Prior approval indicated in TOC

Table of contents and policy structure identify Prior Approval sections, indicating some services may require prior approval; providers should expect to use the prior approval process for services referenced under Subsections 5.1–5.3.

No explicit prior authorization rules in excerpt

The provided excerpt does not include concrete prior authorization rules or step-by-step PA criteria in the body text; only headings referencing Prior Approval and Prior Approval Requirements are present.

Attachment A informs prior auth & claims

Attachment A (Claims-Related Information) is referenced as the place where codes, claim type, modifiers, billing units, and place-of-service rules are specified; prior authorization processes and claim submission must align with Attachment A guidance.

• Consult Attachment A for claim type, ICD-10-CM/PCS, Codes, Modifiers, Billing Units, and Place of Service.

Attachment A contains claims & billing rules

Attachment A contains the claims-related sections (A–G/H) that enumerate required claim elements and billing rules; providers must follow those Attachment A requirements when submitting authorizations and claims.

• Attachment A includes Claim Type; ICD-10-CM/PCS; Code(s); Modifiers; Billing Units; Place of Service; Co-payments; Reimbursement.

Consult Attachment A for coding/billing rules

Providers should consult Attachment A for code- and submission-specific guidance that can affect prior authorization and claim adjudication (e.g., correct codes, modifiers, billing units, and POS).

• Ensure coding, modifiers, and billing units in Attachment A are followed when requesting authorizations and submitting claims.

Attachment A referenced for claim submission

Attachment A is the referenced source for claim submission details; the excerpt does not reproduce those specific submission instructions—providers must use Attachment A when preparing claims or PA packets.

No concrete PA rules in provided chunks

This excerpt contains no detailed prior authorization decision rules—only headings and references to where PA rules appear; providers must refer to the full policy sections (5.1–5.3) or LME‑MCO/UM vendor guidance for concrete PA criteria.

Prior authorization not specified in this excerpt

No prior authorization specifics are stated in these excerpted chunks; the policy lists PA sections but does not state which services require PA in this extract.

Verify eligibility/enrollment before service

An individual must be enrolled with the LME‑MCO on or prior to the date of service and providers shall verify eligibility each time a service is rendered before billing state funds.

• Verify member enrollment with the LME‑MCO on or before date of service.
• Verify eligibility at each encounter prior to billing state funds.

Prior authorization required for audio-only services

Providers must obtain prior authorization in advance to deliver services via telephonic (audio-only) communication; telephonic services require PA per the telephonic-specific criteria.

• Obtain PA before providing telephone-only services.
• Document consent and two-point identity verification per telephonic criteria when requesting PA.

Prior approval generally not required but available

State funds generally do not require prior approval for outpatient behavioral health services, but providers may seek prior approval if the individual is expected to exceed unmanaged visit limits; submit PA requests before unmanaged limits are exceeded.

• Providers can request PA when uncertain about unmanaged visit limits.
• Submit PA prior to exceeding unmanaged visit limits (see 5.3.1.1/5.3.1.2 timing guidance).

PA required when psych testing > 8 hours/year

Prior approval is required for psychological testing services that will exceed the unmanaged limit of eight hours per state fiscal year; submit the PA with supporting records prior to exceeding that limit.

• Unmanaged psychological testing limit = 8 hours per state fiscal year.
• Prior approval required when services will exceed the 8-hour unmanaged limit.

Behavioral health CPTs may be subject to prior approval

Behavioral health CPT and assessment codes listed in the policy may be subject to prior approval or visit limits when utilized; providers should reference the policy code table and Attachment A when planning services that may require PA.

• Behavioral health-specific codes in the policy may have PA or visit-limit implications.
• Check the CPT table and Attachment A for PA flags and telehealth/telephonic eligibility.

Follow CPT/HCPCS rules for unlisted codes and Special Reports

For services without a specific CPT/HCPCS code, follow CPT/HCPCS unlisted procedure instructions and submit the Special Report per the current codebook when requesting authorization or submitting claims.

• Use appropriate unlisted CPT/HCPCS code when no specific code exists.
• Provide Special Report per CPT/HCPCS instructions when billing unlisted services.

No actionable content in placeholder chunk

Several planner placeholders in the excerpt contain no actionable provider steps in the provided chunks; refer to the full policy for those items.

No step therapy information in excerpt

The excerpt contains no step therapy requirements or protocols; no step therapy rules are present in these chunks.

