State Plan Personal Care Services (PCS) (for North Carolina Only)
Defines UnitedHealthcare's policy references and applicability for State Plan Personal Care Services (PCS) in North Carolina, directing providers to the North Carolina Medicaid Clinical Coverage Policies for medical necessity criteria in in-home and congregate settings.
Updated instruction to refer to the North Carolina Medicaid Clinical Coverage Policy, Community-Based Services: 3L, for medical necessity clinical coverage criteria for in-home settings.
Added instruction to refer to the North Carolina Medicaid Clinical Coverage Policy, Community-Based Services: 3L-1, for medical necessity clinical coverage criteria for congregate settings.
Updated References section to reflect the most current information.
Coverage Criteria
Medical Necessity Determination
Covered when medical necessity is determined per the referenced NC Medicaid clinical coverage policy.
Follow the referenced 3L policy for the exact AND/OR/N-of logic, required documentation, and prior authorization procedures.
Follow the referenced 3L-1 policy for the exact AND/OR/N-of logic, required documentation, and prior authorization procedures.
Codes shown in the Applicable Codes section are provided for reference only. Codes labeled with an asterisk (*) are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program. Providers should confirm fee-schedule status and coverage with the applicable state Medicaid program or the member's benefit plan before billing.
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