SPECIAL BULLETIN: Prior Approval Requirements for Level of Care and CAP Waiver Services

N.C. Division of Medical Assistance (DMA) implemented a prior approval (PA) process for the Community Alternatives Program for Children and Disabled Adults (CAP/C and CAP/DA) home- and community-based services waivers for Level of Care (LOC) and CAP waiver services.

The CAP/C and CAP/DA waivers rely on an electronic system called e-CAP to manage PA transmittals to NCTracks for CAP claim reimbursement and adjudication. The system is operated by VieBridge.

A PA record is created and electronically transmitted to NCTracks for each new LOC determination decision made after Feb. 5, 2017, and for each currently approved CAP waiver service for all currently eligible CAP beneficiaries. The PA is only transmitted to NCTracks upon the acceptance of a service authorization (SA) in the e-CAP system by the approved CAP provider.

To manage the receipt and acceptance of SAs, DMA implemented a direct service provider interface (DSP) in the e-CAP system in March 2017. 

For claims to adjudicate in NCTracks, the claims must match details listed on the SA, as well as mandatory fields in NCTracks related to:

• Procedure code/taxonomy
• Approved service amount
• Authorized service period
• Exact location of the rendering provider
• Ordering and referring physician(s)

CAP providers must have the correct waiver taxonomy code on the manage change request (MCR) file to obtain reimbursement for a rendered service. 

The claim may deny or pend if the claiming information is not submitted accurately. 

Procedure Code for Nurse Respite

The future procedure code for nurse respite will be T1005. On an interim basis – while system changes are being made) – select the procedure code of T1005 TD when nurse respite is included in the plan of care. VieBridge will transmit a PA record to NCTracks for T1005 TD.

Special Attention Required When Submitting Claims

NCTracks uses eligibility information obtained from the local Department of Social Services and PA records obtained from VieBridge to adjudicate Medicaid waiver claims. The submitted claim will deny or pend when eligibility and PA information do not match. 

Within 72 hours of the change, a notification must be provided to local Departments of Social Services regarding changes made to the beneficiary waiver enrollment status. This will ensure accuracy of waiver eligibility information 

For example:

• If a beneficiary is approved to participate in consumer direction, Case Management Entities (CMEs) must notify the appropriate DSS of the change for the new waiver evidence to be added.
• If a beneficiary is approved at a higher or lower acuity, CMEs must notify the appropriate DSS of the change in the acuity level for the new waiver evidence to be added.