At Alliance Health (Alliance), 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 NC DHHS Clinical Coverage Policies for Utilization Management. Where medical necessity criteria is not specific or defined in the NC DHHS Clinical Coverage Policies, or where NC DHHS does not have a policy, Alliance will use Clinical Coverage Policy approved by Alliance and MCG Health or InterQual criteria, as permitted by NC DHHS.
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. NC DHHS 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 & Enrollment Manual
CCP References
Allergies
NC DHHS Clinical Coverage Policies: Allergies
1N-1, Allergy Testing
Alliance will follow NC DHHS Clinical Coverage Policy 1N-1
1N-2, Allergy Immunotherapy
Alliance will follow NC DHHS Clinical Coverage Policy 1N-2
Ambulance
NC DHHS Clinical Coverage Policies: Ambulance
15, Ambulance Services
Alliance will follow NC DHHS Clinical Coverage Policy 15
- Alliance NEMT Policy
- For Non-Emergency Medical Transportation (NEMT) and Non-Emergency Ambulance Transportation (NEAT) Prior Authorizations: Contact ModivCare at xxx-xxx-xxxx
Anesthesia
NC DHHS Clinical Coverage Policies: Anesthesia
1L-1, Anesthesia Services
Alliance will follow NC DHHS Clinical Coverage Policy L-1
Auditory Implants External Parts
NC DHHS Clinical Coverage Policies: Auditory Implants External Parts
13A, Cochlear and Auditory Brainstem Implant External Parts Replacement and Repair
Alliance will follow NC DHHS Clinical Coverage Policy 13A
- This is a required Clinical Coverage Policy by NC DHHS for members enrolled in Tailored Plans
13B, Soft Band and Implantable Bone Conduction Hearing Aid External Parts
Alliance will follow NC DHHS Clinical Coverage Policy 13B
Behavioral Health
NC DHHS Clinical Coverage Policies: Behavioral Health
8A, Enhanced Mental Health and Substance Abuse Services
Alliance will follow NC DHHS Clinical Coverage Policy 8A
8A-1, Assertive Community Treatment (ACT) Program
Alliance will follow NC DHHS Clinical Coverage Policy 8A-1
- This is a required Clinical Coverage Policy by NC DHHS for members enrolled in Medicaid Direct
8A-2, Facility-Based Crisis Service for Children and Adolescents
Alliance will follow NC DHHS Clinical Coverage Policy 8A-2
- This is a required Clinical Coverage Policy by NC DHHS for members enrolled in Medicaid Direct
8A-5, Diagnostic Assessment
Alliance will follow NC DHHS Clinical Coverage Policy 8A-5
8A-6, Community Support Team (CST)
Alliance will follow NC DHHS Clinical Coverage Policy 8A-6
- This is a required Clinical Coverage Policy by NC DHHS for members enrolled in Medicaid Direct
8B, Inpatient Behavioral Health Services
Alliance will follow NC DHHS Clinical Coverage Policy 8B
- This is a required Clinical Coverage Policy by NC DHHS for members enrolled in Medicaid Direct
8C, Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers
Alliance will follow NC DHHS Clinical Coverage Policy 8C
- This is a required Clinical Coverage Policy by NC DHHS for members enrolled in Tailored Plan and Medicaid Direct
8D-1, Psychiatric Residential Treatment Facilities for Children under the Age of21
Alliance will follow NC DHHS Clinical Coverage Policy 8D-1
- This is a required Clinical Coverage Policy by NC DHHS for members enrolled in Medicaid Direct
8D-2, Residential Treatment Services
Alliance will follow NC DHHS Clinical Coverage Policy 8D-2
- This is a required Clinical Coverage Policy by NC DHHS for members enrolled in Medicaid Direct
8E, Intermediate Care Facilities for Individuals with Intellectual Disabilities
Alliance will follow NC DHHS Clinical Coverage Policy 8E
- This is a required Clinical Coverage Policy by NC DHHS for members enrolled in Medicaid Direct
8F, Research-Based Behavioral Health Treatment (RB-BHT) For Autism Spectrum Disorder (ASD)
Alliance will follow NC DHHS Clinical Coverage Policy 8F
- This is a required Clinical Coverage Policy by NC DHHS for members enrolled in Medicaid Direct
8G, Peer Support Services
Alliance will follow NC DHHS Clinical Coverage Policy 8G
