This bulletin applies to NC Medicaid Direct and NC Managed Care.
The policy revision consolidates Clinical Coverage Policy (CCP) 10A and 10B into a single, comprehensive policy: 10A, Outpatient Specialized Therapies. As a result, CCP 10B is terminated.
Key Details
Definition of Independent Practitioner Provider (IPP)
Subsection 1.1 added the following: An individual or group of individuals in private practice who are licensed in their field to provide OST services. The IPP does not provide services through an institutional provider and is not employed by a physician’s office.
Expanded Provider Eligibility
Subsection 6.0 includes IPPs as a recognized provider type that may treat adult beneficiaries aged 21 and older.
Claims and Billing Information
Subsection Attachment A: A., C., D. and F. consolidates claims-related information and professional billing codes from CCP 10B. Language restricting IPPs to billing for services rendered to beneficiaries under the age of 21 has been removed.
- Providers submitting claims for beneficiaries enrolled in NC Medicaid Direct should consult the NCTracks Provider Claims and Billing Assistance Guide for specific claims instruction.
- For beneficiaries enrolled in NC Medicaid Managed Care, refer to the respective health plan for claims and billing instructions.
Visit Limit Reminder
For NC Medicaid Direct beneficiaries, the visit limitations for beneficiaries 21 years of age and older outlined in Subsection 5.3 are applicable for OST treatment visits. For Managed Care beneficiaries, refer to the specific health plan’s utilization management guidelines.
Important Note: This update does not pertain to CCP 10D, Respiratory Therapy Services by IPPs.
Additional Resources
- NC Medicaid Clinical Coverage Policies
- For Medicaid Direct Utilization Review, refer to Constellation Quality Health (CCME Services) Choice PA website
Contact
NC Medicaid Contact Center: 888-245-0179
For beneficiaries enrolled in a Prepaid Health Plan (PHP), refer to Health Plan Contacts and Resources