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Clinical Coverage Policy Reference Tool

NC Medicaid and NC Health Choice Clinical Coverage Policies for Utilization Management. Where medical necessity criteria is not specific or defined in the NC DHHS Clinical Coverage Policies, or where NCDHHS does not have a policy, Alliance will use Clinical Coverage Policy approved by Alliance and MCG Health or InterQual criteria, as permitted by NCDHHS.

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Cell and Gene Therapy Access Policy and Billing Guidance

 

Alliance Health provides access to cell and gene therapy in line with NCDHHS requirements enabling coverage of certain U.S. Food and Drug Administration-approved treatments that meet medical necessity criteria. NC Medicaid’s access policy for cell and gene therapy comprises: Alliance Health aligns our billing requirements for cell and gene therapy with NC Medicaid billing guidance. For additional guidance, call Alliance's Provider Support Service Line at 855-759-9700

Introduction

At Alliance Health we are committed to working closely with providers to improve the health and well-being of the people we serve by ensuring highly effective, community-based support and care.

Alliance generally uses the NCDHHS Clinical Coverage Policies for utilization management. Where medical necessity criteria is not specific or defined in the NCDHHS clinical coverage policies, or where NCDHHS does not have a policy, Alliance will use clinical coverage policy approved by Alliance and MCG Health, as permitted by NCDHHS.

Unless otherwise carved out, Alliance cover benefits consistent with any approved State Plan Amendments (SPAs) to the North Carolina Medicaid or NC Health Choice State Plans and consistent with any approved Medicaid waivers, except to the extent the service is carved out of Medicaid Managed Care. This list will be updated periodically to reflect updates to the NC DHHS clinical coverage policies and other policies referenced. NCDHHS reserves the right to require Alliance follow additional NC Medicaid Direct clinical coverage policies. For additional questions, please direct inquiries to Alliance Provider Helpdesk at 1-919-651-8500.

NC Medicaid clinical coverage policies will be followed except for:

  1. The codes requiring prior authorization;
  2. Prior authorization submission process;
  3. Medicaid Direct compliance requirements; and
  4. Claim submission logistics (billing guidance in the NCTracks Provider Claims and Billing Assistance Guide)

Unless otherwise specified, clinical criteria present in each NC Medicaid will be used by Alliance for medical necessity determinations for requested services. Alliance may adopt additional clinical criteria, including but not limited to MCG Health used in determining medical necessity.

  • For Alliance provider compliance responsibilities: Refer to the controlling authority under Article I of the Medicaid Network Participating Provider Contract and/or Article I of the Network Participating Provider Contract for Publicly and State-Funded Services.
  • For Alliance Prior Authorization submission logistics: Provider Manual Section: Prior Authorization
  • For Alliance Prior Authorization requirements: Refer to the Alliance Service Code Lookup Tool to determine which procedure code requires prior authorization.
  • For Alliance claim submission logistics: Billing and Enrollment Manual

NCDHHS CCP References

All program-specific Clinical Coverage Policies can be found on the NCDHHS website.

Allergies

1N-1, Allergy Testing
1N-2, Allergy Immunotherapy

Ambulance

15, Ambulance Services

  • Alliance NEMT Policy
  • For Non-Emergency Medical Transportation (NEMT) and Non-Emergency Ambulance Transportation (NEAT) Prior Authorizations: Contact ModivCare at (phone number TBA)

Anesthesia

1L-1, Anesthesia Services
IL-2, Moderate (Conscious) Sedation, AKA Procedural Sedation and Analgesia (PSA)

Auditory Implants External Parts

13A, Cochlear and Auditory Brainstem Implant External Parts Replacement and Repair
13B, Soft Band and Implantable Bone Conduction Hearing Aid External Parts

Behavioral Health

At a minimum, all behavioral health services require a Person Centered Plan and Comprehensive Clinical Assessment for initial submission. Reauthorization requires updated clinical information.