- This is a required Clinical Coverage Policy by NC DHHS for members enrolled in Medicaid Direct
8I, Psychological Services in Health Departments and School-Based Health Centers Sponsored by Health Departments to the under-21 Population
Alliance will follow NC DHHS Clinical Coverage Policy 8I
- This is a required Clinical Coverage Policy by NC DHHS for members enrolled in Medicaid Direct
8P, North Carolina Innovations
Alliance will follow NC DHHS Clinical Coverage Policy 8P
- This is a required Clinical Coverage Policy by NC DHHS
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
NC DHHS Clinical Coverage Policies: Burn Treatments and Skin Substitutes
1G-1, Burn Treatment
Alliance will follow NC DHHS Clinical Coverage Policy 1G-1
1G-2, Skin Substitutes
Alliance will follow NC DHHS Clinical Coverage Policy 1G-2
Cardiac Procedures
NC DHHS Clinical Coverage Policies: Cardiac Procedures
1R-1, Phase II Outpatient Cardiac Rehabilitation Program
Alliance will follow NC DHHS Clinical Coverage Policy 1R-1
1R-4, Electrocardiography, Echocardiography, and Intravascular Ultrasound
Alliance will follow NC DHHS Clinical Coverage Policy 1R-1
Chiropractic Services
NC DHHS Clinical Coverage Policies: Chiropractic Services
1F, Chiropractic Services
Alliance will follow NC DHHS Clinical Coverage Policy 1F
Community Based Services
NC DHHS Clinical Coverage Policies: Community Based Services
3A, Home Health Services
Alliance will follow NC DHHS Clinical Coverage Policy 3A
3D, Hospice Services
Alliance will follow NC DHHS Clinical Coverage Policy 3D
3G-1, Private Duty Nursing for Beneficiaries Age 21 and Older
Alliance will follow NC DHHS Clinical Coverage Policy 3G-1
3G-2, Private Duty Nursing for Beneficiaries Under 21 years of Age
Alliance will follow NC DHHS Clinical Coverage Policy 3G-2
3H-1, Home Infusion Therapy
Alliance will follow NC DHHS Clinical Coverage Policy 3H-1
3L, State Plan Personal Care Services (PCS)
Alliance will follow NC DHHS Clinical Coverage Policy 3L
Dietary Evaluation and Counseling
NC DHHS Clinical Coverage Policies: Dietary Evaluation and Counseling
1-I, Dietary Evaluation and Counseling and Medical Lactation Services
Alliance will follow NC DHHS Clinical Coverage Policy 1-l
Facility Services
NC DHHS Clinical Coverage Policies: Facility Services
2A-1, Acute Inpatient
Alliance will follow NC DHHS Clinical Coverage Policy 2A-1
- 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
Alliance will follow NC DHHS Clinical Coverage Policy 2A-2
2A-3, Out-of-Sate Services
Alliance will follow NC DHHS Clinical Coverage Policy 2A-3
- If Clinical Criteria is 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 Facility Services
Alliance will follow NC DHHS Clinical Coverage Policy 2B-1
- Providers should continue to follow the current process for PASSR via NCMUST as described in 2B-1
2B-2, Geropsychiatric Units in Nursing Facilities
Alliance will follow NC DHHS Clinical Coverage Policy 2B-2
- 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
NC DHHS Clinical Coverage Policies: Hearing Aid Services
7, Hearing Aid Services
Alliance will follow NC DHHS Clinical Coverage Policy 7
- Exclusion includes Attachment B: Instructions for Submitting Attachments for Electronic Prior Approval Requests and Claims
Laboratory Services
NC DHHS Clinical Coverage Policies: Laboratory Services
1S-1, Genotyping and Phenotyping for HIV Drug Resistance Testing
Alliance will follow NC DHHS Clinical Coverage Policy 1S-1
1S-2, HIV Tropism Assay
Alliance will follow NC DHHS Clinical Coverage Policy 1S-2
1S-3, Laboratory Services
Alliance will follow NC DHHS Clinical Coverage Policy 1S-3
1S-4, Genetic Testing
Alliance will follow NC DHHS Clinical Coverage Policy 1S-4
- 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)
Alliance will follow NC DHHS Clinical Coverage Policy 1S-5
1S-7, Gene Expression Profiling for Breast Cancer
Alliance will follow NC DHHS Clinical Coverage Policy 1S-7
1S-8, Drug Testing for Opioid Treatment and Controlled Substance Monitoring
