Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.31
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyNorth Carolina Medicaid PCS Update | OpenPayer
    Ask Trek AI about this page
    ModifiedNorth Carolina MedicaidPolicy N/A

    PCS Rate Reimbursement Methodology for Individuals Living in Congregate Settings

    Customize your policy alerts

    Sign up for all North Carolina Medicaid policy alerts

    Know when North Carolina Medicaid releases new policies or updates existing guidance.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This policy governs how North Carolina Medicaid reimburses Personal Care Services (PCS) for individuals living in specified congregate settings. It establishes per-diem pricing, prior-authorization-based rate calculation, claim-line billing requirements, and related adjudication rules effective for dates of service on or after April 1, 2025.

    Policy Summary
    PayerNorth Carolina Medicaid
    PolicyPCS Rate Reimbursement Methodology for Individuals Living in Congregate Settings
    Policy CodePolicy N/A
    Change TypeRevised reimbursement methodology
    Effective DateApril 1, 2025
    Next Review DateN/A
    Key ActionBill one unit per day for PCS services; NCTracks automatically calculates the daily rate.
    SourceLink
    POLICY UPDATE CHANGES

    North Carolina Medicaid revised the reimbursement method for PCS provided to individuals living in congregate settings from the prior methodology to per-diem pricing.

    Claims for congregate-setting PCS must be billed with one date of service and one unit representing one calendar day.

    The daily reimbursement rate is calculated using prior authorization information available at claim adjudication.

    The reimbursement process requires providers to bill one unit per day while NCTracks automatically calculates the daily rate.

    Apr 1, 2025Effective date

    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.

    1 date / 1 unit
    Required claim structure
    14 daysMissing-authorization pend period
    28-31Full-month claim lines
    11.61/dayIllustrative daily units

    Congregate-Setting Reimbursement Requirements

    Congregate-setting PCS reimbursement requirements

    PCS reimbursement under this methodology applies to services rendered in the listed congregate settings and billed under the corresponding 99509 modifier. Claims must satisfy the daily claim-line and prior-authorization pricing rules.

    ALL of the following

    • ONE of

      • Service is rendered in an Adult Care Home, Combination Home, Special Care Home, Family Care Home, Supervised Living Facility for adults with mental illness/substance abuse, or Supervised Living Facility for adults with intellectual/developmental disabilities.
      • Claim uses the applicable 99509 modifier for the congregate setting.
    • Each claim line contains one date of service and one unit representing one calendar day.
    • Claim pricing can match the applicable prior authorization at adjudication.

    Daily-rate billing requirements

    PCS claims in congregate settings must follow the daily-unit and system-calculated-rate requirements.

    ALL of the following

    • Bill 1 unit per day.
    • Do not include the calculated daily rate on the claim; NCTracks calculates it automatically.

    Codes, Units, and Claim-Line Structure

    Covered Congregate-Setting PCS CodesHCPCSCovered
    99509-HCPCS for Adult Care Homes
    99509-TTPCS for Combination Homes
    99509-SCPCS for Special Care Homes or Special Care units
    99509-HQPCS for Family Care Homes
    99509-HHPCS for Supervised Living Facilities for adults with mental illness/substance abuse
    99509-HIPCS for Supervised Living Facilities for adults with intellectual/developmental disabilities
    Example PA and Claim CodeHCPCS
    99509-HCExample PCS code/modifier used in a prior authorization and claim-line scenario
    Units per claim line
    Required quantity1 unit per calendar day
    More than one unitA claim line containing a unit greater than one will deny
    Billing scopeThe requirement applies to congregate-setting PCS claims with dates of service on or after April 1, 2025
    Dates of service per claim line
    Required dates1 date of service per claim line
    Multiple datesA claim line spanning multiple dates will deny
    Daily representation

    Prior Authorization and Billing Actions

    Prior Authorization

    Continue the Existing PA Process

    Continue the existing PCS prior authorization process in NCTracks. Submit PAs with the approved PCS hours and modify them when adjustments are identified; the referral process, assessment tool, assessed hours, and rate remain unchanged.

