Prior Authorization

Medical necessity is defined for Carolina Complete Health beneficiaries as healthcare services, supplies or equipment provided by a licensed healthcare professional that are:

• Appropriate and consistent with the diagnosis or treatment of the patient’s condition, illness, or injury;
• In accordance with the standards of good medical practice consistent with evidence based and clinical practice guidelines;
• Not primarily for the personal comfort or convenience of the beneficiary, family, or provider;
• The most appropriate services, supplies, equipment, or level of care that can be safely and efficiently provided to the beneficiary;
• Furnished in a setting appropriate to the patient’s medical need and condition and, when supplied to the care of an inpatient, further mean that the beneficiary’s medical symptoms or conditions require that the services cannot be safely provided to the beneficiary as an outpatient service;
• Not experimental or investigational or for research or education.
• For information on the medical necessity “EPSDT Guarantee” please see the “Early Periodic Screen, Diagnostic and Treatment Services” section

Experimental studies and related guidance is found in the following:

• Clinical Policy: Experimental Technologies
• Clinical Policy: Medical Necessity Criteria

See Provider Manual for additional details.

Notice to Behavioral Health (BH) Providers:

Carolina Complete Health (CCH), in collaboration with NC Division of Health Benefits (DHB), is committed to vigilant oversight of BH Utilization Management Guidelines to ensure ongoing compliance with the Mental Health Parity and Addiction Equity Act of 2008. Effective 01/01/2025, Utilization Management measures (i.e. prior authorization), where previously applied, are suspended for the following services:

• Geropsychiatric Units in Nursing Facilities
• Partial Hospitalization
• Substance Abuse Intensive Outpatient Program
• Substance Abuse Comprehensive Outpatient Treatment
• Peer Support Services
• Facility-Based Crisis (adult and children/adolescent)
• Medically Monitored Inpatient Withdrawal Management Services (non-hospital detox)
• Ambulatory Withdrawal Management With and Without Extended On-Site Monitoring
• Psychological Testing

Once UM guidelines/authorization requirements have been approved by NC DHB, another communication will be sent outlining those guidelines specific to CCH.

UM requirements will continue for the following services:

• Behavioral Health (MH & SUD) Inpatient Services (following the first 72 hours of admission)
• Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorders
• Any non-covered services applicable under EPSDT
• Out-of-network providers

The following services will continue to have no prior authorization requirements:

• Mobile Crisis Management
• Behavioral Health Urgent Care
• Diagnostic Assessment
• Opioid Treatment Program
• Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers (Outpatient Therapy (Individual, Group, Family) and Medication Management)

For additional information/questions, please email networkrelations@cch-network.com.