Comunicación para el Proveedor 013

Reminders

Key Updates to NC Medicaid Clinical Coverage Policy 10A, Outpatient Specialized Therapy Services

Telehealth Updates 

One key update is the availability of occupational therapy (OT) and physical therapy (PT) telehealth service delivery for select service codes, with updated Outpatient Specialized Therapy (OST) telehealth and discharge criteria. The updated telehealth language was developed in consideration of Session Law 2025-64 (House Bill 546), research and stakeholder feedback. 

OST telehealth criteria are in Subsection 3.1.1 of Clinical Coverage Policy (CCP) 10A. Current Procedural Terminology (CPT) codes that may be provided via telehealth service delivery are indicated in Attachment A., Section C. Codes. 

Standard of Care Requirements 

NC Medicaid beneficiaries shall receive high-quality care aligned with best practices for telehealth service delivery and may request in-person services at any time. 

If a provider cannot meet the same standard of care as in-person services with telehealth service delivery, or if in-person services cannot be accommodated upon beneficiary request, the beneficiary must be discharged. At discharge, the therapist shall identify indicators for potential follow-up care or referral (Subsection 3.2.1.9).

Removal of Same-Day Local Education Agency and OST Service Restrictions

The other key change is the removal of language that precluded same day service delivery when OST services are also provided by a local education agency (LEA). This update complies with federal regulations 34 Code of Federal Regulations (CFR) 300.154 and IDEA: PL 108-446.

Non-Substantive Policy Updates 

All sections and attachments are updated with non-substantive changes such as: 

• Grammatical corrections 
• Template language 
• Style guide alignment
• Clarity enhancements 
• Billing and compliance reminders 

All claims must comply with the Medicaid National Correct Coding Initiative (NCCI). Modifier GT must be appended to the CPT code to indicate that a service has been provided via interactive audio-visual communication (telehealth).

Transition to American Medical Association Maternity Current Procedural Terminology 2027 Code Changes Effective Jan. 1, 2027

Beginning Jan. 1, 2027, all current maternity service codes, including global billing, will be deleted from the fee schedule, and the new maternity billing codes, released by the American Medical Association (AMA), will become effective as of this date. 

A list of all new, revised and deleted codes can be found on the AMA’s website. 

Transition Period-Starting Sept. 1, 2026 

To support a smooth transition, beginning Sept. 1, 2026, NC Medicaid Direct and NC Medicaid Managed Care providers are encouraged to use Evaluation and Management codes (E/M 99202-99215) with the TH modifier, to indicate prenatal or postpartum care. These codes should be used for: All claims and documentation for beneficiaries presenting for their first prenatal visit after confirmation Antepartum visits where the delivery and/or the postpartum visit is anticipated to occur after Jan. 1, 2027. In addition to the E/M codes, the appropriate ICD-10-CM code should be recorded including the weeks of gestation for verification. Documentation must support medical decision making or time consistent with Current Procedural Terminology (CPT) guidelines. 

Services Completed Before Jan. 1, 2027

For pregnancies that culminate with a postpartum visit prior to Jan. 1, 2027, all current existing codes, including global, 59425 (Antepartum care only; 4-6 visits) and 59426 (Antepartum Care only; 7 or more visits) may be billed. Health plans may not require the use of individual E/M codes in lieu of current bundled codes for dates of service prior to Jan. 1, 2027. 

Clinical Coverage Update

Clinical Coverage 1E-5 is being revised to reflect the updated information.

Innovations Direct Care Workers rate increase

C Medicaid recently announced that the incremental Innovations Waiver Direct Care Worker (DCW) rate increases are effective October 1, 2026. The initiative is supported by $21.3 million in recurring state funds appropriated under Session Law 2026-41, Section 9E.14.

The rate increase is intended to benefit eligible Innovations Waiver direct care workers. Providers may use the increased funding to support eligible DCWs through:

• Increased hourly wages;
• Employee benefits; and/or
• Associated payroll costs.

Innovations Waiver DCW Rate Add-Ons

Implementation and Claims Reprocessing

Trillium has released an updated fee schedule containing the Innovations DCW increases.  Providers can begin using the updated rates on or after October 5, 2026. If you have questions regarding the Innovations Waiver DCW rate increases, please contact the Rates Team at RatesFinance@TrilliumNC.org.

Trillium will also reprocess claims with dates of service on or after July 1, 2026, to ensure that providers receive the increased rates retroactive to that date. Innovations claims that have already been processed and are impacted by the rate increase will be reprocessed by Trillium back to July 1, 2026. No action is required by providers at this time.

Additional Requirements

Please be aware that additional requirements apply to providers receiving the DCW rate increase. These requirements include:

• Completion and submission of a signed attestation;
• Annual reporting; and
• Maintenance of appropriate supporting documentation, including payroll and other records demonstrating how the increased funds are being utilized.

Additional communication regarding these requirements will be provided in the future.

