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. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. Clinical policies help identify whether services are medically necessary.
As part of the Partners Benefit Plan, below you will find a list of Medicaid and Clinical Coverage Policies by which Partners has adopted Clinical Criteria to make Medical Necessity Decisions. The full policies can be found on the NCDHHS Program Specific Clinical Coverage Policies page.
For more information, or if you have questions about clinical coverage policies, please email UMQuestions@PartnersBHM.org.
North Carolina Medicaid Program Specific Clinical Coverage Policies
- 1N-1, Allergy Testing
- 1N-2, Allergy Immunotherapy
- 15, Ambulance Services
- For guidance in reference to fixed-wing transport, refer to the Carolina Complete Health policy for Air Ambulance
- 1L-1, Anesthesia Services
- 1L-2, Moderate (Conscious) Sedation, AKA Procedural Sedation and Analgesia (PSA)
Auditory Implants External Parts
- 13A, Cochlear and Auditory Brainstem Implant External Parts Replacement and Repair
- 13B, Soft Band and Implantable Bone Conduction Hearing Aid External Parts Replacement and Repair
- 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
Burn Treatments & Skin Substitutes
- 1G-1, Burn Treatment
- 1G-2, Skin Substitutes
- 1R-1, Phase II Outpatient Cardiac Rehabilitation Programs
- 1R-4, Electrocardiography, Echocardiography, and Intravascular Ultrasound
- The following procedures do require prior authorization and should be obtained through Evolent: Transthoracic Echocardiography (TTE); Transesophageal Echocardiography (TEE); Stress Echocardiography.
- Also refer to the Carolina Complete Health policy for Holter Monitors
- 1F, Chiropractic Services
- 3A, Home Health Services
- 3D, Hospice Services
- 3G-1, Private Duty Nursing for Beneficiaries Age 21 and Older
- 3G-2, Private Duty Nursing for Beneficiaries Under 21 years of Age
- 3H-1, Home Infusion Therapy
- 3L, State Plan Personal Care Services (PCS)
- 3L-1, State Plan Personal Care Services (PCS) Provided in Congregate Settings
Dietary Evaluation and Counseling
- 1-I, Dietary Evaluation and Counseling and Medical Lactation Services
- 2A-1, Acute Inpatient Hospital Services
- 2A-2, Long Term Care Hospital Services
- 2A-3, Out-of-State Services
- 2B-1, Nursing Facilities
- 2B-2, Geropsychiatric Units in Nursing Facilities
Genetic Testing
The following procedures require prior authorization, which should be obtained through EviCore:
- Gene Expression
- Next Generation Sequencing (NGS)
- Genetic Testing for Carrier and Prenatal
- Genetic Testing for Diagnosis and Treatment
- 7, Hearing Aid Services
- 1S-1, Genotyping and Phenotyping for HIV Drug Resistance Testing
- 1S-2, HIV Tropism Assay
- 1S-3, Laboratory Services
- 1S-8, Drug Testing for Opioid Treatment and Controlled Substance Monitoring
- Prior authorization is required for G0482 and G0483.
- Drugs of Abuse: Definitive Testing
- 1S-9, Genetic Testing for Diagnosis and Treatment
- Prior authorization is required for all genetic testing.
- 1S-10, Genetic Testing for Carrier and Prenatal
- Prior authorization is required for all genetic testing.
- 1S-13, Cell and Gene Therapies
Maternal Support Services (Baby Love)
- 1M-2, Childbirth Education
- 1M-3, Health and Behavior Intervention
- 1M-4, Home Visit for Newborn Care and Assessment
- 1M-5, Home Visit for Postnatal Assessment and Follow-up Care
- 1M-6, Maternal Care Skilled Nurse Home Visit
- 5A-1, Physical Rehabilitation Equipment and Supplies
- Also refer to the Carolina Complete Health policy for Osteogenic Stimulation
- 5A-2, Respiratory Equipment and Supplies
- Prior approval is required prior to the initiation of oxygen therapy and for continuation of active oxygen therapy on at least an annual basis.
- 5A-3, Nursing Equipment and Supplies
- 5B, Orthotics & Prosthetics
- 1E-1, Hysterectomy
- 1E-2, Therapeutic and Non-therapeutic Abortions
- 1E-3, Sterilization Procedures
- 1E-4, Fetal Surveillance
- 1E-5, Obstetrics
- 1E-6, Pregnancy Management Program
- 1E-7, Family Planning Services
- 1T-1, General Ophthalmological Services
- 1T-2, Special Ophthalmological Services
Clinical Coverage Criteria and Prior Approval request forms
- 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
Physician-Administered Drug Program
1B Physician Administered Drug Program (PADP)
Physician Clinical Coverage Policies
- 1A-2, Preventive Medicine Annual Health Assessment
- 1A-3, Noninvasive Pulse Oximetry
- 1A-4, Cochlear and Auditory Brainstem Implants
- 1A-5, Child Medical Evaluation and Medical Team Conference for Child Maltreatment
- 1A-6, Invasive Electrical Bone Growth Stimulation
- Also refer to the Carolina Complete Health policy for Osteogenic Stimulation
- 1A-7, Neonatal and Pediatric Critical and Intensive Care Services
- 1A-8, Hyperbaric Oxygenation Therapy
- 1A-9, Blepharoplasty/Blepharoptosis (Eyelid Repair)
- 1A-11, Extracorporeal Shock Wave Lithotripsy
- 1A-12, Breast Surgeries
- 1A-13, Ocular Photodynamic Therapy
- 1A-14, Surgery for Ambiguous Genitalia
- 1A-15, Surgery for Clinically Severe or Morbid Obesity
- Also refer to the Carolina Complete Health policy for Bariatric Surgery
- 1A-16, Surgery of the Lingual Frenulum
- 1A-17, Stereotactic Pallidotomy
- 1A-19, Transcranial Doppler Studies
- 1A-20, Sleep Studies and Polysomnography Services
- 1A-21 Endovascular Repair of Aortic Aneurysm
- 1A-22, Medically Necessary Circumcision
- 1A-23, Physician Fluoride Varnish Services
- 1A-24, Diabetes Outpatient Self-Management Education
- 1A-25, Spinal Cord Stimulation
- Also refer to the Carolina Complete Health policy for Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation
- 1A-26, Deep Brain Stimulation
- 1A-27, Electrodiagnostic Studies
- 1A-28, Visual Evoked Potential (VEP)
- Also refer to the Carolina Complete Health policy for Evoked Potential Testing
- 1A-30 Spinal Surgeries
- 1A-31, Wireless Capsule Endoscopy
- Also refer to the Carolina Complete Health policy for Wireless Motility Capsule
- 1A-32, Tympanometry and Acoustic Reflex Testing
- 1A-33, Vagus Nerve Stimulation for the Treatment of Seizures
- Also refer to the Carolina Complete Health policy for Vagus Nerve Stimulation for the Treatment of Seizures
- 1A-34, Dialysis Services
- 1A-36, Implantable Bone Conduction Hearing Aids (BAHA)
- 1A-38, Special Services: After Hours
- 1A-39, Routine Patient Costs Furnished in Connection with Participation in Qualifying Clinical Trials
- 1A-40, Fecal Microbiota Transplantation
- Prior authorization is required for all transplant procedures.
- 1A-42, Balloon Ostial Dilation
- 1C-1, Podiatry Services
- 1C-2, Medically Necessary Routine Foot Care
- 1K-1, Breast Imaging Procedures
- MRI breast procedures do require prior authorization and should be obtained through Evolent.
- 1K-2, Bone Mass Measurement
- 1K-6 Radiation Oncology
- 1-O-1, Reconstructive and Cosmetic Surgery
- Also refer to the Carolina Complete Health policy for Cosmetic and Reconstructive Procedures
- 1-O-2, Craniofacial Surgery
- 1-O-3, Keloid Excision and Scar Revision
- 1-O-5, Rhinoplasty and/or Septorhinoplasty
Rural Health Clinics, FQHC and Health Departments. (RHC, FQHC, Health Depts)
- 1D-1, Refugee Health Assessments Provided in Health Departments
- 1D-2, Sexually Transmitted Disease Treatment Provided in Health Departments
- 1D-3, Tuberculosis Control and Treatment Provided in Health Departments
- 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics
Prior authorization is required for all transplant procedures.
- 11B-1, Lung Transplantation
- 11B-2, Heart Transplantation
- 11B-3, Islet Cell Transplantation
- Also refer to the Carolina Complete Health policy for Pancreas Transplantation
- 11B-4, Kidney (Renal) Transplantation
- Also refer to the Carolina Complete Health policy for Pediatric Kidney Transplant
- 11B-5, Liver Transplantation
- Also refer to the Carolina Complete Health policy for Pediatric Liver Transplant
- 11B-6, Heart/Lung Transplantation
- Also refer to the Carolina Complete Health policy for Heart-Lung Transplant
- 11B-7, Pancreas Transplant
- Also refer to the Carolina Complete Health policy for Pancreas Transplantation
- 11B-8, Small Bowel and Small Bowel/Liver and Multivisceral Transplants
- Also refer to the Carolina Complete Health policy for Intestinal and Multivisceral Transplant
- 11B-9, Thymus Tissue Implantation
- 10A, Outpatient Specialized Therapies
- 10D, Independent Practitioners Respiratory Therapy Services
Prior authorization is required for all transplant procedures.
