Personal Care Services (PCS)

Providers

Overview | PCS Referral Process | General Issues for PCS | Appeals and Mediation

Personal Care Services Overview

FAQs - PCS Referral Process

Who can make a PCS referral?

The beneficiary's treating primary care physician (PCP) will be the one to make the referral. If the beneficiary does not have an identified PCP, the physician assigned to treatment of beneficiary's disability may make the referral. Exceptions to a PCP or a physician treating beneficiary's condition of disability, (if beneficiary does not have a PCP), making the PCS referral may happen in cases in which the beneficiary is in the discharge process from an inpatient facility. Inpatient facilities may include a skilled nursing facility (SNF), rehabilitation center, or hospital. In this situation, the attending doctor/physician, physician's assistant, or nurse practitioner may submit the referral, listing the case manager's or discharge planner's name as the contact person on the referral form.

What is the process to submit a PCS referral?

The referring primary care physician (PCP), physician treating beneficiary's condition of disability (if beneficiary does not have a PCP), or attending physician, physician's assistant, or nurse practitioner in cases where beneficiary is discharging from an inpatient facility, must complete the NC Medicaid referral form in its entirety. The form can be found on Acentra Health's website. The completed form should then be faxed to Acentra Health at 833-521-2626.

Can a beneficiary's physician choose the provider agency for PCS?

Only the beneficiary or beneficiary's legal guardian or legally responsible person (LRP) may select the PCS provider agency. The referral form must have the beneficiary's or LRP's choice of provider agency in order to be honored by Acentra Health.

Does Acentra Health verify beneficiary's Medicaid eligibility prior to submitting PCS referrals to providers?

Yes, Acentra Health verifies that the beneficiary is Medicaid eligible for PCS before the independent assessment is conducted. Medicaid coverage may lapse between the time of the assessment and the time the referral is received by the provider. Once the referral is received, it is the responsibility of the provider agency to also verify beneficiary's active Medicaid coverage. Furthermore, PCS providers should verify Medicaid eligibility every month moving forward for all beneficiaries receiving their services, to continuously monitor for a lapse in coverage, as beneficiaries' Medicaid eligibility may change at any month in time. If a beneficiary loses or has a lapse in Medicaid coverage for PCS, providers may direct them to their local Department of Social Services (DSS) office for support with reinstating eligibility. More information can be found in Section 10, page 47 of the Provider Claims and Billing Guide on the NC Tracks website. The guide can be found at https://www.nctracks.nc.gov/content/public/providers/provider-manuals.html.

How do I check a beneficiary's eligibility?

Providers may verify NC Medicaid eligibility through the NCTracks provider portal or by contacting Provider Services AVRS system at 1-800-723-4337. If the provider is unable to verify eligibility through these options, please contact the NCTracks Call Center at 1-800-688-6696. To check eligibility on claims over one year old, providers may call 919-855-4045. More information on how to use the provider portal in NCTracks can be found in Section 10.2 of the Provider Claims and Billing Assistance Guide on the NCTracks website. https://www.nctracks.nc.gov/content/public/providers/provider-manuals.html

How is the eligibility assessment for PCS completed?

The eligibility assessment, or independent assessment (IA), will be conducted by a clinical assessor using an assessment tool approved by NC Medicaid. The clinical assessor will combine observation, interviews, and simulation of Activities of Daily Living (ADLs), and review of beneficiary records to determine eligibility for PCS.

Qualifications for PCS include:

Beneficiary must have a medical condition of intellectual and/or developmental disability.
Of the five ADLs (eating, dressing, bathing, toileting, mobility), the beneficiary must demonstrate a need for limited hands-on assistance with three of the ADLs, OR
Of the five ADLs (eating, dressing, bathing, toileting, mobility), the beneficiary must demonstrate a need for extensive assistance with two ADLs, OR
Of the five ADLs (eating, dressing, bathing, toileting, mobility), the beneficiary must demonstrate a need for total, fully dependent assistance with two ADLs.

What available documentation may be used in a PCS eligibility assessment?

The clinical assessor may review the following beneficiary records as part of the eligibility assessment:

List of beneficiary's medications or Medication Administration Record (MAR)
Beneficiary's Person-Centered Plan
Beneficiary's service plan
Confidentiality statement/agreement
Guardianship documents (if applicable)
Emergency medical release form
Resident admission records
FL-2 or MR-2
Medical order issued by treating physician
Treatment supervision notes
Other relevant documentation provided by beneficiary or LRP

When do PCS providers start services for a beneficiary?

