Chapter 25 – medical assistance provided

 

SUbchapter 25A – general

 

section .0100 – reserved for future codification

 

10A NCAC 25A .0100       reserved for future codification

section .0200 – Medical Services

 

10A NCAC 25A .0201       MEDICAL SERVICES

All medical services performed must be medically necessary and may not be experimental in nature.  Medical necessity is determined by generally accepted North Carolina community practice standards as verified by independent Medicaid consultants.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 440.230(d);

Eff. March 1, 1990;

Transferred from 10A NCAC 22O .0301 Eff. May 1, 2012.

 

 

subchapter 25B – reserved for future codification

 

 

subchapter 25C – behavioral health/substance abuse

 

section .0100 – Reserved for future codification

 

10a ncac 25c .0101       reserved for future codification

section .0200 – mental health center services

 

10A NCAC 25C .0201       MENTAL HEALTH CENTER SERVICES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.70;

Eff. February 1, 1976;

Amended Eff. September 30, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. January 1, 1984; December 1, 1981;

Transferred from 10A NCAC 22O .0107 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

section .0300 – inpatient psychiatric hospital services

 

10A NCAC 25C .0301       INPATIENT PSYCHIATRIC HOSPITAL SERVICES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. February 1, 1991;

Transferred from 10A NCAC 22O .0111 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

10A NCAC 25C .0302       NC MEDICAID CRITERIA FOR CONTINUED ACUTE STAY IN AN INPATIENT PSYCHIATRIC FACILITY

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 42 C.F.R. 441, Subpart D;

Eff. January 1, 1998;

Temporary Amendment Eff. August 20, 1999;

Amended Eff. March l9, 2001;

Transferred from 10A NCAC 22O .0113 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

 

 

subchapter 25D – intellectual and developmental disabilities

 

section .0100 – Reserved for future codification

 

10a ncac 25d .0100       reserved for future codification

section .0200 – intermediate care facilities

 

10A NCAC 25D .0201       INTERMEDIATE CARE FACILITIES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.50; 42 C.F.R. 440.150; 42 C.F.R. 440.230(d);

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Transferred from 10A NCAC 22O .0108 and 10A NCAC 22O .0408 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

 

 

subchapter 25E – reserved for future codification

 

 

subchapter 25F – case management

 

section .0100 – Reserved for future codification

 

10a ncac 25F .0100        reserved for future codification

section .0200 – general case management

 

10a NCAC 25F .0201        CASE MGMT SVCS/ADULTS/CHILDREN AT‑RISK/ABUSE/ NEGLECT/ EXPLOITATION

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; Social Security Act, 1915(g);

Eff. October 1, 1992;

Recodified from 10 NCAC 26B .0122 Eff. October 1, 1993;

Temporary Amendment Eff. January 9, 1997;

Recodified from 10 NCAC 26B .0123 Eff. January 1, 1998;

Amended Eff. August 1, 1998;

Transferred from 10A NCAC 22O .0123 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

section .0300 – hiv case managment

 

10A NCAC 25F .0301        HIV CASE MANAGEMENT

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.169; Social Security Act 1915(b);

Eff. April 1, 1994;

Amended Eff. July 1, 1995;

Recodified from 10 NCAC 26B .0124 Eff. January 1, 1998;

Transferred from 10A NCAC 22O .0124 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

 

 

subchapter 25G – reserved for future codification

 

 

subchapter 25H – Dental services

 

section .0100 – Reserved for future codification

 

10a ncac 25h .0100       reserved for future codification

SECTION .0200 ‑ general

 

10A NCAC 25H .0201       DEFINITIONS

(a)  "Dental Services" means diagnostic, preventive or corrective procedures or dentures provided by or under the supervision of a dentist.  These services include treatment of the teeth and associated structures of the oral cavity, and of disease, injury, or impairment which may affect the oral or general health of the individual.

(b)  "Emergency dental care services" means those necessary to control bleeding, relieve pain, or eliminate acute infection, including emergency endodontic therapy; operative procedures which are required to prevent pulpal death and the imminent loss of teeth; or treatment of injuries to the teeth or supporting structures (e.g., bone or soft tissues contiguous to the teeth).  Prosthetic repairs that, if delayed for prior approval, would adversely affect the health of the patient may be considered emergency procedures.

