Chapter 25 – medical assistance provided

SUbchapter 25A – general

section .0100 – reserved for future codification

10A NCAC 25A .0100 reserved for future codification

section .0200 – Medical Services

10A NCAC 25A .0201 MEDICAL SERVICES

Pursuant to the State Plan, all medical services performed shall be medically necessary and may not be experimental in nature. Medical necessity shall be determined by generally accepted North Carolina community practice standards as verified by independent Medicaid consultants.

History Note: Authority G.S. 108A‑25(b); 108A-54; 108A-54.1B; 42 C.F.R. 440.230(d);

Eff. March 1, 1990;

Transferred from 10A NCAC 22O .0301 Eff. May 1, 2012;

Readopted Eff. June 1, 2019.

subchapter 25B – reserved for future codification

subchapter 25C – behavioral health/substance abuse

section .0100 – Reserved for future codification

10a ncac 25c .0101 reserved for future codification

section .0200 – mental health center services

10A NCAC 25C .0201 MENTAL HEALTH CENTER SERVICES

History Note: Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.70;

Eff. February 1, 1976;

Amended Eff. September 30, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. January 1, 1984; December 1, 1981;

Transferred from 10A NCAC 22O .0107 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

section .0300 – inpatient psychiatric hospital services

10A NCAC 25C .0301 INPATIENT PSYCHIATRIC HOSPITAL SERVICES

History Note: Authority G.S. 108A‑25(b); 108A‑54;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. February 1, 1991;

Transferred from 10A NCAC 22O .0111 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

10A NCAC 25C .0302 NC MEDICAID CRITERIA FOR CONTINUED ACUTE STAY IN AN INPATIENT PSYCHIATRIC FACILITY

History Note: Authority G.S. 108A-25(b); 108A-54; 42 C.F.R. 441, Subpart D;

Eff. January 1, 1998;

Temporary Amendment Eff. August 20, 1999;

Amended Eff. March l9, 2001;

Transferred from 10A NCAC 22O .0113 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

subchapter 25D – intellectual and developmental disabilities

section .0100 – Reserved for future codification

10a ncac 25d .0100 reserved for future codification

section .0200 – intermediate care facilities

10A NCAC 25D .0201 INTERMEDIATE CARE FACILITIES

History Note: Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.50; 42 C.F.R. 440.150; 42 C.F.R. 440.230(d);

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Transferred from 10A NCAC 22O .0108 and 10A NCAC 22O .0408 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

subchapter 25E – reserved for future codification

subchapter 25F – case management

section .0100 – Reserved for future codification

10a ncac 25F .0100 reserved for future codification

section .0200 – general case management

10a NCAC 25F .0201 CASE MGMT SVCS/ADULTS/CHILDREN AT‑RISK/ABUSE/ NEGLECT/ EXPLOITATION

History Note: Authority G.S. 108A‑25(b); 108A‑54; Social Security Act, 1915(g);

Eff. October 1, 1992;

Recodified from 10 NCAC 26B .0122 Eff. October 1, 1993;

Temporary Amendment Eff. January 9, 1997;

Recodified from 10 NCAC 26B .0123 Eff. January 1, 1998;

Amended Eff. August 1, 1998;

Transferred from 10A NCAC 22O .0123 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

section .0300 – hiv case managment

10A NCAC 25F .0301 HIV CASE MANAGEMENT

History Note: Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.169; Social Security Act 1915(b);

Eff. April 1, 1994;

Amended Eff. July 1, 1995;

Recodified from 10 NCAC 26B .0124 Eff. January 1, 1998;

Transferred from 10A NCAC 22O .0124 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

subchapter 25G – reserved for future codification

subchapter 25H – Dental services

section .0100 – Reserved for future codification

10a ncac 25h .0100 reserved for future codification

SECTION .0200 ‑ general

10A NCAC 25H .0201 DEFINITIONS

(a) "Dental Services" means diagnostic, preventive or corrective procedures or dentures provided by or under the supervision of a dentist. These services include treatment of the teeth and associated structures of the oral cavity, and of disease, injury, or impairment which may affect the oral or general health of the individual.

