North Carolina Medicaid psychological testing coverage: telehealth and limits
The short answerNC Medicaid allows 8 hours of psychological testing per state fiscal year without prior approval, and no more than 8 hours on one date of service. Testing must happen in person, cannot be educational, and needs a DSM-5 diagnosis or suspected diagnosis. This policy is from 2021, so check for later amendments.
By Javier Alvarez · Updated · 1 min read
1 row: Medicaid (by state) · North Carolina. Public policy, not the member's benefits.
North Carolina Medicaid
Clinical Coverage Policy 8C, Outpatient Behavioral Health Services by Direct-Enrolled Providers (amended 09/01/2021) · North Carolina
| Where it applies | All criteria are required: a DSM-5 diagnosis or suspicion of one, functional impairment consistent with it, the ability to engage in testing, and no evidence that other tests would be more effective. Testing results must inform treatment selection and planning. [1] |
|---|---|
| Telehealth POS | Policy 8C (amended September 1, 2021) says testing is not covered if the service is not provided in person. Billing must occur only on dates when the beneficiary is seen in person, although testing activities on other dates may be billed. Check NC Medicaid's current telehealth policy. [1] |
| Visit limits | Per Policy 8C (amended September 1, 2021), unmanaged coverage is limited to eight hours of psychological testing per state fiscal year; prior approval is required to exceed it. A limit of eight units (hours) of testing per date of service also applies. A diagnostic interview is not allowed on the same day as testing by the same provider. [1] |
| Also | Not covered for educational testing, when requested by the school or legal system unless medically necessary, when measures lack standardized norms or documented validity, or when the focus is not the symptoms of the DSM-5 diagnosis. A written report to the referral source is required. [1] |
What North Carolina Medicaid's documents say
The table above has every field we found for North Carolina Medicaid, with numbered sources. In short:
- Visit limits. Per Policy 8C (amended September 1, 2021), unmanaged coverage is limited to eight hours of psychological testing per state fiscal year; prior approval is required to exceed it. A limit of eight units (hours) of testing per date of service also applies. A diagnostic interview is not allowed on the same day as testing by the same provider.
- Telehealth POS. Policy 8C (amended September 1, 2021) says testing is not covered if the service is not provided in person. Billing must occur only on dates when the beneficiary is seen in person, although testing activities on other dates may be billed. Check NC Medicaid's current telehealth policy.
- Where it applies. All criteria are required: a DSM-5 diagnosis or suspicion of one, functional impairment consistent with it, the ability to engage in testing, and no evidence that other tests would be more effective. Testing results must inform treatment selection and planning.
Check North Carolina Medicaid's claim against the row
Before the claim goes out, compare it with the row above: the evaluation and administration codes pair the way the policy says, the hours fit any cap, the referral question is documented, and prior authorization covers the units. The psychological testing table compares Medicaid with every other payer we checked.