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NC Medicaid Direct Clinical Coverage Policies

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Partners is committed to the care of the members and recipients we serve. Clinical coverage policies are the primary criteria used to assist in administering health plan benefits. Clinical policies help identify whether services are medically necessary. The official posting of mental health, substance use disorder and intellectual and developmental disability service definitions are located on the web page of the NC Medicaid Division of Health Benefits at NCDHHS Program Specific Clinical Coverage Policies page, which includes, but is not limited to, the following clinical coverage policies.

For more information, or if you have questions about clinical coverage policies, please email UMQuestions@PartnersBHM.org.

Behavioral Health

  • 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-7, Ambulatory Withdrawal Management (WM) without Extended On-Site Monitoring
  • 8A-8, Ambulatory Withdrawal Management with Extended On-Site Monitoring
  • 8A-9, Treatment Program Service Opioid
  • 8A-10, Clinically Managed Residential Withdrawal Management Services
  • 8A-11, Medically Monitored Inpatient Withdrawal Management Service
  • 8A-12, Substance Abuse Intensive Outpatient Program (SAIOP)
  • 8A-13, Substance Abuse Comprehensive Outpatient Treatment (SACOT)
  • 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
  • 8D-3, Clinically Managed Low-Intensity Residential Treatment Services
  • 8D-4, Clinically Managed Population Clinical Specific High-Intensity Residential Program
  • 8D-5, Clinically Managed Residential Services
  • 8D-6, Medically Monitored Intensive Inpatient 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 & Support (IPS) for Mental Health & 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
  • 8L, Mental Health/Substance Abuse Targeted Case Management
  • 8P, North Carolina Innovations

For more information, or if you have questions about clinical coverage policies, please email UMQuestions@PartnersBHM.org.

‘In Lieu of’ Services

Partners can develop and present ideas for new services to the NC Division of Health Benefits (DHB) for approval. These services are covered through “Alternative” or “in lieu of” service definitions. These services are not available in the traditional benefit plan and are different from 1915(i) services. DHB can approve these new services for reimbursement under Medicaid and, in some cases, with State funding.

Partners’ In Lieu of Services Policy.

In Lieu of Service Definitions:

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