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  • NC Medicaid Medicaid and Health Choice North Carolina Innovations Clinical Coverage Policy No: 8-P Amended Date: December 15, 2019

    19C5 i

    To all beneficiaries enrolled in a Prepaid Health Plan (PHP): for questions about benefits and services available on or after implementation, please contact your PHP.

    Table of Contents

    1.0 Description of the Procedure, Product, or Service ........................................................................... 1 1.1 Definitions .......................................................................................................................... 1

    2.0 Eligibility Requirements .................................................................................................................. 2 2.1 Provisions............................................................................................................................ 2

    2.1.1 General ................................................................................................................... 2 2.1.2 Specific .................................................................................................................. 2

    2.2 Special Provisions ............................................................................................................... 2 2.2.1 EPSDT Special Provision: Exception to Policy Limitations for a Medicaid

    Beneficiary under 21 Years of Age ....................................................................... 2 2.2.2 EPSDT does not apply to NCHC beneficiaries ..................................................... 4 2.2.3 Health Choice Special Provision for a Health Choice Beneficiary age 6 through

    18 years of age ....................................................................................................... 4 2.3 Eligible Coverage Groups ................................................................................................... 4 2.4 Coordination of the Waiver and Regular Medicaid Services ............................................. 4

    3.0 When the Procedure, Product, or Service Is Covered ...................................................................... 4 3.1 General Criteria Covered .................................................................................................... 4 3.2 Specific Criteria Covered .................................................................................................... 5

    3.2.1 Specific criteria covered by both Medicaid and NCHC ........................................ 5 3.2.2 Medicaid Additional Criteria Covered ................................................................... 5 3.2.3 NCHC Additional Criteria Covered ...................................................................... 5

    4.0 When the Procedure, Product, or Service Is Not Covered ............................................................... 5 4.1 General Criteria Not Covered ............................................................................................. 5 4.2 Specific Criteria Not Covered ............................................................................................. 5

    4.2.1 Specific Criteria Not Covered by both Medicaid and NCHC ................................ 5 4.2.2 Medicaid Additional Criteria Not Covered ............................................................ 6 4.2.3 NCHC Additional Criteria Not Covered................................................................ 6

    5.0 Requirements for and Limitations on Coverage .............................................................................. 6 5.1 Prior Approval .................................................................................................................... 6 5.2 Prior Approval Requirements ............................................................................................. 6

    5.2.1 General ................................................................................................................... 6 5.2.2 Specific .................................................................................................................. 6

    5.3 Plan of Care (Individual Support Plan) ............................................................................... 6 5.3.1 Plan of Care Development ..................................................................................... 6 5.3.2 Assessments ......................................................................................................... 12 5.3.3 ISP Implementation - ........................................................................................... 12 5.3.4 ISP Implementation and Monitoring ................................................................... 13

    5.4 Plan of Care Approval Process ......................................................................................... 14 5.4.1 Oversight of the Plan of Care Approval Process ................................................. 14 5.4.2 ISP Approval and Service Authorization Process ............................................... 15 5.4.2 A. ISP Approval Requirements ........................................................................... 15

  • NC Medicaid Medicaid and Health Choice North Carolina Innovations Clinical Coverage Policy No: 8-P Amended Date: December 15, 2019

    19C5 ii

    5.4.3 Additional Service Specific Requirements: ......................................................... 16 Assistive Technology, Equipment, Supplies, Home Modifications and Vehicle

    Adaptations .......................................................................................................... 16 5.4.4 Timelines for ISP approval .................................................................................. 18 5.4.5 Individual Support Plan Approval Notifications ................................................. 18 5.4.6 ISP Disapproval Notifications ............................................................................. 18 5.4.7 Additional Limitations or Requirements ............................................................. 19

    6.0 Providers Eligible to Bill for the Procedure, Product, or Service .................................................. 19 6.1 Provider Qualifications and Occupational Licensing Entity Regulations ......................... 19 6.2 Provider Certifications ...................................................................................................... 20

    7.0 Additional Requirements ............................................................................................................... 20 7.1 Compliance ....................................................................................................................... 20 7.2 General Documentation Requirements ............................................................................. 20

    7.2.1 Service Note ......................................................................................................... 21 7.2.2 Service Grid ......................................................................................................... 21 7.2.3 Signatures ............................................................................................................ 21 7.2.4 Frequency of Service Documentation .................................................................. 21 7.2.5 Corrections in the Service Record ....................................................................... 22 7.2.6 Short-Range Goals, Task Analysis/Strategies ..................................................... 22

    7.3 Service Specific Documentation ....................................................................................... 22 7.3.1 Assistive Technology Equipment and Supplies ................................................... 22 7.3.2 Community Navigator ......................................................................................... 23 7.3.3 Community Networking ...................................................................................... 23 7.3.4 Community Transition Services .......................................................................... 23 7.3.5 Crisis Services...................................................................................................... 23 7.3.6 Home Modifications ............................................................................................ 23 7.3.7 Individual Directed Goods and Services.............................................................. 24 7.3.8 Natural Supports Education ................................................................................. 24 7.3.9 Respite Service .................................................................................................... 24 7.3.10 Specialized Consultation Services ....................................................................... 24 7.3.11 Vehicle Adaptation .............................................................................................. 25

    7.4 General Records Administration and Availability of Records ......................................... 25 7.5 How Long Records Must Be Kept .................................................................................... 25 7.6 Individual/Family Directed Services Documentation ....................................................... 26

    8.0 Policy Implementation/Revision Information ................................................................................ 27

    Attachment A: Claims-Related Information ............................................................................................... 29 A. Claim Type .........................................................................