(c)  "Routine services" means examinations, radiographs, preventive services, tooth extractions, minor oral surgical procedures, restorative services, prosthetic repairs and adjunctive services, such as general anesthesia, professional consultations and visits and the intramuscular injections of medicaments and drugs.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.100;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1992; December 1, 1987; February 29, 1980;

Transferred from 10A NCAC 22O .0201 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10a NCAC 25H .0202       ELIGIBILITY

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; S.L. 1985, c. 479, s. 86;

42 C.F.R. 440.210; 42 C.F.R. 440.220;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. February 29, 1980;

Transferred from 10A NCAC 22O .0203 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

10a NCAC 25H .0203       STANDARDS FOR PARTICIPATION

(a)  Dentists who provide services under the Medicaid program are required to meet the following standards:

(1)           must be licensed by the appropriate state authority;

(2)           must provide services in accordance with the rules and regulations of the Medicaid program;

(3)           must agree that the State Medicaid Agency or its designated agents may audit Medicaid dental records as necessary;

(4)           must agree that payment received from Medicaid is accepted as payment in full for covered services rendered.  No additional charges may be made to the patient for such services, except for authorized co‑payment.

(b)  All providers will insure:

(1)           Services are offered in accordance with Title VI of the 1964 Civil Rights Act;

(2)           Services are offered in accordance with Section 504 of the Rehabilitation Act of 1973, as amended;

(3)           All services provided maintain a high standard of quality and shall be within the reasonable limits of those which are customarily available and provided to most persons in the community with the limitations and exclusions hereinafter specified.

 

History Note:        Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. February 29, 1980;

Transferred from 10A NCAC 22O .0202 Eff. May 1, 2012.

 

10A NCAC 25H .0204       AMOUNT: DURATION: AND SCOPE OF SERVICES

(a)  Necessary and essential dental services, subject to the criteria and restrictions in the North Carolina Dental Manual are covered for all eligible Medicaid recipients.  Only the procedures listed in the North Carolina Dental Manual are generally covered under the North Carolina Dental Program.

(b)  Exceptions may be made when recommended by the Dental Consultant and approved by the agency head when:

(1)           An emergency condition causing pain or suffering needs immediate attention; or

(2)           An alternative dental treatment plan is safe, medically acceptable and less expensive but is not on the procedure list; or

(3)           The procedure is medically necessary and is of such complexity and the circumstances are so unusual that a coverage decision requires individual consideration based on the medical condition of the client, diagnosis, prognosis, and the unavailability of other alternative treatment options.

 

History Note:        Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1990; February 29, 1980;

Transferred from 10A NCAC 22O .0204 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10a NCAC 25H .0205       RESTRICTIONS AND PRIOR APPROVAL

(a)  The Division of Medical Assistance shall have the right of prior approval for dental services except for routine and emergency services.

(b)  All other dental services are subject to prior approval.  Dental services categories requiring dental prior approval are as follows:  Elective root canal treatment, periodontal services, orthodontic services, complex oral surgical and reconstructive procedures, complete and partial dentures, denture relines and analgesia (nitrous oxide).  Each specific procedure under the American Dental Association (ADA) service category in this Paragraph will be listed in the provider dental manual and provider bulletins with the appropriate prior approval service restriction guidelines.    

(c)  The Division of Medical Assistance may require prior approval for any services for individual providers who have been investigated by the Division under 10A NCAC 22F or by the Attorney General's Fraud Control Unit under 42 Code of Federal Regulations 455.300, and the investigation resulted in monetary recovery of payments made by Medicaid to the provider or criminal conviction of the provider.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; S.L. 1985, c. 479, s. 86;

Eff. February 1, 1976;

Amended Eff. September 30, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1992; February 29, 1980;

Transferred from 10A NCAC 22O .0205 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10a NCAC 25H .0206       PRIOR APPROVAL

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; S.L. 1985, c. 479, s. 86;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Transferred from 10A NCAC 22O .0211 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

section .0300 – services provided

 

10A NCAC 25H .0301       GUIDELINES ON SERVICES

10a NCAC 25H .0302       SPECIFIC GUIDELINES

10A NCAC 25H .0303       ANESTHESIA

10A NCAC 25H .0304       ANALGESIA

10A NCAC 25H .0305       DRUGS

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; S.L. 1985, c. 479, s. 86;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1992; December 1, 1987; January 1, 1982; February 29, 1980; October 31, 1977;

Transferred from 10A NCAC 22O .0206-.0210 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

 

 

subchapter 25I – reserved for future codification

 

 

subchapter 25J – reserved for future codification

 

 

subchapter 25K – drugs/pharmacy

 

section .0100 – Reserved for future codification

 

10a ncac 25k .0100       reserved for future codification

section .0200 – pharmacy services

 

10A NCAC 25K .0201       PHARMACY SERVICES

(a)  Reimbursement is provided for legend drugs, insulin, and over-the-counter (OTC) drugs documented in General Policy A2 on the Division of Medical Assistance (DMA) website.  The list of covered OTC drugs is on Attachment A of General Policy No. A-2.  The following is a list of requirements for coverage of drugs.

