North Carolina Medicaid Fee Schedule
NC Medicaid pays $54.26 for an established-patient office visit (99213): 11th-lowest of 45 Medicaid programs, at 76% of the median. Its rates for the most-billed codes are below, ranked against every state.
- Schedule as of
- January 2026
- Codes priced
- 8,402
- 99213 vs. median
- 76% of median
Current NC Medicaid rates for common codes
Each amount is the unmodified non-facility rate in the January 2026 schedule. Where a code appears under more than one rate type, it is the state's ordinary statewide rate when its rules name one, and otherwise the median across rate types. Modifier-specific and facility-only rows are listed separately under the service.
| Code | Service | Non-facility rate |
|---|---|---|
| 99213 | Office visit, established patient (low complexity) | $54.26In effect since Oct 1, 202511th-lowest of 45 · 76% of median |
| 99214 | Office visit, established patient (moderate complexity) | $81.76In effect since Oct 1, 202511th-lowest of 45 · 81% of median |
| 99203 | Office visit, new patient (low complexity) | $80.86In effect since Oct 1, 202516th-lowest of 45 · 90% of median |
| 99204 | Office visit, new patient (moderate complexity) | $125.39In effect since Oct 1, 202518th-lowest of 45 · 93% of median |
| 99285 | Emergency department visit, high severity with threat to function | $138.64In effect since Oct 1, 202521st-lowest of 42 · 100% of median |
Dot: North Carolina. Tick: median across state programs. Line: lowest to highest state. Base fee-for-service rates; supplemental payments some states add are not included.
North Carolina is 11th-lowest of 45 for 99213. See where all 8,402 NC Medicaid codes rank.
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Compare any other code across state programs. The free view shows a few states per code; North Carolina's full schedule is in the complete dataset.
What to know about the NC Medicaid fee schedule
- Physician fees are 86% of the Medicare fee schedule in effect on January 1 of the year each code was first established. NC State Plan, Attachment 4.19-B (SPA 20-0007)
- Primary care E/M codes billed by qualifying physicians and OB/GYNs pay 100% of 2018 Medicare, and 85% for nurse practitioners and PAs. SPA 18-0012 (CMS)
- Standard and Tailored Plans must pay at least 100% of the NC Medicaid Direct rate unless plan and provider agree otherwise. NC Medicaid fee schedules and rate floors
- An 8% physician cut and 10% emergency visit cut from October 1, 2025 were reversed in December 2025, with claims reprocessed. NC Medicaid rate reductions, Oct. 1, 2025 NC Medicaid rate reduction reversal
NC Medicaid fee schedule FAQ
Does a listed code mean the service is covered by NC Medicaid?
No. A listed NC Medicaid fee is not a coverage, authorization, or payment guarantee. Coverage criteria, prior approval and billing limits are set in NC Medicaid's Clinical Coverage Policies, including the Physician Clinical Coverage Policies.
Does this North Carolina rate apply to Medicaid managed-care plans?
Most NC Medicaid beneficiaries are in managed care (Standard Plans, Tailored Plans and the EBCI Tribal Option); NC Medicaid Direct is the fee-for-service program. The fee-for-service rates apply when NC Medicaid pays a claim directly. Physician Services is a rate-floor schedule: health plans must pay at least 100% of the NC Medicaid Direct rate unless the plan and provider agree otherwise.
Why might my actual payment differ from the displayed rate?
These are the January 2026 NC Medicaid rates. A claim can pay a different amount because of the date of service, modifier, place of service, units billed, provider enrollment or taxonomy, bundling with another service, coverage policy, prior authorization, and claim edits.
Why is there no published rate for this code?
NC Medicaid does not publish a fixed amount for every code. A code may also be bundled into another service or priced on a different NC Medicaid schedule. A missing rate does not mean the service is noncovered or pays $0.
Where can I find other NC Medicaid fee schedules?
NC Medicaid publishes separate fee schedules by provider type alongside the NC Medicaid Physician Services fee schedule, and its provider manual sets the coverage and billing rules.
How does NC Medicaid set physician fees?
Under the state plan, each physician service has a statewide maximum fee 'based on 86 percent of the Medicare Resource-Based Relative Value Scale (RBRVS) physician fee schedule (PFS) in effect January 1 of the year in which the service was initially established.' Payment is the lower of that fee or the provider's charge, the same for every specialty and setting.
Does NC Medicaid pay primary care at the Medicare rate?
Yes, for qualifying providers. Since January 1, 2019, E/M codes 99201-99499 billed by ACA primary care physicians, including OB/GYNs, have been priced at 100% of the 2018 Medicare fee schedule; nurse practitioners and physician assistants get 85%. The KFF fee index for 2024 puts North Carolina at 0.78 of Medicare for primary care and 0.82 overall, above the national 0.66 and 0.75.
Do NC Medicaid health plans have to pay at least the Medicaid Direct rate?
Yes, by default. Physician Services is a rate-floor schedule: Standard Plans and Tailored Plans must pay 'no less than 100% of the applicable NC Medicaid Direct rate', unless the plan and provider mutually agree to an alternative arrangement. That opt-out is not available for DME providers or physician-administered drug program (PADP) services, where the floor always applies.
What happened to NC Medicaid physician rates in late 2025?
To stay within the funding the General Assembly had appropriated, NC Medicaid cut Physician Services codes by 8% and emergency department visits (99281-99285) by 10% for dates of service from October 1, 2025. The state reversed the cuts on December 10, 2025, restored rates to their September 30, 2025 levels and reprocessed affected claims, with health plans given 45 days to load the restored rates and 30 more to reprocess.
How are nurse practitioners and physician assistants paid in North Carolina?
New nurse practitioner and physician assistant services are paid at 100% of the Physician Services fee in effect when the service is established, but primary care E/M codes are paid at 85% of Medicare rather than the 100% physicians receive. NPs, PAs and CRNAs have their own schedules, which are also rate floors for health plans.
Where does NC Medicaid announce rate changes?
NC Medicaid announces rate changes and their effective dates in the NC Medicaid Bulletin and in provider blog posts, and changes to the payment methodology go to CMS as state plan amendments.
Neighboring and high-enrollment Medicaid fee schedules
States bordering North Carolina first, then the largest programs.