These services benefit Tailored Plan eligible people who require assistance with activities of daily living (ADLs) and/or instrumental activities of daily living (IADLs), including, but limited to:

• Eating
• Dressing
• Bathing
• Toileting
• Mobility
• Light housekeeping
• Meal preparation
• Shopping

To qualify for PCS, an individual must have a medical condition, disability or cognitive impairment and demonstrate unmet needs for the following:

• Three of the five ADLs with limited hands-on assistance
• Two ADLs, one of which requires extensive assistance.
• Two ADLs, one of which requires assistance at the full dependence level.

PCS program eligibility is determined by an independent assessment conducted by a Partners registered nurse face-to-face with the individual and is provided according to an individualized service plan.

Partners DHB-3051 form should be completed by the member’s primary care provider or physician.

Fax the completed form to Partners at 704-457-5261.

Once this form is completed, a member of our team will contact you within 30 days to schedule a face-to-face meeting to complete your assessment.

After the assessment has been completed and the start date has been determined, an authorization will be created/submitted by Carolina Complete Health (CCH) and will be shared with the Provider agency. Providers will receive notification of authorization via ProviderCONNECT.

View the Personal Care Services Clinical Coverage Policy.

If you have questions related to PCS, please submit them to Partners_PCSInquiry@PartnersBHM.org

Provider(s) shall follow applicable modifier guidelines.

• 99509 HA : Any beneficiary Under 21 Years regardless of setting
• 99509 HB: In-Home Care Agencies, Beneficiary 21 Years and Older
• 99509 HC: Adult Care Homes
• 99509 TT: Combination Homes
• 99509 SC: Special Care Units
• 99509 HQ: Family Care Homes
• 99509 HI: Supervised Living Facilities for adults with MI/SA HH Supervised Living Facilities for adults with I/DD

As of April 1, 2025, Partners, in compliance with North Carolina Medicaid requirement no longer uses time-based rounding for personal care services (PCS) provided to individuals in congregate settings. Instead, reimbursement is based on a daily, per diem rate, which is derived from the total units approved in the individual’s prior authorization.

However, for personal care services provided in in-home settings, providers still follow a unit-based system for billing.

For personal care services in in-home settings:

• Units are calculated based on 15-minute increments of service, with rounding applied to the total time spent. According to the North Carolina Department of Health and Human Services, this rounding follows a clear schedule:
  • 0–7 minutes: 0 units
  • 8–22 minutes: 1 unit
  • 23–37 minutes: 2 units
  • 38–52 minutes: 3 units
  • 53–67 minutes: 4 units
  • 53–67 minutes: 4 units
  • 68–82 minutes: 5 units
  • 83–97 minutes: 6 units
  • 98–112 minutes: 7 units

For personal care services in congregate settings:

Effective April 1, 2025, providers in congregate settings switched from a 15-minute unit-based system to a per diem (daily) reimbursement model. Reimbursement is no longer based on the exact amount of time spent each day. Instead, payment is calculated using the total units authorized in the individual’s prior authorization, which is then converted into a daily rate.

Important: both the service start, and end times are used to calculate NC Medicaid EVV visits, as they are among the seven required data points for Electronic Visit Verification (EVV) of home health care services under the 21st Century Cures Act. These times are captured through technology like GPS-enabled mobile apps and are essential for verifying that beneficiaries receive the services they are authorized to receive.

Beginning on April 1, 2025, Partners Health Management will adjudicate claim using a per diem methodology to accompany Medicaid clinical coverage policy (CCP) 3L-1 (see the Policy Guidance for Personal Care Services Beneficiaries and In-Home Settings) bulletin for more information on this topic. Providers have until March 31, 2025, to make the necessary changes to their systems related to this change.

