The North Carolina Medicaid fee schedule is like the state’s big official price book! It tells everybody how much money is paid for each covered service and which procedure codes can be billed. Doctors, billing helpers and health plans all peek inside it to figure out what a service pays.
Here’s the secret most grown-ups forget: there is NOT just one fee schedule for every Medicaid service in the state. Nope! NC Medicaid keeps lots of different dates for different kinds of providers and services. And each one can change whenever the policies about reimbursement, procedure codes or state requirements change. Want to see how other states do it? The state-by-state Medicaid fee schedule breakdown lines them all up side by side.
Today, everything goes through the NC Medicaid Fee Schedule and Covered Codes Portal. It has fee-schedule downloads, fee-schedule lookups, covered procedure codes and covered revenue codes. Pretty cool, right?
What Is the North Carolina Medicaid Fee Schedule?
Imagine a price list with rules stuck to it. For every covered service, a schedule can have:
- CPT or HCPCS procedure codes
- Applicable modifiers
- Provider or program categories
- Service descriptions
- Reimbursement rates
- Effective or revision dates
- Coverage information
- Special billing requirements
Always pick the schedule that matches your exact service, procedure code, provider type and date of service. If you forget even one of those, you might grab the wrong number.
NC Medicaid also has two ways of doing things: NC Medicaid Direct and NC Medicaid Managed Care. Sometimes a fee-for-service rate is like a guide or a rate floor (a “lowest step” on the stairs) in certain managed-care situations. But the health plan also pays by following its contract and its payment methodology.
Where Can You Find the Current NC Medicaid Fee Schedule?
Start at the official portal! NC Medicaid moved its current fee-schedule updates there on November 3, 2022, and the older schedules live in the archive, like old toys in the attic.
The portal does four jobs:
- Fee Schedule Download — grab current and archived schedules.
- Fee Schedule Lookup — search for single codes and rates.
- Covered Procedure Codes — check if a procedure code is covered.
- Covered Revenue Codes — look at revenue-code information for your claim.
NC Medicaid Fee Schedules and Covered Codes Portal
Rates get changed all the time. An old PDF you find on a search engine is a risky guess, so use the live portal instead!
What Types of NC Medicaid Fee Schedules Are Available?
There are SO many! Here are some examples by service or provider area:
| Service or provider area | Examples |
|---|---|
| Physician services | Physician procedure codes and reimbursement |
| Nurse practitioners/CRNAs | Professional services |
| Dental | Dental procedure codes |
| Ambulance | Emergency and non-emergency transportation services |
| DME | Durable medical equipment |
| Laboratory | Laboratory services |
| Home health | Covered home-health services |
| Nursing facilities | Facility reimbursement |
| Pharmacy | Pharmacy-related rates and programs |
| Optometry | Vision-related services |
| Podiatry | Podiatric services |
| Personal Care Services | PCS procedure codes |
| Behavioral health | Various behavioral-health services |
| Radiology/imaging | Imaging services |
| Therapy | Specialized therapy services |
Here’s one tiny detail on the state’s archived fee-schedule page that really matters: schedules with an asterisk (that little star *) can be rate floors for certain managed-care arrangements. Keep your eyes open for it! 👀
How to Look Up a Medicaid Procedure Code
Already know your code? Zoom straight to the official Fee Schedule Lookup! It’s way faster than digging through the whole library.
Step 1: Identify the procedure code
Find the CPT or HCPCS code that matches the service.
Step 2: Confirm the provider type
Physicians, dentists, DME suppliers and therapists each follow their own reimbursement rules. Everybody has different rules, just like different games on the playground!
Step 3: Check the applicable schedule
Pick the right program or fee schedule inside the NC Medicaid portal.
Step 4: Check modifiers and settings
The base rate doesn’t work for every claim. Modifiers, place of service and units can all change the payment.
