NC Medicaid Nursing Facility Services
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Defines coverage, eligibility, prior approval, provider qualifications, and operational requirements for nursing facility services under Clear Health Alliance for NC Medicaid beneficiaries.
No material clinical or coverage changes in this revision.
Coverage and PASRR Requirements
inv-01: Coverage Overview
Medicaid shall cover Nursing Facility Services when the beneficiary meets the following structure of requirements:
inv-02: PASRR Submission Requirements
PASRR-related activities and required submission steps for nursing facility placement:
Decision thresholds and Level II referral criteria are in the full PASRR attachments.
The table of contents shows dedicated sections titled "When the Procedure, Product, or Service Is Not Covered", "General Criteria Not Covered", and "Specific Criteria Not Covered", indicating the policy defines explicit exclusions in the full document. The specific excluded items and operational details for those sections are not present in the extracted chunks shown here.
Within the extracted material there are no explicit exclusion statements; the available content (Attachment C and PASRR-related listings) does not include named services or conditions that are expressly excluded in these chunks.
The document includes a labeled "Not Covered" area (references to Specific Criteria Not Covered and Medicaid Additional Criteria Not Covered in the table of contents), but the extract does not carry the detailed text that lists particular services or situations that Medicaid considers not covered.
No statements framed as "not medically necessary" appear in the provided chunks. The excerpts focus on PASRR forms, tracking, transfers, and prior approval attachments rather than explicit medical necessity denials in this segment.
Prior Approval, PASRR, Documentation, and Sanctions
Obtain prior approval for specified nursing facility services
Prior approval is required for certain nursing facility services; failure to obtain required prior approval may trigger denial of coverage per the policy's Prior Approval and Prior Approval Requirements sections.
Follow general prior approval procedures
Follow the policy's general prior approval procedures (see Prior Approval Requirements: General and Specific) when requesting authorization; the table of contents directs providers to sections describing general and specific prior approval rules.
Prior approval required for ventilator services
Prior approval is required for ventilator services and is addressed in a dedicated subsection; providers must follow the Prior Approval for Ventilator Services process described in the Prior Approval Process (Attachment E).
Complete and track PASRR Level I/II forms in NC MUST
Complete and submit North Carolina Level I and, if indicated, Level II PASRR screening forms and record submissions in the NC MUST Tracking Module as required by the PASRR process.
- Complete the North Carolina Level I Screening Form.
- If Level I indicates, complete the North Carolina Level II Screening Form.
- Use the NC MUST Tracking Module to track PASRR status.
Use Attachment E Prior Approval Process
Use the Prior Approval Process (Attachment E) for requests: follow requesting prior approval steps, processing steps for an electronic FL-2, and retroactive prior approval instructions as outlined in Attachment E.
- Request prior approval using the steps in Attachment E.
- If submitting an electronic FL-2, follow the processing steps in Attachment E.
- Follow the retroactive prior approval instructions if applicable.
Submit electronic FL-2 for prior approval
For prior approval of nursing facility services, submit the electronic FL-2 (Attachment F/FL-2 form) and follow the prior approval workflow including physician signature requirements.
- Submit electronic FL-2 as part of the prior approval request.
- Ensure physician signature per Attachment E/Attachment G requirements.
Maintain PASRR and continued-stay documentation
PASRR Level I/II, annual reviews, continued stay documentation, and other PASRR-related documentation are listed as required elements; providers must maintain documentation related to PASRR and continued stays per the policy's PASRR/Documentation sections.
- Maintain annual resident review documentation for Level II when required.
- Retain documentation for continued stays and Level II findings.
Submit NC Level I/II screening forms and use NC MUST
Complete and submit North Carolina Level I and Level II Screening Forms as part of the PASRR process and use the NC MUST module to submit and track screening forms and attachments.
- Complete the NC Level I Screening Form prior to admission.
- Submit Level II when indicated and track in NC MUST.
