The North Carolina Medicaid Personal Care Services (PCS) program is an essential service for many beneficiaries, providing crucial support for individuals needing assistance with daily living activities. For providers, staying informed about program updates, policy changes, and compliance requirements is paramount to ensure seamless service delivery and proper reimbursement. This article consolidates key announcements and updates related to the NC Medicaid PCS program, offering a comprehensive overview for providers.
Recent Policy and Reimbursement Updates
Transition to Daily Reimbursement Rates for Congregate Settings
Effective January 1, 2025, NC Medicaid is implementing a significant change in how Personal Care Services (PCS) are reimbursed for individuals residing in congregate settings such as adult care homes, combination homes, and special care units. This shift moves away from the previous 15-minute increment billing to a daily per diem rate.
This adjustment means that reimbursement will no longer be directly tied to the specific time spent delivering services each day. Instead, providers will be reimbursed based on a calculated daily rate. This daily rate is determined by the total units prior-approved by NC Medicaid for PCS for each beneficiary during an authorized period.
The “APPROVED DAILY UNITS” are calculated using the existing Prior Authorization (PA) information at the time of claim adjudication. The formula used is: PA Approved Daily Units / Approved PA days, where “Approved PA days” is defined as “PA End date – PA Beg Date + 1 Day.” For instance, if a beneficiary’s PA authorizes 320 total units over a 30-day period, the approved daily units would be 320/30 = 10.666. Providers will then submit one line per date of service for billing.
Two Clinical Coverage Policies (CCPs) detailing this new payment methodology are available in Attachment A- Claims-Related Information. These policies, effective January 1, 2025, are accessible on the NC Medicaid website and are crucial for providers to understand the new billing procedures. The relevant CCPs are:
- Personal Care Services in In-home settings (3L)
- Personal Care Services in Congregate Settings (3L-1)
Specifically, CCP 3L-1, Personal Care Services in Congregate Settings, applies to providers billing with CPT code 99509 HC- Adult Care Homes, 99509 TT – Combination Homes, and 99509 SC – Special Care Units. Providers are encouraged to review the Medicaid Bulletins for in-depth information on this change.
To further support providers through this transition, informational webinars were held on December 3rd and 11th. Recordings and materials from these sessions may be available through NC Medicaid resources for those who could not attend live.
Important Notice Regarding DHB Form DHB3051
Starting April 1, 2025, providers must use the current version of the DHB 3051, Request for Services and Instructions form when submitting Personal Care Services (PCS) requests. Submissions using older versions of the DHB3051 form will face processing delays as providers will be required to correct their requests using the updated form. This change is crucial for ensuring efficient processing of PCS requests and avoiding unnecessary delays in service authorization.
Compliance and Quality Improvement Program Updates
Annual Compliance with Clinical Coverage Policy 3L
Adherence to Clinical Coverage Policy 3L is a critical aspect of participating in the NC Medicaid Personal Care Services (PCS) program. Annually, all enrolled PCS providers authorized to render services must formally attest to their compliance with Section 7.7 of this policy, which pertains to the Internal Quality Improvement Program.
To fulfill this requirement, providers must complete and sign the Quality Improvement Attestation Form, designated NC Medicaid 3136, on or before December 31st of each calendar year. Guidance on completing this form can be found in the instructional document NC-Medicaid 3136 I. After completing the attestation, providers are required to upload the signed form to the QiRePort portal. NC Medicaid utilizes the QiRePort portal to monitor and audit provider compliance with Section 7.7. All providers are mandated to use this portal for submitting their signed attestation forms.
Session Law 2013-306 PCS Training Attestation
For providers serving beneficiaries approved for additional service hours under Session Law 2013-306, there’s a specific requirement to submit a Session Law 2013-306 PCS Training Attestation Form, NC Medicaid 3085. This form must be submitted before serving these beneficiaries. Completion of this attestation confirms that the provider’s aide training curriculum meets the necessary standards to support beneficiaries requiring additional hours. This attestation is a one-time requirement, only necessary when additional hours are requested for a beneficiary. Instructional guidance for this form is available via NC Medicaid-3085 I. This form also needs to be uploaded to the QiRePort Portal.
QiRePort Portal for Form Submissions
NC Medicaid has streamlined the submission process for forms 3136 and 3085 by mandating electronic uploads through the QiRePort portal. This system serves as the primary database for verifying form submissions during compliance audits, making it essential for providers to utilize it correctly.
Steps to Upload Forms Electronically via QiRePort:
- PI Setup Menu Access: Navigate to the PI Setup Menu within QiRePort.
- Locate Provider Documents: Click on “Documents” and find your Provider Name/NPI#. (Note: Access to the Setup menu and document upload is restricted to providers with administrative rights).
