North Carolina Provider Enrollment - Frequently Asked Questions
Who needs to enroll in North Carolina Medicaid?
Beginning with date of service February 1, 2016, attending, rendering, ordering, prescribing or referring providers are required to be enrolled in Medicaid or if they are included on a claim billed to NCTracks. This requirement also applies to operating, other operating, service facility NPI, assistant surgeon and supervising providers.
What will happen if the attending, rendering, ordering, prescribing, or referring provider included on the claim is not enrolled?
Beginning with date of service, February 1, 2016 DHHS implemented an interim action for any claim from a provider who has an NPI but is not enrolled in Medicaid. If the attending, rendering, ordering, prescribing or referring provider included on the claim is not enrolled in Medicaid, the claim will ”pay and report.” Effective November 1, 2016 the edit disposition will change from a “pay and report” status to “suspend” status.
What happens if the attending, rendering, ordering, prescribing, or referring provider is enrolled after the 90th day claim suspension and the claim denied?
The effective date of the enrollment may not be more than 365 days prior to the date of the enrollment application is submitted. Once the attending, rendering, ordering, prescribing, or referring provider is enrolled, the claim can be resubmitted.
Are there any changes related to billing or rendering providers?
As of Feb. 1, 2016, the billing and rendering provider taxonomy code must be valid for the service location billed on the claim. (In the past, the service location simply had to be valid for at least one taxonomy code on the provider record.)
Additionally, effective Aug. 9, 2020, all individual providers (excluding disaster relief and Out-of-State Lite providers) are required to complete the additional questions on enrollment, re-enrollment and re-verification applications on the new Provider Supplemental Information page.
Why are these new enrollment requirements for individual providers being implemented?
Federal regulation 42 CFR 455.410 requires that all ordering, prescribing or referring physicians – as well as other professionals providing services under NC Medicaid or their respective waiver programs – be enrolled as participating providers. This includes anyone who orders, prescribes or refers services or items (such as pharmaceuticals) to NC Medicaid recipients and seeks reimbursement.
NCTracks is collecting this additional information to assist in streamlining the data collection process for providers and Prepaid Health Plans (PHPs) to facilitate managed care network eligibility determinations.
Is a taxonomy code required in addition to an NPI number for OPR claims? Example: if a home health agency who is billing Medicaid and providing the referring physician's NPI number, is the taxonomy code also required?
The system may capture the taxonomy if it is submitted. But, it is not displayed on the claim record and is not used in claims processing. The system displays in the claim record the taxonomy for billing, rendering and referring on professional claims and billing and attending on institutional claims. There is no editing around taxonomy except for billing, rendering and attending.
Who should I contact with further questions?
You may submit your question to the NCTracks Call center by Email NCTracksprovider@nctracks.com or you may call the NCTracks Call Center Toll Free Number 1-800-688-6696. For questions concerning why Envolve requires providers to take this action, please contact Envolve Customer Service at (833)-678-1324.