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North Carolina Administrative Code (Last Updated: November 13, 2014) |
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TITLE 10A. HEALTH AND HUMAN SERVICES |
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CHAPTER 22. MEDICAL ASSISTANCE ELIGIBILITY |
| SUBCHAPTER A. IDENTIFYING INFORMATION |
| 10A NCAC 22A .0101. SCOPE |
| 10A NCAC 22A .0102. RESERVED FOR FUTURE CODIFICATION |
| SUBCHAPTER B. PROVIDER ISSUES |
| 10A NCAC 22B .0101. INSTITUTIONAL HEALTH SERVICES |
| 10A NCAC 22B .0102. COORDINATION WITH TITLE XVIII |
| 10A NCAC 22B .0103. INSTITUTIONAL STANDARDS |
| 10A NCAC 22B .0104. TIME LIMITATION |
| 10A NCAC 22B .0105. OVERUTILIZER IDENTIFICATION |
| 10A NCAC 22B .0201. MANUALS |
| 10A NCAC 22B .0202. FORMS |
| SUBCHAPTER C. AMOUNT: DURATION: AND SCOPE OF ASSISTANCE |
| 10A NCAC 22C .0101. COST SHARING |
| 10A NCAC 22C .0102. MEDICALLY NEEDY |
| 10A NCAC 22C .0103. CATEGORICALLY NEEDY |
| 10A NCAC 22C .0104. HEALTH INSURING ORGANIZATIONS |
| SUBCHAPTER D. RECIPIENT ISSUES |
| 10A NCAC 22D .0101. CO‑PAYMENT |
| SUBCHAPTER E. COOPERATIVE AGREEMENTS |
| 10A NCAC 22E .0101. DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES |
| 10A NCAC 22E .0102. VOCATIONAL REHABILITATION |
| 10A NCAC 22E .0103. MENTAL HEALTH, DEVELOP/DISABILITIES/SUBSTANCE ABUSE SVCS |
| 10A NCAC 22E .0104. FACILITY SERVICES |
| 10A NCAC 22E .0105. BLUE CROSS AND BLUE SHIELD |
| SUBCHAPTER F. PROGRAM INTEGRITY |
| 10A NCAC 22F .0101. SCOPE |
| 10A NCAC 22F .0102. ORGANIZATION |
| 10A NCAC 22F .0103. FUNCTIONS |
| 10A NCAC 22F .0104. PREVENTION |
| 10A NCAC 22F .0105. DETECTION |
| 10A NCAC 22F .0106. CONFIDENTIALITY |
| 10A NCAC 22F .0107. RECORD RETENTION |
| 10A NCAC 22F .0201. DEFINITION OF PROVIDER FRAUD |
| 10A NCAC 22F .0202. INVESTIGATION |
| 10A NCAC 22F .0203. REFERRAL TO LAW ENFORCEMENT AGENCY |
| 10A NCAC 22F .0301. DEFINITION OF PROVIDER ABUSE |
| 10A NCAC 22F .0302. INVESTIGATION |
| 10A NCAC 22F .0401. PURPOSE |
| 10A NCAC 22F .0402. RECONSIDERATION REVIEW FOR PROGRAM ABUSE |
| 10A NCAC 22F .0403. PROCESS |
| 10A NCAC 22F .0501. GENERAL |
| 10A NCAC 22F .0502. PEER REVIEW ESTABLISHED |
| 10A NCAC 22F .0503. CHOICE OF PROCEDURES |
| 10A NCAC 22F .0504. COMPOSITION OF PEER REVIEW BOARD |
| 10A NCAC 22F .0505. NOTICE OF PEER REVIEW |
| 10A NCAC 22F .0506. VENUE |