Key elements of the new reimbursement methodology include:

• Impacted Procedure Codes: Only procedure code 99509 and modifiers SC, HC, TT, HH, HI, HQ will be impacted by the change.
• Reimbursement will no longer be based on the actual time spent delivering the service on a specific day. Instead, reimbursement will be based on a calculated per diem (daily) rate.
• The APPROVED DAILY UNITS will be calculated using the available PA information at the time of adjudication, according to the following formula: PA Approved Daily Units/Approved PA days, with the latter defined as “PA End date minus PA Beg Date plus 1 Day.” For example, if a beneficiary’s PA allows 320 total units for a period that spans 30 days, the approved daily units would be 320/30 = 10.666.
• Providers will submit one line per date of service.

Sample Claim Submission Guide Below:

3L-1, Personal Care Services in Congregate Settings covers providers billing with CPT 99509 HC- Adult Care Homes, 99509 TT – Combination Homes, 99509 SC – Special Care Units, 99509 HQ – Family Care Homes, 99509 HH – Supervised Living Facilities for adults with MI/SA, and 99209 HI – Supervised Living Facilities for adults with I/DD.

SAMPLE Per Diem Claim

• Provider should bill their usual and customary charge. Continue using the same claim form type.​
• When billing per diem, each day of care should be listed on a separate line of the claim.​
• A claim line that spans multiple dates or includes a unit greater than one, will deny.​
• Claims submitted for dates of service on or after the effective date of 4/1/25 must be billed for a single date of service and bill 1 unit at the claims line level.​
• Claims created in advance under the current guidelines of 1 unit = 15 minutes will not be compatible with the new billing guidelines of 1 unit per day.

PCS Per Diem Rate Change: Q&A

• Q: Can multiple claims be billed at one time?​
  • A: Yes, 1 claim line = 1 date of service, and a full month of claim lines (28, 29, 30 or 31 lines) can be on a claim.​
• Q: Can a claim be submitted weekly?​
  • A: Yes​
• Q: Should the calculated daily rate be included in the claim when filing?​
  • A: No, the provider should bill 1 unit per day and Carolina Complete Health’s billing system will calculate the daily rate.​
• Q: With this new change, does billing have to be completed monthly, only?​
  • A: No, billing can be completed at the same cadence as before; however, 1 unit must be billed per day.

For claims questions please contact Partners Health Management Claims Department at claimsdepartment@partnersbhm.org.  

The 21st Century Cures Act requires NC Medicaid to begin using an Electronic Visit Verification (EVV) system for Home Health Care Services (HHCS) and Personal Care Services (PCS) for both physical and behavioral health services.

Read more about EVV.

Clinical Coverage & Policy Updates

• PCS Clinical Coverage Policy: NC Medicaid Clinical Policy
• Medicaid Bulletin Updates: PCS Medicaid Bulletin Updates

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Claims, Billing & EVV Requirements

General Billing Information

• CPT Code: 99509
• Required Modifiers: HA (under 21), HB (21 and older)
• Electronic Visit Verification (EVV): Required for PCS claims billed with 99509 + HA/HB

EVV Implementation

• EVV Vendor: HHAeXchange (used by Partners)
• Hard Launch Date: July 1, 2024
  • Claims for dates of service on or after 7/1/24 must be submitted through EVV or they will be denied
• Modifiers Required: Refer to the NC Medicaid Fee Schedules for approved code/modifier combinations
• More Info: Review the EVV Welcome Letter from Partners

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Out-of-Network (OON) Provider Billing

• OON providers billing 99509 with HA or HB must:
  • Use HHAeXchange to submit PCS claims for Partners members
  • Follow EVV requirements
• OON providers billing other PCS 99509 codes should:
  • File claims via paper or through a clearinghouse
  • Submit to Payer ID: 68069
• More Info: Out-of-Network Provider Guide (Partners)

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Authorization, Billing & Claims Guide

• PCS Provider Companion Guide (Partners): Download the Guide (.pdf)

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Authorization Contact Info (Physical Health)

• For Service Requests: PHManualAuthorizations@PartnersBHM.org
• For General Questions (no PHI): PHUMQuestions@PartnersBHM.org

Personal Care Services Rate Reimbursement Methodology for Individuals Living in Congregate Settings