North Carolina NC

NC Medicaid (DHB) expresses medical-necessity/PA criteria as Program-Specific Clinical Coverage Policies (CCPs): a clean per-service public PDF catalog on medicaid.ncdhhs.gov, organized by numbered service codes (1A surgeries, 8A/8D behavioral health, 9 pharmacy, 11A/11B transplants, 13A auditory implants, etc.). 171 CCPs total. Each catalog entry links directly to its PDF via /<slug>/download?attachment (application/pdf, no bot-wall). CCPs are the authoritative DHB-published criteria for NC Medicaid Direct (FFS); Standard Plans + Tailored Plans must cover at least the CCP scope but run their own provider portals for PA submission (NCTracks for FFS only; FFS pharmacy PAs migrate to Prime Therapeutics PBA 2026-05-02). Authority = NC DHB Clinical Policy Development & Operations. Harvested a representative 14 of 171 high-PA-density CCPs.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

Last award: 2019-02-04. Next due: TBD — re-procurement to begin per April 2025 NCDHHS policy paper 'Improving Member Health Through Managed Care Program Enhancements'. Contracts extended through: approximately 2027-11-30 (inferred from re-procurement start).

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## 1. How NC requires PA North Carolina's Medicaid program mandates prior authorization (PA) for numerous services and treatments. Requirements are detailed in the Program-Specific **Clinical Coverage Policies (CCPs)**, which serve as a comprehensive catalog of per-service criteria specifying when PA is necessary, what documentation is required, and whether step therapy applies. Examples from the sample include Transcranial Doppler Studies, Fetal Contraction Stress Testing, Electrodiagnostic Studies, Wireless Capsule Endoscopy, the Physician-Administered Drug Program, and a broad range of behavioral-health services (Opioid Treatment Program, ASAM-criteria withdrawal management, ACT, residential treatment). (Specific CPT/HCPCS codes appearing in the source summaries are unreliable — verify against the CCP itself.) ## 2. How NC publishes and reports PA North Carolina publishes its Clinical Coverage Policies on the official Medicaid website (medicaid.ncdhhs.gov) under "Programs and Services," organized by service code. CCPs are regularly updated and include effective dates. The state does not maintain a fully centralized PA portal; providers access CCPs directly or through their Managed Care Organizations / Prepaid Health Plans (PHPs) where applicable. A PA codes master concept exists but is not always real-time accurate, leading to occasional gaps between published policy and implementation. ## 3. NC's CMS-0057-F and PA-reform compliance posture - **WISeR: Not applicable.** NC is **not** one of the six WISeR (CMS "Wasteful and Inappropriate Service Reduction" Medicare PA model) states — those are AZ, NJ, OH, OK, TX, WA. Any prior reference to an "NC WISeR pilot" was a model fabrication. - **CMS-0057-F**: CMS-0057-F is a federal interoperability/PA **rule** that NC (like all states) must align with; NC has **not** "submitted a CMS-0057-F application/waiver" (no such instrument exists). The state's posture is best described as ongoing alignment, reflected in continuing CCP updates. - **1115 Demonstration**: NC operates a Medicaid Reform Section 1115 demonstration that includes **Tailored Plans** (integrated BH/IDD/TBI populations) and **Healthy Opportunities Pilots (HOPs)** (non-medical drivers of health). These shape PA processes for specific populations. - **Carve-outs**: BH/IDD/TBI services are managed via Tailored Plans; pharmacy has specific criteria; LTSS is mostly carved into managed care with residual FFS. ## 4. How NC runs its own program North Carolina operates through a combination of managed care (Standard Plans / Tailored Plans / PHPs) and Fee-for-Service for specific carve-outs. The managed-care model is predominant for most beneficiaries. ### Key Components: - **Managed Care**: Multi-year procurement with amendments/extensions (per source documents; specific dates in the synthesis are unverified). - **Fee-for-Service (FFS)**: Handles specific carve-outs and certain services. - **Children and Families Specialty Plan (CFSP)**: Manages foster-care services. - **Tailored Plans / HOPs**: Part of the 1115 demonstration. (A named fiscal-agent transition chain — ACS-Inc → Conduent/Gainwell — appears in the synthesis but is template-injected and unverified for NC.) The state publishes detailed CCPs outlining PA requirements per service, available on the Medicaid website and regularly updated. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Comprehensive CCPs**: A detailed, code-indexed catalog of per-service PA criteria is the defining feature of NC's program. - **1115 Demonstration**: Active Tailored Plans and Healthy Opportunities Pilots. - **Managed-Care Model**: Majority of services delivered through PHPs. ### What's Missing/Uncertain: - **Centralized Portal**: Only partial; providers rely on direct CCP access and MCO-specific guidance. - **CMS-0057-F status**: Alignment is ongoing; the synthesis's "application" framing was incorrect and has been removed. - **Procurement specifics**: Dates and criteria in the synthesis are unverified. - **Per-document codes**: CPT/HCPCS codes in source summaries are unreliable. Overall, North Carolina's program is anchored on a robust Clinical Coverage Policy catalog, with 1115-demonstration Tailored Plans and HOPs driving PA reform. NC is not a WISeR participant.