Additional Information

For more information, please refer to:

• Direct Care Worker Wage Increase Initiatives - SFY 2027 webpage
• DCW Wage Increase Initiative FAQs - SFY 2027

Provider Reverification Application Reminders

All providers enrolled in the Medicaid program must complete the reverification application process every five years, as mandated by federal law 42 CFR § 455.414. This process ensures that provider information is accurate and current and includes an evaluation of the provider’s credentials and qualifications to ensure they meet professional requirements and remain in good standing. 

Providers are given 70 days from the initial notification date to complete the re-verification application. Although applicable to all providers (but especially those that require fingerprinting and site visit) acting promptly upon receiving the notice allows ample time to complete the process, and when necessary, to resubmit a new application if their original application is denied, withdrawn, or abandoned.

Do not wait to submit. Providers should take advantage of the 70-day timeframe given to ensure completion without adverse action. 

Additional reverification reminders to consider 

Corrections cannot be made to any application once submitted, so any errors or omissions in a reverification application can result in the application being abandoned, denied or withdrawn. Providers who respond early to the reverification notice will have more time to resubmit a new application to correct any mistakes or incomplete data. Providers who wait until their suspension date nears risk suspension and termination. 

Confirm that all active taxonomies are used by the provider. Each service location must have at least one active taxonomy, but some require additional credentials, screenings (i.e. site visit and fingerprinting), or a federal fee as published on the Provider Permission Matrix (PPM). If a taxonomy is no longer in use, end-date it to avoid possible expense and additional screening.

If your taxonomy is designated as High or Medium Categorical Risk on the PPM, you will be asked whether you have paid the federal fee or had a site visit through Medicare or another state’s Medicaid program. Site visits are required per 42 CFR § 455.432. 

If the fee or site visit was conducted for the name, NPI, and location matching the reverification application being submitted, answer the question “Have you completed the Federal Fee (site visit) for this site to NC Medicaid, another state or Medicare within the past five years?” affirmatively with the correct response. 

It is crucial to answer these questions correctly to avoid adverse action and delays in processing the application. 
Review each active owner and managing employee (ME), being sure to end-date any who are no longer associated with the individual provider or organization, as background checks are required for everyone who is active on the record. The reverification must be completed, and applicable fees paid, by or before 5 p.m. on the due date; otherwise, the provider record will be suspended and claims will pend. 

As a convenience, NC Medicaid offers an Active Provider Reverification Report on the Provider Recredentialing webpage. This report is now updated monthly and offers reverification due dates over a period of 12 months. Providers should review the reverification due date list and frequently check their NCTracks Provider Message Inbox for notifications or the reverification section of the Status and Management page in the NCTracks Secure Portal for the option to reverify.

Unannounced Site Visits Effective October 1, 2026

Beginning Oct. 1, 2026, site visits mandated under 42 Code of Federal Regulation (CFR) § 455.432 will no longer be scheduled. The Public Consulting Group (PCG) is contracted by NC Medicaid to perform the federally mandated screening of Medicaid providers classified as moderate and high-risk. Providers will receive a notification from PCG that a visit will occur within a specified timeframe, rather than the traditional scheduled visit with a predetermined date and time.

Pursuant to 42 CFR § 455.432(b): The State Medicaid agency must require any enrolled provider to allow CMS, its agents, its designated contractors, and/or the State Medicaid agency to conduct unannounced on-site inspections of any and all provider locations. 

Pursuant to Section 7.c. of the NCDHHS Provider Administrative Participation Agreement: Provider agrees to cooperate with all announced and unannounced site visits, audits, investigations, or program integrity activities conducted by Federal and State officials, Department personnel and/ or its legally authorized agents, contractors, or vendors, their successors and assigns for the purpose of certification and compliance surveys, inspections, medical and professional reviews, monitoring, and audits of costs and data relating to services to recipients. 

Such visits, including unannounced visits, must be allowed at any time during normal hours of operation. Failure to grant prompt and reasonable access upon reasonable request may result in suspension of the Provider and/or of reimbursements or termination from participation in the North Carolina Medicaid program.

What Providers Can Expect 

Providers subject to site visits on or after Oct. 1, 2026, should expect to receive a notification from Public Consulting Group (PCG) that a visit will occur within a specified timeframe. A site visit will not be scheduled on a specific date or time Oct. 1, 2026. However, providers who had a site visit scheduled in advance of the Oct. 1, 2026 policy change can expect the site visit to be conducted as scheduled. 

Additionally, providers who have already completed a site visit through Medicare within the past five years should indicate this on their application. These providers will not need to complete another site visit at this time.

Trillium’s Provider Access API

Trillium’s Provider Access API allows providers to electronically request certain data about your members that we cover directly from us. We are providing instructions on how to use the API to simplify this process. 

