Medicaid & Health Choice Clinical Coverage Policies
and Provider Manuals
Pursuant to N.C. Gen. Stat. § 108A-70.21(b): Except as otherwise provided for eligibility, fees, deductibles, copayments, and other cost sharing charges, health benefits coverage provided to children eligible under the Program shall be equivalent to coverage provided for dependents under the North Carolina Medicaid Program except for the following:
- No services for long‑term care.
- No nonemergency medical transportation.
- No EPSDT.
- Dental services shall be provided on a restricted basis in accordance with criteria adopted by the Department to implement this subsection.
All North Carolina Health Choice Program (NCHC) clinical coverage policies are posted electronically with the North Carolina Medicaid Program clinical coverage policies and provider manuals listed below.
Because of the legislative directive to have Medicaid equivalent benefits, DMA has developed a joint clinical coverage policy template for Medicaid and NCHC. Please read each policy section carefully for program specific coverage, exceptions and limitations.
Prior approval (PA) may be required for some services, products or procedures to verify documentation of medical necessity.
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) information is not included in all provider manuals. For information about EPSDT:
The Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), as amended by the Health Care and Education Recovery Act of 2010 (P.L. 111-152), together referred to as the Affordable Care Act (ACA) requires state Medicaid programs to be compliant with the National Correct Coding Initiative (NCCI) in claims processing by March 31, 2011. DMA has implemented the NCCI for all Medicaid and NCHC claims. Each provider shall comply with NCCI methodologies and can access information about NCCI and its impact on claims processing.
Unless directed otherwise, institutional claims must be billed in accordance with the National Uniform Billing Guidelines. All claims must comply with National Coding Guidelines.
CPT codes, descriptors, and other data only are copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.
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General Clinical Coverage Policies
Program-Specific Clinical Coverage Policies
Practitioners/Clinics (1A through 1T)
- Physicians
- 1A-1, Compression Garments (8/1/05)
- 1A-2, Preventive Medicine Annual Health Assessment (3/12/12)
- 1A-3, Noninvasive Pulse Oximetry (3/12/12)
- 1A-4, Cochlear and Auditory Brainstem Implants (3/12/12)
- 1A-5, Case Conference for Sexually Abused Children (3/12/12)
- 1A-6, Electrical Osteogenic Stimulators (3/12/12)
- 1A-7, Neonatal and Pediatric Critical and Intensive Care Services (3/12/12)
- 1A-8, Hyberbaric Oxygenation Therapy (3/1/12)
- 1A-9, Blepharoplasty/Blepharoptosis (Eyelid Repair) (3/12/12)
- 1A-11, Extracorporeal Shock Wave Lithotripsy (3/1/12)
- 1A-12, Breast Surgeries (posted 12/6/10; eff. 12/1/10)
- 1A-13, Ocular Photodynamic Therapy (5/1/07)
- 1A-14, Gender Transformation (5/1/07)
- 1A-15, Surgery for Clinically Severe Obesity (1/1/12)
- 1A-16, Surgery of the Lingual Frenulum (7/1/07)
- 1A-17, Stereotactic Pallidotomy (3/1/12)
- 1A-18, Scanning Laser Glaucoma Test (5/1/07)
- 1A-19, Transcranial Doppler Studies (3/12/12)
- 1A-20, Sleep Studies and Polysomnography Services (3/12/12)
- 1A-21, Endovascular Repair of Aortic Aneurysm (3/12/12)
- 1A-22, Medically Necessary Circumcision (7/1/07)
- 1A-23, Physician Fluoride Varnish Services (11/1/07)
- 1A-24, Diabetes Outpatient Self-Management Education (5/1/09)
- 1A-25, Spinal Cord Stimulation (3/1/12)
- 1A-26, Deep Brain Stimulation (3/1/10)
- 1A-27, Electrodiagnostic Studies (7/1/11)
- 1A-28, Visual Evoked Potential (VEP) (1/15/12)
- 1A-31, Wireless Capsule Endoscopy (3/12/12)
- 1A-32, Tympanometry and Acoustic Reflex Testing (1/1/12)
- 1A-38, Special Services: After Hours (3/12/12)
- Physicians Drug Program
- Podiatry
- Clinics
- Obstetrics & Gynecology
- 1F, Chiropractic Services (11/1/07)
- Burn Treatments
