The North Carolina Division of Medical Assistance (DMA) has contracted with CCME to conduct prior authorization (PA) reviews of certain outpatient therapies for Medicaid recipients of all ages. These therapies include:
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Physical Therapy
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Occupational Therapy
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Speech/Language-Audiology Therapy
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Respiratory Therapy
The purpose of the reviews is to determine if the recipient’s medical condition and needs justify the frequency and intensity of service to be provided and to safeguard against duplication of services, inappropriate services, and excess payments. More detailed information about coverage criteria, billing, and other program requirements can be found in North Carolina DMA Outpatient Specialized Therapies, Clinical Coverage Policy 10A.
Effective with dates of service beginning December 1, 2009, PA is required for recipients under 21 years of age. PA for recipients 21 years of age and older is required for dates of service beginning January 1, 2010.
The provider types that are required to obtain PA for therapy services are limited to:
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Home Health Agencies
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Public Health
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Independent Practicing Providers
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Local Management Entities
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Hospital Outpatient Clinics
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Physician Offices and other Clinics
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Children’s Development Services Agencies
Therapy providers are required to submit their PA requests using  which also features provider training, helpful hints, and frequently asked questions. Through the website, providers have the ability to track the status of PA requests, respond to any requests for additional information, and participate in a provider discussion board moderated by CCME staff.
In addition to conducting PA reviews, CCME is responsible for performing post-payment reviews of therapy services. Our retrospective review will help DMA evaluate the appropriateness of the care delivered and the accuracy of billing charges.
For questions or additional information about the review process, contact the Therapy Services Department at 800-228-3365, option 1, or priorauth@thecarolinascenter.org.
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