(b) "Emergency dental care services" means those necessary to control bleeding, relieve pain, or eliminate acute infection, including emergency endodontic therapy; operative procedures which are required to prevent pulpal death and the imminent loss of teeth; or treatment of injuries to the teeth or supporting structures (e.g., bone or soft tissues contiguous to the teeth). Prosthetic repairs that, if delayed for prior approval, would adversely affect the health of the patient may be considered emergency procedures.

(c) "Routine services" means examinations, radiographs, preventive services, tooth extractions, minor oral surgical procedures, restorative services, prosthetic repairs and adjunctive services, such as general anesthesia, professional consultations and visits and the intramuscular injections of medicaments and drugs.

History Note: Authority G.S. 108A‑25(b); 108A‑54; S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.100;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1992; December 1, 1987; February 29, 1980;

Transferred from 10A NCAC 22O .0201 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

10a NCAC 25H .0202 ELIGIBILITY

History Note: Authority G.S. 108A‑25(b); 108A‑54; S.L. 1985, c. 479, s. 86;

42 C.F.R. 440.210; 42 C.F.R. 440.220;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. February 29, 1980;

Transferred from 10A NCAC 22O .0203 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

10a NCAC 25H .0203 STANDARDS FOR PARTICIPATION

(a) Dentists who provide services under the Medicaid program shall meet the following standards:

(1) be licensed by the appropriate state authority;

(2) comply with State and federal statutes, rules, and regulations of the Medicaid program; and

(3) agree that the State Medicaid Agency or its designated agents may audit Medicaid dental records.

(b) Dentists who provide services under the Medicaid program shall ensure all services:

(1) are offered in accordance with Title VI of the 1964 Civil Rights Act, which is incorporated by reference with subsequent amendments and editions and available free of charge at http://uscode.house.gov/;

(2) are offered in accordance with Section 504 of the Rehabilitation Act of 1973, which is incorporated by reference with subsequent amendments and editions and available free of charge at http://uscode.house.gov/; and

(3) are within accepted dental standards for quality in the community and medically necessary pursuant to 10A NCAC 25A .0201.

History Note: Authority G.S. 108A‑25(b); 108A-54; 108A-54.1B;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. February 29, 1980;

Transferred from 10A NCAC 22O .0202 Eff. May 1, 2012;

Readopted Eff. June 1, 2019.

10A NCAC 25H .0204 AMOUNT: DURATION: AND SCOPE OF SERVICES

(a) Necessary and essential dental services, subject to the criteria and restrictions in the North Carolina Dental Manual are covered for all eligible Medicaid recipients. Only the procedures listed in the North Carolina Dental Manual are generally covered under the North Carolina Dental Program.

(b) Exceptions may be made when recommended by the Dental Consultant and approved by the agency head when:

(1) An emergency condition causing pain or suffering needs immediate attention; or

(2) An alternative dental treatment plan is safe, medically acceptable and less expensive but is not on the procedure list; or

(3) The procedure is medically necessary and is of such complexity and the circumstances are so unusual that a coverage decision requires individual consideration based on the medical condition of the client, diagnosis, prognosis, and the unavailability of other alternative treatment options.

History Note: Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1990; February 29, 1980;

Transferred from 10A NCAC 22O .0204 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

10a NCAC 25H .0205 RESTRICTIONS AND PRIOR APPROVAL

(a) The Division of Medical Assistance shall have the right of prior approval for dental services except for routine and emergency services.

(b) All other dental services are subject to prior approval. Dental services categories requiring dental prior approval are as follows: Elective root canal treatment, periodontal services, orthodontic services, complex oral surgical and reconstructive procedures, complete and partial dentures, denture relines and analgesia (nitrous oxide). Each specific procedure under the American Dental Association (ADA) service category in this Paragraph will be listed in the provider dental manual and provider bulletins with the appropriate prior approval service restriction guidelines.

(c) The Division of Medical Assistance may require prior approval for any services for individual providers who have been investigated by the Division under 10A NCAC 22F or by the Attorney General's Fraud Control Unit under 42 Code of Federal Regulations 455.300, and the investigation resulted in monetary recovery of payments made by Medicaid to the provider or criminal conviction of the provider.

