Last updated: November 2026
A North Carolina certificate of need (CON) application is the filing a provider makes with the Department of Health and Human Services before it offers or develops a new institutional health service, makes certain acquisitions, or incurs an obligation for a capital expenditure that is itself a new institutional health service. The Department decides it against review criteria in Chapter 131E, Article 9.
Integral Healthcare Solutions (IHS) turns those criteria into a work plan, drafts the narrative sections, worksheets and review calendar, and prepares the applicant for comments and a hearing. IHS was founded in 2002 by Thomas G. Goddard, JD, PhD, former URAC COO and General Counsel, and has three practice lines: accreditation consulting, compliance services and program development. This page sits in compliance services.
What is a North Carolina certificate of need application?
It is the application for the Department's certificate of need under Chapter 131E, Article 9, Certificate of Need of the North Carolina General Statutes. We read sections 131E-176, 131E-178, 131E-181 through 131E-186, 131E-188 and 131E-189 there, and the Overview of Certificate of Need from the Division of Health Service Regulation (all pages opened November 6, 2026).
Division rules, forms and the State Medical Facilities Plan sit outside the statute article; counsel reads them alongside it. The Division's FAQ page says an application may not be needed. The General Assembly page marks some provisions, including 131E-183(a)(1), with a note that we did not read, and counsel reads it.
Which acts need a certificate before they start?
Section 131E-178 names three separate triggers.
- Offering or developing a new institutional health service (178(a)). No person may do so without first obtaining a certificate from the Department, subject to a dated proviso for certain gastrointestinal endoscopy settings.
- Acquisition by donation, lease, transfer or comparable arrangement (178(b)). A certificate is required first if the acquisition would have been a new institutional health service had it been made by purchase.
- Capital expenditure obligations (178(c)). No person may incur an obligation for a capital expenditure that is a new institutional health service without first obtaining a certificate. An obligation is incurred when an enforceable contract is entered into for construction, acquisition, lease or financing of a capital asset, excepting contracts expressly contingent upon issuance of a certificate of need. The subsection lists two other ways an obligation is incurred.
What counts as a new institutional health service is defined in 131E-176(16). It includes a new health service facility, a change in bed capacity, listed services and equipment, and the obligation of a capital expenditure exceeding four million dollars as the statute states it, to develop or expand a health service or health service facility or that relates to the provision of a health service. That amount is adjusted each September 30 using the Medical Care Index and is subject to exceptions, so counsel confirms the figure in force on the date of the act. The magnetic resonance imaging scanner entry and the definitions of diagnostic center and major medical equipment each show one version effective until November 21, 2026 and another effective on that date.
Section 131E-184 exempts certain services and expenditures from review, each on written notice to the Department, and portions of a project not proposed for an exempt purpose remain subject to review if they are themselves new institutional health services.
What must the application show?
The Department reviews all applications against the criteria in section 131E-183(a) and must determine that an application is either consistent with or not in conflict with them before a certificate is issued. Subsection (a) lists more criteria than the three below, including population need, financial feasibility and effects on competition, and subsection (b) lets the Department adopt rules for particular types of applications that apply in addition to those criteria.
- Consistency with the State Medical Facilities Plan (183(a)(1)). The proposed project must be consistent with applicable policies and need determinations in the Plan, and the Plan's need determination is a determinative limitation on the provision of any health service, health service facility, facility beds, dialysis stations, operating rooms or home health offices that may be approved.
- Least costly or most effective alternative (183(a)(4)). Where alternative methods of meeting the needs exist, the applicant must demonstrate that the least costly or most effective alternative has been proposed.
- No unnecessary duplication (183(a)(6)). The applicant must demonstrate that the project will not result in unnecessary duplication of existing or approved health service capabilities or facilities.
A certificate is valid only for the defined scope, physical location and person named in the application, and the recipient must materially comply with the representations made in it (131E-181(a), (b)).
How does the Department's review run?
Except as provided in subsection (c), the statute sets a time limit of 90 days for review, which the Department may extend by up to 60 days (for expedited reviews, only if it has requested additional substantive information) (131E-185(a1), (c)). The Division's overview describes batched review periods and a filing deadline of 5:00 p.m. on the 15th of the month before the period begins, or 5:00 p.m. on the next business day when the 15th falls on a weekend or holiday.
Any person may file written comments and exhibits with the Department not later than 30 days after the application begins review. The Department must ensure a public hearing is conducted, no more than 20 days after the comment period ends, if any one of four circumstances applies: the review is competitive; the proponent proposes to spend five million dollars or more; an affected party asks for a hearing in writing before the comment period ends; or the agency determines a hearing is in the public interest (131E-185(a1)(2)). No hearing is held when an expedited review has been approved (131E-185(a2)). Under 131E-182(a), the review schedules shall provide that applications for similar proposals in the same service area will be reviewed together.
The Department decides to approve, approve with conditions or deny, with written notice of findings to the applicant within five business days after the decision (131E-186). An affected person may petition for a contested case hearing within 30 days after the decision (131E-188(a)).
