Reminder: Annual Office Visit Limit

North Carolina has an annual office visit limit for both mandatory and optional services within the Medicaid program:

Medicaid has designated specific procedure codes that are subject to the annual visit count, and diagnosis codes that are not subject to the annual visit count. Lists of these codes are available on the NC Medicaid Annual Visit webpage. In addition, the following beneficiaries are exempt from the annual visit limitation:

• Medicaid beneficiaries under the age of 21
• NC Health Choice beneficiaries
• Beneficiaries enrolled in a Community Alternatives Program (CAP)
• Pregnant beneficiaries who are receiving prenatal and pregnancy-related services

If a provider anticipates that additional care will be needed for a specific condition and the care is medically necessary, the rendering provider may request an exception to the annual visit limit for mandatory services. This only applies to beneficiaries who do not meet any of the exception criteria listed above and have exhausted, or are close to exhausting, their 22 total visits allowed for the fiscal year. 

A provider may verify the number of remaining visits by viewing the service limit section on the beneficiary eligibility inquiry screen in the NCTracks Provider Portal. This count is updated as providers file their claims. Requesting an exception is done through the NCTracks Provider Prior Approval (PA) Portal. Mailed or faxed PA requests will not be processed. 

To submit a request for an exception, providers should access the prior approval module through the NCTracks secure provider portal. 

• Providers must enter their NCID, then click on “Prior Approval” and submit a PA request selecting PA Type A23-EXC. TO LE. 
• If the PA is entered with a PA type other than A23-EXC. TO LE, it will not be processed. 
• The provider should enter the requested procedure code(s), how many extra visits are being requested, and select the unit type “Visit.” 
• Providers must present information explaining why additional visits are needed. This documentation should be attached electronically to the PA in NCTracks. 

PA requests for extra visits will only be granted to the office that requests them. If a beneficiary is seeing multiple providers and have exhausted their 22 visits, each provider that beneficiary sees is responsible for requesting their own extra visits.

Note: PA requests cannot be authorized for an extension of optional service limits or mandatory services that have already been rendered.

The exception must be requested and approved before the service is rendered. If a claim is submitted prior to receiving approval for an exception, and the claim is denied for exceeding the visit limit, the provider may submit a Medicaid Claim Adjustment Request Form to Medicaid’s fiscal vendor (NCTracks). A copy of the beneficiary’s medical record documenting the visit with the specific condition and medical necessity of the visit to actively manage or treat the condition must be submitted with the adjustment along with the remittance advice received from NCTracks for the denied date of service. The adjustment request and supporting documentation will be reviewed for medical necessity by NCTracks.

Please refer to NC Medicaid Bulletin: Accepting and Billing Medicaid Beneficiaries and 10A NCAC 22J.0106 for more information on provider billing of patients who are Medicaid beneficiaries. 

Please refer to Medicaid’s Annual Visit web page at https://medicaid.ncdhhs.gov/providers/programs-services/annual-visit for more information.