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North Carolina - Home Health Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

North Carolina requires a Certificate of Need (CON) from the Division of Health Service Regulation (DHSR) before an agency can submit a licensure application to provide Medicare-certified Home Health Services. The Acute and Home Care Licensure and Certification Section (AHCLCS) licenses these agencies under 10A NCAC 13J to deliver intermittent skilled nursing and therapy under a physician-ordered plan of care.

Medicaid enrollment for this service is processed through the NCTracks portal and requires prior Medicare certification. Agencies must first secure the CON based on the annual State Medical Facilities Plan (SMFP), pass an initial state licensure survey, and complete a Medicare survey after serving a minimum of 10 skilled care patients and 7 active non-Medicare patients.

1. Service Definition and Scope

Home Health Services in North Carolina provide intermittent skilled nursing, physical therapy, occupational therapy, and speech-language pathology to homebound beneficiaries. Services are delivered under a physician-established plan of care and are subject to strict clinical oversight.

This service is distinct from in-home aide or personal care services, as it requires Medicare certification and focuses on acute, restorative, or rehabilitative care rather than long-term custodial assistance.

2. Regulatory and Oversight Agencies

The North Carolina Department of Health and Human Services (NCDHHS) oversees home health agencies through multiple specialized divisions. The Division of Health Service Regulation (DHSR) handles the physical licensure and need determination.

Medicaid enrollment and claims processing are managed by the Division of Health Benefits (NC Medicaid) through its fiscal agent portal.

3. Gatekeeping Prerequisites: Who Can Even Apply

North Carolina strictly limits the development of new home health agencies through a Certificate of Need (CON) process. An applicant cannot even submit a licensure application unless the state has identified a numerical need for a new agency in a specific county.

This need is published annually in the State Medical Facilities Plan (SMFP). If the SMFP shows zero need for a county, no CON can be issued, and no new home health agency can be licensed or enrolled in Medicaid for that area.

4. Licensure and Certification Requirements

Agencies must obtain a multi-program home care license from the DHSR AHCLCS. The statutory authority is N.C.G.S. 131E-135 through 142, and the administrative rules are found in 10A NCAC 13J.

Applicants must submit a comprehensive application packet, including policies, procedures, and personnel documents, and pass an unannounced initial on-site survey.

5. Medicaid Provider Enrollment

Once licensed and Medicare-certified, the agency must enroll in NC Medicaid via the NCTracks Provider Portal. Enrollment is governed by G.S. 108C-9.

Applicants must complete mandatory state trainings and submit an attestation regarding corporate compliance and tax liabilities before enrollment is finalized.

6. Staffing, Training and Background Checks

Home health agencies must employ qualified clinical and administrative staff as dictated by 10A NCAC 13J. The agency must designate an administrator and a clinical director.

All personnel providing direct patient care must undergo criminal background checks and verify their credentials with the appropriate North Carolina occupational licensing boards.

7. Documentation, Policies and Records

Agencies must maintain comprehensive clinical records for every patient, adhering to both Medicare Conditions of Participation and NC DHSR rules. The initial licensure survey heavily scrutinizes the agency's written policies.

A physician-signed plan of care must be on file and updated regularly according to state and federal intervals.

8. Billing, Rates and Claims

Medicaid claims for home health services are submitted electronically through the NCTracks MMIS. Services are billed using specific HCPCS/CPT codes designated for home health.

Rates are established by the NC Division of Health Benefits and are published on the NC Medicaid fee schedule website.

9. Approval Sequence and Timeline

The approval process is sequential and lengthy, beginning with the SMFP publication. If a need is identified, the provider applies for a CON, which takes at least 35 days post-approval to be issued.

Following CON issuance, the provider applies for state licensure, completes the CMS 855A, treats the required initial patient census, undergoes the Medicare survey, and finally enrolls in NCTracks.

10. Common Denials and Survey Findings

The most absolute denial occurs at the CON phase; applications submitted for counties without a projected SMFP need are rejected outright. During licensure, failures often result from inadequate policy documentation.

AHCLCS notes that the primary reason applicants fail the initial licensure survey is non-compliance with the Initial Home Care Survey Checklist and 10A NCAC 13J rules.

11. Key Contacts and Resources

Providers must interact with multiple NCDHHS sections to navigate the CON, licensure, and enrollment processes. The DHSR Acute and Home Care Licensure and Certification Section is the primary contact for the physical license.

NCTracks handles all final Medicaid enrollment and billing inquiries.

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