| 10A NCAC 22F .0507. DOCUMENTATION |
| 10A NCAC 22F .0508. PEER REVIEW PROCEDURES |
| 10A NCAC 22F .0509. DISQUALIFICATION OF BOARD MEMBERS |
| 10A NCAC 22F .0510. FAILURE OF PROVIDER TO ATTEND THE REVIEW |
| 10A NCAC 22F .0601. RECOUPMENT |
| 10A NCAC 22F .0602. ADMINISTRATIVE SANCTIONS AND REMEDIAL MEASURES |
| 10A NCAC 22F .0603. PROVIDER LOCK-OUT |
| 10A NCAC 22F .0604. WITHHOLDING OF MEDICAID PAYMENTS |
| 10A NCAC 22F .0605. TERMINATION |
| 10A NCAC 22F .0606. TECHNIQUE FOR PROJECTING MEDICAID OVERPAYMENTS |
| 10A NCAC 22F .0701. DEFINITION OF FRAUD AND ABUSE |
| 10A NCAC 22F .0702. GENERAL |
| 10A NCAC 22F .0703. WARNING NOTIFICATION |
| 10A NCAC 22F .0704. RECIPIENT MANAGEMENT LOCK‑IN SYSTEM |
| 10A NCAC 22F .0705. OVERUTILIZATION SURVEILLANCE (SUR INDICATOR) |
| 10A NCAC 22F .0706. RECOUPMENT OF OVERPAYMENTS |
| 10A NCAC 22F .0707. REPORTS AND REVIEWS |
| SUBCHAPTER G. REIMBURSEMENT PLANS |
| 10A NCAC 22G .0101. REIMBURSEMENT PRINCIPLES |
| 10A NCAC 22G .0102. RATE SETTING METHODS |
| 10A NCAC 22G .0103. REASONABLE AND NON‑ALLOWABLE COSTS |
| 10A NCAC 22G .0104. COST REPORTING: AUDITING |
| 10A NCAC 22G .0105. CASE-MIX INDEX CALCULATION |
| 10A NCAC 22G .0106. RECONSIDERATION REVIEWS |
| 10A NCAC 22G .0107. PAYMENT ASSURANCE |
| 10A NCAC 22G .0108. REIMBURSEMENT METHODS FOR STATE‑OPERATED FACILITIES |
| 10A NCAC 22G .0109. PROVIDER ASSESSMENT |
| 10A NCAC 22G .0110. DEFINITIONS |
| 10A NCAC 22G .0201. REIMBURSEMENT PRINCIPLES |
| 10A NCAC 22G .0202. DRG RATE SETTING METHODOLOGY |
| 10A NCAC 22G .0203. EXCEPTIONS TO DRG REIMBURSEMENT |
| 10A NCAC 22G .0204. DISPROPORTIONATE SHARE HOSPITALS (DSH) |
| 10A NCAC 22G .0205. OUT OF STATE HOSPITALS |
| 10A NCAC 22G .0206. SPECIAL SITUATION |
| 10A NCAC 22G .0207. COST REPORTING AND AUDITS |
| 10A NCAC 22G .0208. ADMINISTRATIVE RECONSIDERATION REVIEWS |
| 10A NCAC 22G .0209. BILLING STANDARDS |
| 10A NCAC 22G .0210. PAYMENT OF MEDICARE PART A DEDUCTIBLES |
| 10A NCAC 22G .0211. PAYMENT ASSURANCES |
| 10A NCAC 22G .0212. PROVIDER PARTICIPATION |
| 10A NCAC 22G .0213. PAYMENT IN FULL |
| 10A NCAC 22G .0301. PAYMENT FOR SERVS‑PROSPECTIVE REIMBURSEMENT PLAN ICF‑MR FACILITIES |
| 10A NCAC 22G .0302. REPORTING REQUIREMENTS |
| 10A NCAC 22G .0303. REQUIREMENTS FOR FINANCIAL RECORDS |
| 10A NCAC 22G .0304. RATE SETTING METHOD FOR NON-STATE FACILITIES |