Provider actions placeholder (no details)

Another provider-actions placeholder in the excerpt contains no explicit requirements in these chunks; consult the full policy for details.

Placeholder retained — no details in excerpt

An additional placeholder chunk in the extract contains no provider action text; the full policy should be referenced for any missing actions.

Attachment A mapping for provider actions

Attachment A is repeatedly referenced in the policy TOC and contains the claims-related information (Claim Type; ICD-10-CM/PCS; Codes; Modifiers; Billing Units; Place of Service; Co-payments) that providers must use when preparing authorizations and claims.

Placeholder (chunk retained)

A retained placeholder chunk in the excerpt contains no provider action text; review the full policy for any required actions referenced there.

Placeholder (no content in excerpt)

An additional placeholder chunk is present with no explicit provider action in this extract; consult the full policy for specifics.

No step therapy rules present

No step therapy rules are present in these chunks; providers should not assume any step therapy requirements from this excerpt.

SBIRT is ASAM 0.5 early intervention — use standardized tools

SBIRT is described as an ASAM level 0.5 early intervention approach; providers must use standardized screening tools (e.g., AUDIT, DAST-10, S2BI) when delivering SBIRT services.

• Use standardized tools (AUDIT, DAST-10, S2BI) for SBIRT screening.
• Bill SBIRT only when clinician provides screening and brief intervention; if no BI indicated, incorporate screening time into other services.

Consider conservative / less costly treatment alternatives

Before delivering more intensive services, providers must consider whether equally effective, more conservative, or less costly statewide treatment options are available and select the appropriate level per NC community practice standards.

• Evaluate if a more conservative or less costly statewide treatment is equally effective before authorizing the requested service.

Authorize most cost-effective medically necessary option

When multiple clinically equivalent options exist, medically necessary services should be authorized in the most cost‑effective mode; authorization validates provision of medically necessary covered services.

• Authorization supports provision of medically necessary services in the most cost-effective mode when alternatives are similarly effective.

Placeholder retained (no content)

A retained placeholder chunk in the plan inventory contains no actionable text in this excerpt; consult the full policy.

Placeholder (chunk 222 retained)

Another placeholder chunk is present with no provider action details in these chunks; review the full policy for completion.

Placeholder (chunk 234 retained)

Yet another placeholder chunk in the excerpt contains no provider action text; providers should reference the full policy for missing items.

Maintain CCA, individualized plan, and service/progress notes

The policy contains multiple clinical documentation requirements: maintain a Comprehensive Clinical Assessment (CCA) when required, develop an individualized treatment plan, and keep service notes and progress notes per the clinical documentation section.

• Complete CCA per Section 7.3.3 when required; licensed professional signature required.
• Develop individualized plan within 15 business days of first face-to-face contact (see Subsection 7.3.4).
• Maintain service and progress notes per 7.3.5 for each encounter.

Follow Service Notes, Progress Notes, Referral documentation sections

The policy lists Service Notes and Progress Notes (7.3.5) and Referral and Service Access Documentation (7.3.6) as required documentation sections; providers must follow those subsections when preparing records for PA or claims.

Required documentation sections listed (7.3.5–7.3.7)

Service notes, progress notes, referral and service access documentation, and electronic signature requirements are explicitly referenced (Sections 7.3.5–7.3.7); providers must keep these records and adhere to timing and content rules.

• Progress notes must document date, service, contact type, purpose tied to plan goals, interventions, response, duration in minutes, and signature with credentials.

Required documentation elements for PA & records

Documentation elements required across the policy include: CCA/DA, individualized treatment plan, service order, progress/service notes, testing reports, and coordination-of-care records—these must be submitted with PA requests and retained in service records.

• Submit CCA or DA, service order for medical necessity, and treatment plan/PCP with PA requests.
• Keep demographic info, service record number, and documentation of entrance/continued/discharge criteria in each service record.

Attachment A lists required claim fields

Attachment A lists claim type, ICD-10-CM/PCS, Codes, Modifiers, Billing Units, Place of Service and Co-payments; providers must follow these Attachment A requirements when submitting claims and authorization requests.

Follow Attachment A for claims submission elements

Attachment A enumerates claim type and coding/billing elements that providers must follow for state-funded claims submission and for assembling PA requests.

• Adhere to NCTracks guidance, CPT/HCPCS and ICD-10 coding, modifiers, billing units, POS and co-payment rules listed in Attachment A.

Attachment A specifies codes, modifiers, billing units, POS

Attachment A lists required claim type, ICD-10-CM/PCS references, codes, modifiers, billing units, place of service, and co-payments which providers must follow for claims and authorization documentation.

