This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care.
NC Medicaid is issuing this bulletin to clarify existing policy requirements related to the concurrent service request of Child and Adolescent Day Treatment and Residential Treatment Services (Level II Program Type - IV).
Clinical Coverage Policy 8A and the North Carolina Medicaid State Plan specify that Child and Adolescent Day Treatment services may not be provided during the same authorization period as the following services:
- Intensive In-Home Services;
- Multisystemic Therapy;
- Individual, Group, and Family Therapy;
- Substance Abuse Intensive Outpatient Program;
- Child Residential Treatment Services Levels II (Program Type)–IV;
- Psychiatric Residential Treatment Facility (PRTF);
- Substance Use Residential Services; or
- Inpatient Hospitalization.
For Medicaid beneficiaries under age 21, service limitations in clinical coverage policies may be exceeded or may not apply when the requested service is medically necessary under Early and Periodic Screening, Diagnostic and Treatment (EPSDT) to correct or ameliorate a physical or mental illness or condition. EPSDT review remains individualized and must be supported by provider documentation.
Requests submitted to the beneficiary’s health plan for review under EPSDT do not guarantee approval. The health plan must determine that the request is medically necessary, clinically appropriate and non-duplicative. Requests submitted for EPSDT review for concurrent services otherwise limited by clinical coverage policy, including Child and Adolescent Day Treatment and Residential Treatment Services, must clearly document:
- Why the requested combination of services is medically necessary to correct or ameliorate the beneficiary’s condition;
- The distinct therapeutic role of each service; and
- How the requested services are expected to avoid unnecessary duplication of interventions.
Documentation should demonstrate the distinct therapeutic purpose and non-duplicative nature of each service.
Additional information about EPSDT can be found at NC Medicaid: Health Check and EPSDT.
Contact
- NC Medicaid Contact Center: 888-245-0179
- NC Medicaid Behavioral Health Policy: DHHS-Medicaid.BHPolicy@dhhs.nc.gov