Effective Oct. 15, 2021, Children’s Developmental Services Agencies (CDSAs) and independent practitioners providing individualized family service plan (IFSP) services are required to resume the submission of prior approval (PA) requests to the applicable NC Medicaid vendor. PA requests shall be submitted in accordance with the requirements outlined in clinical coverage policy 8J, Children’s Developmental Services Agencies:
Prior Approval Requirements for Outpatient Specialized Therapies
Refer to Section 5.0 of clinical coverage policies 10A, Outpatient Specialized Therapies and 10B, Independent Practitioners for details on prior approval requirements for these services.
For independent practitioners providing IFSP services, The Carolinas Center for Medical Excellence (CCME) ChoicePA web portal will require the referring CDSA to be selected from a drop-down menu in order for the PA request to be accepted.
Prior Approval Requirements for Outpatient Behavioral Health Services Provided by Direct Enrolled Providers
Refer to Section 5.0 of clinical coverage policy 8C, Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers for details on prior approval requirements for these services. Please submit all requests for these services to Beacon Health Options ProviderConnect.
PA must be obtained before rendering a service, product or procedure that requires PA. Obtaining PA does not:
- Guarantee payment;
- Ensure beneficiary eligibility on the date of service; or
- Guarantee that a post-payment review that verifies a service medically necessary will not be conducted.
Please contact or CCME at 800-228-3365 or Beacon Health Options at 800-753-3224 with any questions or concerns.