History Note: Authority G.S. 108A‑25(b); 108A‑54; S.L. 1985, c. 479, s. 86;

Eff. February 1, 1976;

Amended Eff. September 30, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1992; February 29, 1980;

Transferred from 10A NCAC 22O .0205 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

10a NCAC 25H .0206 PRIOR APPROVAL

History Note: Authority G.S. 108A‑25(b); 108A‑54; S.L. 1985, c. 479, s. 86;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Transferred from 10A NCAC 22O .0211 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

section .0300 – services provided

10A NCAC 25H .0301 GUIDELINES ON SERVICES

10a NCAC 25H .0302 SPECIFIC GUIDELINES

10A NCAC 25H .0303 ANESTHESIA

10A NCAC 25H .0304 ANALGESIA

10A NCAC 25H .0305 DRUGS

History Note: Authority G.S. 108A‑25(b); 108A‑54; S.L. 1985, c. 479, s. 86;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1992; December 1, 1987; January 1, 1982; February 29, 1980; October 31, 1977;

Transferred from 10A NCAC 22O .0206-.0210 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

subchapter 25I – reserved for future codification

subchapter 25J – reserved for future codification

subchapter 25K – drugs/pharmacy

section .0100 – Reserved for future codification

10a ncac 25k .0100 reserved for future codification

section .0200 – pharmacy services

10A NCAC 25K .0201 PHARMACY SERVICES

History Note: Authority G.S. 90-85.26; 108A-25(b); 108A-54; 42 C.F.R. 440.90; 42 CFR 447.331; S.L. 1985, c. 479, s. 86; 42 U.S.C. 1396r-8(d)(1)(A); S.L 2009-451;

Eff. September 30, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. January 1, 1984;

Recodified from 10 NCAC 26B .0116 Eff. October 1, 1993;

Recodified from 10 NCAC 26B .0117 Eff. January 1, 1998;

Amended Eff. May 1, 2010;

Transferred from 10A NCAC 22O .0118 Eff. May 1, 2012;

Repealed Eff. June 1, 2019.

SECTION .0300 ‑ DRUG USE REVIEW BOARD

10A NCAC 25K .0301 ESTABLISHMENT

The Division of Health Benefits will establish a Drug Use Review Board. The Drug Use Review Board shall not have rule making authority. The Division of Health Benefits shall have the authority to reject recommendations of the Drug Use Review Board. In the event of such rejections, Division of Health Benefits shall notify the Drug Use Review Board, in writing, of the reasons for its action and allow the DUR Board an opportunity to reconsider its recommendation or decision.

History Note: Authority G.S. 108A-68; Social Security Act Section 1927(g);

Eff. January 4, 1993;

Transferred from 10A NCAC 22M .0101 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016;

Amended Eff. March 1, 2020.

10A NCAC 25K .0302 MEMBERSHIPS

(a) The DUR Board shall consist of the Division of Health Benefits Drug Use Review Coordinator and the following appointed positions:

(1) five licensed and practicing physicians;

(2) five licensed and practicing pharmacists; and

(3) at least two additional individuals with knowledge and expertise in one or more of the following:

(A) prescribing of Medicaid covered outpatient drug;

(B) dispensing and monitoring of Medicaid covered outpatient drugs;

(D) medical quality assurance.

(b) The Division shall appoint members of the DUR Board for up to three one-year terms. Either party shall have the right to terminate the membership upon five days notice in writing to the other party. The DUR Coordinator is not an appointed member, is not subject to the term requirement and only serves on the Board while actively employed with DHB as the DUR Coordinator.

(c) The North Carolina Association of Pharmacists, the North Carolina Medical Society, and the Old North State Medical Society shall be asked by DHB's DUR Coordinator to make nominations for some of the positions on the Board. The Director may accept or reject nominations received.

History Note: Authority G.S. 108A-68; 42 U.S.C. 1396r-8(g)(3)(B);

Eff. January 4, 1993;

Amended Eff. April 1, 2010;

Transferred from 10A NCAC 22M .0102 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016;

Amended Eff. March 1, 2020.