After the independent assessment (IA) for eligibility has been completed and processed, Acentra Health will send a referral letter to the provider of beneficiary's or LRP's choice (this will be the provider listed on the referral form). The letter will display the beneficiary's name, Medicaid identification number (MID) and the service level authorized. Providers will have two (2) business days to accept or deny the referral in provider's QiReport Provider Interface.

For new PCS referrals, the provider will be issued a "Notice of Decision on Initial Request for Medicaid Services." This letter will have the number of authorized hours beneficiary will receive for PCS, along with an authorized effective date for the services. Providers may begin services on the effective date indicated in this letter and not the date on the referral letter. The referral notice letter is not an official authorization and should not be used as such.

The agency acceptance letter from Acentra Health may state that the effective date for beneficiary's PCS service authorization will begin 10 days from the date of the notice of service authorization. This will be 10 calendar days.

How will providers be notified of ongoing PCS services after the initial authorization period?

For services continuing after the initial PCS authorization period with the provider agency, Acentra Health will issue a letter to the provider each authorization period thereafter, titled "Notice of Decision on a Continuing Request for Medicaid Services." The new effective date for each continuing authorization period will be indicated on this letter. If a beneficiary's authorized PCS hours are reduced after the most recent assessment, provider will be issued a letter titled "Notice of Change in Services." This letter will include the revised/reduced number of authorized hours and the effective date.

How many PCS hours will the beneficiary receive?

The IA, conducted by a Clinical Assessor using a standardized process and NC Medicaid approved assessment tool, will determine the level of care and number of PCS hours beneficiary demonstrates need for. The number of authorized service hours will vary with each assessment and each beneficiary. The number of authorized hours beneficiary may receive for PCS will be on the Notice of Decision on Initial Request for Medicaid Services letter. Providers may also review the beneficiary's record in QiReport Provider Interface to verify authorized PCS hours, or providers may call Acentra Health at 833-522-5429.

What happens if the beneficiary does not use all of the approved/authorized service hours for PCS?

If occasional incidences occur where the beneficiary does not receive services during a certain week due to illness, travel, etc., but will proceed with services as regularly scheduled the following week, no changes are needed to the IA or service plan. If a beneficiary wants to change the days services are received, the provider will need to update the beneficiary's service plan to reflect the scheduling changes, and document the deviation in services.

If the beneficiary does not want to receive all the authorized PCS service hours each week or has had a change in caregiver status or living situation, impacting authorized service hours, the provider must submit a Non-Medical Change of Status (COS) request to initiate a new assessment to revise authorized service hours. If a Non-Medical COS has been submitted, the beneficiary may continue to receive PCS services under the current authorization period while awaiting completion of a new assessment. Non-Medical COS forms may be submitted by the provider, the beneficiary, the beneficiary's legal guardian or LRP. The provider may submit the request from the QiReport Provider Interface.

If the beneficiary has been hospitalized or had another medical situation impacting functionality, a Medical Change of Status (COS) must be submitted to justify a reduction in authorized service hours due to a documented alteration in medical condition. A Medical COS may only be submitted by beneficiary's treating physician.

What qualifies as a significant change in medical status (needing Medical COS)?

Any medically related change that impedes the beneficiary's ability to participate in the ADLs qualifying beneficiary for services.

Do PCS providers need to submit a service plan to Acentra Health?

Yes. Each time a provider accepts a PCS referral, the provider will need to complete a service plan for the beneficiary referred in QiReport Provider Interface.

When are Annual Reviews submitted?

Beneficiaries receiving ongoing PCS services must receive a reassessment each year within 365 calendar days of beneficiary's last assessment. The reassessment is called an "Annual Review."

When do PCS services term for beneficiaries that receive a denial for reauthorization of services?

The Notice of Decision on a Continuing Request for Medicaid Services letter will indicate the end date for beneficiary's PCS authorization.

FAQs -General Issues for PCS

Where can I find information for Clinical Coverage Policy 3L, Personal Care Services (PCS) to review program requirements and procedures?

The policy, along with the PCS provider manual, can be found at the following link under the Policy Manuals section of the webpage.

https://medicaid.ncdhhs.gov/providers/programs-and-services/long-term-care/personal-care-services-pcs

How can I obtain licensure for my home or facility to provide PCS?

You can enroll using the Online Provider Enrollment Application in the link below, under the Applications section. Enrollment includes credentialing, endorsement, and licensure verification to ensure good standing. All program requirements must be met to become enrolled as an NC Medicaid provider. https://medicaid.ncdhhs.gov/providers/provider-enrollment

How can I make sure my agency is on the PCS provider list for all the counties our agency serves?