8A, Enhanced Mental Health and Substance Abuse Services
8A-1, Assertive Community Treatment (ACT) Program
8A-2, Facility-Based Crisis Service for Children and Adolescents
8A-5, Diagnostic Assessment
8A-6, Community Support Team (CST)
8A-7, Ambulatory Withdrawal Management (WM) without Extended On-Site Monitoring
8A-8, Ambulatory Withdrawal Management with Extended On-Site Monitoring
8A-9, Treatment Program Service Opioid
8A-10, Clinically Managed Residential Withdrawal Management Services
8A-11, Medically Monitored Inpatient Withdrawal Management Service
8A-12, Substance Abuse Intensive Outpatient Program (SAIOP)
8A-13, Substance Abuse Comprehensive Outpatient Treatment (SACOT)
8B, Inpatient Behavioral Health Services
8C, Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers
8D-1, Psychiatric Residential Treatment Facilities for Children Under the Age of 21
8D-2, Residential Treatment Services
8D-3, Clinically Managed Low-Intensity Residential Treatment Services
8D-4, Clinically Managed Population Clinical Specific High-Intensity Residential Program
8D-5, Clinically Managed Residential Services
8D-6, Medically Monitored Intensive Inpatient Services
8E, Intermediate Care Facilities for Individuals with Intellectual Disabilities
8F, Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD)
8G, Peer Support Services
8H-1, 1915 (i) Supported Employment for I/DD and TBI
8H-2, 1915 (i) Individual Placement and Support (IPS) for Mental Health and Substance Use
8H-3, 1915(i) Individual and Transitional Support (ITS)
8H-4, 1915(i) Respite
8H-5, Community Living and Supports
8H-6, 1915(i) Community Transition
8I, Psychological Services in Health Departments and School-Based Health Centers Sponsored by Health Departments to the Under-21 Population
8J, Children’s Developmental Service Agencies (CDSAs)
8L, Mental Health/Substance Abuse Targeted Case Management
8-O, Services for Individuals with Intellectual and Developmental Disabilities and Mental Health or Substance Abuse Co-Occurring Disorders
8P, North Carolina Innovations

TBI Waiver – NC Medicaid MCBS Waiver
Alliance will follow NC DHHS approved waiver application for TBI waiver services.

1915i Waiver Services
North Carolina is currently in the process of developing a SPA to CMS to cover these services through 1915(i) authority. Alliance will follow NC DHHS approved SPA for the following (i) waiver services:
Supported Employment
Individual Transition and Support
Community Living and Supports
Community Transition

(The 1915(i) waiver SPA will be a required Clinical Coverage Policy by NC DHHS for members enrolled in Medicaid Direct.)

Burn Treatments and Skin Substitutes

1G-1, Burn Treatment
1G-2, Skin Substitutes

Cardiac Procedures

1R-1, Phase II Outpatient Cardiac Rehabilitation Program
1R-4, Electrocardiography, Echocardiography, and Intravascular Ultrasound

Chiropractic Services

1F, Chiropractic Services

Community Based Services

3A, Home Health Services
3B, PACE (Program of All-Inclusive Care for the Elderly)
3D, Hospice Services
3G-1, Private Duty Nursing for Beneficiaries Age 21 and Older
3G-2, Private Duty Nursing for Beneficiaries Under 21 Years of Age
3H-1, Home Infusion Therapy
3K-1, Community Alternatives Program for Children (CAP/C)
3K-2, Community Alternatives Program for Disabled Adults (CAP/DA)
3L, State Plan Personal Care Services (PCS)
3L-1 State Plan Personal Care Services (PCS) Provided in Congregate Settings

Dental

4A, Dental Services
4B, Orthodontic Services

Dietary Evaluation and Counseling

1-I, Dietary Evaluation and Counseling and Medical Lactation Services

Facility Services

2A-1, Acute Inpatient

  • MCG Health criteria will be used by Alliance for medical necessity determinations for requested services which fall under this Clinical Coverage Policy.

2A-2, Long Term Care Hospital Services

2A-3, Out-of-State Services

  • If clinical criteria are not present in the NC DHHS Clinical Coverage Policy, Alliance will use MCG Health criteria for medical necessity determinations according to the service requested.
  • All out-of-state providers require prior approval for service with the exception of children placed in Foster Care.

2B-1, Nursing Facilities

  • Providers should continue to follow the current process for PASSR via NCMUST as described in 2B-1.

2B-2, Geropsychiatric Units in Nursing Facilities

  • Providers should continue to follow the current process for PASSR via NCMUST as described in 2B-2 and notify Alliance UM of updates through the provider portal authorization system.

