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NC Department of Health and Human Services
NC Division of
Medical Assistance
 
 

Provider Enrollment

The Division of Medical Assistance (DMA) recognizes the need to promote access to care by enrolling all providers in a timely manner and is committed to ensuring the provision of quality care for our citizens. The enrollment process includes credentialing, endorsement, and licensure verification to ensure that all providers are in good standing in the community.

Applicants must meet all program requirements and qualifications for which they are seeking enrollment. The NCTracks Provider Enrollment "Getting Started" web page provides a Provider Qualifications and Requirements Checklist for each provider type, as well as access to the online provider enrollment application.

Application receipts will be acknowledged by email or by mail. Whenever possible, CSC will communicate via email if missing or additional information is needed from providers. If approved, providers will receive a Welcome Email.

Providers are not guaranteed a retroactive effective date and are strongly encouraged to provide services only after they are enrolled as an N.C. Medicaid and/or N.C. Health Choice (NCHC) provider. However, DMA will consider specific requests for retroactive effective dates if a beneficiary has been granted retroactive eligibility, an emergency service was provided, or medically necessary services were rendered and the provider's credentials, licensure, certifications, etc. were active and in good standing for the earliest effective date of service.

DMA cannot provide special consideration for processing of enrollment applications due to provider error, incomplete information, or due to a delay in obtaining credentialing, endorsement or licensure information from another agency.


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Fees (Enrollment, Re-enrollment and Re-credentialing)

Affordable Care Act (ACA) Fees

October 1, 2012, the N.C. Division of Medical Assistance (DMA) began collecting the federal application fee required under Section 1866(j)(2)(C)(i)(l) of the Affordable Care Act (ACA) from certain N.C. Medicaid and NCHC providers.

The Centers for Medicare & Medicaid Services (CMS) set the application fee, which may be adjusted annually. The application fee for enrollment in calendar year 2014 is $542. The fee is used to cover the cost of screening and other program integrity efforts.

The application fee will be collected per site location prior to executing a provider agreement from an initial or re-enrolling provider.

This requirement does not apply to the following providers:

     (1) Individual physicians or non-physician practitioners
     (2) (i) Providers who are enrolled in either of the following categories:
              (A) Title XVIII of the Social Security Act (“Health Insurance for the Aged and Disabled”); or,
              (B) Another State's Medicaid or Children’s Health Insurance Program plan
          (ii) Providers who have paid the applicable application fee to:
              (A) A Medicare contractor; or
              (B) Another State

Providers who are required to pay this fee will be sent an invoice via mail. States must collect the applicable fee for any initial or re-enrolling provider.

Providers newly enrolling or re-enrolling in the N.C. Medicaid or NCHC program that do not pay the fee within 30 days of receipt of invoice will have their applications voided by CSC. Providers in border states located within 40 miles of N.C. who have paid the fee to their state will be required to provide proof of payment.

North Carolina Enrollment Fee

Session Law 2011-145 Section 10.31(f)(3) mandated that DMA collect a $100 enrollment fee from providers upon initial enrollment with the Medicaid/NCHC programs, upon program re-enrollment and at three-year intervals when the providers are re-credentialed.

Initial enrollment is defined as an in-state or border-area provider who has never enrolled to participate in the N.C. Medicaid/NCHC programs. The provider's tax identification number is used to determine if the provider is currently enrolled or was previously enrolled.

With the NCTracks system, providers submitting applications for enrollment, re-enrollment or re-credentialing are automatically linked from the Provider Portal to the secure PayPoint website to pay the required fee using a credit card or one-time automated bank draft (e-check). Once the transaction is completed, a confirmation email is sent to the provider.

Requests for N.C. Medicaid enrollment, re-enrollment or re-credentialing will not be processed unless the payment is received. Applications will be held for up to 30 days. After 30 days, applications will be voided if payment has not been received.

PAYMENT OF THE ENROLLMENT FEE DOES NOT GUARANTEE ACCEPTANCE INTO THE N.C. MEDICAID OR NCHC PROGRAMS.

Screening and Training

Beginning October 1, 2012, the N.C. Division of Medical Assistance (DMA) implemented Federal Regulations 42 CFR 455.410 and 455.450 – requiring all participating providers to be screened according to their categorical risk level. These screenings will take place both upon initial enrollment and re-enrollment.

