denial or incorrect payment.
Provide ≥1 bundled service per weekly unit to bill bundled rate
To bill the bundled weekly rate, provide at least one service included in Section 6.3.5 within that weekly payment unit; billing the bundled rate without providing an included service may trigger denial or adjustment.
- At least one bundled activity (e.g., counseling session, nursing related to medication, drug test) must occur within the weekly unit to bill the bundled rate.
Key Terms and Unit Definitions
Level of Care and Setting-Specific Criteria
Medication-Assisted Treatment and Counseling Modalities
Medication-Assisted Treatment (MAT)
Medications address physiological aspects of OUD and are combined with counseling and supports.
Medication Assisted Treatment (MAT) via OTP
Transition plans should be coordinated to OBOT when indicated.
Medication-assisted treatment (MAT) and counseling
Clinical services must be identified and meet medical necessity and documented in the PCP.
MAT — Medication Assisted Treatment
Dose reviewed as indicated by treatment course; includes monitoring for biomedical problems.
Medication-Assisted Treatment (MAT)
Licensed professionals listed include LCAS, LCAS-A, LCSW, LCSWA, LCMHC, LCMHCA, LMFT, LMFTA, LPA or LP.
Service Orders, Bundling, and Counseling Frequency
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