Include FL-2 and physician signature forms with PA requests
Use the FL-2 (Attachment F) and the physician signature form (Attachment G) when submitting prior approval/authorization requests as specified in the prior approval attachments.
- Include a completed FL-2 (Attachment F) with prior approval requests.
- Provide physician signature on Attachment G when required.
Maintain documentation for compliance and residents' rights
Follow Additional Requirements (Section 7.0) including Compliance and Residents' Rights, and retain documentation supporting compliance with these sections as part of the provider's recordkeeping obligations.
- Adhere to Section 7.1 Compliance and Section 7.2 Residents' Rights requirements.
- Maintain records to demonstrate compliance and residents' funds handling per Sections 7.3.x.
Use Attachment A coding and claims instructions
Follow Attachment A (Claims-Related Information) for coding, claim type, place of service, billing units, modifiers, and other claims instructions when submitting claims; Attachment A provides the claims and coding guidance referenced in the policy.
- Use Attachment A coding instructions for claim submission.
- Ensure place of service and billing units align with Attachment A guidance.
Noncompliance may lead to sanctions or denial
Sanctions are identified in the policy (section 6.3); failure to comply with provider qualifications, compliance, or residents' rights requirements may result in sanctions or denial of coverage.
Section 6.3 sanctions apply for policy violations
Sanctions are referenced (section 6.3) and tied to compliance and residents' funds/property rules; providers should be aware that violations referenced in these sections may trigger sanctions.
Claims/billing errors can cause denials
Attachment A indicates that incorrect claim type, place of service, modifiers, or billing units could result in claim denials; ensure claims follow Attachment A instructions to reduce denial risk.
- Confirm correct claim type/place of service per Attachment A.
- Use proper billing units and modifiers as specified.
Failure to submit PASRR forms may risk payment/placement denial
Failure to complete or submit required PASRR Level I or Level II screening forms or to use the NC MUST tracking process could trigger denial of facility placement or payment; the policy emphasizes completing and submitting these forms.
Missing or improper prior approval/FL-2 processing risks denial
Lack of required prior approval or improper processing of the FL-2 (including electronic FL-2 processing or retroactive PA procedures) may result in denial; follow the prior approval process and FL-2 processing steps in Attachment E.
- Follow processing steps for electronic FL-2 in Attachment E.
- Adhere to retroactive prior approval procedures when applicable.
No specific prior-authorization codes listed in this excerpt
Attachment A lists claims, coding, and billing sections but this excerpt does not list specific prior authorization codes; providers must consult Attachment A and the full prior approval sections for code-level PA requirements.
- This excerpt contains no specific PA CPT/HCPCS codes — consult attachments and full policy for code-level PA details.
No step therapy requirements in this excerpt
No step therapy or sequencing rules are present in the provided extract; the policy does not include step therapy requirements in these chunks.
Codes and Billing References
| ICD-10-CM / PCS | International Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification and Procedural Coding System referenced |
Attachment A contains claim/coding guidance
Attachment A lists claim/coding sections and should be used for claims submission; it contains guidance on ICD-10, modifiers, billing units, and place of service.
Use Attachment A for ICD-10, modifiers, billing units, place of service
Follow Attachment A for claims documentation details including ICD-10-CM/PCS, modifiers, billing units, and place of service when preparing claims.
- Use ICD-10-CM / PCS coding as directed in Attachment A.
- Apply billing units, modifiers, and place-of-service values per Attachment A guidance.
