Program Specific Clinical Coverage Policies
Related Links
For archived versions of clinical coverage policies, contact Clarissa Fleet.
Medicaid providers can research their questions and submit inquires through: Frequently Asked Questions and Answers - Medicaid Providers.
Policies
Allergies
Ambulance
Anesthesia
- 1L-1, Anesthesia Services
- 1L-2, Moderate (Conscious) Sedation, AKA Procedural Sedation and Analgesia (PSA)
Auditory Implants External Parts
- 13A, Cochlear and Auditory Brainstem Implant External Parts Replacement and Repair
- 13B, Soft Band and Implantable Bone Conduction Hearing Aid External Parts Replacement and Repair
Behavioral Health
- 8A, Enhanced Mental Health and Substance Abuse Services
- 8A-1, Assertive Community Treatment (ACT) Program
- 8A-2, Facility-Based Crisis Service for Children and Adolescents
- 8A-5, Diagnostic Assessment
- 8A-6, Community Support Team (CST)
- 8A-7, Ambulatory Withdrawal Management (WM) without Extended On-Site Monitoring
- 8A-8, Ambulatory Withdrawal Management with Extended On-Site Monitoring
- 8A-9, Opioid Treatment Program Service
- 8A-11, Medically Monitored Inpatient Withdrawal Management Service
- 8B, Inpatient Behavioral Health Services
- 8C, Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers
- 8D-1, Psychiatric Residential Treatment Facilities for Children under the Age of 21
- 8D-2, Residential Treatment Services
- 8E, Intermediate Care Facilities for Individuals with Intellectual Disabilities
- 8F, Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)
- 8G, Peer Support Services
- 8H-1, 1915 (i) Supported Employment for I/DD and TBI
- 8H-2, 1915(i) Individual Placement & Support (IPS) for Mental Health & Substance Use
- 8H-3, 1915(i) Individual and Transitional Support (ITS)
- 8H-4, 1915(i) Respite
- 8H-5, Community Living and Supports
- 8H-6, 1915(i) Community Transition
- 8I, Psychological Services in Health Departments and School-Based Health Centers Sponsored by Health Departments to the under-21 Population
- 8J, Children's Developmental Service Agencies (CDSAs)
- 8L, Mental Health/Substance Abuse Targeted Case Management
- 8O, Services for Individuals with Intellectual and Developmental Disabilities and Mental Health or Substance Abuse Co-Occurring Disorders
- 8P, North Carolina Innovations
Burn Treatments & Skin Substitutes & Skin Substitutes
Cardiac Procedures
- 1R-1, Phase II Outpatient Cardiac Rehabilitation Programs
- 1R-4, Electrocardiography, Echocardiography, and Intravascular Ultrasound
Chiropractic Services
Community-Based Services
- 3A, Home Health Services
- 3B, PACE (Program of All-Inclusive Care for the Elderly)
- 3D, Hospice Services
- 3G-1, Private Duty Nursing for Beneficiaries Age 21 and Older
- 3G-2, Private Duty Nursing for Beneficiaries Under 21 years of Age
- 3H-1, Home Infusion Therapy
- 3K-1, Community Alternatives Program for Children (CAP/C)
- 3K-2, Community Alternatives Program for Disabled Adults (CAP/DA)
- 3L, State Plan Personal Care Services (PCS)
Dental
Dietary Evaluation and Counseling
Facility Services
- 2A-1, Acute Inpatient Hospital Services
- 2A-2, Long Term Care Hospital Services
- 2A-3, Out-of-State Services
- 2B-1, Nursing Facilities
- 2B-2, Geropsychiatric Units in Nursing Facilities
Hearing Aid Services
Laboratory Services
- 1S-1, Genotyping and Phenotyping for HIV Drug Resistance Testing
- 1S-2, HIV Tropism Assay
- 1S-3, Laboratory Services
- 1S-8, Drug Testing for Opioid Treatment and Controlled Substance Monitoring
- 1S-9, Genetic Testing for Diagnosis and Treatment
- 1S-10, Genetic Testing for Carrier and Prenatal
- 1S-11, Genetic Testing - Gene Expression
- 1S-12, Genetic Testing - Next Generation Sequencing (NGS)
- 1S-13, Cell and Gene Therapies
Maternal Support Services (Baby Love)
- 1M-2, Childbirth Education
- 1M-3, Health and Behavior Intervention
- 1M-4, Home Visit for Newborn Care and Assessment
- 1M-5, Home Visit for Postnatal Assessment and Follow-up Care
- 1M-6, Maternal Care Skilled Nurse Home Visit
Medical Equipment
- 5A-1, Physical Rehabilitation Equipment and Supplies
- 5A-2, Respiratory Equipment and Supplies
- 5A-3, Nursing Equipment and Supplies
- 5B, Orthotics & Prosthetics
Obstetrics & Gynecology
- 1E-1, Hysterectomy
- 1E-2, Therapeutic and Non-therapeutic Abortions
- 1E-3, Sterilization Procedures
- 1E-4, Fetal Surveillance
- 1E-5, Obstetrics
- 1E-6, Pregnancy Management Program
- 1E-7, Family Planning Services