Alliance will follow NC DHHS Clinical Coverage Policy 1S-8
WNC.CP.84, Cell free Fetal DNA Testing
Alliance will follow WellCare’s Clinical Coverage Policy WNC.CP.84 Cell Free Fetal DNA Testing
Maternal Support Services (Baby Love)
NC DHHS Clinical Coverage Policies: Maternal Support Services (Baby Love)
1M-2, Childbirth Education
Alliance will follow NC DHHS Clinical Coverage Policy 1M-2
1M-3, Health and Behavior Intervention
Alliance will follow NC DHHS Clinical Coverage Policy 1M-3
1M-4, Home Visit for Newborn Care and Assessment
Alliance will follow NC DHHS Clinical Coverage Policy 1M-4
1M-5, Home Visit for Postnatal Assessment and Follow-up Care
Alliance will follow NC DHHS Clinical Coverage Policy 1M-5
1M-6, Maternal Care Skilled Nurse Home Visit
Alliance will follow NC DHHS Clinical Coverage Policy 1M-6
Medical Equipment
NC DHHS Durable Medical Equipment
5A-1, Physical Rehabilitation Equipment and Supplies
Alliance will follow NC DHHS Clinical Coverage Policy 5A-1
5A-2, Respiratory Equipment and Supplies
Alliance will follow NC DHHS Clinical Coverage Policy 5A-2
5A-3, Nursing Equipment and Supplies
Alliance will follow NC DHHS Clinical Coverage Policy 5A-3
5B, Orthotics & Prosthetics
Alliance will follow NC DHHS Clinical Coverage Policy 5A-5
Obstetrics & Gynecology
NC DHHS Clinical Coverage Policies: Obstetrics & Gynecology
1E-1, Hysterectomy
Alliance will follow NC DHHS Clinical Coverage Policy 1E-1
- Providers should continue to complete forms in Attachment B-C as outlined in 1E-1
1E-2, Therapeutic and Non-therapeutic Abortions
Alliance will follow NC DHHS Clinical Coverage Policy 1E-1
- Providers should continue to complete and submit consents and Abortion Statements in Attachments B-C as outlined in 1E-2
1E-3, Sterilization Procedures
Alliance will follow NC DHHS Clinical Coverage Policy 1E-3
- Providers should continue to complete and submit consents consistent with Attachments B-C in 1E-3
1E-4, Fetal Surveillance
Alliance will follow NC DHHS Clinical Coverage Policy 1E-4
1E-5, Obstetrical Services
Alliance will follow NC DHHS Clinical Coverage Policy 1E-5
1E-6, Pregnancy Management Program
Alliance will follow NC DHHS Clinical Coverage Policy 1E-6
1E-7, Family Planning Services
Alliance will follow NC DHHS Clinical Coverage Policy 1E-3
- This is a required Clinical Coverage Policy by NC DHHS for Tailored Plan
Ophthalmological Services
NC DHHS Clinical Coverage Policies: Ophthalmological Services
1T-1 General Ophthalmological Services
Alliance will follow NC DHHS Clinical Coverage Policy 1T-1
1T-2, Special Ophthalmological Services
Alliance will follow NC DHHS Clinical Coverage Policy 1T-2
Additional Clinical Criteria
300_SEC No. 300.01 FUNDUS PHOTOGRAPHY
Alliance will follow Avesis Clinical Criteria for FUNDUS PHOTOGRAPHY
300_SEC No. 300.02 Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
Alliance will follow Avesis Clinical Criteria for Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
400_SEC No. 400.01 Nasolacrimal Duct Probing and Punctum Dilation
Alliance will follow Avesis Clinical Criteria for Nasolacrimal Duct Probing and Punctum Dilation
300_SEC No. 300.04 VISUAL FIELD TESTING
Alliance will follow Avesis Clinical Criteria for VISUAL FIELD TESTING
300_SEC No. 300.06 Electroretinography Testing (ERG)
Alliance will follow Avesis Clinical Criteria for Electroretinography Testing
400_SEC No. 400.02 Punctal Occlusion by Plugs
Alliance will follow Avesis Clinical Criteria for Punctal Occlusion by Plugs
400_SEC No. 400.03 Vision Therapy
Alliance will follow Avesis Clinical Criteria for Vision Therapy
500_SEC No. 500.01 Adult Strabismus Surgery
Alliance will follow Avesis Clinical Criteria for Strabismus Surgery
500_SEC No. 500.03 Cataract Extraction with Insertion of IOL
Alliance will follow Avesis Clinical Criteria for Cataract Extraction with Insertion of IOL
500_SEC No. 500.05 YAG (Yittrium-Aluminum Garnet) Laser Surgery
Alliance will follow Avesis Clinical Criteria for YAG (Yittrium-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 April 1, 2023.