    Billing Rule

    Adjudication Uses Active PA Information

    NCTracks calculates the daily reimbursement rate using the active PA information available when the claim is adjudicated. Ensure the PA reflects the approved units and duration before the claim is processed.

    Key Reimbursement Terms

    Congregate settings
    Adult Care HomesCovered congregate setting; use 99509-HC
    Combination HomesCovered congregate setting; use 99509-TT
    Special Care Homes or Special Care unitsCovered congregate setting; use 99509-SC
    Family Care HomesCovered congregate setting; use 99509-HQ
    Supervised Living Facilities for adults with mental illness or substance abuseCovered congregate setting; use 99509-HH
    Supervised Living Facilities for adults with intellectual/developmental disabilitiesCovered congregate setting; use 99509-HI
    Policy Summary
    PayerNorth Carolina Medicaid
    PolicyPCS Rate Reimbursement Methodology for Individuals Living in Congregate Settings
    Policy CodePolicy N/A
    Change TypeRevised reimbursement methodology
    Effective DateApril 1, 2025
    Next Review DateN/A
    Key ActionBill one unit per day for PCS services; NCTracks automatically calculates the daily rate.
    SourceLink
    On This Page
    Congregate-Setting Reimbursement RequirementsCodes, Units, and Claim-Line StructurePrior Authorization and Billing ActionsKey Reimbursement Terms
    Each line represents one calendar day of service
    Illustrative PA daily-unit calculation
    Approved units360 units
    PA duration31 PA days
    Daily authorized units360 approved units ÷ 31 PA days = 11.61 units per day
    Full-month claim-line range
    28-day month28 daily claim lines
    29-day month29 daily claim lines
    30-day month30 daily claim lines
    31-day month31 daily claim lines
    Daily billing unit
    Billing quantity1 unit per day
    Rate entryDo not include the calculated daily rate on the claim
    Rate calculationNCTracks automatically calculates the daily rate
    Monthly claim-line range
    28-day month28 claim lines
    29-day month29 claim lines
    30-day month30 claim lines
    31-day month31 claim lines
    Denial Risk

    Match the PA to Each Claim

    The PA must match and capture to the claim line for pricing. Dates of service, units, and modifiers must align; a retroactive PA update does not automatically adjust or reprocess a claim that has already been adjudicated.

    Billing Rule

    Watch for PA Unit Cutbacks

    A PA cutback applies when the remaining PA units are fewer than the reimbursable units. The system may reimburse the final day at a lower percentage when approved PCS hours are exhausted before the end of the month.

    Denial Risk

    Correct Modifier and Missing PA Issues

    An incorrect modifier that results in no matching PA causes the claim to pend for 14 days under the missing-PA rules. Correct the PA or modifier while the claim is pending so the line can price with the matching PA; after denial, submit a corrected claim because a new or corrected PA will not automatically reprocess it.

    Billing Rule

    Submit One PCS Unit per Day

    For dates of service on or after April 1, 2025, bill one unit per calendar day for PCS, including procedure code 99509 with applicable modifiers. Do not enter the calculated daily rate; NCTracks calculates it automatically, and providers should bill their usual and customary charge.

    Billing Rule

    Follow the Permitted Claim Cadence

    Claims may be submitted weekly or at the same cadence used before the change. Billing does not have to be completed monthly, but each billed day must be represented by one unit.

    Denial Risk

    Use One Claim Line per Date

    Structure claims by date of service: use one claim line for each calendar date and bill one unit on each line. A full month may be submitted on one claim using 28, 29, 30, or 31 daily lines, as applicable; claim lines spanning multiple dates or containing more than one unit will deny.

    Billing Rule

    Account for End-of-Month Rate Cutback

    NCTracks automatically applies the lower percentage when approved PCS hours run out before the end of the month. Account for this end-of-month rate cutback when reviewing expected reimbursement.

    Per diem pricing
    Pricing periodPer-diem pricing reimburses one calendar day of service
    Daily authorized unitsDerived by dividing approved prior-authorization units by the prior-authorization days
    Reimbursement calculationDaily authorized units are multiplied by the effective rate to determine the daily reimbursable amount