(1)           The prescribed drug must have a Federal Drug Administration (FDA) approved indication.

(2)           The prescribed drug must bear the federal legend statement.

(3)           The legend drug must be manufactured by a company that has signed a National Medicaid Drug Rebate Agreement with the Centers for Medicare and Medicaid Services (CMS).

(4)           The OTC drugs selected for coverage by DMA must be manufactured by a company that has signed a National Medicaid Drug Rebate Agreement with CMS.

(5)           Compounded drugs are covered when a mixture of two or more ingredients is physically inseparable, at least one of the components of the compounded drug is a legend drug, the quantity of legend drug is sufficient to have a therapeutic effect, and the legend drug is manufactured by a company that has signed a national Medicaid Drug Rebate Agreement with the Centers for Medicare and Medicaid Services (CMS).

(6)           Reimbursement is not provided for prescribed drugs documented on the CMS Drug Efficacy Study Implementation (DESI) list.  These drugs are also known as less than effective (LTE) drugs.

(b)  A prescription for a drug written under its brand or trade name shall be filled with a generic version of the drug when one is commercially available unless the prescriber has indicated that the brand name drug is medically necessary for the recipient.  The prescriber shall indicate this by writing "medically necessary" on the face of the prescription order for the drug.  The selection of a drug product shall not be more expensive than the brand or trade name originally written by the prescriber.  The pharmacist shall fill the prescription with the least expensive generic in the pharmacy.

(c)  All prescriptions must comply with state and federal laws and regulations for legal prescriptions.

(d)  A credit must be issued by the pharmacy provider for returned medications returned to stock.

(e)  The maximum days supply for all drugs is 34-day supply unless the medication meets the criteria for a 90-day supply indicated in Clinical Coverage Policy 9 on the DMA website.

(f)  DMA shall impose a prior authorization program for covered outpatient drugs that comply with requirements of 42 U.S.C. 1396r–8 (d)(1)(A) and in accordance with Session Law 2009-451, and any subsequent amendments.

(g)  DMA shall impose quantity limitations for drugs that are meant to be used episodically and dispensed in quantities that support less than daily use.  Those drugs designated as episodic drugs are defined in Clinical Coverage Policy 9 on the DMA website.

(h)  Recipients who receive more than 11 unduplicated prescriptions per month shall be evaluated as part of a Focused Risk Management (FORM) Program.  The FORM Program is an interdisciplinary, team-based approach including the pharmacy and the recipient's personal care physician for coordination of recipient care.  The following are requirements for the FORM Program:

(1)           The pharmacist shall coordinate, integrate, and communicate a comprehensive review plan with the patient's primary care provider.

(2)           The comprehensive review plan shall identify, resolve, and recommend cost-effective, safe, and efficacious drug alternatives; and shall include a list of all medications dispensed at the pharmacy during the review period and a list of recommendations to improve the recipients drug regimen.

(3)           The pharmacy shall communicate the comprehensive review plan to the recipient's PDP for review and coordination of care.  The pharmacist shall obtain a written response from the PDP that accepts or modifies the comprehensive review plan.  If the PDP fails to provide a response within one month from the date of the communication, the pharmacy shall document such failure on the comprehensive review plan.

(4)           The first review must be completed within two months of the recipient's identification for the program. Reviews thereafter shall be performed quarterly.

(5)           DHHS, Division of Medical Assistance shall make a professional services fee to the pharmacy provider on a quarterly basis, based on the completion of the comprehensive review plan under FORM Program for each identified recipient.  The professional services fee is based on average time for the pharmacist to complete the review at an estimated average pharmacist hourly wage.

(6)           A failure to perform a required comprehensive review plan or failure to have documentation of the review on file at the time of audit, shall result in the recoupment of professional service fee and payment for all claims that exceed the limit of 11 unduplicated prescriptions per month during those periods of time when a completed comprehensive review plan was not in place.

(i)  All recipients receiving more than 11 unduplicated prescriptions per month must participate in the FORM program. The following rules apply to the recipient:

(1)           The recipient shall choose a single pharmacy of his/her choice.

(2)           The recipient may elect to change his/her pharmacy provider by request made to DMA or DMA's fiscal agent from the current pharmacist or from the recipient's primary care provider.

(3)           Emergency fills for recipients are limited to a four-day supply.

(4)           The following recipients are exempt from the FORM program:

                (A)          recipients under the age of 21;

                (B)          recipients residing in a nursing facility or an intermediate care facility for individuals with mental retardation; and

                (C)          recipients residing in an assisted living facility or group home.