Hearing Aid Services

7, Hearing Aid Services

  • Exclusion includes Attachment B: Instructions for Submitting Attachments for Electronic Prior Approval Requests and Claims

Laboratory Services

1S-1, Genotyping and Phenotyping for HIV Drug Resistance Testing
1S-2, HIV Tropism Assay
1S-3, Laboratory Services
1S-8, Drug Testing for Opioid Treatment and Controlled Substance Monitoring
1S-9, Genetic Testing for Diagnosis and Treatment
1S-10, Genetic Testing for Carrier and Prenatal
1S-11, Genetic Testing-Gene Expression
1S-12 Genetic Testing-Next Generation Sequencing
1S-13, Cell and Gene Therapies

Maternal Support Services (Baby Love)

1M-2, Childbirth Education
1M-3, Health and Behavior Intervention
1M-4, Home Visit for Newborn Care and Assessment
1M-5, Home Visit for Postnatal Assessment and Follow-up Care
1M-6, Maternal Care Skilled Nurse Home Visit

Medical Equipment

5A-1, Physical Rehabilitation Equipment and Supplies
5A-2, Respiratory Equipment and Supplies
5A-3, Nursing Equipment and Supplies
5B, Orthotics and Prosthetics

Obstetrics and Gynecology

1E-1, Hysterectomy

  • Providers should continue to complete forms in Attachment B-C as outlined in 1E-1

1E-2, Therapeutic and Non-therapeutic Abortions

  • Providers should continue to complete and submit consents and Abortion Statements in Attachments B-C as outlined in 1E-2

1E-3, Sterilization Procedures

  • Providers should continue to complete and submit consents consistent with Attachments B-C in 1E-3

1E-4, Fetal Surveillance
1E-5, Obstetrics
1E-6, Pregnancy Management Program
1E-7, Family Planning Services

Ophthalmological Services

1T-1, General Ophthalmological Services
1T-2, Special Ophthalmological Services

Alliance follows the Avesis Clinical Criteria, Guidelines and Practice Standards for vision services.

Pharmacy Services

Alliance Health will not be providing outpatient pharmacy claims processing, outpatient pharmacy prior authorization, and pharmacy lock-in programs for NC Medicaid Tailored Plan beneficiaries until Tailored Plans launch in 2024.

9, Outpatient Pharmacy Program
9A, Over-The-Counter Products
9B, Hemophilia Specialty Pharmacy Program
9D, Off Label Antipsychotic Safety Monitoring in Beneficiaries Through Age 17
9E, Off Label Antipsychotic Safety Monitoring in Beneficiaries 18 and Older

Resources:
Pharmacy Prior Approval Drugs and Criteria
Clinical Coverage Criteria and Prior Approval Request Forms
Preferred Drug List (PDL)

Physician Administered Drug Program

1B, Physician’s Drug Program

Physician Clinical Coverage Policies

1A-2, Preventive Medicine Annual Health Assessment
1A-3, Noninvasive Pulse Oximetry
1A-4, Cochlear and Auditory Brainstem Implants
1A-5, Child Medical Evaluation and Medical Team Conference for Child Maltreatment
1A-6, Invasive Electrical Bone Growth Stimulation
1A-7, Neonatal and Pediatric Critical and Intensive Care Services
1A-8, Hyperbaric Oxygenation Therapy
1A-9, Blepharoplasty/Blepharoptosis (Eyelid Repair)

  • For clinical criteria not covered under CCP 1A-9, Alliance will utilize Avesis Clinical Coverage Policy Blepharoplasty and Ptosis Repair 500_SEC No. 500.02 for medical necessity determinations.

1A-11, Extracorporeal Shock Wave Lithotripsy
1A-12, Breast Surgeries

  • For requests not addressed by the clinical criteria in 1A-12, Alliance will utilize MCG Health criteria for medical necessity determinations.

1A-13, Ocular Photodynamic Therapy
1A-14, Surgery for Ambiguous Genitalia
1A-15, Surgery for Clinically Severe or Morbid Obesity
1A-16, Surgery of the Lingual Frenulum
1A-17, Stereotactic Pallidotomy
1A-19, Transcranial Doppler Studies
1A-20, Sleep Studies and Polysomnography Services
1A-21, Endovascular Repair of Aortic Aneurysm
1A-22, Medically Necessary Circumcision
1A-23, Physician Fluoride Varnish Services
1A-24, Diabetes Outpatient Self-Management Education
1A-25, Spinal Cord Stimulation
1A-26, Deep Brain Stimulation
1A-27, Electrodiagnostic Studies

1A-28, Visual Evoked Potential (VEP)

  • Alliance will use Clinical Coverage Policy 300_SEC No. 300.03 Visual Evoked Potential (VEP) Testing for medical necessity criteria.