NC DHHS Clinical Coverage Policies: Pharmacy Services
Alliance will follow NC DHHS Pharmacy Services Clinical Coverage Policies
- 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
- 1B, Physician’s Drug Program
These are required Clinical Coverage Policy by NC DHHS
Physician Clinical Coverage Policies
NC DHHS Clinical Coverage Policies: Physician Clinical Coverage Policies
1A-2, Preventive Medicine Annual Health Assessment
Alliance will follow NC DHHS Clinical Coverage Policy 1A-2
1A-3, Noninvasive Pulse Oximetry
Alliance will follow NC DHHS Clinical Coverage Policy 1A-3
1A-4, Cochlear and Auditory Brainstem Implants
Alliance will follow NC DHHS Clinical Coverage Policy 1A-4
- This is a required Clinical Coverage Policy by NC DHHS
1A-5, Child Medical Evaluation and Medical Team Conference for Child Maltreatment
Alliance will follow NC DHHS Clinical Coverage Policy 1A-5
- This is a required Clinical Coverage Policy by NC DHHS
1A-6, Invasive Electrical Bone Growth Stimulation
Alliance will follow NC DHHS Clinical Coverage Policy 1A-6
1A-7, Neonatal and Pediatric Critical and Intensive Care Services
Alliance will follow NC DHHS Clinical Coverage Policy 1A-7
1A-8, Hyperbaric Oxygenation Therapy
Alliance will follow NC DHHS Clinical Coverage Policy 1A-8
1A-9, Blepharoplasty/Blepharoptosis (Eyelid Repair)
Alliance will follow NC DHHS Clinical Coverage Policy 1A-9
- 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
Alliance will follow NC DHHS Clinical Coverage Policy 1A-9
1A-12, Breast Surgeries
Alliance will follow NC DHHS Clinical Coverage Policy 1A-9
- 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
Alliance will follow NC DHHS Clinical Coverage Policy 1A-13
1A-14, Surgery for Ambiguous Genitalia
Alliance will follow NC DHHS Clinical Coverage Policy 1A-14
1A-15, Surgery for Clinically Severe or Morbid Obesity
Alliance will follow NC DHHS Clinical Coverage Policy 1A-15
1A-16, Surgery of the Lingual Frenulum
Alliance will follow NC DHHS Clinical Coverage Policy 1A-16
1A-17, Stereotactic Pallidotomy
Alliance will follow NC DHHS Clinical Coverage Policy 1A-17
1A-19, Transcranial Doppler Studies
Alliance will follow NC DHHS Clinical Coverage Policy 1A-19
1A-20, Sleep Studies and Polysomnography Services
Alliance will follow NC DHHS Clinical Coverage Policy 1A-20
1A-21, Endovascular Repair of Aortic Aneurysm
Alliance will follow NC DHHS Clinical Coverage Policy 1A-21
1A-22, Medically Necessary Circumcision
Alliance will follow NC DHHS Clinical Coverage Policy 1A-22
1A-23, Physician Fluoride Varnish Services
Alliance will follow NC DHHS Clinical Coverage Policy 1A-23
- This is a required Clinical Coverage Policy by NC DHHS
1A-24, Diabetes Outpatient Self-Management Education
Alliance will follow NC DHHS Clinical Coverage Policy 1A-24
1A-25, Spinal Cord Stimulation
Alliance will follow NC DHHS Clinical Coverage Policy 1A-25
1A-26, Deep Brain Stimulation
Alliance will follow NC DHHS Clinical Coverage Policy 1A-26
1A-27, Electrodiagnostic Studies
Alliance will follow NC DHHS Clinical Coverage Policy 1A-27
1A-28, Visual Evoked Potential (VEP)
Alliance will follow NC DHHS Clinical Coverage Policy 1A-28
- 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
Alliance will use Clinical Coverage Policy 300_SEC No. 300.04 Visual Field Testing
300_No.300.05 Tear Osmolarity Testing
Alliance will use Clinical Coverage Policy 300_SEC No. 300.05 Tear Osmolarity Testing
1A-30 Spinal Surgeries
Alliance will follow NC DHHS Clinical Coverage Policy 1A-30
1A-31, Wireless Capsule Endoscopy
Alliance will follow NC DHHS Clinical Coverage Policy 1A-31
1A-32, Tympanometry and Acoustic Reflex Testing
Alliance will follow NC DHHS Clinical Coverage Policy 1A-32
1A-33, Vagus Nerve Stimulation for the Treatment of Seizures
Alliance will follow NC DHHS Clinical Coverage Policy 1A-33
1A-34, Dialysis Services