| 10A NCAC 22G .0305. ALLOWABLE COSTS |
| 10A NCAC 22G .0306. PAYMENT ASSURANCE |
| 10A NCAC 22G .0307. REIMBURSEMENT METHODS FOR STATE‑OPERATED FACILITIES |
| 10A NCAC 22G .0308. RATE APPEALS |
| 10A NCAC 22G .0309. AUDITS |
| 10A NCAC 22G .0401. PHYSICIAN’S FEE SCHEDULE |
| 10A NCAC 22G .0402. OTHER SERVICES PERFORMED BY PHYSICIANS AND OTHER PRACTITIONERS |
| 10A NCAC 22G .0501. CLINIC SERVICES |
| 10A NCAC 22G .0502. MENTAL HEALTH CLINIC SERVICES |
| 10A NCAC 22G .0503. INPATIENT HOSPITAL: INAPPROPRIATE LEVEL OF CARE |
| 10A NCAC 22G .0504. HEALTH MAINTENANCE ORGANIZATIONS AND PREPAID HEALTH PLANS |
| 10A NCAC 22G .0505. PERSONAL CARE SERVICES |
| 10A NCAC 22G .0506. INDEPENDENT LABORATORY SERVICES |
| 10A NCAC 22G .0507. DURABLE MEDICAL EQUIPMENT AND RELATED SUPPLIES |
| 10A NCAC 22G .0508. PRIVATE DUTY NURSING |
| 10A NCAC 22G .0509. REIMBURSEMENT PRINCIPLES, HEARING AIDS/ACCESSORIES/BATTERIES |
| 10A NCAC 22G .0510. CASE MANAGEMENT SERVICES |
| 10A NCAC 22G .0601. REIMBURSEMENT PRINCIPLES |
| 10A NCAC 22G .0602. REIMBURSEMENT METHODS |
| 10A NCAC 22G .0603. APPEALS |
| 10A NCAC 22G .0604. COST REPORTING AND AUDITING |
| 10A NCAC 22G .0605. PAYMENT ASSURANCES |
| SUBCHAPTER H. APPEALS PROCEDURES |
| 10A NCAC 22H .0101. PURPOSE AND SCOPE |
| 10A NCAC 22H .0102. REQUESTS FOR FORMAL AND INFORMAL APPEALS |
| 10A NCAC 22H .0103. TIME LIMITS ON REQUESTS FOR RECIPIENT/APPLICANT INFORMAL APPEALS |
| 10A NCAC 22H .0104. PAYMENT PENDING APPEALS |
| 10A NCAC 22H .0105. DISMISSAL OF APPEAL |
| 10A NCAC 22H .0201. DEFINITIONS |
| 10A NCAC 22H .0202. TRANSFER AND DISCHARGE REQUIREMENTS |
| 10A NCAC 22H .0203. INITIATING A HEARING |
| 10A NCAC 22H .0204. HEARING PROCEDURES |
| 10A NCAC 22H .0205. HEARING OFFICER'S FINAL DECISION |
| 10A NCAC 22H .0301. DEFINITIONS |
| 10A NCAC 22H .0302. PASARR REQUIREMENTS |
| 10A NCAC 22H .0303. INITIATING A HEARING |
| 10A NCAC 22H .0304. HEARING PROCEDURES |
| 10A NCAC 22H .0305. HEARING OFFICER'S FINAL DECISION |
| SUBCHAPTER I. TITLE XIX REIMBURSEMENT AND ADMINISTRATIVE REVIEW PROCESS |
| 10A NCAC 22I .0101. AUDIT TO BE CONDUCTED |
| 10A NCAC 22I .0102. EXIT CONFERENCE |
| 10A NCAC 22I .0103. NOTICE OF PROGRAM REIMBURSEMENT |
| 10A NCAC 22I .0104. RECONSIDERATION REVIEW |
| SUBCHAPTER J. TITLE XIX APPEALS PROCEDURES |
| 10A NCAC 22J .0101. PURPOSE AND SCOPE |