42 CFR 455.450 establishes the following three categorical risk levels for N.C. Medicaid and NCHC providers to assess the risk of fraud, waste, and abuse:

  • Low
  • Moderate
  • High

Provider types and specialties that fall into the moderate- and high-risk categories are subject to a pre-enrollment site visit, unless a screening and site visit has been successfully completed by Medicare or an appropriate State agency within the previous 12 months. Session Law 2011-399 §108C-3 further defines provider types that fall into each category.

This requirement does not apply to the following providers:

      (1) Individual physicians or non-physician practitioners
      (2) (i) Providers who are enrolled in either of the following categories:
                (A) Title XVIII of the Social Security Act (“Health Insurance for the Aged and Disabled”)
                (B) Another State's Medicaid or Children’s Health Insurance Program plan
           (ii) Providers that have paid the applicable application fee to:
                (A) A Medicare contractor; or
                (B) Another State

Session Law 2011-399 §108C-3 also requires that – prior to initial enrollment in the N.C. Medicaid or NCHC programs – an applicant’s representative shall attend training sessions as designated by DMA, including, but not limited to, the following:

    • The NCTracks Provider Claims and Billing Assistance Guide, common billing errors, and how to avoid them.
    • Audit procedures, including explanation of the process by which the DMA extrapolates audit results.
    • Identifying N.C. Medicaid beneficiary fraud.
    • Reporting suspected fraud or abuse.
    • N.C. Medicaid beneficiary due process and appeal rights.

This training is completely Web-based.

It is imperative that providers submit their application with a valid email address that is frequently checked. Providers will be notified via email when it is time to complete the training and the steps necessary to complete the training. 

ATTENTION: BEHAVIORAL HEALTH PROVIDERS: 

As a reminder, NCHC providers must still enroll directly with DMA/CSC, regardless of whether or not these providers accept N.C. Medicaid. This also applies to providers billing N.C. Medicaid for children aged 0-3,  as children these ages are not covered by the LME-MCO waiver at this time. Most new behavioral health providers are considered Moderate or High risk and should expect pre-screening. More information will be forthcoming regarding procedures for providers enrolling both through DMA/CSC and the LME-MCOs.

Ordering, Prescribing and Referring (OPR) Providers

Healthcare practitioners often provide services to N.C. Medicaid or NCHC beneficiaries based on another practitioner's order, prescription or referral. For N.C. Medicaid or NCHC to reimburse for these services, the Ordering, Prescribing or Referring (OPR) practitioner must be enrolled in N.C. Medicaid or NCHC. (Affordable Care Act, Section 6401(b)(7)).

Examples of Medicaid- or NCHC-enrolled providers who may be impacted by this section are:

  • Durable Medical Equipment/Prosthetic, Orthotics and Supplies (DME/POS) Providers
  • Home Health Agencies
  • Imaging Centers
  • Laboratories
  • Pharmacists/Pharmacies
  • Physician Specialists

If such providers plan to submit claims on behalf of N.C. Medicaid or NCHC beneficiaries, they must ensure that the OPR practitioner is also enrolled in Medicaid or NCHC.

If uncertain that the OPR practitioner is enrolled in N.C. Medicaid or NCHC, please contact the NCTracks Call Center at 1-800-688-6696.

Provider Re-credentialing (also known as re-verification)

On behalf of DMA, CSC must re-credential (re-verify) active N.C. Medicaid and NCHC providers a minimum of every three years to ensure that provider information is accurate and current.  As part of this process, the provider’s credentials and qualifications will be evaluated to ensure that they continue to meet N.C. Medicaid and/or NCHC guidelines for enrollment in the program.  The re-credentialing process also includes a criminal background check.

CSC will re-credential providers in cycles.  Providers will receive a Re-credentialing Invitation via their NCTracks secure portal inbox or e-mail when they are scheduled to begin the re-credentialing process.  Instructions for accessing the re-credentialing application will be sent along with the Re-credential Invitation.  Providers cannot access the re-credentialing application until they receive an invitation to begin the process.

For more information on re-credentialing, visit the "Provider User Guides and Training" web page in NCTracks, and click on the bullet which reads: "How to Complete the Re-Credentialing, Re-Verification Process in NCTracks" under "Enrollment and Verification."

Enrollment Forms, Guides and Attestations

Provider Suspension Due to Incorrect Address

If any correspondence cannot be delivered due to an incorrect billing address in the provider’s file, all claims for the provider number are suspended. Any correspondence that is returned to DMA or CSC as undeliverable due to an incorrect billing address will result in the suspension of the provider number. Once a suspension has been placed on the provider number, the provider has 90 days to submit an address change. After 90 days, if the address has not been corrected, suspended claims will be denied and the provider will be terminated. Once terminated, a provider must complete a new application and agreement to re-enroll and may have a lapse in eligibility as an N.C. Medicaid or NCHC provider.