Providers can log into the Provider Interface of QiReport. Click on the Referrals tab; then click on the Counties Served link on the left side of the screen. Acentra Health keeps a database of PCS providers enrolled in NCTracks as a Medicaid provider and it is updated weekly. If your agency is not displayed, please contact NCTracks at 800-688-6696 or email NCTracksprovider@nctracks.com.

My client has transitioned to a managed Care Plan and I am having issues with billing. Who can I contact to assist with my concerns?

Please contact the Medicaid Managed Care Provider Ombudsman:

Phone: 866-304-7062
Email: Medicaid.ProviderOmbudsman@dhhs.nc.gov
NC Medicaid Ombudsman: 877-201-3750
Contact NC Medicaid Ombudsman

FAQs - Appeals and Mediation

What is included in a "Notice of Decision" letter that indicates a reduction, denial, or termination of services?

The letter will include a reason to explain the reduction, denial, or termination of PCS. The date for when the reduction or termination will go into effect will be listed on the letter. Also included are website resources for regulations surrounding the adverse decision on beneficiary's services, information on how to appeal the decision (including a Request for Hearing form), and contact information for further questions about the decision.

How can a beneficiary appeal a decision to reduce, deny or term PCS?

The beneficiary, or beneficiary's guardian or legally responsible person (LRP), has the right to appeal a decision on services, and must complete and submit the Request for Hearing form that accompanies the Notice of Decision letter within 30 calendar days from the date on the letter. The instructions for submitting the appeal will be included in the letter. When the form is received, a mediation representative will contact the beneficiary or beneficiary's guardian/LRP to schedule a mediation.

What is a mediation as part of the appeal process for PCS?

Mediations take place over the phone or in person. The beneficiary, beneficiary's guardian/LRP (if applicable), an NC Medicaid representative, and a mediator will be present during the scheduled date/time of the mediation phone call or in-person meeting. Discussion will take place surrounding beneficiary's assessment and service needs. After this discussion takes place, a determination will be made on whether beneficiary's services will be increased or reduced, or approved or denied. If the beneficiary and if applicable, guardian/LRP, agree with the determination, the appeal will be considered resolved. The decision made from the mediation is legally binding. If the beneficiary and beneficiary's guardian/LRP do not agree with the decision made from the mediation, they will receive instructions on moving forward with a hearing to appeal the decision.

What happens at a hearing to appeal decision on PCS?

The Office of Administrative Hearings (OAH) will set the date for the hearing. This should occur within 55 days of the beneficiary's submission of the appeal request, if possible. In most cases, a preconference hearing will occur with the Attorney for the the Attorney General's office. If the beneficiary and beneficiary's guardian/LRP agree with the decision made on beneficiary's services at the preconference, the case will be settled. If the beneficiary and beneficiary's guardian/LRP do not agree with the determination made at the preconference, the case will go before an Administrative Law Judge at a formal hearing either by phone or in person. Information on the date/time/location of the hearing will be sent to the beneficiary by mail. After the hearing, the Administrative Law Judge is legally required to enter a decision on the case with twenty days of receiving the case from the OAH. If the beneficiary and beneficiary's guardian/LRP do not agree with this decision, they will receive instructions on appealing the decision at the Supreme Court level. An appeal at this level must be submitted within 30 calendar days of the date of the letter of the Administrative Law Judge's decision letter.

How does Maintenance of Service (MOS) work during the appeals process?

For beneficiaries that have not previously received PCS and are denied the service, MOS will not apply during the appeals process and the agency should not provide services as there is no authorization to do so.

For beneficiaries that have previously received PCS and submit an appeal within ten calendar days of the Notice of Decision letter, the authorization of service will be continued at the hours authorized prior to the date listed on the Notice of Decision letter, not to exceed eighty hours per month. This will prevent a lapse in services.

For beneficiaries that have previously received PCS and submit an appeal more than ten calendar days, but within thirty calendar days of the Notice of Decision letter, there will be a break in services from the effective date listed on the Notice of Decision letter until the date the Office of Administrative Hearing (OAH) receives the request for appeal. Services will be reauthorized beginning on the date the OAH receives this. Services should not occur in between.

For beneficiaries that have previously received PCS and submit an appeal after thirty calendar days of the Notice of Decision letter, the beneficiary will not be authorized for MOS.

For beneficiaries wanting to change PCS providers while on MOS during the appeals proceedings, the MOS authorization will be transferred to the new provider and will be effective ten days after the date of letter.