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NC Medicaid Clinical Coverage Policy No. 3L-1 - State Plan Personal Care Services (PCS), Section 5.4 (Assessments and Reassessments)

North Carolinasub-regulatoryNorth Carolina Department of Health and Human Services (NC DHHS), Division of Health Benefits (NC Medicaid)

What this rule requires your agency to do

  • 1The provider must report beneficiary discharges to the CIAE within seven (7) business days of the discharge via the Provider Interface. (Sec. 5.4.5(c))(NC Medicaid Clinical Coverage Policy No. 3L-1 - State Plan Personal Care Services (PCS), Section 5.4 (Assessments and Reassessments))
  • 2The provider must refer all beneficiaries requiring PCS assessments for authorizing services to the designated CIAE and may not perform the assessments itself. (Sec. 5.4(b))(NC Medicaid Clinical Coverage Policy No. 3L-1 - State Plan Personal Care Services (PCS), Section 5.4 (Assessments and Reassessments))
  • 3The agency (CIAE) must conduct reassessments not less frequently than once every 365 calendar days, with the next reassessment date set no later than 365 days from the approval date. (Sec. 5.4(e) / 5.4.5(d))(NC Medicaid Clinical Coverage Policy No. 3L-1 - State Plan Personal Care Services (PCS), Section 5.4 (Assessments and Reassessments))
  • 4The agency must conduct reassessments face-to-face, except where telephonic assessment is permitted under specified circumstances. (Sec. 5.4.5(f))(NC Medicaid Clinical Coverage Policy No. 3L-1 - State Plan Personal Care Services (PCS), Section 5.4 (Assessments and Reassessments))
  • 5The agency/provider must ensure all PCS assessments, expedited assessments, reassessments, and change-of-status reviews for eligibility and service authorization are conducted by the CIAE designated by NC Medicaid, not by the service provider. (Sec. 5.4(a))(NC Medicaid Clinical Coverage Policy No. 3L-1 - State Plan Personal Care Services (PCS), Section 5.4 (Assessments and Reassessments))
  • 6The provider must develop and validate the beneficiary service plan within seven (7) business days of accepting a referral. (Sec. 6.1.4(i))(NC Medicaid Clinical Coverage Policy No. 3L-1 - State Plan Personal Care Services (PCS), Section 5.4 (Assessments and Reassessments))

Applies to: personal care services

NC Medicaid Clinical Coverage Policy 3L-1 requires that all PCS assessments and reassessments for eligibility and service authorization be conducted by the designated Comprehensive Independent Assessment Entity (CIAE), sets reassessment at least every 365 days conducted face-to-face, and imposes provider obligations for service planning and discharge reporting.

Regulatory information, not legal advice — always confirm against the cited official source. Verification reduces error; it does not certify compliance.