North Carolina Administrative Code

SECTION .0300 - ICF-MR PROSPECTIVE RATE PLAN 10A NCAC 22G .0301 PAYMENT FOR SERVS-PROSPECTIVE REIMBURSEMENT PLAN ICF-MR FACILITIES History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C; Eff. January 1, 1982; Temporary Amendm…

10A NCAC 22G .0302 REPORTING REQUIREMENTS History Note: Temporary Amendment Eff. July 8, 1993, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner. Authority G.S. 108A-25(b); 108A-54; 108A-55; 42 C.F.R. 447, Subpart C; Eff. January 1, 1982;…

10A NCAC 22G .0303 REQUIREMENTS FOR FINANCIAL RECORDS History Note: Temporary Amendment Eff. July 8, 1993, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner; Temporary Amendment Eff. July 1, 1992 for a period of 180 days to expire on Dece…

10A NCAC 22G .0304 RATE SETTING METHOD FOR NON-STATE FACILITIES History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; 42 C.F.R. Part 447, Subpart C; Eff. December 1, 1984; Amended Eff. March 1, 1988; January 1, 1987; Temporary Amendment Eff. July 8, 1993 for a period of 180 …

section .0400 - PROVIDER FEE SCHEDULES 10A ncac 22G .0401 PHYSICIAN’S FEE SCHEDULE History Note: Authority G.S. 108A-25(b); Eff. October 1, 1982; Amended Eff. July 1, 1997; July 1, 1995; January 4, 1993; June 1, 1990; December 1, 1988; Temporary Amendment Eff. July 22, 1998; Janu…

10A ncac 22G .0402 OTHER SERVICES PERFORMED BY PHYSICIANS AND OTHER PRACTITIONERS History Note: Authority G.S. 108A-25(b); S.L. 1985, c. 479, s. 86; Eff. January 4, 1993; Temporary Amendment Eff. March 7, 2002; Temporary Amendment Expired December 27, 2002; Amended Eff. August 1,…

section .0500 – reimbursement for services 10a NCAC 22G .0501 CLINIC SERVICES History Note: Authority G.S. 108A-25(b); S.L. 1985, c. 479, s. 86; Eff. February 1, 1984; Temporary Amendment Eff. November 9, 2001; Temporary Amendment Expired August 30, 2002; Amended Eff. April 1, 20…

10a NCAC 22G .0502 MENTAL HEALTH CLINIC SERVICES History Note: Authority G.S. 108A-25(b); S.L. 1985, c. 479, s. 86; Eff. February 1, 1984; Repealed Eff. July 1, 2018.

10A NCAC 22G .0503 INPATIENT HOSPITAL: INAPPROPRIATE LEVEL OF CARE History Note: Authority G.S. 108A-25(b); 42 C.F.R. 447.253; S.L. 1985, c. 479, s. 86; Eff. May 1, 1984; Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

10A NCAC 22G .0504 HEALTH MAINTENANCE ORGANIZATIONS AND PREPAID HEALTH PLANS History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; S.L. 1985, c. 479, s. 86; 42 C.F.R. Part 434; 42 C.F.R. Part 438.6; Eff. August 1, 1984; Amended Eff. February 1, 1985; Readopted Eff. July 1, 2…

10A ncac 22G .0505 PERSONAL CARE SERVICES History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; 131D-4.1; 131D-4.2; S.L. 1995 c. 507, s. 23.10; 42 C.F.R. 440.170(f); Eff. January 1, 1986; Temporary Amendment Eff. April 22, 1996; January 9, 1997; Amended Eff. August 1, 1998; …

10A NCAC 22G .0506 INDEPENDENT LABORATORY SERVICES History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; P.L. 93-369; P.L. 99-272; 42 C.F.R. 447.10; 42 C.F.R. 447.342; Eff. March 1, 1987; Amended Eff. September 1, 1991; Expired Eff. September 1, 2015 pursuant to G.S. 150B-21…

10A NCAC 22G .0507 DURABLE MEDICAL EQUIPMENT AND RELATED SUPPLIES History Note: Authority G.S. 108A-25(b); 42 C.F.R. 447, Subpart D; 1991 S.L, s. 95, c. 689; Eff. March 1, 1990; Temporary Amendment Eff. August 1, 1991 for a period of 180 days to expire on January 31, 1992; Amende…

10A NCAC 22G .0508 PRIVATE DUTY NURSING History Note: Authority G.S. 108A-25(b); 108A-54; 42 C.F.R. 440.80; Eff. January 1, 1994; Temporary Amendment Eff. December 20, 2002; July 1, 2002; Temporary Amendment Expired November 28, 2003; Expired Eff. September 1, 2015 pursuant to G.…

10A NCAC 22G .0509 REIMBURSEMENT PRINCIPLES, HEARING AIDS/ACCESSORIES/BATTERIES History Note: Authority G.S. 108A-25(b); 108A-54; Eff. January 4, 1993; Recodified from 10 NCAC 26H .0509 Eff. January 1, 1994; Repealed Eff. July 1, 2018.

