With the exception of behavioral health services, 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, CCME’s 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.
PA is required for medical approval only and 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.
A temporary waiver of prior approval for behavioral health services remains in place, although providers are required to document medical necessity for service and are subject to audit. Additional guidance about prior approval requirements for behavioral health services is forthcoming.
Contact
CCME, 800-228-3365