- Add Document: Select the Provider Name hyperlink, then click “Add Document.” This action will open the “Upload Record” screen.
- Specify Document Details: On the “Upload Record” screen, choose the Document Type, Document Year, and upload the relevant file (Record). (Important: Ensure the NC Medicaid 3136 and/or 3085 forms are saved on your computer or an external device before attempting to upload).
- Complete and Save: Click “Done” to place the uploaded document in the Provider Documents table for storage. Finally, select “Save” to finalize the record and complete the upload process.
Key Points Regarding Form Uploads:
- Only authorized individuals with administrative rights at the provider agency can upload Forms 3136 and 3085.
- Forms 3136 and 3085 are uploaded at the provider level and are not specific to individual beneficiaries.
- QiRePort is the central repository for storing and managing these forms.
For any questions concerning administrative rights, document uploads, or other QiRePort portal issues, providers should contact VieBridge Support at 888-705-0970. For PCS program-specific questions, contact NC Medicaid at [email protected] or 919-855-4360.
NCLIFTSS and Comprehensive Independent Assessment Entity (CIAE) Transition
NCLIFTSS and KEPRO (Acentra Health)
NC Medicaid has transitioned to a new Comprehensive Independent Assessment Entity (CIAE), KEPRO, also known as Acentra Health, under the NC Linking Individuals and Families for Long Term Services and Supports (NCLIFTSS) initiative. This transition aims to enhance and streamline the assessment process for beneficiaries requiring long-term services and supports, including Personal Care Services.
To ensure a smooth transition and prevent any service gaps for PCS beneficiaries, NC Medicaid implemented an extension of all eligible Medicaid Direct PCS beneficiaries’ prior approvals (PAs) during the initial phase of annual assessment scheduling by Kepro/Acentra. Scheduling of these annual appointments commenced after October 2023.
Extending Beneficiary Prior Authorizations (PAs)
To manage the transition to the new CIAE and avoid service disruptions, NC Medicaid has implemented a system for automatically extending Prior Authorizations (PAs) for beneficiaries whose annual assessments are delayed beyond their anniversary date.
Monthly PA Extension Process:
- System Check: At the end of each month, the system identifies beneficiaries who have not had an annual assessment within the past year and whose current authorization is set to expire that month (e.g., PAs expiring 11/30/2023).
- Automatic PA Extension Generation: For beneficiaries meeting these criteria, QiReport automatically generates PA extensions and transmits them to NC Tracks on the last day of the month (e.g., PAs transmitted on 11/30/2023).
- Provider Verification: Providers should check NC Tracks two business days after the last day of each month (not before) to confirm that PAs have been extended for their beneficiaries (e.g., check NC Tracks on 12/04/2023 for authorizations expiring 11/30/2023).
- Contacting Medicaid (If Necessary): Providers should only contact Medicaid if they determine that a PA was not extended for a beneficiary whose authorization expired in the previous month (e.g., if a provider checks NC Tracks on 12/04/2023 and the last PA in the system is still 11/01/2023-11/30/2023).
This automated extension process is designed to ensure continuity of care for beneficiaries during the CIAE transition and assessment scheduling period.
Electronic Visit Verification (EVV) Implementation
EVV System Requirement
In compliance with the 21st Century Cures Act, NC Medicaid is implementing Electronic Visit Verification (EVV) for Personal Care Services (PCS). EVV is mandated for personal care services and home health care services that require in-home visits by a provider. This requirement applies to State Plan Personal Care (PCS) [In-Home], CAP/DA, CAP/C, Self-directed Personal Attendant Care Services, Innovations Waiver, TBI Waiver, and the 1115 Managed Care Demonstration Waiver programs.
EVV serves as a method to electronically verify service delivery for home- and community-based service programs. It enhances accountability, ensuring that beneficiaries authorized for services actually receive them. NC implemented EVV effective January 1, 2021, partnering with Sandata Technologies, LLC as the state’s EVV vendor.
NC Medicaid is committed to supporting providers through this EVV implementation. Resources and training materials are available, and providers are encouraged to utilize these to ensure smooth adoption of EVV systems.
Conclusion
Staying abreast of updates and changes within the North Carolina Medicaid Personal Care Services program is crucial for providers. From reimbursement model shifts and form updates to CIAE transitions and EVV implementation, the program landscape is continually evolving. Providers are encouraged to regularly consult official NC Medicaid communications, participate in webinars and training sessions, and utilize available resources to ensure they remain compliant, informed, and capable of delivering high-quality care to beneficiaries under the Personal Care Services program. For further information and resources, providers should visit the official NC Medicaid website and the NCLIFTSS portal.