10A NCAC 25K .0303 CHAIRMEN

One pharmacist and one physician shall serve as co‑chairmen of the Board. Beginning in calendar year 1996, each co‑chairman shall be elected by his peers, the term of the chairmen shall be one year, and membership on the Board of at least one previous year shall be required to establish eligibility for serving as the chairman.

History Note: Authority G.S. 108A‑68; Social Security Act Section 1927(g);

Eff. January 4, 1993;

Transferred from 10A NCAC 22M .0103 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

10A NCAC 25K .0304 ACTIVITIES

(a) The activities of the Drug Use Review Board shall include but are not limited to making recommendations for rules to the Division Directors for Medicaid recipients for the following:

(1) retrospective review of Medicaid claims information for drug therapy problems;

(2) application of standards for prospective and retrospective Drug Use Review;

(3) ongoing interventions for prescribers, pharmacists, and recipients targeted toward therapy problems identified in the course of Medicaid retrospective drug use reviews;

(4) preparation of an annual report to the Division of Health Benefits on the Drug Use Review process;

(5) programs to educate pharmacists and prescribers on common drug therapy problems identified in the Medicaid drug use reviews with the aim of improving prescribing or dispensing practices.

(b) The criteria and standards for the drug therapy review adopted by the Division upon recommendation by the Drug Use Review Board shall be available to pharmacists, prescribers, and the general public.

History Note: Authority G.S. 108A-68; Social Security Act Section 1927(g);

Eff. January 4, 1993;

Transferred from 10A NCAC 22M .0104 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016;

Amended Eff. March 1, 2020.

SECTION .0400 - PROSPECTIVE DRUG REVIEW

10A NCAC 25K .0401 PATIENT COUNSELING

(a) Rule 21 NCAC 46 .2504, as adopted by the North Carolina Board of Pharmacy, shall apply to Medicaid, and is hereby incorporated by reference including subsequent amendments and editions.

(b) If a pharmacy fails to comply with the requirements of 21 NCAC 46 .2504, any claim for reimbursement associated with the pharmacy's non-compliance shall be denied, or if already paid, shall be recouped.

History Note: Authority G.S. 108A-54; 108A-54.1B; 108A-68; 42 U.S.C. 1396r-8(g)(2)(A)(ii);

Eff. June 1, 1993;

Amended Eff. March 1, 2010;

Transferred from 10A NCAC 22M .0201 Eff. May 1, 2012;

Readopted Eff. June 1, 2019.

SECTION .0500 - RETROSPECTIVE DRUG USE REVIEW (DUR)

10A NCAC 25K .0501 RETROSPECTIVE DRUG USE REVIEW (DUR)

History Note: Authority G.S. 108A‑68; 42 U.S.C. 1396R-8(2)(b)-(C);

Eff. January 4, 1993;

Amended March 1, 2010;

Transferred from 10A NCAC 22M .0301 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

10a NCAC 25K .0502 SCREENING AND PATTERN ANALYSIS

At least quarterly, the Medicaid drug claims, in conjunction with other Medicaid claims as needed for clinical purposes, shall be subjected to screening against standards approved by the Drug Use Review Board. The objective of the screening is to identify patterns of behavior involving prescribers and pharmacists,

or patterns associated with specific drugs or groups of drugs. Health care patterns of individual Medicaid recipients shall be screened. In addition, individual incidences of screen failure associated with a specific recipient shall be identified for intervention alerts.

History Note: Authority G.S. 108A‑68; Social Security Act Section 1927(g);

Eff. January 4, 1993;

Transferred from 10A NCAC 22M .0302 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

10A NCAC 25K .0503 INTERVENTIONS

The primary objective of the retrospective Drug Use Review is to provide education to pharmacists and prescribers, both individually and collectively, in order to improve prescribing and dispensing practices. The intervention and educational programs shall be developed by the Drug Use Review Board and shall be updated as more information is available from the retrospective review process.