10A NCAC 22G .0510 CASE MANAGEMENT SERVICES History Note: Authority G.S. 108A-25(b); 108A-54; 1915 (g) of the Social Security Act; Eff. April 1, 1994; Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

SECTION .0600 - HOME HEALTH PROSPECTIVE REIMBURSEMENT 10A NCAC 22G .0601 REIMBURSEMENT PRINCIPLES History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.70; Eff. October 1, 1987; Amended Eff. October 1, 1992; Temporary Amendment Eff. Au…

10a NCAC 22G .0602 REIMBURSEMENT METHODS History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; S.L. 1985, c.479, s. 86; 42 C.F.R. 440.70; Eff. October 1, 1987; Amended Eff. October 1, 1992; May 1, 1990; Temporary Amendment Eff. October 4, 1996; Amended Eff. April 1, 1997; Te…

10A NCAC 22G .0603 APPEALS History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; S.L. 1985. c. 479, s. 86; 42 C.F.R. 440.70; Eff. October 1, 1987; Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

10A NCAC 22G .0604 COST REPORTING AND AUDITING History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.70; Eff. October 1, 1987; Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

10A NCAC 22G .0605 PAYMENT ASSURANCES History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; S. L. 1985, c. 479, s. 86; 42 C.F.R. 440.70; Eff. October 1, 1987; Amended Eff. October 1, 1992; May 1, 1990; Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

SUBCHAPTER 22h - APPEALS PROCEDURES SECTION .0100 - beneficiary appeals FOR DENIAL, TERMINATION, SUSPENSION, OR REDUCTION OF a medicaid service or an authorization for a medicaid service 10A NCAC 22H .0101 APPEALS BY MEDICAID BENEFICIARIES History Note: Authority G.S. 108A-25(b);…

10A NCAC 22H .0104 PAYMENT PENDING APPEALS History Note: Authority G.S. 108A-25(b); 108A-70.9A; 108A-70.9B; 42 C.F.R. 431.230(b); Eff. April 13, 1979; Amended Eff. December 1, 1995; October 4, 1979; Readopted Eff. July 1, 2018; Expired Eff. September 1, 2025 pursuant to G.S. 150B…

10A NCAC 22H .0105 DISMISSAL OF APPEAL History Note: Authority G.S. 108A-25(b); 42 C.F.R. Part 431; Eff. April 13, 1979; Amended Eff. December 1, 1995; May 1, 1990; Repealed Eff. July 1, 2018.

SECTION .0200 - HEARINGS: TRANSFER AND DISCHARGES FROM NURSING FACILITIES 10A NCAC 22H .0201 DEFINITIONS The following definitions shall apply throughout this Section: (1) "Division" means the North Carolina Division of Health Benefits, Department of Health and Human Services. (2…

10A NCAC 22H .0202 TRANSFER AND DISCHARGE REQUIREMENTS (a) To transfer or discharge a resident, a facility shall comply with all of the requirements of 42 C.F.R. 483.15, which is adopted and incorporated by reference with subsequent changes or amendments and available free of cha…

10A NCAC 22H .0203 INITIATING A HEARING (a) In order to initiate an appeal of a facility's intent to transfer or discharge, a resident, family member, or legal representative shall submit a written request for a hearing to the Hearing Unit. The request for hearing shall be receiv…

10A NCAC 22H .0204 HEARING PROCEDURES (a) Upon timely receipt of a request for a hearing of a transfer or discharge by a nursing facility as set out in Rule .0203 of this Section, the Hearing Unit shall notify the parties of the request. (b) The parties shall be notified by certi…

10A NCAC 22H .0205 HEARING OFFICER'S FINAL DECISION (a) The Hearing Officer's final decision shall uphold or reverse the facility's decision regarding the transfer or discharge of a resident. Copies of the final decision shall be mailed via certified mail to the parties. (b) A pa…

SECTION .0300 - PASRR HEARINGS 10A NCAC 22H .0301 DEFINITIONS The following definitions shall apply throughout this Section: (1) "Division" means the North Carolina Division of Health Benefits, Department of Health and Human Services. (2) "Hearing Officer" means the person design…

10A NCAC 22H .0302 PASRR REQUIREMENTS (a) The evaluated individual and family member or legal representative shall be notified in writing of the Division of MH/DD/SAS' PASRR determination under the provisions of 42 CFR 483.130 which is incorporated by reference with subsequent ch…

10A NCAC 22H .0303 INITIATING A HEARING (a) In order to initiate an appeal of a PASRR determination, the evaluated individual, family member, or legal representative shall submit a Hearing Request Form to the Hearing Unit. The form shall be received by the Hearing Unit within 11 …

