DMA Clinical Policy and Programs
Phone Number 919-855-4260
Fax 919-733-2796
For changes and updates to coverage criteria, billing information, and other program requirements refer to the N.C. Medicaid general and special bulletins.
Inpatient hospital services are those items and services ordinarily furnished by the hospital for the care and treatment of inpatients. These must be provided under the direction of either a physician with privileges or a dentist in an institution maintained primarily for treatment and care of patients with disorders other than mental disease.
Medically necessary and nonexperimental inpatient hospital services are available to all eligible Medicaid recipients within hospital utilization review guidelines. Medical necessity is determined as generally accepted North Carolina community practice standards as verified by independent medical consultants.
Outpatient hospital services are preventive, diagnostic, therapeutic, rehabilitative or palliative services or items furnished under the direction of a physician or dentist to a Medicaid recipient by an institution that is licensed or formally approved as a hospital. Outpatient hospital services are available to all Medicaid recipients who are not inpatients.
All non-emergency clinical care and services provided by a hospital that is located beyond the 40-mile radius of North Carolina’s border to a N.C. Medicaid recipient requires prior approval, except:
An emergency medical condition is one in which the sudden onset of a medical condition, including emergency labor and delivery, manifests itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in:
