North Carolina Medicaid pediatric speech and OT coverage: codes, telehealth, limits and prior authorization
The short answerSLP and OT. NC Medicaid requires prior approval before any treatment visit, but not for evaluations. For children under 21, speech visits are set by severity (mild 6 to 26, moderate up to 46, severe up to 52 per authorization) and approvals run at most six months. 92507, 97530 and 97535 are telehealth eligible.
By Javier Alvarez · Updated · 2 min read
1 row: Medicaid (by state) · North Carolina. Public policy, not the member's benefits.
North Carolina Medicaid
NC Medicaid Outpatient Specialized Therapy Clinical Coverage Policy 10A · North Carolina
| 92507 | Listed (1 unit = 1 event; telehealth yes) [1] |
|---|---|
| 92508 | Listed (group; telehealth no) [1] |
| 92521 | Listed (evaluation; telehealth yes) [1] |
| 92522 | Listed (evaluation; telehealth yes) [1] |
| 92523 | Listed (evaluation; telehealth yes) [1] |
| 92524 | Listed (evaluation; telehealth yes) [1] |
| 92526 | Listed (telehealth yes for oral motor only) [1] |
| 97165 | Listed (oT evaluation; telehealth yes) [1] |
| 97166 | Listed (oT evaluation; telehealth yes) [1] |
| 97167 | Listed (oT evaluation; telehealth yes) [1] |
| 97168 | Listed (oT re-evaluation; telehealth yes) [1] |
| 97530 | Listed (1 unit = 15 minutes; telehealth yes) [1] |
| 97535 | Listed (1 unit = 15 minutes; telehealth yes) [1] |
| Where it applies | Evaluation and re-evaluation reports are required; treatment plans must be reviewed and renewed or revised at least every six calendar months, and an annual re-evaluation is required for continued treatment. [1] |
| Telehealth rules | Telehealth needs informed consent and must not be used solely for therapist convenience. Telehealth claims carry modifier GT. [1] |
| Visit limits | Under 21, speech-language therapy is limited by severity: mild 6 to 26 visits, moderate up to 46, severe up to 52, within an authorization period of no more than six calendar months. Physical and occupational therapy are limited to the medically necessary visits within a period of up to six months. Age 21 and older: up to 30 treatment visits per calendar year each for OT and PT habilitative (combined), OT and PT rehabilitative (combined), speech habilitative and speech rehabilitative. [1] |
| Prior authorization | Prior approval is required before all treatment services and is obtained from the DHHS utilization review contractor. Prior approval is not required for an evaluation or re-evaluation visit. For a child under 21 the request must show EPSDT criteria are met. [1] |
| Referral | A verbal or written order is required before all outpatient specialized therapy services. A written order is valid up to six months. [1] |
| Who can bill | Billing providers include independent practitioners, children's developmental service agencies, health departments, FQHCs, rural health clinics, hospital outpatient facilities and physician offices employing licensed therapists. A speech-language pathologist in the supervised experience year may work under a licensed SLP, and the supervising SLP bills. [1] |
| Payment | Timed units follow the CMS 8 minute rule: 1 unit is 8 to 22 minutes, 2 units 23 to 37 minutes, and so on. Evaluation and treatment must be on separate claims. [1] |
- NC Medicaid: Outpatient Specialized Therapy Clinical Coverage Policy 10A (amended Oct 1, 2026), checked October 30, 2026
What North Carolina Medicaid's documents say
The table above has every field we found for North Carolina Medicaid, with numbered sources. In short:
- Prior authorization. Prior approval is required before all treatment services and is obtained from the DHHS utilization review contractor. Prior approval is not required for an evaluation or re-evaluation visit. For a child under 21 the request must show EPSDT criteria are met.
- Visit limits. Under 21, speech-language therapy is limited by severity: mild 6 to 26 visits, moderate up to 46, severe up to 52, within an authorization period of no more than six calendar months. Physical and occupational therapy are limited to the medically necessary visits within a period of up to six months. Age 21 and older: up to 30 treatment visits per calendar year each for OT and PT habilitative (combined), OT and PT rehabilitative (combined), speech habilitative and speech rehabilitative.
- Who can bill. Billing providers include independent practitioners, children's developmental service agencies, health departments, FQHCs, rural health clinics, hospital outpatient facilities and physician offices employing licensed therapists. A speech-language pathologist in the supervised experience year may work under a licensed SLP, and the supervising SLP bills.
- Codes. 92507, 92508, 92521, 92522, 92523, 92524, 92526, 97165, 97166, 97167, 97168, 97530 and 97535 are listed.
Codes we checked at North Carolina Medicaid
What Medicaid's own text says about one code: 92507.
Check North Carolina Medicaid's claim against the row
Before the claim goes out, compare it with the row above: the evaluation and treatment codes are ones the policy lists, the plan of care and any prior authorization cover the date, and the visit count fits the limit. The pediatric speech and OT table compares Medicaid with every other payer we checked.