10A NCAC 22H .0304 HEARING PROCEDURES (a) Upon receipt of a Hearing Request Form to appeal a PASRR determination, the Hearing Unit shall notify the Division of MH/DD/SAS of the request. (b) The parties shall be notified by certified mail of the date, time, and place of the hearin…

10A NCAC 22H .0305 HEARING OFFICER'S FINAL DECISION (a) The Hearing Officer's final decision shall uphold or reverse the Division of MH/DD/SAS' PASRR decision. Copies of the final decision shall be mailed via certified mail to the parties. (b) A party may appeal the Hearing Offic…

SUBCHAPTER 22I - TITLE XIX REIMBURSEMENT AND ADMINISTRATIVE REVIEW PROCESS SECTION .0100 - AUDIT REVIEW PROCESS 10A NCAC 22I .0101 AUDIT TO BE CONDUCTED An audit of a provider may be conducted by the Division of Health Benefits, or by an auditing firm subcontracted by them. Histo…

10A NCAC 22I .0102 EXIT CONFERENCE At the conclusion of the audit, the provider may request an exit conference to discuss the audit findings with the provider that shall be held by personnel of the unit conducting the audit. History Note: Authority G.S. 108A-25(b); Eff. September…

10A NCAC 22I .0103 NOTICE OF PROGRAM REIMBURSEMENT Based on the audit findings the Division of Health Benefits will issue to the provider a Notice of Program Reimbursement which shall state the amount of reimbursement, if any, payable to the Division of Health Benefits or payable…

10A NCAC 22I .0104 RECONSIDERATION REVIEW History Note: Authority G.S. 108A-25(b); Eff. September 24, 1980; Amended Eff. January 1, 1988; Repealed Eff. July 1, 2018.

SUBCHAPTER 22j - TITLE XIX APPEALS PROCEDURES 10A NCAC 22J .0101 PURPOSE AND SCOPE The purpose of these regulations is to specify the rights of providers to appeal reimbursement rates, payment denials, disallowances, payment adjustments and cost settlement disallowances and adjus…

10A NCAC 22J .0102 PETITION FOR RECONSIDERATION REVIEW (a) A provider may request a reconsideration review within 30 calendar days from receipt of final notification of payment, payment denial, disallowances, payment adjustment, notice of program reimbursement, and adjustments. A…

10A NCAC 22J .0103 RECONSIDERATION REVIEW PROCESS (a) Upon receipt of a request for a reconsideration review that is submitted timely pursuant to Rule .0102 of this Subchapter, the Deputy Director shall appoint a reviewer or panel to conduct the review. The Division shall arrange…

10A NCAC 22J .0104 PETITION FOR A CONTESTED CASE HEARING If the provider disagrees with the reconsideration review decision, the provider may request a contested case hearing in accordance with G.S. 150B, Article 3 and 26 NCAC 03 .0103. History Note: Authority G.S. 108A-25(b); 10…

10a NCAC 22J .0105 PAYMENT STATUS History Note: Authority G.S. 108A-25(b); 108A-54; 150B-11; 42 U.S.C. 1396b(d)(2); Eff. January 1, 1988; Repealed Eff. September 1, 2018.

10A NCAC 22J .0106 PROVIDER BILLING OF PATIENTS WHO ARE MEDICAID RECIPIENTS (a) A provider may refuse to accept a patient as a Medicaid patient and bill the patient as a private pay patient only if the provider informs the patient that the provider will not bill Medicaid for any …

SUBCHAPTER 22K - QUALIFIED PROVIDERS 10A NCAC 22K .0101 DEFINITION A provider qualified to make presumptive determinations of Medicaid eligibility for pregnant women shall meet the conditions required by Section 1920 of the Social Security Act, which is adopted and incorporated b…

10A NCAC 22K .0102 AGREEMENT (a) The provider shall participate in training offered by the Division or its agents and make presumptive eligibility determinations in accordance with 42 C.F.R. 435.1103, which is adopted and incorporated by reference with subsequent changes or amend…

10A NCAC 22K .0103 PRESUMPTIVE DETERMINATIONS (a) Presumptive determinations of eligibility shall apply only to pregnant women whose family income does not exceed the federal poverty guidelines issued in the Federal Register by the US Department of Health and Human Services and r…

10A NCAC 22l .0105 EMERGENCY ROOM CARE History Note: Authority G.S. 108A-25(b); Section 93(h) of Chapter 689, 1991 North Carolina Session laws; Eff. August 3, 1992; Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

SECTION .0200 - PREPAID PLANS 10A NCAC 22L .0201 PROGRAM DEFINITION History Note: Authority G.S. 108A-25(b); Eff. August 3, 1992; Amended Eff. April 1, 1999; Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015; Repealed Eff. Jul…

10A NCAC 22L .0202 ENROLLMENT History Note: Authority G.S. 108A-25(b); Eff. August 3, 1992; Amended Eff. April 1, 1999; Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.