| 10A NCAC 22J .0102. PETITION FOR RECONSIDERATION REVIEW |
| 10A NCAC 22J .0103. RECONSIDERATION REVIEW PROCESS |
| 10A NCAC 22J .0104. PETITION FOR A CONTESTED CASE HEARING |
| 10A NCAC 22J .0105. PAYMENT STATUS |
| 10A NCAC 22J .0106. PROVIDER BILLING OF PATIENTS WHO ARE MEDICAID RECIPIENTS |
| SUBCHAPTER K. QUALIFIED PROVIDERS |
| 10A NCAC 22K .0101. DEFINITION |
| 10A NCAC 22K .0102. AGREEMENT |
| 10A NCAC 22K .0103. PRESUMPTIVE DETERMINATIONS |
| SUBCHAPTER L. MANAGED CARE AND PREPAID PLANS |
| 10A NCAC 22L .0101. PROGRAM DEFINITION |
| 10A NCAC 22L .0102. COORDINATION FEE |
| 10A NCAC 22L .0103. ACCESS TO CARE |
| 10A NCAC 22L .0104. ENROLLMENT |
| 10A NCAC 22L .0105. EMERGENCY ROOM CARE |
| 10A NCAC 22L .0201. PROGRAM DEFINITION |
| 10A NCAC 22L .0202. ENROLLMENT |
| 10A NCAC 22L .0203. ACCESS TO CARE |
| SUBCHAPTER M. DRUG USE REVIEW (DUR) |
| 10A NCAC 22M .0101. ESTABLISHMENT (TRANSFERRED TO 10A NCAC 25K .0301) |
| 10A NCAC 22M .0102. MEMBERSHIPS (TRANSFERRED TO 10A NCAC 25K .0302) |
| 10A NCAC 22M .0103. CHAIRMEN (TRANSFERRED TO 10A NCAC 25K .0303) |
| 10A NCAC 22M .0104. ACTIVITIES (TRANSFERRED TO 10A NCAC 25K .0304) |
| 10A NCAC 22M .0201. PATIENT COUNSELING (TRANSFERRED TO 10A NCAC 25K .0401) |
| 10A NCAC 22M .0301. RETROSPECTIVE DRUG USE REVIEW (DUR) (TRANSFERRED TO 10A NCAC 25K .0501) |
| 10A NCAC 22M .0302. SCREENING AND PATTERN ANALYSIS (TRANSFERRED TO 10A NCAC 25K .0502) |
| 10A NCAC 22M .0303. INTERVENTIONS (TRANSFERRED TO 10A NCAC 25K .0503) |
| 10A NCAC 22M .0304. COMPLIANCE MONITORING (TRANSFERRED TO 10A NCAC 25K .0504) |
| SUBCHAPTER N. PROVIDER ENROLLMENT |
| 10A NCAC 22N .0101. DEFINITIONS |
| 10A NCAC 22N .0102. SIGNED AGREEMENTS |
| 10A NCAC 22N .0201. DEFINITIONS |
| 10A NCAC 22N .0202. DISCLOSURE OF OWNERSHIP |
| 10A NCAC 22N .0203. ENROLLMENT RESTRICTIONS |
| 10A NCAC 22N .0301. DEFINITIONS |
| 10A NCAC 22N .0302. DISCLOSURE OF OWNERSHIP |
| 10A NCAC 22N .0303. ENROLLMENT RESTRICTIONS |
| SUBCHAPTER O. MEDICAL ASSISTANCE PROVIDED |
| 10A NCAC 22O .0101. HOSPITAL INPATIENT |
| 10A NCAC 22O .0102. HOSPITAL OUTPATIENT (TRANSFERRED TO 10A NCAC 25M .0301) |
| 10A NCAC 22O .0103. HOME HEALTH SERVICES (TRANSFERRED TO 10A NCAC 25O .0201(A)) |
| 10A NCAC 22O .0104. LABORATORY AND X‑RAY SERVICES (ITEMS (1)-(3) TRANSFERRED TO 10A NCAC 25P .0406 AND ITEMS (4)-(5) TRANSFERRED TO 10A NCAC 25U .0201)) |
