Where do you submit a therapy prior authorization in NC Medicaid?
It depends on the patient's plan. Clinical Coverage Policy 10A applies to both Medicaid Direct and managed care, but each managed care plan runs its own prior authorization process, and some let a set number of visits go without one. Check the plan on the patient's card first. Plan details below were checked October 4, 2026.
| Patient's coverage | Where the request goes |
|---|---|
| NC Medicaid Direct | The state's utilization review contractor, through the ChoicePA website. Prior approval before every treatment visit |
| AmeriHealth Caritas North Carolina (Standard Plan) | The plan's prior authorization process, after a set number of visits: members under 21 can have up to 72 PT, 72 OT and 72 speech visits a year without it, and adults up to 27 of each |
| Carolina Complete Health (Standard Plan) | The plan's own process. WellCare of North Carolina merged into Carolina Complete Health on April 1, 2026, and its members moved over automatically |
| Healthy Blue (Standard Plan) | Carelon Medical Benefits Management, which has reviewed Healthy Blue's PT, OT and speech requests since May 1, 2023 |
| UnitedHealthcare Community Plan (Standard Plan) | Its provider portal. UnitedHealthcare requires prior authorization for outpatient PT, OT and speech therapy at every age; it extended the rule to adults on November 1, 2025 |
| Healthy Blue Care Together (Children and Families Specialty Plan) | The plan's own process |
| Behavioral Health I/DD Tailored Plans (Alliance, Trillium, Vaya Partners) | The plan's own process. Vaya Health and Partners Health Management merged into Vaya Partners on October 1, 2026 |
| Medicare and Medicaid together | No Medicaid prior approval for treatment; Medicare's rules apply |
WellCare's Medicaid members moved to Carolina Complete Health automatically, but verify the patient's current plan in NCTracks rather than going by an old card. Policy 10A requires checking eligibility every time a service is given anyway. NC Medicaid's own health plan list may still show Carolina Complete Health in only three regions; since the merger it covers the whole state.
Which dates does an NC therapy office have to track?
Four, and each runs on its own clock. These are Clinical Coverage Policy 10A's rules (amended October 1, 2026), which govern Medicaid Direct; managed care plans can set their own approval periods and visit counts.
| Date | How long it lasts | What else the policy says | 10A section |
|---|---|---|---|
| Physician order | A written order is valid up to six months from the ordering practitioner's signature | A verbal order is valid up to six months from the day it's received and must be countersigned within 60 calendar days. Faxed orders and electronic signatures with printed dates are accepted; backdating isn't | 3.1.2 |
| Plan of care | No more than six calendar months from its start date to its end date | Must be reviewed and renewed or revised at least every six months, and signed on or before its start date | 3.2.1.6 |
| Prior approval | An approval period can't exceed six calendar months | For patients 21 and older, one request covers up to 12 visits | 5.3, 5.4 |
| Evaluation report and annual re-evaluation | A prior approval request needs a written evaluation dated within three months of the requested treatment start | Continued treatment needs a written re-evaluation every year. Neither the evaluation nor the re-evaluation needs prior approval | 5.2.2, 3.2.1.5, 3.2.1.8 |
Every service, evaluations included, needs an order first, from an NC Medicaid-enrolled MD, DO, podiatrist, certified nurse midwife, physician assistant or nurse practitioner.
The clocks rarely line up. An order signed in March, a plan of care starting in April and an approval dated the week after each expire on different days. Under 10A, treatment must be given under a current order, a current plan of care and the required approval. A missed visit can only be made up within 30 days and inside the same approval period.
What does an NC Medicaid therapy prior approval request need?
The request plus the health records showing the patient meets the policy's criteria. Under 10A, the request must:
- show clearly that the service needs a licensed therapist
- include a written evaluation dated within three months of the requested start
- for a renewal, document that treatment is working, with a written re-evaluation every year
- for a patient under 21, show that every EPSDT criterion is met, with supporting research if available
The plan of care sent with it must include start and end dates no more than six months apart, the treatment and related medical diagnoses, rehabilitation or habilitation potential, measurable goals, the skilled interventions, the frequency and the length of each visit in minutes. It also needs the therapist's name, credentials and signature, dated on or before the start date, and the patient's name with a date of birth or Medicaid ID.
An approval is a medical approval only. It doesn't guarantee payment or that the patient will still be eligible on the date of service.
How many visits does NC Medicaid allow?
Under Policy 10A, which governs Medicaid Direct, it depends on the patient's age. Managed care plans can differ; AmeriHealth's visit counts are in the plan table above.
| Patient | Visit limit |
|---|---|
| 21 and older | Up to 12 visits and six months per request. Each calendar year: 30 visits for OT and PT habilitative services combined, 30 for OT and PT rehabilitative services combined, 30 for speech habilitative and 30 for speech rehabilitative |
| Under 21, PT and OT | The medically necessary number of visits within an approval period of up to six months |
| Under 21, speech and audiology | By severity, per approval period of up to six months: mild 6 to 26 visits, moderate up to 46, severe up to 52 |
For patients under 21, EPSDT allows these limits to be exceeded when documentation shows the extra visits are medically necessary, but prior approval is still required.
How do you keep the four dates from slipping?
Give each date its own place and look at whichever comes due first, not at the patient. In a spreadsheet, that means a column each for the order end, the approval end, the plan-of-care renewal and the annual re-evaluation, plus a column for the earliest of the four, sorted soonest first. Re-check it every week, and chase any renewal order that hasn't come back within a few days of faxing it.
GetDocsSigned's tracker was built around these clocks with a speech therapy practice in Wilmington. Each patient row holds the order end date, the authorization end date and two evaluation due dates, which an NC office can use for the six-month plan-of-care renewal and the annual re-evaluation. A Due board shows what is overdue, due this month and due in each half of next month, and you fax renewal orders straight from it. See how it works for speech therapy or occupational therapy.
Sources: NC Medicaid Clinical Coverage Policy 10A, Outpatient Specialized Therapy Services, NC Medicaid bulletin on the July 2026 Policy 10A update, AmeriHealth Caritas North Carolina prior authorizations, Carolina Complete Health on the WellCare merger, Carelon rehabilitation program, UnitedHealthcare on North Carolina Medicaid therapy services, NC Medicaid letter on the Vaya Health and Partners Health Management merger and NC Medicaid's health plan list. Checked October 2026. Not legal or billing advice. Plans change their processes; confirm with the patient's plan before you submit.