The Drug Use Review Board may establish referral processes to the Board of Pharmacy, the Board of Medical Examiners, the Board of Dental Examiners, other health care licensing agencies, or the Division of Health Benefits Program Integrity Section for individual pharmacists or prescriber who continue to demonstrate patterns of prescribing or dispensing which put the Medicaid recipient at risk from drug therapy problems even after repeated warnings through Drug Use Review interventions.

History Note: Authority G.S. 108A-68; Social Security Act Section 1927(g);

Eff. January 4, 1993;

Transferred from 10A NCAC 22M .0303 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016;

Amended Eff. March 1, 2020.

10A NCAC 25K .0504 COMPLIANCE MONITORING

The prescriber's and pharmacist's responses to the interventions undertaken as a result of the retrospective Drug Use Review shall be tracked. The Drug Use Review Board may establish selection criteria for intensified review and monitoring of individual pharmacists and prescribers.

History Note: Authority G.S. 108A‑68; Social Security Act Section 1927(g);

Eff. January 4, 1993;

Transferred from 10A NCAC 22M .0304 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

subchapter 25L – reserved for future codification

subchapter 25M – Facilities

section .0100 – Reserved for future codification

10a ncac 25m .0100 reserved for future codification

section .0200 – inpatient hospital services

10A NCAC 25M .0201 INPATIENT HOSPITAL SERVICES

History Note: Authority G.S. 108A‑25(b); 108A‑54; S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.10; 42 C.F.R. 440.230(d); 42 C.F.R.447.253; 42 C.F.R. 456.1;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1986; August 1, 1986; October 1, 1982;

Temporary Amendment Eff. October 15, 1999;

Temporary Amendment Expired July 28, 2000;

Temporary Amendment Eff. September 25, 2000;

Temporary Amendment Expired June 29, 2001;

Paragraphs (a)-(d) transferred from 10A NCAC 22O .0401 Eff. May 1, 2012.

Paragraph (e) transferred from 10A NCAC 22O .0114 Eff. May 1, 2012 (Previously recodified from 10 NCAC 26B .0112 Eff. October 1, 1993 and recodified from 10 NCAC 26B .0113 Eff. January 1, 1998);

Repealed Eff. June 1, 2019.

section .0300 – outpatient hospital services

10A NCAC 25M .0301 HOSPITAL OUTPATIENT

History Note: Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.20;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. January 1, 1984;

Temporary Amendment Eff. September 1, 2000;

Temporary Amendment Expired May 29, 2001;

Transferred from 10A NCAC 22O .0102 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

section .0400 – skilled nursing facility services

10a NCAC 25M .0401 SKILLED NURSING FACILITY

History Note: Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.20; C.F.R. 440.40; 42 C.F.R. 440.230(d)

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1977; September 1, 1981;

Paragraphs (a)-(c) transferred from 10A NCAC 22O .0116 Eff. May 1, 2012 (Previously recodified from 10 NCAC 26B .0114 Eff. October 1, 1993 and recodified from 10 NCAC 26B .0115 Eff. January 1, 1998);

Paragraph (d) transferred from 10A NCAC 22O .0403 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

section .0500 – other facilites

10A NCAC 25M .0501 THERAPEUTIC LEAVE

History Note: Authority G.S. 108A‑25(b); 108A‑62;

Eff. September 4, 1979;

Amended Eff. May 1, 2006; August 1, 1991; April 1, 1987;

Transferred from 10A NCAC 22O .0409 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

subchapter 25N – hearing and vision

section .0100 – Reserved for future codification

10a ncac 25n .0100 reserved for future codification

section .0200 – hearing services

10A NCAC 25N .0201 Hearing aid services

History Note: Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.110;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. November 2, 1992;

Transferred from 10A NCAC 22O .0109 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

section .0300 – vision services

10A NCAC 25N .0301 EYEGLASSES AND OPTOMETRIC SERVICES

History Note: Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.120;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. August 1, 1996; January 1, 1984;

Transferred from 10A NCAC 22O .0105 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

subchapter 25O – home and community-based services

section .0100 – Reserved for future codification

10a ncac 25o .0100 reserved for future codification

section .0200 – Home Health Services

10A NCAC 25O .0201 HOME HEALTH SERVICES

History Note: Authority G.S. 108‑25(b); 108A‑25(b); 108A‑54; 42 C.F.R. 440.70; 42 C.F.R. 440.230(d);

