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12 <br /> NC Medicaid Medicaid and Health Choice <br /> Ambulance Services Clinical Coverage Policy No: 15 <br /> Effective Date:January 15,2020 <br /> all EPSDT criteria,including to correct or improve or maintain the <br /> beneficiary's health in the best condition possible, compensate for a health <br /> problem,prevent it from worsening, or prevent the development of additional <br /> health problems. <br /> b. EPSDT and Prior Approval Requirements <br /> 1. If the service,product, or procedure requires prior approval,the fact that <br /> the beneficiary is under 21 years of age does NOT eliminate the <br /> requirement for prior approval. <br /> 2. IMPORTANT ADDITIONAL INFORMATION about EPSDT and <br /> prior approval is found in the NCTracks Provider Claims and Billing <br /> Assistance Guide, and on the EPSDT provider page. The Web addresses <br /> are specified below. <br /> NCTracks Provider Claims and Billing Assistance Guide: <br /> https://www.nctracks.nc.gov/content/public/providers/provider- <br /> manuals.html <br /> EPSDT provider page: https:Hmedicaid.ncdhhs.gov/ <br /> 2.2.2 EPSDT does not apply to NCHC beneficiaries <br /> 2.2.3 Health Choice Special Provision for a Health Choice Beneficiary age 6 <br /> through 18 years of age <br /> NC Medicaid shall deny the claim for coverage for an NCHC beneficiary who <br /> does not meet the criteria within Section 3.0 of this policy. Only services <br /> included under the NCHC State Plan and the NC Medicaid clinical coverage <br /> policies, service definitions, or billing codes are covered for an NCHC <br /> beneficiary. <br /> 3.0 When the Procedure, Product, or Service Is Covered <br /> Note:Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for a <br /> Medicaid Beneficiary under 21 Years of Age. <br /> 3.1 General Criteria Covered <br /> Medicaid and NCHC shall cover procedures,products,and services related to this policy <br /> when they are medically necessary, and: <br /> a. the procedure,product, or service is individualized, specific,and consistent with <br /> symptoms or confirmed diagnosis of the illness or injury under treatment, and not in <br /> excess of the beneficiary's needs; <br /> b. the procedure,product, or service can be safely furnished, and no equally effective <br /> and more conservative or less costly treatment is available statewide; and <br /> c. the procedure,product, or service is furnished in a manner not primarily intended for <br /> the convenience of the beneficiary,the beneficiary's caretaker, or the provider. <br /> 20A13 6 <br />