CurrentUnitedHealthcarePolicy CSNCT0376.02

State Plan Personal Care Services (PCS) (for North Carolina Only)

Defines UnitedHealthcare's guidance for State Plan Personal Care Services (PCS) in North Carolina and directs users to the North Carolina Medicaid Clinical Coverage Policies for medical necessity criteria; applies to providers and claims in North Carolina.

Policy Summary

PayerUnitedHealthcare

PolicyState Plan Personal Care Services (PCS) (for North Carolina Only)

Policy CodePolicy CSNCT0376.02

Change TypeMaterial revision — delegation references updated

Effective DateSep 1, 2025

Next Review Date

Key ActionRefer to the North Carolina Medicaid Clinical Coverage Policies (3L and 3L-1) to determine medical necessity and prior authorization requirements for PCS.

SourceLink

POLICY UPDATE CHANGES

Updated instruction to refer to the North Carolina Medicaid Clinical Coverage Policy, Community-Based Services: 3L, for In-Home Settings medical necessity clinical coverage criteria.

Added instruction to refer to the North Carolina Medicaid Clinical Coverage Policy, Community-Based Services: 3L-1, for Congregate Settings medical necessity clinical coverage criteria.

Updated References section to reflect the most current information.

2Medicaid policies ref'd

1CPT codes listed

NCState governed

Coverage and Medical Necessity

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Delegated medical necessity criteria

Medical necessity and coverage for PCS are governed by the referenced North Carolina Medicaid Clinical Coverage Policies:

In-Home Settings: Refer to North Carolina Medicaid Clinical Coverage Policy, Community-Based Services: 3L, State Plan Personal Care Services (PCS) In-Home Settings for medical necessity clinical coverage criteria for in-home PCS.

UnitedHealthcare delegates medical necessity determinations for in-home PCS to NC Medicaid Clinical Coverage Policy 3L.

Congregate Settings: Refer to North Carolina Medicaid Clinical Coverage Policy, Community-Based Services: 3L-1, State Plan Personal Care Services (PCS) Provided in Congregate Settings for medical necessity clinical coverage criteria for PCS in congregate settings.

UnitedHealthcare delegates medical necessity determinations for congregate-setting PCS to NC Medicaid Clinical Coverage Policy 3L-1.

This information is provided for context only: personal care services are not regulated by the U.S. Food and Drug Administration (FDA). FDA approval or regulation is not applicable to these services and therefore is not a basis for coverage determinations.

Listing a procedure or diagnosis code in this policy is for reference only. Inclusion of a code does not imply the service is covered; benefit coverage, reimbursement rights, and claim payment are determined by applicable federal, state, or contractual requirements and laws, and other policies or guidelines may apply.

Provider Responsibilities and Billing Notes

Prior Authorization

Prior Authorization and Governing Benefit

Prior authorization is determined by the governing benefit; this policy is informational only. Providers must follow federal, state, or contractual requirements for benefit coverage and check those governing documents before submitting claims.

Prior authorization requirements are set by the member's benefit plan — verify prior auth with the payer before providing service.
Listing a code in this policy does not imply coverage; benefits are determined by federal, state, or contractual requirements.
UnitedHealthcare may use third‑party tools (e.g., InterQual) to assist in administering benefits.

Note

Check Governing Benefit Documents

Before using this policy, check the federal, state, or contractual requirements for benefit plan coverage; in the event of a conflict, those governing requirements control. This policy is informational and does not constitute medical advice.

Billing Rule

Code Listing is Informational

Listing of a code in this policy is for reference only and does not imply coverage or guarantee payment. Providers must follow applicable billing and documentation rules and verify coverage with the member's benefit plan.

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.
Inclusion of a code does not imply any right to reimbursement or guarantee claim payment.

Background

This policy delegates medical necessity criteria for State Plan Personal Care Services (PCS) in North Carolina to the North Carolina Medicaid Clinical Coverage Policies. For PCS provided in in‑home settings, refer to North Carolina Medicaid Clinical Coverage Policy, Community‑Based Services: 3L. For PCS provided in congregate settings, refer to North Carolina Medicaid Clinical Coverage Policy, Community‑Based Services: 3L‑1. These referenced NC Medicaid policies contain the specific clinical coverage criteria and govern medical necessity determinations; UnitedHealthcare follows those state Medicaid criteria when applicable to members and claims in North Carolina.