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. August 1, 1986; April 1, 1999; February 1, 1980;

Paragraph (a) transferred from 10A NCAC 22O .0103 Eff. May 1, 2012;

Paragraphs (b)-(e) transferred from 10A NCAC 22O .0406 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

10A NCAC 25O .0202 PERSONAL CARE SERVICES

History Note: Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; S.L. 2002-126; S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.170(f);

Eff. January 1, 1986;

Amended Eff. April 1, 1993; December 1, 1991;

Temporary Amendment Eff. December 27, 2002 (Paragraphs (c)-(e));

Temporary Amendment Expired October 12, 2003 (Paragraphs (c)-(e));

Paragraphs (a)-(b) transferred from 10A NCAC 22O .0120 Eff. May 1, 2012 (previously recodified from 10 NCAC 26B .0119 Eff. October 1, 1993 and recodified from 10 NCAC 26B .0120 Eff. January 1, 1998);

Paragraphs (c)-(e) transferred from 10A NCAC 22P .0410 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

10A NCAC 25O .0203 HOME INFUSION THERAPY

History Note: Authority G.S. 108A‑25(b); 42 C.F.R. 440.230; 42 C.F.R. 440.260;

Eff. March 1, 1993;

Recodified from 10 NCAC 26B .0123 Eff. October 1, 1993;

Recodified from 10 NCAC 26B .0124 Eff. April 1, 1994;

Recodified from 10 NCAC 26B .0125 Eff. January 1, 1998;

Transferred from 10A NCAC 22O .0125 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

10A NCAC 25O .0204 PRIVATE DUTY NURSING

History Note: Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.80;

Eff. May 1, 1990;

Amended Eff. April 1, 1993; June 1, 1992;

Recodified from 10 NCAC 26B .0121 Eff. October 1, 1993;

Recodified from 10 NCAC 26B .0122 Eff. January 1, 1998;

Transferred from 10A NCAC 22O .0122 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

subchapter 25P – medical-surgical

section .0100 – Reserved for future codification

10a ncac 25p .0100 reserved for future codification

section .0200 – inpatient hospital services

10A NCAC 25P .0201 INPATIENT HOSPITAL SERVICES

History Note: Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.230(d); 42 C.F.R.447.253; 42 C.F.R. 456.1;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1986; August 1, 1986; October 1, 1982;

Temporary Amendment Eff. October 15, 1999;

Temporary Amendment Expired July 28, 2000;

Temporary Amendment Eff. September 25, 2000;

Temporary Amendment Expired June 29, 2001;

Transferred from 10A NCAC 22O .0401(e) Eff. May 1, 2012;

Repealed Eff. June 1, 2019.

section .0300 – outpatient hospital services

10A NCAC 25P .0301 OUTPATIENT HOSPITAL SERVICES

History Note: Authority G.S. 108A‑25(b); 42 C.F.R. 440.20; 42 C.F.R. 440.230(d); 42 C.F.R. 456.1;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1986;

Transferred from 10A NCAC 22O .0402 Eff. May 1, 2012;

Repealed Eff. June 1, 2019.

section .0400 – other services

10A NCAC 25P .0401 PHYSICIAN SERVICES

History Note: Authority G.S. 108A‑25(b); 108A‑54; 108A‑55; 42 C.F.R. 440.50; 42 C.F.R. 440.230(d); 42 C.F.R. 456.1;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1986; January 1, 1986;

Transferred from 10A NCAC 22O .0404 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

10A NCAC 25P .0402 CLINIC SERVICES

History Note: Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.20;

Eff. February 1, 1976;

Amended Eff. September 30, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. January 1, 1984;

Recodified from 10 NCAC 26B .0113 Eff. October 1, 1993;

Recodified from 10 NCAC 26B .0114 Eff. January 1, 1998;

Transferred from 10A NCAC 22O .0115 Eff. May 1, 2012;

Repealed Eff. June 1, 2019.

