In order for NC Innovations to cover (pay for) treatment (services) those services must be deemed “medically necessary.” This means treatment and services must be:  

  • Necessary and appropriate for the prevention, diagnosis, palliative, curative, or restorative treatment of a mental health or substance abuse condition.
  • Consistent with Medicaid policies and National or evidence based standards, North Carolina DHHS defined standards or verified by independent clinical experts at the time the procedures, products and services are provided.
  • Provided in the most cost effective, least restrictive environment that is consistent with clinical standards of care.
  • Not provided solely for the convenience of the individual, family members, custodian or provider.
  • Not for experimental, investigational, unproven or solely cosmetic purposes.
  • Furnished by or under the supervision of a licensed professional (as relevant) under State law in the specialty for which they are providing service and in accordance with Title 42 of the Code of Federal Regulations, the Medicaid State Plan, the North Carolina Administrative Code, Medicaid medical coverage policies, and other applicable Federal and state directives;
  • Sufficient in amount, duration and scope to reasonably achieve their purpose, and
  • Reasonably related to the diagnosis for which they are prescribed regarding type, intensity, and duration of service and setting of treatment.

Within the scope of the above guidelines, medically-necessary treatment shall be designed to:

  • Be provided in accordance with the person-centered Individual Service Plan which is based upon a comprehensive assessment, and developed in partnership with the person receiving services (or in the case of a child, the child and the child’s family or legal guardian) and the community team;
  • Conform with any advanced medical or mental health directives that  have been prepared;
  • Respond to the unique needs of linguistic and cultural minorities and furnished in a culturally relevant manner; and
  • Prevent the need for involuntary treatment or institutionalization.

Page last modified: October 26, 2015
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