Provider Educational Resources

• Provider Access in General 
• Provider Education: 
  •    How to pull data for attributed members 

To ensure our Providers receive the right data for the right member, Trillium is providing an explanation of our attribution process. We will use this process to determine which of our members have a treatment relationship with you, our provider. Trillium and 1upHealth work together to figure out which Trillium members each provider has treated. They look at paid claims from the past year. They include all billing providers and do not use any extra rules to remove or filter out providers.
 

NC Medicaid is Changing - What Providers Need to Know

A new federal rule starts on January 1, 2027. Most adults ages 19-64 without a disability will need to work, go to school or volunteer for 80 hours each month to keep Medicaid, or earn at least $580 per household each month. This is called the work and community engagement rule. 

Some people will not have to meet the new work and community engagement rule. For example, members may not have to meet the new rule if they:

•  Are a parent, guardian, caretaker relative or family caregiver for a child under age 14 or a person with a disability
• Have been determined by NC Medicaid as having a disability
• Are pregnant or were pregnant in the last 12 months

There are many exceptions. If members are not sure, please encourage them to contact their local Department of Social Services (DSS). More information is available at New Medicaid Requirements May Affect Your Coverage.

Join Trillium’s Global Quality Improvement Committee

Are you passionate about enhancing healthcare quality and driving meaningful change? Trillium is seeking a dedicated Consumer and Family Advisory Committee (CFAC) representative (North Central region), as well as an Integrated Care Representative to join the Global Quality Improvement Committee (GQIC). The Integrated Care Representative seat is designated for a professional currently working within a primary care setting or an Advanced Medical Home (AMH) who can bring a whole-person, team-based perspective to the committee’s work. An ideal representative actively collaborates across disciplines—behavioral health, physical health, care management, and social supports—to improve outcomes for individuals with complex needs.

The GQIC is a dynamic group of practitioners, providers, specialists, and family representatives working together to improve healthcare quality. By joining, you’ll have the opportunity to:

• Collaborate on impactful quality initiatives.
• Share insights and expertise with peers and Trillium staff.
• Help shape recommendations that guide quality improvement efforts.

If you are interested in joining GQIC, please complete the GQIC Interest Form and submit it to QMInfo@TrilliumNC.org. Visit Trillium Health Resources - Committees or My Learning Campus for more information about GQIC.

Peer Support Clinical Coverage Policy 8G Change

The updated Peer Support Clinical Coverage Policy 8G promulgated on September 1, 2026. All changes to the policy will need to be in place by October 31, 2026. Trillium shall require prior approval for Peer Support Services provided beyond the unmanaged unit limitation of twenty-four (24) units. A beneficiary is permitted unmanaged units once per episode of care. Refer to Subsection 5.3 in 8G for additional limitations. Trillium may cover up to 176 units of PSS over a 60-calendar-day authorization period, not to exceed 88 units per 30-calendar-day period. Authorization requests for more than 88 units per 30-calendar-day period must be reviewed and reauthorized every 30 calendar days.  Please see all updated changes and rules for authorizations of this service.

2026-2027 National Core Indicators I/DD Survey

Trillium is partnering with NCDHHS to support the annual National Core Indicators (NCI) survey, which evaluates the outcomes of individuals receiving Intellectual and Developmental Disability (I/DD) services. This survey examines critical areas such as employment, community involvement, relationships, health and wellness, safety, and access to services.

Standardized questions allow for comparisons between states and provide valuable insights into service quality. 

How Providers Will Be Involved

Beginning in September 2026, providers serving members with I/DD aged 18 and older may be contacted to assist in the following ways: 

• Obtaining member consent for survey participation. 
• Providing background information for consenting members. 

Survey administration will be handled by the Carolina Institute for Neurodevelopmental Disabilities (CIND), a third-party organization contracted by the State. 

Eligibility Requirements for Survey Participation 

Members must meet the following criteria to participate in the survey:

• Be diagnosed with an intellectual or developmental disability. 
• Receive Medicaid-funded services from an I/DD provider agency. 
• Be at least 18 years old. 

Next Steps for Providers 

If your agency provides services to eligible members, please email Surveys@TrilliumNC.org with contact information for the point of contact for the NCI-IDD survey within your agency as soon as possible. Trillium will send additional details, including the list of members selected to participate, via email.

Roadmap 2 Ready - September 2026

Trillium advises providers to continue monitoring tropical activity through November 30, know your risk for hurricanes, and get a kit. The time to put an emergency kit together is before a disaster. It's important to include enough water, food, and supplies in your kit for three to seven days for each person and pet. Being ready for an emergency helps you and your family and allows police, firefighters, and emergency medical workers to focus on helping others who may need it most. 

Review North Carolina Emergency Management emergency kit recommendations for basic supplies, unique needs, and first aid by visiting ReadyNC.gov.

Provider My Learning Campus Reminder

To find updated and current Provider Trainings, please visit: Provider My Learning Campus or this list of provider trainings.