| 10A NCAC 22O .0105. EYEGLASSES AND OPTOMETRIC SERVICES (TRANSFERRED TO 10A NCAC 25N .0301) |
| 10A NCAC 22O .0106. CHIROPRACTIC SERVICES (TRANSFERRED TO 10A NCAC 25P .0403) |
| 10A NCAC 22O .0107. MENTAL HEALTH CENTER SERVICES (TRANSFERRED TO 10A NCAC 25C .0201) |
| 10A NCAC 22O .0108. INTERMEDIATE CARE FACILITIES (TRANSFERRED TO 10A NCAC 25D .0201(A)-(B)) |
| 10A NCAC 22O .0109. HEARING AID SERVICES (TRANSFERRED TO 10A NCAC 25N .0201) |
| 10A NCAC 22O .0110. AMBULANCE SERVICES (TRANSFERRED TO 10A NCAC 25W .0201) |
| 10A NCAC 22O .0111. INPATIENT PSYCHIATRIC HOSPITAL SERVICES (TRANSFERRED TO 10A NCAC 25C .0301) |
| 10A NCAC 22O .0112. PSYCHIATRIC ADMISSION CRITERIA/MEDICAID BENEFICIARIES UNDER AGE 21 |
| 10A NCAC 22O .0113. NC MEDICAID CRITERIA FOR CONTINUED ACUTE STAY IN AN INPATIENT PSYCHIATRIC FACILITY (TRANSFERRED TO 10A NCAC 25C .0302) |
| 10A NCAC 22O .0114. NORTH CAROLINA SPECIALTY HOSPITAL SERVICES (TRANSFERRED TO 25M .0201(E)) |
| 10A NCAC 22O .0115. CLINIC SERVICES (TRANSFERRED TO 10A NCAC 25P .0402) |
| 10A NCAC 22O .0116. SKILLED NURSING FACILITY (TRANSFERRED TO 10A NCAC 25M .0401(A)-(C)) |
| 10A NCAC 22O .0117. ABORTION (TRANSFERRED TO 10A NCAC 25P .0405) |
| 10A NCAC 22O .0118. PHARMACY SERVICES (TRANSFERRED TO 10A NCAC 25K .0201) |
| 10A NCAC 22O .0119. OUT‑OF‑STATE SERVICES (TRANSFERRED TO 10A NCAC 25S .0201) |
| 10A NCAC 22O .0120. PERSONAL CARE SERVICES (TRANSFERRED TO 10A NCAC 25O .0202(A)-(B)) |
| 10A NCAC 22O .0121. DURABLE MEDICAL EQUIPMENT [REPEALED] |
| 10A NCAC 22O .0122. PRIVATE DUTY NURSING (TRANSFERRED TO 10A NCAC 25O .0204) |
| 10A NCAC 22O .0123. CASE MGMT SVCS/ADULTS/CHILDREN AT-RISK/ABUSE/NEGLECT/EXPOITATION (TRANSFERRED TO 10A NCAC 25F .0201) |
| 10A NCAC 22O .0124. HIV CASE MANAGEMENT (TRANSFERRED TO 10A NCAC 25F .0301) |
| 10A NCAC 22O .0125. HOME INFUSION THERAPY (TRANSFERRED TO 10A NCAC 25O .0203) |
| 10A NCAC 22O .0201. DEFINITIONS (TRANSFERRED TO 10A NCAC 25H .0201) |
| 10A NCAC 22O .0202. STANDARDS FOR PARTICIPATION (TRANSFERRED TO 10A NCAC 25H .0203) |
| 10A NCAC 22O .0203. ELIGIBILITY (TRANSFERRED TO 10A NCAC 25H .0202) |
| 10A NCAC 22O .0204. AMOUNT: DURATION: AND SCOPE OF SERVICES (TRANSFERRED TO 10A NCAC 25H .0204) |
| 10A NCAC 22O .0205. RESTRICTIONS AND PRIOR APPROVAL (TRANSFERRED TO 10A NCAC 25H .0205) |
| 10A NCAC 22O .0206. GUIDELINES ON SERVICES (TRANSFERRED TO 10A NCAC 25H .0301) |