10A NCAC 25P .0403 CHIROPRACTIC SERVICES

10A NCAC 25P .0404 PODIATRIST SERVICES

History Note: Authority G.S. 108A‑25(b); 108A‑54; S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.60; 42 C.F.R. 440.230(d)

Eff. February 1, 1976;

Amended Eff. September 30, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. January 1, 2009; May 1, 1990; January 1, 1984;

Transferred from 10A NCAC 22O .0106, .0405 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

10A NCAC 25P .0403 CHIROPRACTIC SERVICES

(a) No reimbursement from North Carolina Medicaid shall be made for x‑rays or other diagnostic or therapeutic services provided by a chiropractor except as provided in this Rule.

(b) Medicaid coverage of chiropractic services is limited to manual manipulation of the spine to correct a subluxation.

(c) Subluxation shall be confirmed by physical examination or by one set of x-rays taken within six months of the initial date of service.

(d) The treatment plan shall document:

(1) the symptoms or diagnosis treated;

(2) diagnostic procedures and treatment modalities used;

(3) results of diagnostic procedures and treatments; and

(4) anticipated length of treatments.

(e) Medical documentation shall support continued treatment.

(f) Chiropractic providers shall meet the educational requirements as outlined in 42 CFR 410.21(a).

History Note: Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.60;

Eff. February 1, 1976;

Amended Eff. September 30, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. January 1, 2009; May 1, 1990; January 1, 1984;

Transferred from 10A NCAC 22O .0106 Eff. May 1, 2012.

10A NCAC 25P .0404 PODIATRIST SERVICES

The trimming of nails and corns shall not be covered.

History Note: Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.230(d);

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Transferred from 10A NCAC 22O .0405 Eff. May 1, 2012.

10a NCAC 25P .0405 ABORTION

Lawful abortions shall be covered under Medicaid in accordance with federal law.

History Note: Authority G.S. 108A‑25(b); 108A‑54; 108A‑56; 42 C.F.R. 440.90; 42 C.F.R. 441, Subpart E;

Eff. March 16, 1976;

Amended Eff. August 24, 1977;

Readopted Eff. October 31, 1977;

Recodified from 10 NCAC 26B .0115 Eff. October 1, 1993;

Recodified from 10 NCAC 26B .0116 Eff. January 1, 1998;

Transferred from 10A NCAC 22O .0117 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

10A NCAC 25P .0406 LABORATORY AND X‑RAY SERVICES

History Note: Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.30; 40 C.F.R. 441.16; 42 C.F.R. Part 493;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. March 1, 1993; April 1, 1992;

Transferred from 10A NCAC 22O .0104(1)-(3) Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

Subchapter 25Q – reserved for future codification

Subchapter 25R – reserved for future codification

Subchapter 25S – out-of-STate services

section .0100 – reserved for future codification

10a ncac 25s .0100 reserved for future codification

section .0200 – out-of-state services

10A NCAC 25S .0201 OUT‑OF‑STATE SERVICES

History Note: Authority G.S. 108A‑25(b); 108A‑54; 108A‑55;

Eff. September 30, 1977;

Readopted Eff. October 31, 1977;

Recodified from 10 NCAC 26B .0117 Eff. October 1, 1993;

Recodified from 10 NCAC 26B .0118 Eff. January 1, 1998;

Transferred from 10A NCAC 22O .0119 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

Subchapter 25T – reserved for future codification

Subchapter 25U – radiology

section .0100 – reserved for future codification

10a ncac 25u .0100 reserved for future codification

section .0200 – x-ray services

10A NCAC 25U .0201 LABORATORY AND X‑RAY SERVICES

History Note: Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.30; 40 C.F.R. 441.16; 42 C.F.R. Part 493;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. March 1, 1993; April 1, 1992;

Transferred from 10A NCAC 22O .0105(4)-(5) Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

subchapter 25V – reserved for future codification

subchapter 25W – transportation

section .0100 – Reserved for future codification

10a ncac 25w .0100 reserved for future codification

section .0200 – ambulance services

10A NCAC 25W .0201 AMBULANCE SERVICES

History Note: Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.170;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1995; January 1, 1995; March 1, 1993;

Transferred from 10A NCAC 22O .0110 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.