Alliance will follow NC DHHS Clinical Coverage Policy 1A-34
1A-36, Implantable Bone Conduction Hearing Aids (BAHA)
Alliance will follow NC DHHS Clinical Coverage Policy 1A-36
- This is a required Clinical Coverage Policy by NC DHHS
1A-38, Special Services: After Hours
Alliance will follow NC DHHS Clinical Coverage Policy 1A-14
1A-39, Routine Costs in Clinical Trial Services for Life Threatening Conditions
Alliance will follow NC DHHS Clinical Coverage Policy 1A-14
- This is a required Clinical Coverage Policy by NC DHHS
1A-40, Fecal Microbiota Transplantation
Alliance will follow NC DHHS Clinical Coverage Policy 1A-14
1A-41- Office Based Opioid Treatment: Use of Buprenorphine and Buprenorphine-Naloxone
Alliance will follow NC DHHS Clinical Coverage Policy 1A-14
1A-42, Balloon Ostial Dilation
Alliance will follow NC DHHS Clinical Coverage Policy 1A-14
Podiatry
NC DHHS Clinical Coverage Policies: Podiatry
1C-1, Podiatry Services
Alliance will follow NC DHHS Clinical Coverage Policy 1C-1
1C-2, Medically Necessary Routine Foot Care
Alliance will follow NC DHHS Clinical Coverage Policy 1C-2
Radiology
NC DHHS Clinical Coverage Policies: Radiology
1K-1, Breast Imaging Procedures
Alliance will follow NC DHHS Clinical Coverage Policy 1K-1
- For Brest Imagining Procedures, Alliance will utilize National Imagining Associates, Inc criteria for Medical Necessity: https://www1.radmd.com/media/988026/2022-magellan-advanced-imaging-guidelines-v2.pdf
1K-2, Bone Mass Measurement
Alliance will follow NC DHHS Clinical Coverage Policy 1K-2
- For Bone Mass Measurement, Alliance will utilize National Imagining Associates, Inc criteria for Medical Necessity NIA: https://www1.radmd.com/media/988026/2022-magellan-advanced-imaging-guidelines-v2.pdf
1K-6, Radiation Oncology
Alliance will follow NC DHHS Clinical Coverage Policy 1K-6
1K-7, Prior Approval for Imaging Services
Alliance will follow NC DHHS Clinical Coverage Policy 1K-7
- Additional exceptions to Clinical Coverage Policy 1K-7 includes eviCore-related process and policies.
- National Imagining Associates, Inc: https://www1.radmd.com/media/988026/2022-magellan-advanced-imaging-guidelines-v2.pdf
Reconstructive Surgery
NC DHHS Clinical Coverage Policies: Reconstructive Surgery
1O-1, Reconstructive and Cosmetic Surgery
Alliance will follow NC DHHS Clinical Coverage Policy 1O-1
1O-2, Craniofacial Surgery
Alliance will follow NC DHHS Clinical Coverage Policy 1O-2
1O-3, Keloid Excision and Scar Revision
Alliance will follow NC DHHS Clinical Coverage Policy 10-3
1O-5, Rhinoplasty and/or Septorhinoplasty
Alliance will follow NC DHHS Clinical Coverage Policy 1O-5
Rural Health Clinics, FQHC and Health Departments, (RHC, FQHC, Health Depts)
1D-1, Refugee Health Assessments Provided in Health Departments
Alliance will follow NC DHHS Clinical Coverage Policy 1D-1
1D-2, Sexually Transmitted Disease Treatment Provided in Health Departments
Alliance will follow NC DHHS Clinical Coverage Policy 1D-2
1D-3, Tuberculosis Control and Treatment Provided in Health Departments
Alliance will follow NC DHHS Clinical Coverage Policy 1D-3
1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics
Alliance will follow NC DHHS Clinical Coverage Policy 1D-4
Solid Organ Transplants
NC DHHS Clinical Coverage Policies: Solid Organ Transplants
11B-1, Lung Transplantation
Alliance will follow NC DHHS Clinical Coverage Policy 11B-1
11B-2, Heart Transplantation
Alliance will follow NC DHHS Clinical Coverage Policy 11B-2
11B-3, Islet Cell Transplantation
Alliance will follow NC DHHS Clinical Coverage Policy 11B-3
11B-4, Kidney (Renal) Transplantation
Alliance will follow NC DHHS Clinical Coverage Policy 11B-4 h
11B-5, Liver Transplantation
Alliance will follow NC DHHS Clinical Coverage Policy 11B-5
11B-6, Heart/Lung Transplantation
Alliance will follow NC DHHS Clinical Coverage Policy 11B-6
