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CMS-Approved NQTLs: Staggered Implementation Plan and Provider Guidance

Issued: October 8, 2025

Effective Dates: Dec. 1, 2025, and Jan. 1, 2026

This communication provides updates and clarifications for providers and Tailored Care Managers regarding the application of CMS-approved Non-Quantitative Treatment Limitations (NQTLs) to Behavioral Health and Substance Use Disorder services. These changes align with Parity compliance requirements and outline the staggered implementation plan for Prior Authorization (PA) and Concurrent Review (CR) for Medical Necessity Review.

What is happening?

The North Carolina Department of Health and Human Services (NCDHHS) has approved Partners Health Management to apply Non-Quantitative Treatment Limitations (NQTLs) that maintain compliance with Mental Health Parity and Addiction Equity Act (MHPAEA) requirements.

This approval was granted in accordance with Section V.B.2.i.(v)(a) of the Contract. Table 1: Decision on Contractor’s Request to Add One or More UM NQTLs to MH/SUD Benefits sets forth the Department’s approval and the effective dates for implementation.

  • CMS Approval Granted: Partners is authorized to apply UM NQTLs to MH/SUD benefits.
  • Provider Stagger Plan: Providers are not required to submit authorizations until the effective date of each phase.
  • Implementation Timeline:
    • Phase 1: Dec. 1, 2025
    • Phase 2: Jan. 1, 2026

The benefit grid will be updated prior to the effective date of each phase.

Implementation Timeline

Phase 1 – Effective Dec. 1, 2025

NQTLs Applied: Prior Authorization (PA) and Concurrent Review (CR) for Medical Necessity Review

  • H0014 (HF) – Ambulatory Withdrawal with Extended Onsite Monitoring
  • H2015 (HT) (HO) “All Code” – Community Support Team (CST)
  • H2022 – Intensive In-Home (IIH)
  • H0035, 0912, 0913 – Partial Hospitalization (PHP)
  • H0038 “All Code”– Peer Support Services
  • H2035 – Substance Abuse Comprehensive Outpatient Treatment (SACOT)
  • H0012 HB – Substance Abuse Non-Medical Community Residential Treatment

Phase 2 – Effective Jan. 1, 2026

NQTLs Applied: Prior Authorization (PA) and Concurrent Review (CR) for Medical Necessity Review

  • T1019 (U4), T1019 (U4) (TS) – 1915(i) Individual and Transitional Supports (ITS)
  • H0014 – Ambulatory Withdrawal without Extended Onsite Monitoring
  • H0040 “All Code” – Assertive Community Treatment (ACT)
  • S9484, S9484 (HA)–Facility-Based Crisis (FBC) – Adult and Children
  • H0010 – Medically Monitored Inpatient Withdrawal Management Services
  • H2033 (M1), H2033 (M2), H2033 (M3), H2033 (M4), H2033 (M5), H2033 (M1) (PB), H2033 (M2) (PB), H2033 (M3) (PB), H2033 (M4) (PB), H2033 (M5) (PB) – Multisystemic Therapy (MST)
  • Residential Services:
    • Maintain passthrough for Level I and II/Family Type
    • Discontinue passthrough for Level II Group Type, Level III, Level IV, and PRTF
  • H0015, H0015 AD – Substance Abuse Intensive Outpatient Program (SAIOP)
  • H0013 – Substance Abuse Medically Monitored Community Residential Treatment

What do providers need to do?

  • Providers must submit authorizations based on the effective date of each phase: Phase 1—Dec. 1, 2025, and Phase 2—Jan. 1, 2026.
  • For additional clinical coverage policy information, providers should click here for the NCDHHS Clinical Coverage Policy Website.
  • Providers should review the updated Partners Benefit Grid.

(Available on the effective dates) to ensure alignment with the new requirements.

Summary Table of NQTLs (PA and CR):

NQTLs Effective 12-1-2025 Summary.xlsx

NQTLs Effective 1-1-2026 Summary.xlsx

Who can providers call if they have questions?

If providers have questions, they can:

Issued: 2022

Updated: