Long Term Community Supports (LTRDS) – Medicaid Direct Only

NC DHHS has determined that for Medicaid Direct members only rather than using multiple modifiers to delineate the different levels of Long-Term Community Supports (LTCS) – now referred to as Long Term Residential and Day Supports – this information should be reported in claim segments by the providers in the Demonstration Project Identifier segment on the claim form.  This information is captured in the REF*P4 segment in Loop 2300 of an 837 professional claim.  The provider will continue to submit procedure code T2016 U5 but will designate the level of service through the REF*P4 segment but not a modifier combination.  The format of the REF*P4 segment will also contain an indication of the program. This change is available in the Provider Portal for those providers manually entering their claims.

Please note this change in billing is a necessary change due to CMS requirements.

The start date is 7/1/2026 date of service. As of this date of service, all LTCS claims for Medicaid Direct members submitted with modifiers U1-U6 and without the proper claim segment will be denied.

Current Authorizations will be transitioned by Alliance and any new authorizations with a start state of 7/1/2026 or after will need to be submitted using T2016 U5.

The submission of Medicaid Direct LTCS (LTRDS) claims without the proper segments indicated could result in a recoupment of any paid claims. Tailored Plan LTCS will continue to be billed with the second modifiers per level.

Alliance will hold a training on this change in claims submission. Please watch for this announcement in Provider News