11B-7, Pancreas Transplant
Alliance will follow NC DHHS Clinical Coverage Policy 11B-7
11B-8, Small Bowel and Small Bowel/Liver and Multivesicular Transplants
Alliance will follow NC DHHS Clinical Coverage Policy 11B-8
Specialized Therapies
NC DHHS Clinical Coverage Policies: Specialized Therapies
10A, Outpatient Specialized Therapies
Alliance will follow NC DHHS Clinical Coverage Policy 10A
10B, Independent Practitioners (IP)
Alliance will follow NC DHHS Clinical Coverage Policy 10B
10D, Independent Practitioners Respiratory Therapy Services
Alliance will follow NC DHHS Clinical Coverage Policy 10D
Stem Cell Transplants
NC DHHS Clinical Coverage Policies: Stem Cell Transplants
11A-1, Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia (ALL)
Alliance will follow NC DHHS Clinical Coverage Policy 11A-1
11A-2, Hematopoietic Stem-Cell Transplant for Acute Myeloid Leukemia
Alliance will follow NC DHHS Clinical Coverage Policy 11A-2
11A-3, Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia
Alliance will follow NC DHHS Clinical Coverage Policy 11A-3
11A-5, Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemias
Alliance will follow NC DHHS Clinical Coverage Policy 11A-5
11A-6, Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors
Alliance will follow NC DHHS Clinical Coverage Policy 11A-6
11A-7, Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma
Alliance will follow NC DHHS Clinical Coverage Policy 11A-7
11A-8, Hematopoietic Stem-Cell Transplantation For Multiple Myeloma and Primary Amyloidosis
Alliance will follow NC DHHS Clinical Coverage Policy 11A-8
11A-9, Allogeneic Stem-Cell Transplantation for Myelodysplastic Syndromes & Myeloproliferative Neoplasms
Alliance will follow NC DHHS Clinical Coverage Policy 11A-9
11A-10, Hematopoietic Stem-Cell Transplantation (HSCT) for Central Nervous System (CNS) Embryonal Tumors & Ependymoma
Alliance will follow NC DHHS Clinical Coverage Policy 11A-10
11A-11, Hematopoietic Stem-Cell Transplant for Non-Hodgkin’s Lymphoma
Alliance will follow NC DHHS Clinical Coverage Policy 11A-11
11A-14, Placental and Umbilical Cord Blood as a Source of Stem Cells
Alliance will follow NC DHHS Clinical Coverage Policy 11A-14
11A-15, Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood
Alliance will follow NC DHHS Clinical Coverage Policy 11A-15
11A-16, Hematopoietic Stem-Cell Transplantation for Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)
Alliance will follow NC DHHS Clinical Coverage Policy 11A-16
11A-17, CAR-T Cell Therapy
Alliance will follow NC DHHS Clinical Coverage Policy 11A-17
Targeted Case Management
NC DHHS Clinical Coverage Policies: 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
NC DHHS Clinical Coverage Policies: Telehealth
1H, Telehealth, Virtual Communications and Remote Patient Monitoring
Alliance will follow NC DHHS Clinical Coverage Policy 1H
- This is a required Clinical Coverage Policy by NC DHHS for members enrolled in Medicaid Direct
Ventricular Assist Device
NC DHHS Clinical Coverage Policies: Ventricular Assist Device
11C, Ventricular Assist Device
Alliance will follow NC DHHS Clinical Coverage Policy 11C
Vision Services
6A, Routine Eye Exam and Visual Aids for Recipients Under Age 21
Alliance will follow NC DHHS Clinical Coverage Policy 6A
- For Medically necessary contact lenses & fittings, Alliance will follow Avesis Policy 200 SEC_No. 200.02
- For Office Visits – Routine, Medical and Evaluation & 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.
6B, Routine Eye Examination and Visual Aids for Beneficiaries 21 Years of Age and Older
Alliance will follow NC DHHS Clinical Coverage Policy 6B
- For Medically necessary contact lenses & fittings, Alliance will follow Avesis Policy 200 SEC_No. 200.02
- For Office Visits – Routine, Medical and Evaluation & 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.