Ophthalmological Services
Pharmacy Services
Clinical Coverage Policies
For Pharmacy Prior Approval Drugs and Criteria use the following link: NC TRACKS
- Clinical Coverage Criteria and Prior Approval request forms
- Preferred Drug List (PDL)
- 9, Outpatient Pharmacy Program
- 9A, Over-The-Counter Products
- 9B, Hemophilia Specialty Pharmacy Program
- 9D, Off Label Antipsychotic Safety Monitoring in Beneficiaries Through Age 17
- 9E, Off Label Antipsychotic Safety Monitoring in Beneficiaries 18 and Older
Physician-Administered Drug Program
Physician Clinical Coverage Policies
- 1A-2, Preventive Medicine Annual Health Assessment
- 1A-3, Noninvasive Pulse Oximetry
- 1A-4, Cochlear and Auditory Brainstem Implants
- 1A-5, Child Medical Evaluation and Medical Team Conference for Child Maltreatment
- 1A-6, Invasive Electrical Bone Growth Stimulation
- 1A-7, Neonatal and Pediatric Critical and Intensive Care Services
- 1A-8, Hyperbaric Oxygenation Therapy
- 1A-9, Blepharoplasty and Blepharoptosis (Eyelid Repair)
- 1A-11, Extracorporeal Shock Wave Lithotripsy
- 1A-12, Breast Surgeries
- 1A-13, Ocular Photodynamic Therapy
- 1A-14, Surgery for Ambiguous Genitalia
- 1A-15, Surgery for Clinically Severe or Morbid Obesity
- 1A-16, Surgery of the Lingual Frenulum
- 1A-17, Stereotactic Pallidotomy
- 1A-19, Transcranial Doppler Studies
- 1A-20, Sleep Studies and Polysomnography Services
- 1A-21, Endovascular Repair of Aortic Aneurysm
- 1A-22, Medically Necessary Circumcision
- 1A-23, Physician Fluoride Varnish Services
- 1A-24, Diabetes Outpatient Self-Management Education
- 1A-25, Spinal Cord Stimulation
- 1A-26, Deep Brain Stimulation
- 1A-27, Electrodiagnostic Studies
- 1A-28, Visual Evoked Potential (VEP)
- 1A-30 Spinal Surgeries
- 1A-31, Wireless Capsule Endoscopy
- 1A-32, Tympanometry and Acoustic Reflex Testing
- 1A-33, Vagus Nerve Stimulation for the Treatment of Seizures
- 1A-34, Dialysis Services
- 1A-36, Implantable Bone Conduction Hearing Aids (BAHA)
- 1A-38, Special Services: After Hours
- 1A-39, Routine Patient Costs Furnished in Connection with Participation in Qualifying Clinical Trials
- 1A-40, Fecal Microbiota Transplantation
- 1A-42, Balloon Ostial Dilation
Podiatry
Radiology
Reconstructive Surgery
- 1-O-1, Reconstructive and Cosmetic Surgery
- 1-O-2, Craniofacial Surgery
- 1-O-3, Keloid Excision and Scar Revision
- 1-O-5, Rhinoplasty and/or Septorhinoplasty
Rural Health Clinics, FQHC and Health Departments. (RHC, FQHC, Health Depts)
- 1D-1, Refugee Health Assessments Provided in Health Departments
- 1D-2, Sexually Transmitted Disease Treatment Provided in Health Departments
- 1D-3, Tuberculosis Control and Treatment Provided in Health Departments
- 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics
Solid Organ Transplants
- 11B-1, Lung Transplantation
- 11B-2, Heart Transplantation
- 11B-3, Islet Cell Transplantation
- 11B-4, Kidney (Renal) Transplantation
- 11B-5, Liver Transplantation
- 11B-6, Heart/Lung Transplantation
- 11B-7, Pancreas Transplant
- 11B-8, Small Bowel and Small Bowel/Liver and Multivisceral Transplants
- 11B-9, Thymus Tissue Implantation
Specialized Therapies
- 10A, Outpatient Specialized Therapies
- 10B, Independent Practitioners (IP)
- 10C, Local Education Agencies (LEAs)
- 10D, Independent Practitioners Respiratory Therapy Services
Stem Cell Transplants
- 11A-1, Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia (ALL)
- 11A-2, Hematopoietic Stem-Cell Transplant for Acute Myeloid Leukemia
- 11A-3, Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia
- 11A-5, Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemias
- 11A-6, Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors
- 11A-7, Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma
- 11A-8, Hematopoietic Stem-Cell Transplantation For Multiple Myeloma and Primary Amyloidosis
- 11A-9, Allogeneic Stem-Cell Transplantation for Myelodysplastic Syndromes & Myeloproliferative Neoplasms
- 11A-10, Hematopoietic Stem-Cell Transplantation (HSCT) for Central Nervous System (CNS) Embryonal Tumors & Ependymoma
- 11A-11, Hematopoietic Stem-Cell Transplant for Non-Hodgkin’s Lymphoma
- 11A-14, Placental and Umbilical Cord Blood as a Source of Stem Cells
- 11A-15, Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood
- 11A-16, Hematopoietic Stem-Cell Transplantation for Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)
- 11A-17, CAR-T Cell Therapy