NC Medicaid Standard Plans vs Tailored Plans: Behavioral Health Billing Guide
NC Medicaid Standard Plans vs Tailored Plans is the first question behind every North Carolina Medicaid behavioral health claim. The state’s managed care plans fall into two groups: Standard Plans, and Behavioral Health and Intellectual/Developmental Disability (I/DD) Tailored Plans, which are run by LME-MCOs. Which plan holds the member decides where you send the claim. This guide to NC Medicaid Standard Plans vs Tailored Plans covers the plans, the state’s outpatient policy and the billing rules for therapists and psychiatrists. It covers North Carolina only. Sources were checked on October 9, 2026.
The plans, in one table
NC Medicaid’s health plans page lists the plans. The state also pays some claims directly through Medicaid Direct, its fee-for-service program.
| Plan type | Plans |
|---|---|
| Standard Plans | AmeriHealth Caritas North Carolina; Healthy Blue of North Carolina; UnitedHealthcare of North Carolina; Carolina Complete Health (Regions 3, 4 and 5) |
| Behavioral Health I/DD Tailored Plans | Alliance; Partners; Trillium; Vaya |
| Medicaid Direct | Fee-for-service, paid by the state |
The NC Medicaid health plan contact page lists provider network emails and phone numbers for each plan. Our North Carolina insurance contact guide collects payer numbers in one place.
NC Medicaid Standard Plans vs Tailored Plans: how do I know which plan pays my claim?
Verify the member’s plan on the date of service. Bill the plan named on the member’s current eligibility, not a plan you guessed from last month. Standard Plans and Tailored Plans each pay their own members. Medicaid Direct pays fee-for-service members. Plan assignment can change, so check at every new episode of care. Our insurance verification service page lists what to confirm, and the eligibility terms glossary defines the language.
What Clinical Coverage Policy 8C says
North Carolina’s outpatient behavioral health rules sit in Clinical Coverage Policy 8C, amended January 1, 2025. It applies to direct-enrolled providers. Plans can have their own rules, and the policy tells plan members to contact their plan about benefits. The key points:
- Covered services. Psychiatric and comprehensive clinical assessments, medication management, individual, group and family therapy, psychotherapy for crisis, and psychological testing.
- Who may bill. Physicians, plus licensed psychologists, clinical mental health counselors, clinical social workers, marriage and family therapists, clinical addiction specialists, physician assistants and nurse practitioners, and their associates in some cases.
- Direct enrollment. Each licensed professional enrolls with their own Medicaid provider number and NPI. “Incident to” billing is not allowed.
- Medical necessity. A current DSM-5 diagnosis, functional impairment, and entrance, continued-service and discharge criteria.
- Prior approval. The policy says Medicaid does not require prior approval for outpatient behavioral health services. Other limits still apply, such as one psychiatric code per beneficiary per day from the same provider.
- Telehealth. Select services can be delivered by telehealth. Audio-only is allowed only when health status or access barriers prevent in-person or video visits, and it requires two-point identity verification and documented consent.
Because coverage depends on medical necessity, your progress notes should show the diagnosis, the functional impairment, and why continued service fits. Associate-level clinicians need a written service order. Review the psychotherapy code guide and the diagnostic evaluation guide to match codes to licenses.
What the state tells health plans about billing
The state publishes billing guidance for plans. Revision 36, dated September 4, 2026, says health plans should follow their contract for billing requirements. It also states:
- Behavioral health claims are copay-exempt. Psychiatric emergency services are copay-exempt.
- Professional claims go on the CMS-1500 form or the 837P electronic format.
- Codes such as H0036 and H0046 are bypass codes for third-party liability, meaning the plan pays as primary for certain plan types.
If you collect copays on Medicaid behavioral health visits, stop and check this item with the plan. For how HCPCS codes differ by state, see our North Carolina Medicaid billing page and the Medicaid HCPCS guide. Terms are in the Medicaid billing glossary.
Psychiatrists and prescribers
Policy 8C covers medication management, so psychiatrists, psychiatric nurse practitioners and physician assistants bill medication management visits under the same direct-enrollment rules. Prescribers have one more date to know: NC Medicaid starts checking DEA numbers on pharmacy claims on November 1, 2026.
Enrollment: NCTracks
Providers enroll through NCTracks. NC Medicaid’s quarterly provider update reminds providers to keep NCTracks records current and to report adverse actions within 30 calendar days. Joining a plan’s network is a separate step. See our credentialing and network status guide and the behavioral health billing glossary.
NC Medicaid Standard Plans vs Tailored Plans checklist
Use this list to keep NC Medicaid Standard Plans vs Tailored Plans straight in your billing.
- Confirm your NCTracks enrollment and keep it current.
- Verify the member’s plan on the date of service.
- Contract with each plan whose members you treat.
- Read your plan contracts for authorization rules, since Policy 8C applies to direct-enrolled providers.
- Submit clean claims. Our electronic claims submission page shows the flow.
- Review copay practices for behavioral health.
NC Medicaid Standard Plans vs Tailored Plans FAQ
Short answers on NC Medicaid Standard Plans vs Tailored Plans follow.
Which plans are Tailored Plans?
Alliance, Partners, Trillium and Vaya. The state’s page lists them as Behavioral Health I/DD Tailored Plans.
Do I need prior approval under Policy 8C?
The policy says Medicaid does not require prior approval for outpatient behavioral health. Plans may differ, so check your contract.
Can an associate bill on their own?
Associates require a written service order under the policy. Confirm credentialing and billing rules with each plan.
Does MCM South work in North Carolina?
Yes. North Carolina is one of the ten states listed below.
Where MCM South Medical Billing Service Works
MCM South Medical Billing Service works with mental and behavioral health practices in ten states: Georgia, Massachusetts, Connecticut, Texas, Florida, New York, Colorado, Tennessee, North Carolina and Illinois. We work with psychotherapists and psychiatrists in solo and medium-size practices, and we bill out-of-network claims. If you run a North Carolina practice and want help with Medicaid billing, you can request a free consultation.