(j)  No pharmacist is required to accept a new recipient.  Pharmacists may accept new recipients of their choice.

(k)  Copayments shall be charged in accordance with 10A NCAC 22D .0101.

 

History Note:        Authority G.S. 90-85.26; 108A-25(b); 108A-54; 42 C.F.R. 440.90; 42 CFR 447.331; S.L. 1985, c. 479, s. 86; 42 U.S.C. 1396r-8(d)(1)(A); S.L 2009-451;

Eff. September 30, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. January 1, 1984;

Recodified from 10 NCAC 26B .0116 Eff. October 1, 1993;

Recodified from 10 NCAC 26B .0117 Eff. January 1, 1998;

Amended Eff. May 1, 2010;

Transferred from 10A NCAC 22O .0118 Eff. May 1, 2012.

 

SECTION .0300 ‑ DRUG USE REVIEW BOARD

 

10A NCAC 25K .0301       ESTABLISHMENT

The Division of Medical Assistance will establish a Drug Use Review Board.  The Drug Use Review Board shall not have rule making authority.  The Division of Medical Assistance shall have the authority to reject recommendations of the Drug Use Review Board.  In the event of such rejections, Division of Medical Assistance shall notify the Drug Use Review Board, in writing, of the reasons for its action and allow the DUR Board an opportunity to reconsider its recommendation or decision.

 

History Note:        Authority G.S. 108A-68; Social Security Act Section 1927(g);

Eff. January 4, 1993;

Transferred from 10A NCAC 22M .0101 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10A NCAC 25K .0302       MEMBERSHIPS

(a)  The DUR Board shall consist of the Division of Medical Assistance Drug Use Review Coordinator and the following appointed positions:

(1)           five licensed and practicing physicians;

(2)           five licensed and practicing pharmacists; and

(3)           at least two additional individuals with knowledge and expertise in one or more of the following:

(A)          prescribing of Medicaid covered outpatient drug;

(B)          dispensing and monitoring of Medicaid covered outpatient drugs;

(C)          drug use review, evaluation, and intervention; or

(D)          medical quality assurance.

(b)  The Division shall appoint members of the DUR Board for up to three one-year terms.  Either party shall have the right to terminate the membership upon five days notice in writing to the other party.  The DUR Coordinator is not an appointed member, is not subject to the term requirement and only serves on the Board while actively employed with DMA as the DUR Coordinator.

(c)  The North Carolina Association of Pharmacists, the North Carolina Medical Society, and the Old North State Medical Society shall be asked by DMA's DUR Coordinator to make nominations for some of the positions on the Board.  The Director may accept or reject nominations received. 

 

History Note:        Authority G.S. 108A‑68; 42 U.S.C. 1396r-8(g)(3)(B);

Eff. January 4, 1993;

Amended Eff. April 1, 2010;

Transferred from 10A NCAC 22M .0102 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10A NCAC 25K .0303       CHAIRMEN

One pharmacist and one physician shall serve as co‑chairmen of the Board.  Beginning in calendar year 1996, each co‑chairman shall be elected by his peers, the term of the chairmen shall be one year, and membership on the Board of at least one previous year shall be required to establish eligibility for serving as the chairman.

 

History Note:        Authority G.S. 108A‑68; Social Security Act Section 1927(g);

Eff. January 4, 1993;

Transferred from 10A NCAC 22M .0103 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10A NCAC 25K .0304       ACTIVITIES

(a)  The activities of the Drug Use Review Board shall include but are not limited to making recommendations for rules to the Division Directors for Medicaid recipients for the following:

(1)           retrospective review of Medicaid claims information for drug therapy problems;

(2)           application of standards for prospective and retrospective Drug Use Review;

(3)           ongoing interventions for prescribers, pharmacists, and recipients targeted toward therapy problems identified in the course of Medicaid retrospective drug use reviews;

(4)           preparation of an annual report to the Division of Medical Assistance on the Drug Use Review process;

(5)           programs to educate pharmacists and prescribers on common drug therapy problems identified in the Medicaid drug use reviews with the aim of improving prescribing or dispensing practices.

(b)  The criteria and standards for the drug therapy review adopted by the Division upon recommendation by the Drug Use Review Board shall be available to pharmacists, prescribers, and the general public.

