Medicaid Direct Annual Visit Limit

The Code of Federal Regulations (CFR) defines the services that must be provided by each state Medicaid program. These services are mandatory services. Each state may decide which, if any, optional services, as defined by the CFR, will be covered. Optional services that are covered by the NC Medicaid Program include optometry, chiropractic services and podiatry.

According to the Centers for Medicare & Medicaid Services (CMS), a visit limit may not combine both mandatory and optional services.

Mandatory Services

Annual Visit Limit Period: July 1 - June 30
Number of Visits: 22

Provider Types Included in Visit Count:

  • Physicians (except for physicians enrolled in Medicaid with a specialty of oncology, radiology, or nuclear medicine)
  • Nurse practitioners
  • Nurse midwives
  • Physician assistants
  • Clinical pharmacy practitioners
  • Health departments
  • Rural health clinics
  • Federally qualified health centers

Optional Services

Annual Visit Limit Period: July 1 - June 30
Number of Visits: 8

Provider Types Included in Visit Count:

  • Chiropractors
  • Optometrists
  • Podiatrists

CPT Procedure Codes Subject to the Annual Visit Count

Medicaid has designated specific CPT procedure codes that count toward the annual visit limitation. The codes will be reviewed on a regular basis and updated as appropriate.

CPT Procedure Codes Spreadsheet

ICD-10-CM Diagnosis Codes that Are Not Subject to the Annual Visit Limitation

Medicaid has designated specific ICD-10-CM diagnosis codes that do not count toward the annual visit limitation for claims with dates of service on or after October 1, 2016. The codes will be reviewed on a regular basis and updated as appropriate.

ICD-10-CM Diagnosis Code Spreadsheet

Beneficiaries Who Are Not Subject to the Annual Visit Limitation

The following beneficiaries are exempt from the annual visit limitation:

  • Beneficiaries under the age of 21
  • Beneficiaries enrolled in a Community Alternatives Program (CAP)
  • Pregnant beneficiaries who are receiving prenatal and pregnancy-related services

Requesting an Exception

If a provider anticipates that additional care will be needed for a specific condition and the care is medically necessary, the rendering provider may request an exception to the annual visit limit for mandatory services. This only applies to beneficiaries who do not meet any of the exception criteria listed above and have exhausted, or are close to exhausting, their 22 total visits allowed for the fiscal year.

A provider may verify the number of remaining visits by viewing the service limit section on the beneficiary eligibility inquiry screen in the NCTracks Provider Portal. This count is updated as providers file their claims. Requesting an exception is done through the NCTracks Provider Prior Approval (PA) Portal. Mailed or faxed PA requests will not be processed.

To submit a request for an exception, providers should access the prior approval module through the NCTracks secure provider portal.

  • Providers must enter their NCID, then click on “Prior Approval” and submit a PA request selecting PA Type A23- EXC. TO LE.
  • If the PA is entered with a PA type other than A23-EXC. TO LE, it will not be processed
  • The provider should enter the requested procedure code(s), how many extra visits are being requested, and select the unit type “Visit.”
  • Providers must present information explaining why additional visits are needed. This documentation should be attached electronically to the PA in NCTracks.

PA requests for extra visits will only be granted to the office that requests them. If a beneficiary is seeing multiple providers and have exhausted their 22 visits, each provider that beneficiary sees is responsible for requesting their own extra visits.

Note: PA requests cannot be authorized for an extension of optional service limits or mandatory services that have already been rendered.

The exception must be requested and approved before the service is rendered. If a claim is submitted prior to receiving approval for an exception, and the claim is denied for exceeding the visit limit, the provider may submit a Medicaid Claim Adjustment Request Form to Medicaid’s fiscal vendor (NCTracks). A copy of the beneficiary’s medical record documenting the visit with the specific condition and medical necessity of the visit to actively manage or treat the condition must be submitted with the adjustment along with the remittance advice received from NCTracks for the denied date of service. The complete packet should be mailed to GDIT Adjustment Unit, PO Box 300009, Raleigh, NC 27622. The adjustment request and supporting documentation will be reviewed for medical necessity by NCTracks.

Exceptions are processed by GDIT: 1-800-688-6696.

Notification Process

The law requires the North Carolina Department of Health and Human Services (DHHS) to establish a threshold for some number of visits for these services. DHHS shall ensure that primary care providers or the appropriate Community Care of North Carolina (CCNC) network are notified when a patient is nearing the established threshold to facilitate care coordination and intervention as necessary.

A provider may verify the number of remaining visits by viewing the Service Limit section on the beneficiary eligibility inquiry screen.

NOTE: The visit counts provided through these portals are based on claims that have been processed.  It is possible that other providers’ claims may process against the limit prior to the submission of your claim.