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NC Medicaid - NCDHHSMedicaid · Prior Auth · Medical Policy · NC · PsychiatryHigh impact

Amendment to Clinical Coverage Policy 8G Peer Support Services

Act
by Sep 1, 2026
Effective date
Sep 1, 2026
Identified
Oct 3, 2026

Summary

NC Medicaid amended Clinical Coverage Policy 8G for Peer Support Services effective September 1, 2026. Key changes include: (1) new prior authorization and utilization management requirements, (2) revised documentation standards requiring start/end times for interventions, (3) telehealth/telephonic services limited to less than 10% of total service time per beneficiary per fiscal year, (4) only NC Certified Peer Support Specialists (NC CPSS) may bill for services, and (5) updated supervision and training requirements for PSS Program Supervisors and Peer Support Specialists.

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What to do

by Sep 1, 2026 · 7 steps
01Billing team must update billing system to enforce prior authorization and concurrent review/reauthorization requirements for all Peer Support Services claims per new utilization management guidance.
02Update documentation requirements in EMR/billing system to mandate that all service notes include start and end times for each intervention delivered.
03Implement system logic to track and limit telehealth and telephonic service delivery to less than 10% of total service time per beneficiary per fiscal year; flag claims exceeding this threshold for denial or correction.
04Restrict billing access to only NC Certified Peer Support Specialists (NC CPSS)—remove billing authorization for non-credentialed staff.
05Providers must maintain and submit upon request a roster of NC CPSS employed by their organization to NC Department of Health and Human Services, contracted PHPs, or PIHPs.
06Clinical/QA staff must ensure PSS Program Supervisors update supervision frequency and beneficiary progress monitoring per new requirements.
07Non-compliance will result in claim denials and potential audit findings.

Original notice

Amendment to Clinical Coverage Policy 8G Peer Support Services
medicaid.ncdhhs.gov · Always check the source before changing claims.
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NC Medicaid - NCDHHS policiesNC policy changesPsychiatry

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