 

History Note:        Authority G.S. 108A‑68; Social Security Act Section 1927(g);

Eff. January 4, 1993;

Transferred from 10A NCAC 22M .0104 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

SECTION .0400 - PROSPECTIVE DRUG REVIEW

 

10A NCAC 25K .0401       PATIENT COUNSELING

Rule 21 NCAC 46 .2504 as adopted by the North Carolina Board of Pharmacy applies to Medicaid and is incorporated by reference including subsequent amendments.  A copy of 21 NCAC 46 .2504 may be downloaded from the N.C. Board of Pharmacy website (http://www.ncbop.org/LawsRules/rules.2500.pdf).  There is no charge.  If a pharmacy fails to comply with the requirements of 21 NCAC 46 .2504, any claim for reimbursement associated with the pharmacy's non-compliance shall be denied, or if already paid, shall be recouped.

 

History Note:        Authority G.S. 108A-68; 42 U.S.C. 1396r-8(g)(2)(A)(ii);

Eff. June 1, 1993;

Amended Eff. March 1, 2010;

Transferred from 10A NCAC 22M .0201 Eff. May 1, 2012.

 

SECTION .0500 - RETROSPECTIVE DRUG USE REVIEW (DUR)

 

10A NCAC 25K .0501       RETROSPECTIVE DRUG USE REVIEW (DUR)

 

History Note:        Authority G.S. 108A‑68; 42 U.S.C. 1396R-8(2)(b)-(C);

Eff. January 4, 1993;

Amended March 1, 2010;

Transferred from 10A NCAC 22M .0301 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

10a NCAC 25K .0502       SCREENING AND PATTERN ANALYSIS

At least quarterly, the Medicaid drug claims, in conjunction with other Medicaid claims as needed for clinical purposes, shall be subjected to screening against standards approved by the Drug Use Review Board.  The objective of the screening is to identify patterns of behavior involving prescribers and pharmacists,

or patterns associated with specific drugs or groups of drugs.  Health care patterns of individual Medicaid recipients shall be screened.  In addition, individual incidences of screen failure associated with a specific recipient shall be identified for intervention alerts.

 

History Note:        Authority G.S. 108A‑68; Social Security Act Section 1927(g);

Eff. January 4, 1993;

Transferred from 10A NCAC 22M .0302 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10A NCAC 25K .0503       INTERVENTIONS

The primary objective of the retrospective Drug Use Review is to provide education to pharmacists and prescribers, both individually and collectively, in order to improve prescribing and dispensing practices.  The intervention and educational programs shall be developed by the Drug Use Review Board and shall be updated as more information is available from the retrospective review process.

The Drug Use Review Board may establish referral processes to the Board of Pharmacy, the Board of Medical Examiners, the Board of Dental Examiners, other health care licensing agencies, or the Division of Medical Assistance Program Integrity Section for individual pharmacists or prescriber who continue to demonstrate patterns of prescribing or dispensing which put the Medicaid recipient at risk from drug therapy problems even after repeated warnings through Drug Use Review interventions.

 

History Note:        Authority G.S. 108A‑68; Social Security Act Section 1927(g);

Eff. January 4, 1993;

Transferred from 10A NCAC 22M .0303 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10A NCAC 25K .0504       COMPLIANCE MONITORING

The prescriber's and pharmacist's responses to the interventions undertaken as a result of the retrospective Drug Use Review shall be tracked.  The Drug Use Review Board may establish selection criteria for intensified review and monitoring of individual pharmacists and prescribers.

 

History Note:        Authority G.S. 108A‑68; Social Security Act Section 1927(g);

Eff. January 4, 1993;

Transferred from 10A NCAC 22M .0304 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

 

 

subchapter 25L – reserved for future codification

 

 

subchapter 25M – Facilities

 

section .0100 – Reserved for future codification

 

10a ncac 25m .0100      reserved for future codification

section .0200 – inpatient hospital services

 

10A NCAC 25M .0201      INPATIENT HOSPITAL SERVICES

(a)  Private and semi‑private rooms shall be reimbursed only when medically necessary (or when a census makes it necessary). Claims must be supported by a physician's statement.

(b)  Medical necessity for acute hospital level‑of‑care and length of stay will initially be determined by a hospital's Utilization Review Committee; however this need will be subject to post‑payment review by the state agency.  All claims will be subject to prepayment review for Medicaid coverage.

(c)  The State agency may grant a maximum of three administrative days to arrange for discharge of a patient to a lower level‑of‑care.  With prior approval by the State Medicaid agency, the hospital may be reimbursed for days in excess of the three administrative days at the statewide average rate for the particular level of care needed in the event a lower level‑of‑care bed in a Medicaid approved health care institution is not available.  The hospital must, however, make every effort to place the recipient in an appropriate institution within the three-day administrative time allowance.