- 1H, Telemedicine and Telepsychiatry (6/1/07)
- 1-I, Dietary Evaluation and Counseling (11/1/09)
- Radiology
- Anesthesia
- Maternal Support Services (Baby Love)
- Allergies
- Reconstructive Surgery
- Cardiac Procedures
- Laboratory Services
- Ophthalmological Services
Ambulance Services
Facility Services
Community Based Services (3A through 3K)
Dental Program (4A and 4B)
Medical Equipment (5A and 5B)
Vision Services
Hearing Aid Services
Behavioral Health (8A through 8N)
- 8A, Enhanced Mental Health and Substance Abuse Services (8/1/11)
- 8B, Inpatient Behavioral Health Services (8/1/07)
- 8C, Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers (1/1/12)
- 8D-1, Psychiatric Residential Treatment Facilities for Children under the Age of 21 (5/1/07)
- 8D-2, Residential Treatment Services (8/1/07)
- 8E, Intermediate Care Facilities for Individuals with Mental Retardation (8/1/07)
- 8I, Psychological Services in Health Departments and School-Based Health Centers Sponsored by Health Departments to the under-21 Population (5/1/07)
- 8J, Children's Developmental Service Agencies (CDSAs) (5/1/07)
- 8L, Mental Health/Substance Abuse Targeted Case Management (7/30/10; eff. 7/1/10)
- 8M, Community Alternatives Program for Persons with Mental Retardation and Developmental Disabilities (CAP-MR/DD) (7/1/10)
- 8N, Intellectual and Developmental Disabilities Targeted Case Management (6/1/11)
Pharmacy Services
Specialized Therapies (10A through 10D)
Transplants and Transplant-Related Services (11A through 11H)
- Stem Cell Transplants
- 11A-1, Hematopoietic Stem-Cell or Bone Marrow Transplantation for Acute Lymphoblastic Leukemia (ALL) (1/1/12)
- 11A-2, Hematopoietic Stem-Cell and Bone Marrow Transplant for Acute Myeloid Leukemia (1/1/12)
- 11A-3, Hematopoietic Stem-Cell & Bone Marrow Transplantation for Chronic Myelogenous Leukemia (1/1/12)
- 11A-4, Donor Leukocyte, Donor Lymphocyte or Buffy Coat Infusion for Hematologic Malignancies that Relapse or at a High Risk for Relapse after Allogeneic Stem Cell Transplantation (Date of termination 12/31/2011)
- 11A-5, Allogeneic Hematopoietic & Bone Marrow Transplant for Genetic Diseases and Acquired Anemias (1/1/12)
- 11A-6, Hematopoietic Stem-Cell & Bone Marrow Transplantation in the Treatment of Germ Cell Tumors (1/1/12)
- 11A-7, Hematopoietic Stem-Cell & Bone Marrow Transplantation for Hodgkin Lymphoma (1/1/12)
- 11A-8, Hematopoietic Stem-Cell Transplantation For Multiple Myeloma and Primary Amyloidosis (3/1/12)
- 11A-9, Allogeneic Stem-Cell & Bone Marrow Transplantation for Myelodysplastic Syndromes & Myeloproliferative Neoplasms (3/1/12)
- 11A-10, Hematopoietic Stem-Cell & Bone Marrow Transplantation for Central Nervous System (CNS) Embryonal Tumors & Ependymoma (3/1/12)
- 11A-11, Hematopoietic Stem-Cell & Bone Marrow Transplant for Non-Hodgkin’s Lymphoma (3/1/12)
- 11A-12, Non-Myeloablative Allogeneic Stem Cell Transplant (Mini-Transplant, Mini-Allograft Reduced Intensity Conditioning) for Treatment of Malignancies (Date of Termination 4/30/12)
- 11A-13, High Dose Chemotherapy, Bone Marrow or Peripheral Stem Cell Transplant for Ovarian Cancer and Germ Cell Tumors Arising in the Ovaries (Date of Termination 3/1/12)
- 11A-14, Placental and Umbilical Cord Blood as a Source of Stem Cells (3/1/12)
- 11A-15, Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood (3/1/12)
- 11A-16, Hematopoietic Stem-Cell Transplantation for Chronic lymphocytic leukemia (CLL) and Small lymphocytic lymphoma (SLL) (3/1/12)
- Solid Organ Transplants
- 11C, Ventricular Assist Device (3/12/12)
- 11D, Biventricular Pacemaker for the Treatment of Congestive Heart Failure (Date of Termination 4/30/12)
- 11E, Implantable Cardioverter Defibrillator (Date of Termination 4/30/12)
- 11F, Extracorporeal Membrane Oxygenation/Extracorporeal Life Support (Date of Termination 4/30/12)
- 11G, Photophoresis for Solid Organ Rejection Autoimmune Disease and GVHD (Date of Termination 3/1/12)
- 11H, Bone Morphogenic Protein-2 (Date of Termination 3/1/12)
Targeted Case Management
Auditory Implant External Parts
Additional Medicaid Information:
