Non-covered benefit general policy
Customize your policy alerts
Sign up for clearhealthalliance Policy CCP-102 alerts
Get alerted when Policy CCP-102 changes without checking for updates manually.
Monitor payer policy activity
Defines Alliance Health's general principles for denying coverage of procedures, products, or services when no other specific policy exists; applies to Alliance Health Tailored Plan Medicaid beneficiaries and providers making coverage requests.
No material clinical or coverage changes in this revision.
Coverage Criteria
Non-Covered Benefit Criteria
Not covered when ANY of the following are met
- i.: The member is not enrolled in an Alliance Health NC Medicaid benefit plan.
- ii.: The procedure, product, or service duplicates another provider's procedure, product, or service.
- iii.: The procedure, product, or service is experimental, investigational, or part of a clinical trial.
- iv.: The procedure, product, or service is in excess of the beneficiary's needs.
- v.: The procedure, product, or service cannot be safely furnished.
- vi.: There is a more effective, more conservative, or less costly treatment available.
- vii.: The procedure, product, or service is furnished primarily for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.
Eligibility and EPSDT Exception
Covered only when ALL of the following are met
Includes standard eligibility verification requirement
Applies only to members <21
This policy lists no specific limitations or exclusions beyond those described elsewhere in the document. Where explicit exclusions exist, they are represented in the clinical criteria sections.
Services are considered not covered when any of the following apply: the member is not enrolled in an Alliance Health NC Medicaid benefit plan; the procedure, product, or service duplicates another provider's service; the procedure, product, or service is experimental, investigational, or part of a clinical trial; the procedure, product, or service is in excess of the beneficiary's needs; the procedure, product, or service cannot be safely furnished; a more effective, more conservative, or less costly treatment is available; or the procedure, product, or service is furnished primarily for the convenience of the beneficiary, caretaker, or provider.
Coding
Provider Actions & Requirements
Prior authorization required
Prior authorization is required for services governed by this policy; prior authorization is always required.
Conservative therapy preference
Coverage prefers more effective, more conservative, or less costly treatments when available; such alternatives may be required prior to coverage of the requested service.
Verify Medicaid eligibility and enrollment
Providers must verify each Medicaid beneficiary's eligibility each time a service is rendered and ensure the beneficiary is enrolled in Alliance Health Tailored Plan. EPSDT rules exempt members under 21 from policy limitations when the service is medically necessary to correct or ameliorate a condition identified through screening.
Denial triggers and coverage exclusions
Requests will be denied when any of the following apply: member not enrolled in an Alliance Health NC Medicaid benefit plan; the service duplicates another provider's service; the service is experimental, investigational, or part of a clinical trial; the service is in excess of beneficiary needs; the service cannot be safely furnished; a more effective/conservative/less costly treatment exists; or the service is furnished primarily for convenience.
Definitions
Background
Services that are unsafe, ineffective, experimental or investigational, not medical in nature, or not generally recognized as accepted medical practice are excluded from coverage under this policy and are considered not medically necessary.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.