(d)  Preadmission Authorization

(1)           Preadmission authorization to admit a Medicaid patient for elective acute hospital level of care is required by the State Agency in accordance with physician developed criteria except under the following conditions:

(A)          Medicare is a primary payor; or

(B)          The admission is for a delivery; or

(C)          The patient is determined Medicaid eligible after admission has occurred.

(2)           The admitting physician is responsible for securing the authorization.  A denial to authorize the admission may be appealed by the physician, or hospital.  Failure to secure authorization shall result in denial or recoupment for any inappropriate or unnecessary admission.

(3)           The State Agency will establish Administrative mechanisms to evaluate request for retroactive approvals to consider cases where either events occurred that were outside the provider's control or technical processing errors prevented obtaining an authorization prior to the patient's being admitted to the hospital.

(4)           In all cases involving a denial or recoupment, neither the hospital nor practitioner may bill the patient.

(e)  Inpatient care in North Carolina state specialty hospitals of persons with pulmonary or chronic diseases shall be covered.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.10; 42 C.F.R. 440.230(d); 42 C.F.R.447.253; 42 C.F.R. 456.1;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1986; August 1, 1986; October 1, 1982;

Temporary Amendment Eff. October 15, 1999;

Temporary Amendment Expired July 28, 2000;

Temporary Amendment Eff. September 25, 2000;

Temporary Amendment Expired June 29, 2001;

Paragraphs (a)-(d) transferred from 10A NCAC 22O .0401 Eff. May 1, 2012.

Paragraph (e) transferred from 10A NCAC 22O .0114 Eff. May 1, 2012 (Previously recodified from 10 NCAC 26B .0112 Eff. October 1, 1993 and recodified from 10 NCAC 26B .0113 Eff. January 1, 1998).

 

section .0300 – outpatient hospital services

 

10A NCAC 25M .0301      HOSPITAL OUTPATIENT

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.20;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. January 1, 1984;

Temporary Amendment Eff. September 1, 2000;

Temporary Amendment Expired May 29, 2001;

Transferred from 10A NCAC 22O .0102 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

section .0400 – skilled nursing facility services

 

10a NCAC 25M .0401      SKILLED NURSING FACILITY

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.20; C.F.R. 440.40; 42 C.F.R. 440.230(d)

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1977; September 1, 1981;

Paragraphs (a)-(c) transferred from 10A NCAC 22O .0116 Eff. May 1, 2012 (Previously recodified from 10 NCAC 26B .0114 Eff. October 1, 1993 and recodified from 10 NCAC 26B .0115 Eff. January 1, 1998);

Paragraph (d) transferred from 10A NCAC 22O .0403 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

section .0500 – other facilites

 

10A NCAC 25M .0501      THERAPEUTIC LEAVE

 

History Note:        Authority G.S. 108A‑25(b); 108A‑62;

Eff. September 4, 1979;

Amended Eff. May 1, 2006; August 1, 1991; April 1, 1987;

Transferred from 10A NCAC 22O .0409 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

 

 

subchapter 25N – hearing and vision

 

section .0100 – Reserved for future codification

 

10a ncac 25n .0100       reserved for future codification

section .0200 – hearing services

 

10A NCAC 25N .0201       Hearing aid services

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.110;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. November 2, 1992;

Transferred from 10A NCAC 22O .0109 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

section .0300 – vision services

 

10A NCAC 25N .0301       EYEGLASSES AND OPTOMETRIC SERVICES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.120;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. August 1, 1996; January 1, 1984;

Transferred from 10A NCAC 22O .0105 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

 

 

subchapter 25O – home and community-based services

 

section .0100 – Reserved for future codification

 

10a ncac 25o .0100       reserved for future codification

section .0200 – Home Health Services

 

10A NCAC 25O .0201       HOME HEALTH SERVICES

 

History Note:        Authority G.S. 108‑25(b); 108A‑25(b); 108A‑54; 42 C.F.R. 440.70; 42 C.F.R. 440.230(d);

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. August 1, 1986; April 1, 1999; February 1, 1980;

Paragraph (a) transferred from 10A NCAC 22O .0103 Eff. May 1, 2012;

Paragraphs (b)-(e) transferred from 10A NCAC 22O .0406 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

10A NCAC 25O .0202       PERSONAL CARE SERVICES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 2002-126; S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.170(f);

Eff. January 1, 1986;

Amended Eff. April 1, 1993; December 1, 1991;

Temporary Amendment Eff. December 27, 2002 (Paragraphs (c)-(e));

Temporary Amendment Expired October 12, 2003 (Paragraphs (c)-(e));

Paragraphs (a)-(b) transferred from 10A NCAC 22O .0120 Eff. May 1, 2012 (previously recodified from 10 NCAC 26B .0119 Eff. October 1, 1993 and recodified from 10 NCAC 26B .0120 Eff. January 1, 1998);