| 10A NCAC 22O .0207. SPECIFIC GUIDELINES (TRANSFERRED TO 10A NCAC 25H .0302) |
| 10A NCAC 22O .0208. ANESTHESIA (TRANSFERRED TO 10A NCAC 25H .0303) |
| 10A NCAC 22O .0209. ANALGESIA (TRANSFERRED TO 10A NCAC 25H .0304) |
| 10A NCAC 22O .0210. DRUGS (TRANSFERRED TO 10A NCAC 25H .0305) |
| 10A NCAC 22O .0211. PRIOR APPROVAL (TRANSFERRED TO 10A NCAC 25H .0206) |
| 10A NCAC 22O .0301. MEDICAL SERVICES (TRANSFERRED TO 10A NCAC 25A .0201) |
| 10A NCAC 22O .0401. INPATIENT HOSPITAL SERVICES (PARAGRAPHS (A)-(D) TRANSFERRED TO 10A NCAC 25M .0201 AND PARAGRAPH (E) TRANSFERRED TO 10A NCAC 25P .0201)) |
| 10A NCAC 22O .0402. OUTPATIENT HOSPITAL SERVICES (TRANSFERRED TO 10A NCAC 25P .0301) |
| 10A NCAC 22O .0403. SKILLED NURSING FACILITY SERVICES (TRANSFERRED TO 10A NCAC 25M .0401(D)) |
| 10A NCAC 22O .0404. PHYSICIAN SERVICES (TRANSFERRED TO 10A NCAC 25P .0401) |
| 10A NCAC 22O .0405. PODIATRIST SERVICES (TRANSFERRED TO 10A NCAC 25P .0404) |
| 10A NCAC 22O .0406. HOME HEALTH SERVICES (TRANSFERRED TO 10A NCAC 25O .0201(B)-(E)) |
| 10A NCAC 22O .0407. PRESCRIBED DRUGS [REPEALED] |
| 10A NCAC 22O .0408. INTERMEDIATE CARE FACILITIES (TRANSFERRED TO 10A NCAC 25D .0201(C)-(J)) |
| 10A NCAC 22O .0409. THERAPEUTIC LEAVE (TRANSFERRED TO 10A NCAC 25M .0501) |
| 10A NCAC 22O .0410. PERSONAL CARE SERVICES (TRANSFERRED TO 10A NCAC 25O .0202(C)-(E)) |
| SUBCHAPTER P. |
| 10A NCAC 22P .0101. PURPOSE AND SCOPE |
| 10A NCAC 22P .0201. DEFINITIONS |
| 10A NCAC 22P .0301. SERVICE DELIVERY |
| 10A NCAC 22P .0302. ACCESS TO CARE |
| 10A NCAC 22P .0303. COORDINATION OF BENEFITS |
| 10A NCAC 22P .0401. CERTIFICATION REQUIREMENTS |
| 10A NCAC 22P .0402. GOOD STANDING |
| 10A NCAC 22P .0403. MEDICAL DIRECTOR REQUIREMENTS |
| 10A NCAC 22P .0404. CLINICAL DIRECTOR |
| 10A NCAC 22P .0405. QUALITY MANAGEMENT DIRECTOR |
| 10A NCAC 22P .0406. TRAINING DIRECTOR |
| 10A NCAC 22P .0407. EXCEPTION PROCESS |
| 10A NCAC 22P .0408. MEDICAL SCHOOL/ TEACHING HOSPITAL EXCEPTION |
| 10A NCAC 22P .0501. LETTER OF ATTESTATION AND DESK REVIEW |
| 10A NCAC 22P .0502. INTERVIEW |
| 10A NCAC 22P .0503. VERIFICATION REVIEW |
| 10A NCAC 22P .0504. EXISTING CRITICAL ACCESS BEHAVIORAL HEALTH AGENCIES |
| 10A NCAC 22P .0601. MONITORING |
| 10A NCAC 22P .0602. DECERTIFICATION AND SUSPENSION |
| 10A NCAC 22P .0603. APPEAL PROCEDURES |