300_No.300.04 Visual Field Testing
300_No.300.05 Tear Osmolarity Testing

1A-30 Spinal Surgeries
1A-31, Wireless Capsule Endoscopy
1A-32, Tympanometry and Acoustic Reflex Testing
1A-33, Vagus Nerve Stimulation for the Treatment of Seizures
1A-34, Dialysis Services
1A-36, Implantable Bone Conduction Hearing Aids (BAHA)
1A-38, Special Services: After Hours
1A-39, Routine Patient Costs Furnished in Connection with Participation in Qualifying Clinical Trials
1A-40, Fecal Microbiota Transplantation
1A-42, Balloon Ostial Dilation

Podiatry

1C-1, Podiatry Services
1C-2, Medically Necessary Routine Foot Care

Radiology

1K-1, Breast Imaging Procedures

1K-2, Bone Mass Measurement

1K-6, Radiation Oncology

Reconstructive Surgery

1-O-1, Reconstructive and Cosmetic Surgery
1-O-2, Craniofacial Surgery
1-O-3, Keloid Excision and Scar Revision
1-O-5, Rhinoplasty and/or Septorhinoplasty

Rural Health Clinics, FQHC and Health Departments, (RHC, FQHC, Health Departments)

1D-1, Refugee Health Assessments Provided in Health Departments
1D-2, Sexually Transmitted Disease Treatment Provided in Health Departments
1D-3, Tuberculosis Control and Treatment Provided in Health Departments
1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics

Solid Organ Transplants

11B-1, Lung Transplantation
11B-2, Heart Transplantation
11B-3, Islet Cell Transplantation
11B-4, Kidney (Renal) Transplantation
11B-5, Liver Transplantation
11B-6, Heart/Lung Transplantation
11B-7, Pancreas Transplant
11B-8, Small Bowel and Small Bowel/Liver and Multivisceral Transplants
11B-9, Thymus Tissue Implantation

Specialized Therapies

10A, Outpatient Specialized Therapies
10C, Local Education Agencies (LEAs)
10D, Independent Practitioners Respiratory Therapy Services

Stem Cell Transplants

11A-1, Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia (ALL)
11A-2, Hematopoietic Stem-Cell Transplant for Acute Myeloid Leukemia
11A-3, Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia
11A-5, Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemias
11A-6, Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors
11A-7, Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma
11A-8, Hematopoietic Stem-Cell Transplantation For Multiple Myeloma and Primary Amyloidosis
11A-9, Allogeneic Stem-Cell Transplantation for Myelodysplastic Syndromes & Myeloproliferative Neoplasms
11A-10, Hematopoietic Stem-Cell Transplantation (HSCT) for Central Nervous System (CNS) Embryonal Tumors & Ependymoma
11A-11, Hematopoietic Stem-Cell Transplant for Non-Hodgkin’s Lymphoma
11A-14, Placental and Umbilical Cord Blood as a Source of Stem Cells
11A-15, Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood
11A-16, Hematopoietic Stem-Cell Transplantation for Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)
11A-17, CAR-T Cell Therapy

Targeted Case Management

12B, Human Immunodeficiency Virus (HIV) Case Management

  • Alliance will coordinate with existing case management programs and providers and current case managers to ensure coordination and appropriate transition of care for involved members.

Telehealth

1H, Telehealth, Virtual Communications and Remote Patient Monitoring

Ventricular Assist Device

11C, Ventricular Assist Device

Vision Services

6A, Routine Eye Exam and Visual Aids for Recipients Under Age 21
6B, Routine Eye Examination and Visual Aids for Beneficiaries 21 Years of Age and Older

For both of the above:

  • For medically necessary contact lenses and fittings, Alliance will follow Avesis Policy 200 SEC_No. 200.02.
  • For Office Visits – Routine, Medical and Evaluation and Management Code, Alliance will follow Avesis Policy 100 SEC_100.01.
  • Providers continue to obtain prior authorization through NCTracks and receive eyeglasses from the State optical laboratory. Eyeglass dispensing fees must be submitted to Avesis for reimbursement.

Alliance Health CCP References

Alliance uses the NCDHHS Clinical Coverage Policies for utilization management. Where the medical necessity criteria are not specified or defined in the NCDHHS Clinical Coverage Policies, or where NCDHHS does not have a policy, Alliance will use MCG Health criteria as permitted by NCDHHS. If neither of these sources provides guidance, Alliance develops its own Medical Policies.

Alliance Medical Policies are evidence-based documents that detail the medical necessity criteria of given procedures or technologies. They are used to assist in administering health plan benefits and to establish consistency for coverage and efficiencies in the clinical decision-making process.

The following Medical Policies have been reviewed and adopted by Alliance’s Medical Policy Committee.

  • Introduction
  • NCDHHS CCP References
  • Alliance Health CCP References