Paragraphs (c)-(e) transferred from 10A NCAC 22P .0410 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

10A NCAC 25O .0203       HOME INFUSION THERAPY

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 440.230; 42 C.F.R. 440.260;

Eff. March 1, 1993;

Recodified from 10 NCAC 26B .0123 Eff. October 1, 1993;

Recodified from 10 NCAC 26B .0124 Eff. April 1, 1994;

Recodified from 10 NCAC 26B .0125 Eff. January 1, 1998;

Transferred from 10A NCAC 22O .0125 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

10A NCAC 25O .0204       PRIVATE DUTY NURSING

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.80;

Eff. May 1, 1990;

Amended Eff. April 1, 1993; June 1, 1992;

Recodified from 10 NCAC 26B .0121 Eff. October 1, 1993;

Recodified from 10 NCAC 26B .0122 Eff. January 1, 1998;

Transferred from 10A NCAC 22O .0122 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

 

 

subchapter 25P – medical-surgical

 

section .0100 – Reserved for future codification

 

10a ncac 25p .0100        reserved for future codification

section .0200 – inpatient hospital services

 

10A NCAC 25P .0201        INPATIENT HOSPITAL SERVICES

Coverage for selected elective surgical procedures is contingent upon the rendering of a second opinion by another qualified practitioner when Medicaid is the primary payor.  Categories of surgery which may be subject to a second surgical opinion requirement include hysterectomy, cholocystectomy, hemorrhoidectomy, knee surgery, coronary bypass, foot surgery, laminectomy, prostatectomy, tonsillectomy and adenoidectomy, inguinal hernia repair, varicose vein stripping and cataract surgery.  This requirement may be waived by the state agency under the following conditions:

(1)           Subsequent to the performance of the procedure the recipient is determined to be retroactively eligible;

(2)           Unanticipated circumstances precluded performance of a second surgical opinion;

(3)           Physician developed criteria precludes a second opinion.

 

History Note:        Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.230(d); 42 C.F.R.447.253; 42 C.F.R. 456.1;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1986; August 1, 1986; October 1, 1982;

Temporary Amendment Eff. October 15, 1999;

Temporary Amendment Expired July 28, 2000;

Temporary Amendment Eff. September 25, 2000;

Temporary Amendment Expired June 29, 2001;

Transferred from 10A NCAC 22O .0401(e) Eff. May 1, 2012.

 

section .0300 – outpatient hospital services

 

10a NCAC 25P .0301        OUTPATIENT HOSPITAL SERVICES

(a)  Injection of medications that can be administered orally shall not be covered.

(b)  Provision of durable medical equipment shall not be covered.

(c)  Take‑home legend drugs shall not be provided, except when dispensed during hours when pharmacies are not open for business.

(d)  Non‑legend drugs shall not be covered.

(e)  Immunization shall not be covered.

(f)  Coverage for selected elective surgical procedures is contingent upon the rendering of a second opinion by another qualified practitioner when Medicaid is the primary payor.  Categories of surgery which may be subject to a second surgical opinion requirement include hysterectomy, cholocystectomy, hemorrhoidectomy, knee surgery, coronary bypass, foot surgery, laminectomy, prostatectomy, tonsillectomy and adenoidectomy, inguinal hernia repair, varicose vein stripping and cataract surgery.  This requirement may be waived by the state agency under the following conditions:

(1)           Subsequent to the performance of the procedure the recipient is determined to be retroactively eligible;

(2)           Unanticipated circumstances precluded performance of a second surgical opinion;

(3)           Physician developed criteria precludes a second opinion.

In all cases the final decision to perform the surgery rests with the recipient.  A third opinion is covered but not required.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 440.20; 42 C.F.R. 440.230(d); 42 C.F.R. 456.1;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1986;

Transferred from 10A NCAC 22O .0402 Eff. May 1, 2012.

 

section .0400 – other services

 

10A NCAC 25P .0401        PHYSICIAN SERVICES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 440.50; 42 C.F.R. 440.230(d); 42 C.F.R. 456.1;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1986; January 1, 1986;

Transferred from 10A NCAC 22O .0404 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

10A NCAC 25P .0402        CLINIC SERVICES

(a)  Clinic services for which the physician or dentist files directly for payment shall not be covered.

(b)  Clinic services specifically covered in other Title XIX programs shall not be covered.

(c)  Clinic services provided at hospital clinics or at volunteer clinics not affiliated with the county health department shall not be covered, regardless of the amount of assistance provided by the county health department.