How IHS helps
- Trigger check. IHS sets the project against 178(a), (b) and (c) and 176(16) so counsel can confirm which applies.
- Criteria map. IHS maps each applicable 131E-183(a) criterion to a narrative section and its evidence.
- Drafting. IHS drafts the narrative and worksheets from the applicant's data.
- Calendar. IHS builds a review, comment and hearing calendar.
The applicant supplies the project facts, capital estimate, financial projections, any architect or engineer certification, the filing, and attendance at any hearing. IHS does not file with, call or correspond with the Department, and it does not predict a decision.
What to have ready
- A one-page project description and the triggering act under 178(a), (b) or (c).
- The current State Medical Facilities Plan policies and need determinations, with a note on consistency (183(a)(1)).
- The alternatives considered and the cost comparison (183(a)(4)).
- An inventory of existing or approved services in the area, with the case that the project does not duplicate them (183(a)(6)).
- The financial and operational projections, showing the funds for capital and operating needs (183(a)(5)).
- The scope, physical location and person to be named in the application (181(a)).
- Each enforceable contract for the capital asset, with a note on whether it is expressly contingent upon issuance of a certificate, because 178(c)(1) excepts contingent contracts from the incurred-obligation rule.
- Where an architect or engineer certifies a cost at or below the expenditure minimum, the written estimate prepared 60 days or more before the obligation is incurred, and written notice to the Department within 30 days, with a copy of the estimate, if the expenditure exceeds the expenditure minimum (178(d)).
- The Department's current application form and fee sheet, posted on the Division's FAQ page.
If the alternatives and duplication analysis do not exist yet, book the free introductory call below before a filing date is set.
How it compares
- No-review determination. The Division's No Reviews and Exemptions page says providers ask each month whether a certificate is required, and it may answer that no review is required, a review is required or the proposal is exempt.
- Facility licensing. The license to operate is covered in the state licensing overview.
What it costs
The Department's application fee is set by section 131E-182(c): five thousand dollars plus three-tenths of one percent of the proposed capital expenditure that exceeds one million dollars, never more than fifty thousand dollars. It is not refundable, whether or not a certificate is issued. Verify current fees with the Division of Health Service Regulation.
Consulting scope turns on the criteria narratives needed, the modeling that exists, whether review is likely to be competitive, and project size. IHS scopes each engagement after a free introductory call.
What this is not
This is not legal advice. IHS is a consulting firm, not a law firm; counsel decides whether a certificate is required and handles any contested proceeding.
Frequently asked questions
When does a North Carolina provider need a certificate of need?
Under 131E-178(a), no person may offer or develop a new institutional health service without first obtaining a certificate of need from the Department, and 131E-176(16) defines the term. Acquisitions (178(b)) and capital expenditure obligations (178(c)) also require one first.
Does leasing or accepting a donation of equipment trigger review?
It can. Section 131E-178(b) bars an acquisition by donation, lease, transfer or comparable arrangement without first obtaining a certificate if the acquisition would have been a new institutional health service had it been made by purchase.
When is a capital expenditure obligation incurred?
Under 131E-178(c), an obligation is incurred when an enforceable contract is entered into for construction, acquisition, lease or financing of a capital asset, excepting contracts expressly contingent upon issuance of a certificate of need. The subsection lists two other ways an obligation is incurred.
What does a certificate cover once it is issued?
A certificate is valid only for the defined scope, physical location and person named in the application, and it may not be transferred or assigned except as provided in 131E-189(c) (131E-181(a)).
Does the State Medical Facilities Plan limit what can be approved?
Section 131E-183(a)(1) requires consistency with applicable policies and need determinations in the Plan, and the Plan's need determination is a determinative limitation on the provision of any health service, facility, beds, dialysis stations, operating rooms or home health offices that may be approved.
What must the narrative show on alternatives and duplication?
Under 131E-183(a)(4), where alternative methods exist, the applicant must demonstrate that the least costly or most effective alternative has been proposed. Under 183(a)(6), it must demonstrate that the project will not result in unnecessary duplication of existing or approved health service capabilities or facilities.
How long is the review, who can comment, and when is a hearing held?
Except as provided in subsection (c), the statute sets a time limit of 90 days, and the Department may extend it by up to 60 days, for expedited reviews only if it has requested additional substantive information (131E-185(a1), (c)). Any person may file written comments not later than 30 days after review begins. A hearing must be conducted if the review is competitive, the proponent proposes to spend five million dollars or more, an affected party requests one in writing before the comment period ends, or the agency determines a hearing is in the public interest. No hearing is held when an expedited review has been approved (131E-185(a1)(2), (a2)).
What does IHS draft, and does IHS deal with the Department?
IHS drafts the narrative, worksheets, review calendar and a comment and hearing outline. IHS does not submit anything to, call or correspond with the Department. The applicant files and attends, with counsel.