- 11A-1, Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia (ALL)
- 11A-2, Hematopoietic Stem-Cell Transplant for Acute Myeloid Leukemia
- 11A-3, Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia
- 11A-5, Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemias
- 11A-6, Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors
- 11A-7, Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma
- 11A-8, Hematopoietic Stem-Cell Transplantation For Multiple Myeloma and Primary Amyloidosis
- 11A-9, Allogeneic Stem-Cell Transplantation for Myelodysplastic Syndromes & Myeloproliferative Neoplasms
- 11A-10, Hematopoietic Stem-Cell Transplantation (HSCT) for Central Nervous System (CNS) Embryonal Tumors & Ependymoma
- 11A-11, Hematopoietic Stem-Cell Transplant for Non-Hodgkin’s Lymphoma
- 11A-14, Placental and Umbilical Cord Blood as a Source of Stem Cells
- 11A-15, Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood
- 11A-16, Hematopoietic Stem-Cell Transplantation for Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)
- 11A-17, CAR T-Cell Therapy
- Also refer to the Carolina Complete Health policy for CAR T-Cell Therapy
- 12B, Human Immunodeficiency Virus (HIV) Case Management
- 11C, Ventricular Assist Device
- Also refer to the Carolina Complete Health policy for Ventricular Assist Devices
- 6A, Routine Eye Exam and Visual Aids for Recipients Under Age 21
- 6A: Routine Eye Examination and Visual Aids for Beneficiaries Under 21 Years of Age (Addendum)
- 6B, Routine Eye Examination and Visual Aids for Beneficiaries 21 Years of Age and Older
- 6B: Routine Eye Examination and Visual Aids for Beneficiaries 21 Years of Age and Older (Addendum)
Policies Adopted from Carolina Complete Health
Diaphragmatic/Phrenic Nerve Stimulation
Drugs of Abuse: Definitive Testing
EEG in the Evaluation of Headache
Electric Tumor Treating Fields (Optune)
Excimer Laser Therapy for Skin Conditions
Facility-based Sleep Studies for Obstructive Sleep Apnea
Fecal Incontinence Treatments NC.CP.MP.137
Fetal Surgery in Utero for Prenatally Diagnosed Malformations NC.CP.MP.129
Gastric Electrical Stimulation
- Prior authorization is required for all transplant procedures.
Helicobacter Pylori Serology Testing
Implantable Intrathecal or Epidural Pain Pump
Implantable Wireless Pulmonary Artery Pressure Monitoring
Intestinal and Multivisceral Transplant
- Prior authorization is required for all transplant procedures.
Intradiscal Steroid Injections for Pain Management
IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures
Lab Testing – Concert Genetics Infectious Disease: Respiratory Testing
Lab Testing – Concert Genetics Infectious Disease: Multisystem Testing
Lab Testing – Concert Genetics Infection Disease: Dermatologic Testing
Lab Testing – Concert Genetics Infectious Disease: Primary Care Preventative Testing
Lab Testing – Concert Genetics Infectious Disease: Vector Borne and Tropical Disease Testing
Lab Testing – Concert Genetics Infectious Disease: Genitourinary Testing
Laser Therapy for Skin Conditions
Measurement of Serum 1,25-dihydroxyvitamin D (aka Vitamin D)
Mechanical Stretching Devices for Joint Stiffness and Contracture
Neonatal Abstinence Syndrome Guidelines
Nerve Blocks and Neurolysis for Pain Management
NICU Apnea Bradycardia Guidelines
Osteogenic Stimulation NC.CP.MP.194
- Prior authorization is required for all transplant procedures.
- Prior authorization is required for all transplant procedures.
Phototherapy for Neonatal Hyperbilirubinemia
Posterior Tibial Nerve Stimulation for Voiding Dysfunction
Proton and Neutron Beam Therapies
Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy
Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation
Therapeutic Utilization of Inhaled Nitric Oxide
Thyroid Hormones and Insulin Testing in Pediatrics
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition
Trigger Point Injections for Pain Management
Urinary Incontinence Devices and Treatments
‘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:
- Acute and Subacute Services Provided in an Institute for Mental Disease
- Behavioral Health Urgent Care (BHUC)
- Child Focused Assertive Community Treatment (Child ACT)
- Family Centered Treatment
- High Fidelity Wraparound
- In Home In Lieu Of Service: In Home Therapy Services (IHTS)
- Long-Term Community Supports (LTCS)
- Rapid Care Services (Low & High)
- Rapid Response Bed Therapeutic Foster Care for Children and Youth
- Residential Services – Complex Needs
- Youth Focused Assertive Community Treatment Team (Youth ACTT)