(d)  Medicaid payments for dental services in clinics shall cover only those dental procedures which do not require prior approval.  All dental services requiring prior approval must be billed separately, using the dentist's own provider number and the appropriate prior approval form.

(e)  Only clinic services furnished by or under the direction of a physician or dentist shall be covered.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.20;

Eff. February 1, 1976;

Amended Eff. September 30, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. January 1, 1984;

Recodified from 10 NCAC 26B .0113 Eff. October 1, 1993;

Recodified from 10 NCAC 26B .0114 Eff. January 1, 1998;

Transferred from 10A NCAC 22O .0115 Eff. May 1, 2012.

 

10A NCAC 25P .0403        CHIROPRACTIC SERVICES

10A NCAC 25P .0404        PODIATRIST SERVICES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.60; 42 C.F.R. 440.230(d)

Eff. February 1, 1976;

Amended Eff. September 30, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. January 1, 2009; May 1, 1990; January 1, 1984;

Transferred from 10A NCAC 22O .0106, .0405 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

10A NCAC 25P .0403        CHIROPRACTIC SERVICES

(a)  No reimbursement from North Carolina Medicaid shall be made for x‑rays or other diagnostic or therapeutic services provided by a chiropractor except as provided in this Rule.

(b)  Medicaid coverage of chiropractic services is limited to manual manipulation of the spine to correct a subluxation.

(c)  Subluxation shall be confirmed by physical examination or by one set of x-rays taken within six months of the initial date of service.

(d)  The treatment plan shall document:

(1)           the symptoms or diagnosis treated;

(2)           diagnostic procedures and treatment modalities used;

(3)           results of diagnostic procedures and treatments; and

(4)           anticipated length of treatments.

(e)  Medical documentation shall support continued treatment.

(f)  Chiropractic providers shall meet the educational requirements as outlined in 42 CFR 410.21(a).

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.60;

Eff. February 1, 1976;

Amended Eff. September 30, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. January 1, 2009; May 1, 1990; January 1, 1984;

Transferred from 10A NCAC 22O .0106 Eff. May 1, 2012.

 

10A NCAC 25P .0404        PODIATRIST SERVICES

The trimming of nails and corns shall not be covered.

 

History Note:        Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.230(d);

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Transferred from 10A NCAC 22O .0405 Eff. May 1, 2012.

 

10a NCAC 25P .0405        ABORTION

Lawful abortions shall be covered under Medicaid in accordance with federal law.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑56; 42 C.F.R. 440.90; 42 C.F.R. 441, Subpart E;

Eff. March 16, 1976;

Amended Eff. August 24, 1977;

Readopted Eff. October 31, 1977;

Recodified from 10 NCAC 26B .0115 Eff. October 1, 1993;

Recodified from 10 NCAC 26B .0116 Eff. January 1, 1998;

Transferred from 10A NCAC 22O .0117 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10A NCAC 25P .0406        LABORATORY AND X‑RAY SERVICES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.30; 40 C.F.R. 441.16; 42 C.F.R. Part 493;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. March 1, 1993; April 1, 1992;

Transferred from 10A NCAC 22O .0104(1)-(3) Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

 

 

Subchapter 25Q – reserved for future codification

 

 

Subchapter 25R – reserved for future codification

 

 

Subchapter 25S – out-of-STate services

 

section .0100 – reserved for future codification

 

10a ncac 25s .0100        reserved for future codification

section .0200 – out-of-state services

 

10A NCAC 25S .0201        OUT‑OF‑STATE SERVICES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑55;

Eff. September 30, 1977;

Readopted Eff. October 31, 1977;

Recodified from 10 NCAC 26B .0117 Eff. October 1, 1993;

Recodified from 10 NCAC 26B .0118 Eff. January 1, 1998;

Transferred from 10A NCAC 22O .0119 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

 

 

Subchapter 25T – reserved for future codification

 

 

Subchapter 25U – radiology

 

section .0100 – reserved for future codification

 

10a ncac 25u .0100       reserved for future codification

section .0200 – x-ray services

 

10A NCAC 25U .0201       LABORATORY AND X‑RAY SERVICES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.30; 40 C.F.R. 441.16; 42 C.F.R. Part 493;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. March 1, 1993; April 1, 1992;

Transferred from 10A NCAC 22O .0105(4)-(5) Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

 

 

subchapter 25V – reserved for future codification

 

 

subchapter 25W – transportation

 

section .0100 – Reserved for future codification

 

10a ncac 25w .0100      reserved for future codification

section .0200 – ambulance services

 

10A NCAC 25W .0201      AMBULANCE SERVICES

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.170;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1995; January 1, 1995; March 1, 1993;

Transferred from 10A NCAC 22O .0110 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.