Clinical coverage policy, 1A-31 requires prior approval (PA) for Wireless Capsule Endoscopy. NC Medicaid has become aware that some providers have rendered this service without obtaining PA.
Effective May 1, 2021, if a provider renders wireless capsule endoscopy to a beneficiary without obtaining PA due to an urgent medical condition, Medicaid and NC Health Choice shall require the provider to submit an electronic request for PA with supporting documentation through the NCTracks provider portal within 72 hours of the date of service.
Please reference Clinical Coverage Policy, 1A-31 Wireless Capsule Endoscopy, section 5.1 Prior Approval for the PA requirement and subsection 3.2.1 for specific criteria covered by both Medicaid and NC Health Choice.
Contact
NCTracks Call Center: 800-688-6696