North Carolina Administrative Code

10A NCAC 23H .0108 WITHHOLDING INFORMATION FROM THE CLIENT (a) When the director or a delegated representative determines on the basis of the exceptions in Rule .0107 of this Section to withhold information from the client, this reason shall be documented in the client record. (b…

10A NCAC 23H .0109 PROCEDURE FOR REVIEW OF RECORDS (a) The director or his or her delegated representative shall be present when the client reviews the record. The director or his or her delegated representative shall document in the client record the review of the record by the …

10A NCAC 23H .0110 CONSENT FOR RELEASE (a) As a part of the application process for Medicaid, the client shall be informed of the need for and give consent to release of information for verification of statements to establish eligibility. (b) No individual shall release any clien…

10A NCAC 23H .0111 DISCLOSURE WITHOUT CLIENT CONSENT (a) Client information from the Medicaid record may be disclosed without the consent of the client under the following circumstances: (1) To other employees of the county department of social services for purpose of making refe…

10A NCAC 23H .0112 DOCUMENTATION OF CONSENT OR DISCLOSURE Whenever client information is disclosed in accordance with rules of this Subchapter, the director or delegated representative shall document the disclosure in the client record. History Note: Authority G.S. 108A-54; 108A-…

10A NCAC 23H .0113 PERSONS DESIGNATED TO DISCLOSE INFORMATION Only directors of county departments of social services and their designated representatives may disclose client information in accordance with rules of this Subchapter. The process for delegation is set out in G.S. 10…

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…

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…

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 22…

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; Transferr…

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 N…

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, 1…

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; Trans…

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 ca…

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,…

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 p…

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 …

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 …

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.

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…

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 recomm…

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 add…

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 …

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 dru…

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 pha…

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…

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…

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 progr…

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…

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. …

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…

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, 19…

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, 201…

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, 201…

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 NC…

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; Fe…

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 (Para…

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 .0…

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; …

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 E…