Admission Requirements for SNF/Nursing Facility
inv-79: SNF — Admission criteria (1 top-level node)
Admission to a skilled nursing facility (SNF) is covered when the following PASRR-related prerequisite is met:
See Attachment D for the North Carolina Level I Screening Form and Attachment C for the PASRR process.
inv-80: SNF — Admission criteria (1 top-level node)
Admission references and administrative prerequisites (table of contents guidance):
This segment lists related sections (7.3–7.10) but does not specify clinical admission criteria.
inv-81: SNF — Admission criteria (1 top-level node)
PASRR attachment guidance for admission screening:
See Attachment C: Preadmission Screening Resident Review Process for details.
inv-82: SNF — Admission criteria (1 top-level node)
Requirement to complete PASRR screens before or at admission:
Attachment D contains the Level I form and Attachment C describes completing/submitting procedures.
inv-83: SNF — Admission criteria (1 top-level node)
Operational admission steps for providers related to PASRR and prior approval:
Prior approval requirements including electronic FL-2 processing are described in Attachment E.
Criteria for Continued Stay/Authorizations
inv-84: SNF — Continued stay criteria (1 top-level node)
Continued stay for SNF residents requires ongoing PASRR and review activities:
See sections 5.4.5–5.4.9 for Annual Resident Review, Continued Stays, and Documentation requirements.
inv-85: SNF — Continued stay criteria (1 top-level node)
Administrative continued-stay considerations referenced in table of contents:
This extract lists headings (7.3–7.10) but does not include explicit clinical continued-stay criteria.
inv-86: SNF — Continued stay criteria (1 top-level node)
Clinical events that affect continued-stay determinations:
Significant change triggers a new Level I screening per Attachment C.
inv-87: SNF — Continued stay criteria (1 top-level node)
Significant change policy note:
See Attachment C: Significant Change (New Level I Required).
inv-88: SNF — Continued stay criteria (1 top-level node)
Operational requirements for continued stays and authorizations:
Attachment E describes prior approval processing including electronic FL-2 and physician signature requirements.
Discharge and Transfer Rules
This extract contains only a table-of-contents style listing for discharge-related topics and does not present formal discharge decision rules. Headings in the document indicate there are sections on Transfer and Discharge, Readmissions, and related operational topics, but the specific discharge criteria text is not included in these chunks.
One section heading in the extract points to resident funds and disposition topics that become relevant at discharge: "7.3.5 Disposition of Funds upon Discharge, Eviction, or Death". This indicates the policy addresses financial handling at discharge, though explicit clinical discharge criteria are not shown here.
The table of contents lists additional discharge/transfer topics under Attachment C and related sections: Transfers, Time Limited Stays, and Significant Change (New Level I Required). These entries imply the policy defines procedures for transfers and circumstances that may prompt reassessment, but the extract does not contain the full discharge/transfer criteria.
Attachment C and its index entries include Transfers as a named subsection, indicating the policy contains guidance on transfer procedures. The extract lists the heading but does not provide the operational discharge criteria or step-by-step transfer requirements in these chunks.
The table of contents references Time-Limited Stays and related policy material under Attachment C. This signals the policy addresses planned short-term stays and their administrative handling, though specific discharge thresholds or criteria are not provided here.
Transfers and discharge procedures are indexed in the document alongside the prior approval and PASRR attachments, indicating continuity between admission, PASRR screening, prior approval, and discharge processes. The extract does not include the explicit discharge decision rules themselves.
Authorized Day Limits and Related Key Values
Definitions and Background
Background and Attachments
Attachment C ("Preadmission Screening Resident Review Process") is structured around the PASRR workflow and includes: (A) The PASRR Process; (B) Completing the North Carolina Level I Screening Form; (C) Submitting the Level I Form; (D) Completing the North Carolina Level II Screening Form; (E) The NC MUST Tracking Module; and (F–H) topics such as Transfers, Time-Limited Stays, and Significant Change (New Level I Required). These components define the administrative steps providers must follow for PASRR screening and tracking as indexed in the table of contents.
Record retention and policy revision references (7.6, 8.0)
Record retention and policy revision/implementation topics are referenced in the Table of Contents (see sections 7.6 and 8.0) and should be consulted for documentation obligations.
TOC lists prior authorization topics (details located in attachments)
The Table of Contents includes prior authorization topics but does not specify detailed prior authorization requirements in the listed excerpt.
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