Step 5: Confirm the effective date
Last year’s right answer can be a wrong answer for a newer date of service. Be extra careful when a code was deleted, revised or replaced!
NC Medicaid Fee Schedule 2026 Rate Changes
North Carolina made some big reimbursement updates during 2026.
Personal Care Services (PCS) is the biggest one. Starting August 1, 2026, NC Medicaid gave an 18% increase to applicable PCS procedure codes. The 2026 Appropriations Act paid for it by setting aside $70.8 million in recurring state funding for PCS rate increases. That’s a LOT of money!
The state shared these updated rates:
| Program/code | Previous rate | New rate |
|---|---|---|
| State Plan PCS 99509 | $5.96 | $7.03 |
| CAP/C S5125 | $5.96 | $7.03 |
| CAP/CD T1004 | $7.34 | $8.66 |
| CAP/CD T1019 | $7.34 | $8.66 |
| CAP/CD S9122 TF | $5.44 | $6.42 |
Numbers like these are why a never-changing “2026 Medicaid rates” list can’t stay right for long. Check the current schedule every single time!
The increase also reaches PCS given through Standard Plans and Tailored Plans. The health plans got some time to load the new rates and reprocess the affected claims.
NC Medicaid Physician Fee Schedule
Physicians need the professional-service fee schedule. Then they check the exact procedure code, modifier and date of service.
Use the state’s own system, not a general national Medicare schedule. North Carolina Medicaid reimbursement follows its own program methodology.
Keep the Medicaid fee schedule apart from these (no mixing!):
- Medicare physician rates
- Commercial insurance rates
- Medicaid managed-care negotiated arrangements
- Self-pay charges
- A provider’s billed charge
The charge you send in and what Medicaid pays are two different numbers.
NC Medicaid Dental Fee Schedule
Dental providers use the latest dental fee schedule. They should also watch NC Medicaid bulletins, because latest Dental Terminology (CDT) codes change every year.
In 2026, NC Medicaid shared updates about dental anesthesia and sedation services, plus other dental procedure-code new changes.
Before any dental claim goes out the door, always double-check the code, modifier, coverage rules and effective date.
NC Medicaid DME Fee Schedule
Durable medical equipment has its very own reimbursement setup and its own fee schedule.
DME providers should keep a close eye on:
- HCPCS codes
- Modifiers
- Manually priced codes
- Prior authorization
- Medical-necessity requirements
- Covered versus non-covered items
- Effective dates
NC Medicaid also shared 2026 guidance about manually priced DME and orthotic/prosthetic procedure codes and prior authorization.
Personal Care Services Fee Schedule
PCS gets its own section because the rates changed in August 2026.
The 18% increase covers certain PCS procedure codes given through NC Medicaid Direct and several Community Alternatives Program services, including CAP/C, CAP/DA and CAP/CD.
Check the current rate for your exact PCS code. A rate from before August 2026 is old news!
Important 2027 Fee Schedule Changes
Now let’s peek at 2027! The biggest change coming is maternity billing.
Starting January 1, 2027, NC Medicaid will delete the current maternity service codes (global billing codes too) from the fee schedule. New maternity billing codes made by the American Medical Association start the very same day.
A transition period started September 1, 2026. During that time, providers were encouraged to use certain E/M codes with the TH modifier for prenatal and postpartum care.
Changes like this are why you should read Medicaid bulletins right next to the fee schedule. Rules are changing in other places too, and the new Medicaid work requirements by state show how fast eligibility policy is moving!
NC Medicaid Fee Schedule vs. NC Medicaid Managed Care
North Carolina Medicaid has NC Medicaid Direct and managed-care programs. The fee schedule matters most for NC Medicaid Direct. With managed care, your contracted health plan and its reimbursement rules join the party too.
The archived fee-schedule information explains the rate-floor rule. Schedules with an asterisk set floors for NC Medicaid Direct rates, and participating PHPs generally have to pay at least 100% of the applicable rate unless an allowed alternative arrangement exists.