Attachment A headings list required claim info (A–G)

Attachment A headings (A–G) include Claim Type; ICD-10-CM/PCS; Code(s); Modifiers; Billing Units; Place of Service; Co-payments; providers must consult these headings when preparing claims and PA requests.

Testing and SBIRT documentation standards

Psychological testing must be culturally and linguistically appropriate, use standardized tests, and produce results that inform treatment selection and planning; SBIRT requires use of standardized screening tools.

• Use standardized, validated tests and culturally appropriate administration for psychological testing.
• For SBIRT, use AUDIT, DAST-10, or S2BI as appropriate.

Required clinical & telephonic documentation elements

Providers must document a current DSM-5 diagnosis (or subsequent edition), evidence of dysfunction/functional impairment tied to the diagnosis, and capacity to engage; for telephonic services also document consent and verify identity using two identifiers.

• Document DSM-5 diagnosis or suspicion when applicable.
• For telephonic services, obtain and document consent and verify identity using two points before the encounter.

Submit PA with supporting service records

Providers must submit the prior approval request along with supporting service records (CCA/DA, service order, treatment plan/PCP) to the LME‑MCO or UM vendor; documentation must support medical necessity.

• Include CCA/DA, service order, treatment plan/PCP, and completed state authorization request form with PA submissions.

Document verbal service orders and countersign within 72 hours

Verbal service orders in urgent/emergent situations must be documented on the date given with specifics (date, who gave/received, services ordered, reason) and be countersigned by the appropriate professional within 72 hours.

• Document verbal service order on the service date with details and rationale.
• Countersign the verbal order within seventy-two (72) hours with a dated signature.

Minimum service record contents required

Service records must include demographic information, the individual's name and service record number on each page, an individualized treatment plan, documentation of entrance/continued/discharge criteria, and copies of testing and evaluation reports.

• Ensure the service record number appears on all state-funded treatment plans, service notes, and billing records.
• Retain copies of testing reports and evaluation notes with full dates.

Progress note requirements for every encounter

A progress note is required for each treatment encounter and must document date, service name, contact type (in-person/telehealth/telephonic/collateral), purpose tied to plan goals, interventions, effectiveness/response, duration in minutes, and signature with credentials.

• Progress notes must be substantive and tie interventions to plan goals; medical providers billing E/M codes must document E/M elements per CPT.

Treatment plan serves as service order; include PA for beyond-unmanaged visits

For individuals under 18 and adults, the signed treatment plan serves as the service order; for visits beyond unmanaged visit limits, include the completed authorization request form and prior approval notification in the service record.

• Keep the signed treatment plan in the record as the service order.
• Attach PA documentation for visits beyond unmanaged limits.

Psychological testing documentation and timing requirements

Psychological testing requires a service note for each contact listing test names and time billed, and a written report with reason, tests used, results, interpretation, diagnosis/impression, recommendations and signatures; service notes must be written/dictated within 24 hours and no later than seven days or the service may not be billed.

• Unmanaged psych testing coverage limit = 8 hours per state fiscal year; prior approval required to exceed limit.
• Service notes must be written/dictated within 24 hours; if not completed within 7 days the service may not be billed.

Obtain written consent at initial service

Obtain written consent from the legally responsible person at the time of the initial service for individuals of all ages and document consent in the service record.

Document outcomes and continued-stay justification

Documentation for continued stay must demonstrate need for ongoing treatment and either progress made or documented efforts to address lack of progress; expected clinical outcomes must relate to treatment plan goals.

• Document expected clinical outcomes tied to plan goals (e.g., reduced symptoms/abstinence, vocational gains, housing stability).
• For continued treatment, include documentation of need plus progress or efforts to address lack of progress.

Documentation must support billed codes and include required modifiers

Clinical documentation must support billed CPT/HCPCS/E/M codes, identify the clinician who provided the service, and include telehealth (GT) or telephonic (KX) modifiers when applicable.

• Append GT for interactive audio-visual telehealth claims; append KX for telephonic (audio-only) claims per Attachment A.
• Ensure documentation supports the components of the billed E/M or psychotherapy codes.

Unlisted procedure reporting and Special Report requirement

Providers must follow CPT/HCPCS instructions for unlisted procedures and submit a Special Report as required by the current codebooks; documentation must clearly indicate who provided the service.

• When using unlisted CPT/HCPCS codes, include the Special Report per the codebook instructions.

