Personal Care Services (PCS) programs are crucial for many individuals, and staying informed about program updates is essential for providers. This article consolidates key announcements and changes related to North Carolina (NC) Medicaid’s Personal Care Services, offering a comprehensive overview for service providers. These updates cover important areas such as reimbursement methodologies, form updates, system changes, and compliance requirements, all designed to streamline processes and ensure quality care.
Reimbursement Methodology Shifts for Congregate Settings
Effective January 1, 2025, NC Medicaid is implementing a significant change in how Personal Care Services are reimbursed for individuals residing in congregate settings like adult care homes, combination homes, and special care units. The previous 15-minute increment billing system is being replaced with a daily per diem rate. This adjustment, in accordance with Session Law 2019-240 Section 1(b), aims to simplify reimbursement and base it on the total prior-approved service units rather than the specific time spent each day.
The daily rate calculation will be based on the total units approved in the Prior Authorization (PA). The “APPROVED DAILY UNITS” will be determined by dividing the total approved units by the number of days in the authorized period (PA End date – PA Beg Date + 1 Day). For instance, if a PA authorizes 320 units over 30 days, the daily approved unit count would be approximately 10.666 (320/30). Providers will then submit claims with one line per service date.
Two new Clinical Coverage Policies (CCPs) will detail this reimbursement methodology: Personal Care Services in In-home settings (3L) and Personal Care Services in Congregate Settings (3L-1). Policy 3L-1 specifically addresses providers using CPT code 99509 HC, 99509 TT, and 99509 SC for congregate settings. These policies will be available on the NC Medicaid website and were set to take effect on January 1, 2025. Informational webinars were held in December 2024 to further explain these changes to providers.
Important Form Updates and QiRePort Portal Usage
Several updates concern required forms and the utilization of the QiRePort portal for submissions. Starting April 1, 2025, requests for PCS using outdated DHB3051 forms will face processing delays. Providers must use the current version of the DHB 3051, “Request for Services and Instructions,” to avoid these delays.
Furthermore, to enhance the efficiency of audits, NC Medicaid now requires all providers to upload their NC Medicaid 3136 and NC Medicaid 3085 forms to the QiRePort portal. This portal will be the sole system used to verify form submissions during compliance audits.
The Quality Improvement Attestation Form (NC Medicaid 3136) is an annual requirement, due by December 31st each year for every NPI. This form confirms provider compliance with Clinical Coverage Policy 3L, Section 7.7, focusing on the Internal Quality Improvement Program. Instructional guidance is available with form NC-3136 I.
Providers serving beneficiaries needing additional hours under Session Law 2013-306 must also submit the Session Law 2013-306 PCS Training Attestation Form (NC Medicaid 3085) before service provision. This one-time form, per agency, verifies that the aide training curriculum is complete and the provider is qualified to support beneficiaries approved for additional hours. Instructions are provided with form NC Medicaid-3085 I.
Steps to Upload Forms to QiRePort:
- Navigate to the PI Setup Menu.
- Click “Documents” and locate your Provider Name/NPI# (Administrative rights are needed for Setup menu access).
- Select the Provider Name hyperlink, then “Add Document.”
- On the “Upload Record” screen, choose Document Type, Document Year, and upload the form file.
- Click “Done” and then “Save” to complete the upload.
It is crucial to note that only individuals with administrative rights can upload these forms, and the forms are provider-specific, not beneficiary-specific. For QiRePort portal support, providers can contact VieBridge Support at 888-705-0970. For PCS program questions, contact NC Medicaid at PCS_Program_Questions@dhhs.nc.gov or 919-855-4360.
Extending Beneficiary Prior Authorizations (PAs)
To ensure continuous service for beneficiaries, NC Medicaid has implemented a system for automatic extension of Prior Authorizations (PAs). Monthly, the system identifies beneficiaries whose annual assessments are delayed and whose authorizations are expiring. For these beneficiaries, QiReport automatically generates PA extensions and transmits them to NC Tracks on the last day of the month.
Providers are advised to check NC Tracks two business days after month-end to confirm PA status. Contacting Medicaid is only necessary if a PA was not extended for a beneficiary whose authorization expired the previous month.
Transition to New Comprehensive Independent Assessment Entity (CIAE)
NC Medicaid transitioned to a new Comprehensive Independent Assessment Entity (CIAE), awarding the contract to Keystone Peer Review Organization, Inc. (Kepro), also known as Acentra Health. This transition involved the launch of the NC Linking Individuals and Families for Long Term Services and Supports (NCLIFTSS) system.
To ensure a smooth transition and prevent service gaps, NC Medicaid extended all eligible Medicaid Direct PCS beneficiaries’ PAs while annual assessments were being scheduled by Kepro/Acentra. Scheduling of these appointments commenced after October 2023. Webinars were conducted to guide providers and beneficiaries through the NCLIFTSS system.
Electronic Visit Verification (EVV) Implementation
North Carolina Medicaid is mandated to implement Electronic Visit Verification (EVV) for personal care services and home health care services as per the 21st Century Cures Act. EVV is a system to electronically verify service visits, ensuring accountability and confirming that authorized services are indeed delivered.
Sandata Technologies, LLC was selected as the state’s EVV vendor, and EVV implementation became effective January 1, 2021. NC Medicaid conducted a survey to understand EVV system usage among providers and offered resources and webinars to support providers and beneficiaries in adopting EVV.
Past CIAE Contract Award and Cancellation
In early 2020, there was a prior contract award for CIAE services to KEPRO, which was subsequently cancelled due to a protest. This historical context clarifies the later announcement of KEPRO (Acentra Health) as the contracted CIAE, indicating a re-awarding of the contract after resolution of the earlier issues. During the interim period following the cancellation, existing contracts for independent assessments were extended to maintain service continuity.
Conclusion
Staying abreast of changes within Personal Care Services programs is critical for NC Medicaid providers. The updates outlined here—from reimbursement methodology and form management to system transitions and EVV implementation—are designed to refine service delivery and administrative processes. Providers are encouraged to utilize the resources mentioned, including Medicaid Bulletins, webinars, and direct contacts, to ensure they remain compliant and continue to provide effective, quality care within the NC Medicaid PCS framework. Continuous engagement with official NC Medicaid communications will ensure providers remain informed of any future changes and updates to these vital programs.
