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 or InterQual criteria, 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:
- The codes requiring Prior Authorization;
- Prior Authorization submission process;
- Medicaid Direct compliance requirements; and
- 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.
Ambulance
- Alliance NEMT Policy
- For Non-Emergency Medical Transportation (NEMT) and Non-Emergency Ambulance Transportation (NEAT) Prior Authorizations: Contact ModivCare at (phone number TBA)
Anesthesia
Auditory Implants 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-9, Treatment Program Service Opioid
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
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
Cardiac Procedures
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)
Dietary Evaluation and Counseling
Facility Services
- 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
- 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.
- 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
- 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-4, Genetic Testing
- For requests where the State’s Clinical Coverage Policy is silent, Alliance will utilize WellCare’s Clinical Policy: CP.MP.89 Genetic and Pharmacogenetic Testing policy.
- If criteria is not referenced in either the State’s Clinical Coverage Policy, WellCare’s Clinical Coverage Policy then Alliance will utilize MCG Health’s criteria for determining Medical Necessity.
1S-5, Genetic Testing for Susceptibility to Breast and Ovarian Cancer (BRCA)
1S-7, Gene Expression Profiling for Breast Cancer
1S-8, Drug Testing for Opioid Treatment and Controlled Substance Monitoring
Maternal Support Services (Baby Love)
Medical Equipment
Obstetrics and Gynecology
- 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 will follow Avesis Clinical Criteria for the following:
300_SEC No. 300.01 Fundus Photography
300_SEC No. 300.02 Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
400_SEC No. 400.01 Nasolacrimal Duct Probing and Punctum Dilation
300_SEC No. 300.04 Visual Field Testing
300_SEC No. 300.06 Electroretinography Testing (ERG)
400_SEC No. 400.02 Punctal Occlusion by Plugs
400_SEC No. 400.03 Vision Therapy
500_SEC No. 500.01 Adult Strabismus Surgery
500_SEC No. 500.03 Cataract Extraction with Insertion of IOL
500_SEC No. 500.05 YAG (Yttrium-Aluminum Garnet) Laser Surgery
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
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
Radiology
1K-1, Breast Imaging Procedures
- For breast imagining procedures Alliance will utilize National Imagining Associates, Inc. criteria for medical necessity.
- For bone mass measurement Alliance will utilize National Imagining Associates, Inc. criteria for medical necessity.
Reconstructive Surgery
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
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.
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.
