Proposed Clinical Coverage Policies
Division of Medical Assistance (DMA) Operations Section
Provider Customer Service
Provider Enrollment or Trading Partner Agreements
Medical or Dental Prior Approval
Pharmacy Prior Approval
North Carolina Health Choice for Children (NCHC) provides free or low-cost health insurance for children and teens ages 6-19. The benefits covered by NCHC are equivalent to the benefits covered by the Medicaid program with the following exceptions:
- No early and periodic screening, diagnosis and treatment (EPSDT)
- No long-term care
- No non-emergency medical transportation
- Restricted dental and orthodontic benefits
NC Health Choice Policies
Pursuant to NC Gen. Stat. § 108A-70.21(b): Except as otherwise provided for eligibility, fees, deductibles, copayments, and other cost sharing charges, health benefits coverage provided to children eligible under the Program shall be equivalent to coverage provided for dependents under the North Carolina Medicaid Program except for the following:
- No services for long-term care
- No nonemergency medical transportation
- No EPSDT
- Dental services shall be provided on a restricted basis in accordance with criteria adopted by the Department to implement this subsection
Because of the legislative directive to have Medicaid equivalent benefits, DMA has developed a joint clinical coverage policy template for Medicaid and NCHC. Please read each policy section carefully for program specific coverage, exceptions and limitations.
CPT codes, descriptors, and other data only are copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.
The Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), as amended by the Health Care and Education Recovery Act of 2010 (P.L. 111-152), together referred to as the Affordable Care Act (ACA) requires state Medicaid programs to be compliant with the National Correct Coding Initiative (NCCI) in claims processing by March 31, 2011. Each provider shall comply with NCCI methodologies and can access information about NCCI and its impact on claims processing.
The EPSDT Special Provision and the Important Notes on EPDST documented in DMA clinical coverage policies do not apply to NC Health Choice policies.
- Combined Medicaid and NC Health Choice Policies
- Chiropractic Services
- Intellectual and Developmental Disabilities Targeted Case Management
Service Reliability Requirements, Coverage Criteria and Limitations
Providers submit claims online for processing and payment through NCTracks.
For more information, call CSC:
If paper versions of claims are permitted under state policy, mail them to:
PO Box 30968
Raleigh, NC 27622-0968
Medicaid-enrolled providers in North Carolina can provide covered services appropriate to their specific licensure and specialization to NCHC beneficiaries.
Mental Health, Alcohol, and Drug Treatment
Children with Special Needs Help Line
Pharmacy Benefit Manager
DMA Claims Analysis