So a fee-schedule rate by itself can’t answer every managed-care payment question. It’s just one puzzle piece!
What If a Medicaid Rate Changes?
When a rate changes, claims can be affected in different ways depending on the date of service. NC Medicaid sometimes gives special instructions for adjustments or reprocessing.
Here’s an example: the reductions that started October 1, 2025. North Carolina reversed them, said the affected NC Medicaid Direct fee schedules would be updated, and said impacted claims would be reprocessed. For managed-care claims, health plans got implementation and reprocessing periods once the updated schedules were ready.
The big lesson for billing: always match the rate to the date of service and the reimbursement methodology.
How Often Does the NC Medicaid Fee Schedule Change?
There’s no one special update day. Schedules can change for reasons like these:
- Annual procedure-code updates
- State legislation
- Budget appropriations
- Rate increases or reductions
- New services
- Deleted procedure codes
- Revised clinical coverage policies
- Federal requirements
- Provider-type changes
- Managed-care implementation requirements
That’s why NC Medicaid’s provider bulletin system should sit right next to the fee-schedule portal in your routine. Also, eligibility decides who gets billed for in the first place, so it’s smart to know the current Medicaid income limits your patients fall under!
What Is the Difference Between a Fee Schedule and a Covered Code?
A fee schedule tells you what rate or methodology applies to a service. A covered-code listing tells you if a procedure or revenue code is covered under the program.
Just because a code is on a fee schedule doesn’t mean every provider can bill it in every situation. Coverage policy, provider enrollment, medical necessity, prior authorization and modifiers still count, along with other billing requirements.
Frequently Asked Questions
1. Where can I find the current North Carolina Medicaid fee schedule?
Use the official NC Medicaid Fee Schedule and Covered Codes Portal. Current schedules, older schedules, code lookups and covered-code information are all there!
2. Is there one North Carolina Medicaid fee schedule?
No! NC Medicaid keeps different plans for different provider types, programs and services.
3. How do I check a specific CPT or HCPCS code?
Type it into the Fee Schedule Lookup in the official portal. Then double-check the provider type, modifier, setting and effective date.
4. Did NC Medicaid increase PCS rates in 2026?
Yes! Starting August 1, 2026, NC Medicaid gave an 18% increase to applicable Personal Care Services procedure codes.
5. Are Medicaid fee-schedule rates the same as Medicare rates?
No. Medicare and North Carolina Medicaid use different reimbursement methods, so you can’t swap one for the other.
6. Do Medicaid managed-care plans use the same rates?
Not always. Managed-care reimbursement uses the applicable NC Medicaid rate methodology, rate floors and health-plan contracts, so check the rules of your own plan.
7. Will NC Medicaid change maternity billing codes in 2027?
Yes! Starting January 1, 2027, current maternity service codes will be deleted from the fee schedule, and new AMA maternity billing codes start.
8. Can an old NC Medicaid fee schedule still be used?
Only for old claims from the past. For current billing, make sure the schedule and revision match the date of service.
9. Where can providers get help with NC Medicaid billing?
NC Medicaid lists the NCTracks Call Center at 800-688-6696 and the NC Medicaid Contact Center at 888-245-0179 among its provider resources.
10. Does a listed procedure code guarantee payment?
Nope! Coverage, medical necessity, provider eligibility, authorization, modifiers and billing requirements all decide if a claim can be paid.
Conclusion
A fee schedule is only as helpful as the question you ask it! Know your code, provider type, program, modifier, setting and date of service. Then see the official NC Medicaid Fee Schedule and Covered Codes site before you bill.
Disclaimer: This article is for general education only and is not billing, legal or reimbursement advice. NC Medicaid rates, coverage rules and procedure codes can change. Providers should confirm latest rates and billing requirements with NC Medicaid, NCTracks and the applicable managed-care health plan before submitting claim forms.