This article applies to NC Medicaid Direct and NC Medicaid Managed Care.
NC Medicaid has amended Clinical Coverage Policy (CCP) 8G Peer Support Services. The amended policy became effective upon promulgation Sept. 1, 2026, and can be accessed on the NC Medicaid Program Specific Clinical Coverage Policies webpage.
The revisions align the policy with current clinical practice standards and include updates to utilization management guidance, program operations, and staff qualifications requirements.
Revisions to CCP 8G Peer Support Services include the following:
Definitions
Added a definition of Serious Mental Illness (SMI) that aligns with Substance Abuse and Mental Health Services Administration (SAMHSA) definitions
Eligibility and Coverage Criteria
Clarified eligibility criteria for beneficiaries receiving Peer Support Services (PSS)
Specific criteria covered
- Revised Specific Criteria Covered by Medicaid
- Revised Admission Criteria
- Revised Continued Stay Criteria
Transition and Discharge Planning
Added requirement specifying the frequency of discharge plan reviews by the PSS Program Supervisor
Requirements for and Limitations on Coverage
- Added prior authorization and utilization management guidance
- Added guidance on prior authorization, concurrent review and reauthorization requirements including non-quantitative treatment limitations (NQTLs)
Documentation Requirements
Revised documentation requirements to specify that service notes must include the start and end times for interventions delivered
Program Requirements
- Clarified how PSS may be coordinated with clinical services
- Updated guidance regarding appropriate use of telehealth and telephonic modalities for the delivery of delivering PSS
- Updated training requirements for the PSS Program Supervisors and Peer Support Specialists
- Updated the required frequency of supervision provided by the PSS Program Supervisor to NC Certified Peer Support Specialist (NC CPSS)
- Updated the required frequency for PSS Program Supervisors to monitor beneficiary progress
- Added a requirement for providers to maintain a roster of NC CPSS employed to provide PSS and make the roster available for review by the North Carolina Department of Health and Human Services or its contracted PHP or PIHP upon request
Billing Units
- Clarified only NC CPSS may bill for Peer Support Services
- Revised telehealth and telephonic service delivery to less than 10% or less of total service time per beneficiary per fiscal year
Contact
Provider Ombudsman:
- 866-304-7062, or
- Medicaid.ProviderOmbudsman@dhhs.nc.gov