Home care billing in North Carolina

Two systems side by side. NC Medicaid Managed Care has four Standard Plans, three Behavioral Health and I/DD Tailored Plans, the Healthy Blue Care Together Children and Families Specialty Plan and the EBCI Tribal Option; NC Medicaid Direct is the fee-for-service program, and its claims go to NCTracks.¹³ Each plan adjudicates its own claims under a state contract posted on the health plans page, so an agency that serves members across the system keeps a rule set for every plan plus NCTracks. The Tailored Plan count fell from four to three on October 1, 2026, when Vaya Health and Partners Health Management merged as Vaya Partners, as NC Medicaid's merger notice sets out.

Open model with three aggregators. Sandata is the state's EVV vendor and hosts the free solution for NC Medicaid Direct; Healthy Blue's free solution is CareBridge, and all other Standard Plans, LME/MCOs and Tailored Plans use HHAeXchange. A provider may pick an alternate vendor, but every visit has to land in the aggregator for that payer.⁷ Two edits enforce it in NCTracks: EOB 02077, EVV not on file for the date of service, pends the claim for 14 days and then denies it; EOB 02079, submitted units exceed verified visit units, pends for seven days and then cuts the claim back to the verified units. EVV began January 1, 2021 for PCS and CAP services, April 1, 2023 for behavioral health and home health in NC Medicaid Direct and the Standard Plans, and July 1, 2024 for Tailored Plan services, and manual visit entry should stay at 15 percent or less.

Services under EVV⁸

• State Plan PCS: 99509 HA for any beneficiary under 21 regardless of setting, 99509 HB for in-home care agencies serving beneficiaries 21 and older
• CAP/C: in-home aide S5125, in-home respite S5150, congregate respite S9122 TF and TG, PNA in-home respite T1004, PNA assistance T1019, personal care assistance T2027 and T2027 TF
• CAP/DA, including the CAPCD consumer-directed lines: attendant care S5125 and S5125 UN, personal care assistance S5135 and S5135 UN, in-home respite S5150, PNA in-home respite T1004, PNA assistance T1019
• Innovations Waiver in-home services: community living and support T2013 TF and T2013 TF HQ, supported living periodic T2033 U1
• TBI Waiver in-home services: personal care S5125, in-home intensive T1015, community living and support T2013 TF and TF HQ, supported living periodic T2033 U1
• 1915(i) services: community living and supports T2013 TF U4 and TF HQ U4, individual and transitional support T1019 U4
• Home health: therapy revenue codes 420, 424, 430, 434, 440 and 444, skilled nursing 550, 551, 559, 580 and 581, and home health aide 570

Prior approval before the first visit. For State Plan PCS in the home the beneficiary needs a physician referral and attestation, an independent assessment from the state's independent assessment entity (CIAE), a service authorization for a set number of hours per month, and an approved service plan from the provider; the hours rest on an assessment of five activities of daily living (bathing, dressing, mobility, toileting and eating) rated from totally independent to totally dependent.⁹ Limits in policy 3L, amended January 1, 2026: up to 80 hours a month at age 18 and older, up to 60 hours a month under 21, and up to 50 additional hours a month for adults who meet every added criterion, including an increased level of supervision and caregivers trained in degenerative memory disease. Retroactive prior approval for an initial request dates from the request date on the Request for Independent Assessment, a reconsideration for more hours uses form NC Medicaid-3114, and providers must register with the state EVV solution or procure an alternate, keep written proof in each file that the beneficiary was told about EVV, and document initial and annual staff EVV training.

NC Medicaid Direct claims go to NCTracks with 365 days from the first date of service to file, counted from the last date of service for hospital inpatient and nursing facility claims.¹² Health plans must allow at least 365 calendar days as well, Standard Plans since July 1, 2023 and Tailored Plans and LME/MCOs since July 1, 2024, including corrected claims; state-funded services through a Tailored Plan keep a 90-day limit.

Palmetto GBA, the home health and hospice contractor for A/B MAC Jurisdiction M, processes Medicare home health and hospice claims for North Carolina agencies and also holds the state's Part A and Part B work.²⁰ Before those claims, DHSR's guide to establishing a certified home health agency sets three steps in order for a Medicare and Medicaid certified agency: a certificate of need, which DHSR issues only after approval under the State Medical Facilities Plan for an agency certified to provide nursing care, therapy, medical social services and home health aide services; a license under G.S. 131E-135 through 142 and 10A NCAC 13J; and Medicare certification, with an unannounced on-site survey scheduled after the agency has served 10 skilled care patients and 7 active non-Medicare patients. An agency accredited by a body named in the Home Care Licensure Act is deemed in compliance with the home care licensure rules and licensed on that basis. If the survey finds deficiencies, certification is effective on the latest date the agency signs a plan of correction.