Provider Suspension Due to Lack of Claims

A provider will be required to complete a "Maintain Eligibility" application if he/she does not submit claims within a twelve-month period. This process is used to verify that the provider record is still active. When a provider has not billed claims within twelve months, CSC will send the provider a notification in the messaging center asking the provider if he/she wishes to remain active. If the provider does not complete the "Maintain Eligibility" application, the provider record will be terminated. If the provider is terminated, he/she will be required to complete a re-enrollment application to participate in the North Carolina Medicaid program.

Getting Help with Your Application

The provider enrollment application is designed to be user-friendly and easy to complete. If help is needed, contact CSC. Contact information can be found by clicking on "NCTracks Contact Information," under "Quick Links" on the NCTracks provider portal.

 

Frequently Asked Questions

As a currently enrolled provider will I be required to complete a new or additional enrollment application?

No. However, each provider must verify information in the provider file and furnish additional information on ownership and criminal background as required by federal and state regulations. CSC will notify each provider prior to initiating the verification and credentialing process and will request providers to complete and return the forms within 30 days.

Will DMA allow providers who that are credentialed by other agencies to be grandfathered and avoid credentialing by CSC?

No. DMA has determined that other credentialing agencies do not collect all required information needed to satisfy all federal and state requirements for N.C. Medicaid and/or NCHC enrollment. Since CSC will source verify the credentials of providers, providers will not be required to submit copies of licenses, certifications, accreditations or endorsements.

Why am I being charged an enrollment fee?

2011-145 Section 10.31(f)(3) mandates that DMA charge an enrollment fee of one hundred dollars ($100.00) to each provider enrolling in the N.C. Medicaid and NCHC programs.

Does the enrollment fee apply to all providers? Is anyone exempt?

  • N.C. Medicaid and NCHC provider applicants who have never enrolled in those programs before, as identified by their tax identification number (SSN or EIN), are required to pay an enrollment fee upon initial enrollment.
  • Active, enrolled providers are required to pay an enrollment fee when they are re-credentialed (approximately every three years).
  • Providers who have been terminated from the N.C. Medicaid or NCHC programs and wish to have their provider number reactivated or reinstated are required to pay the enrollment fee.
  • Out-of-state providers are excluded from paying the enrollment fee.
    (Note: Border-area providers are considered in-state providers and are subject to the fee.)
  • Providers to be enrolled under special circumstances (abbreviated enrollments, atypical enrollments) are subject to the enrollment fee unless they are an out-of-state provider.

As a Community Intervention Services (CIS) provider, am I required to pay an enrollment fee for each service I offer?

If you are a CIS provider offering multiple services under the same tax identification number (SSN or EIN), you are only required to pay only one enrollment fee of $100.00. You are not required to pay an enrollment fee for each service provided.

Do I have to pay an additional enrollment fee to apply as a Carolina ACCESS or Community Alternatives Program (CAP) provider?

If you are an N.C. Medicaid provider applicant applying for participation in Carolina ACCESS or CAP under the same tax identification number (SSN or EIN), you are only required to pay one enrollment fee of $100.00.

I would like to provide services at multiple locations. Do I have to pay an enrollment fee for each location?

If you are providing services under the same tax identification number (SSN or EIN) , you are only required to pay one enrollment fee of $100.00.

What happens if I don't pay the enrollment fee?

Applications will be held for 30 days. If payment is not received after 30 days, the application will be voided.

Any checks returned as non-payment will be assessed a $25.00 penalty fee and interest as provided for under the Statewide Cash Management Plan (Authority: NCGS: 147-86.21 and 147-86.23 and G.S.105-241).

Is the enrollment fee a one-time fee or will I have to pay additional fees to maintain my participation in the N.C. Medicaid or NCHC programs?

On behalf of DMA, CSC will re-credential all active N.C. Medicaid and NCHC providers approximately every three years. 2011-145 Section 10.31(f)(3) mandates that we collect a $100 fee at re-credentialing.

Is there a fee for change requests?

There is no fee for processing most provider change requests; however, for a change of ownership, you are required to complete a new enrollment application, which is subject to the enrollment fee.

 

 

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