The North Carolina Division of Medical Assistance (DMA) contracts with CCME to conduct prior authorization (PA) reviews for treatment services of certain outpatient therapies for Medicaid recipients of all ages. These therapies include:
- Physical Therapy
- Occupational Therapy
- Speech/Language-Audiology Therapy
- 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, Medicaid and Health Choice Clinical Coverage Policies.
All provider types, in all settings, are required to obtain PA for therapy services except hospital/rehabilitation inpatient settings.
The provider types that are required to obtain PA for therapy services are limited to:
- Home Health Agencies
- Public Health
- Independent Practicing Providers
- Local Management Entities
- Hospital Outpatient Clinics
- Physician Offices and Other Clinics
- Children’s Development Services Agencies
Therapy providers are required to submit their PA requests using ChoicePA, a proprietary web-based system with features such as 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.
For questions or additional information about the review process, contact the Therapy Services Department at 800-228-3365, option 1, or email us.
To learn more about CCME Prior Authorization Review Services, please download our fact sheet.
For information on ChoicePA, our proprietary web-based system, please download our fact sheet.