Prior approval may be required for some services

The Table of Contents and headings show Prior Approval sections exist and that prior approval may be required for some services; providers must be aware PA may be part of utilization management even when not required for routine outpatient services.

No explicit denial triggers in excerpt — consult full policy

No explicit denial-trigger language appears in these excerpted chunks beyond general references to Attachment A and coverage/exclusion lists; providers must consult Attachment A and full policy sections for claim denial conditions.

Attachment A contains potential claim-denial triggers

Attachment A includes claims-related rules that could trigger claim denials if not followed; providers should ensure codes, modifiers, billing units, place of service, and co-payment rules in Attachment A are adhered to.

• Noncompliance with Attachment A coding/modifier/billing rules can lead to claim denial.

Incorrect/missing codes or modifiers may affect claims

Missing or incorrect codes or modifiers per Attachment A may affect claims; providers must use the most specific ICD-10 codes and proper CPT/HCPCS codes and modifiers when submitting claims and PAs.

• Report ICD-10 diagnosis codes to the highest level of specificity that supports medical necessity.

Insufficient extract to specify denial triggers

The extract does not provide sufficient detail to list all denial triggers; it references claims-related sections that likely contain billing/authorization rules—use Attachment A and full policy sections for specifics.

Attachment A may include billing rules that affect denials

Although explicit denial triggers are not listed in these chunks, Attachment A is identified as the location of claims-related information which may include billing rules that affect adjudication; follow Attachment A to reduce denial risk.

Claims processed against Attachment A coding & billing rules

Claims can be processed against the code, modifier, billing unit, place of service and co-payment rules listed in Attachment A; missing or incorrect information in any of these fields could trigger claim denials.

• Ensure billing units and place of service match Attachment A requirements.
• Include co-payment information when applicable per Attachment A.

Placeholder — no denial triggers in this chunk

A retained placeholder chunk contains no explicit denial-trigger language in the excerpt; consult the full policy for further details.

Eligibility verification required to avoid denials

Failure to verify each individual's eligibility at the time of service may result in denial of state-funded billing; verify LME‑MCO enrollment and Benefit Plan eligibility before providing services.

• Verify enrollment with the LME‑MCO on or prior to the date of service.
• Confirm the individual meets state-funded Benefit Plan criteria.

General denial triggers: eligibility, criteria, duplication, experimental

Services will not be covered if the individual fails to meet eligibility (Section 2.0) or the clinical criteria (Section 3.0), if the service duplicates another provider's service, or if the service is experimental/in a clinical trial.

• Do not bill state funds if the individual does not meet Section 2.0 or 3.0 requirements.
• Avoid duplicate services across providers for the same dates of service.

Service-specific denial triggers (in-person/Attachment A/medical necessity)

Specific non‑coverage triggers include services not provided in-person or per Attachment A when required, services that do not address symptoms of the diagnosis, and testing or crisis services billed for educational purposes or without medical necessity.

• Do not bill for psychological testing for educational purposes absent medical necessity.
• Ensure psychotherapy for crisis addresses current-diagnosis symptoms and is provided in allowable settings.

Authorization does not guarantee payment — verify medical necessity

Prior authorization is not a guarantee of payment; services must meet medical necessity as verified by the LME‑MCO or utilization management contractor and be supported by submitted service records at claim time.

• Authorization validates approval but payment requires meeting medical necessity and submission of supporting documentation.

Failure to obtain PA for audio-only services can cause denial

Services provided via telephonic, audio-only communication require prior approval; failure to obtain PA for these services can trigger claim denials.

• Obtain and document PA before delivering telephonic services to avoid denial.

Psych testing note timelines — late entry and billing risk

For psychological testing, service notes must be written or dictated within 24 hours of the service (late entry rules apply), and if not completed within seven days the service may not be billed; adhere to these timelines to avoid denial.

• Write/dictate psych testing service notes within 24 hours; late entries require dated signature and must be indicated.
• If service note not written/dictated within 7 days, the service may not be billed.

Claims and coding noncompliance can cause denial

Noncompliance with NCTracks Provider Claims/Billing Guide, Joint Communications, fee schedules, Division clinical policies, or incorrect ICD-10/CPT/HCPCS coding and modifiers may lead to claim denials.

• Follow NCTracks and Division MH/DD/SAS billing guides and fee schedules when submitting claims.

Conversion therapy is not reimbursable

State funds will not be used to reimburse conversion therapy; do not bill state funds for conversion therapy services.