Provider Enrollment

NPI Exemption List Extension to Aug. 31, 2018 – Update

In response to provider feedback, the use of the NPI Exemption List for residents and interns enrolled in graduate dental and medical programs, and area health education centers will be extended from April 30, 2018 to Aug. 31, 2018.

DMA will continue to utilize the NPI exemption list in NCTracks which allows residents and interns enrolled in graduate dental and medical programs, and area health education centers to be exempt from the provider enrollment requirement only through August 31, 2018. The exemption from the provider enrollment requirement does not include an exemption from the DEA registration requirement for controlled substances.

The most recent information is available in the April Medicaid Bulletin.

DMA Stakeholders Meetings

DMA held Stakeholders Meetings (click here for slides) to discuss N.C. Medicaid and N.C. Health Choice (NCHC) program changes which will impact providers. (Note: Slides 3 and 4 were changed in 2017)

The agenda included:

  • Rendering Provider Service Location
  • OPR Requirement
  • Incident-to Billing
  • CCNC/CA Payment Authorization and Auto Assignment
  • Provider Affiliation (new implementation date: May 1)
  • Additional Resources

Applications

NCTracks Provider Enrollment provides the online application and a checklist for provider qualifications and requirements.

  • Providers must provide services only after they are enrolled as an NC Medicaid or NC Health Choice (NCHC) provider.
  • Providers must submit their applications with a valid email address.
  • Application receipts will be acknowledged by email or by mail.
  • The Division of Medical Assistance fiscal agent, CSRA, will communicate by email if missing or additional information is needed from providers.

DMA will consider specific requests for retroactive effective dates if:

  • A customer has been granted retroactive eligibility
  • An emergency service was provided
  • 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.

Public Consulting Group (PCG) is contracted by NC Medicaid to perform the federally mandated screening of Medicaid providers classified as moderate and high-risk (reference 42 CFR 455 Subpart E and NCGS 108C).  PCG is also contracted to conduct our online training component (NCGS 108C-9).

Recredentialing

Note: As announced in the Medicaid bulletin, recent system changes to the re-credential (re-verification) process has resulted in reset due dates for providers. No providers have a due date set for the months of May and June 2018.

Providers are required to recredential every five years, using the online process in NCTracks, to continue Medicaid program participation. You will receive a notice posted to your NCTracks Message Center Inbox 45 days in advance of your recredentialing deadline.

Providers who do not complete the recredentialing process on time will be suspended from Medicaid program participation. If recredentialing is not completed within 30 days after the notification, participation will be terminated.

North Carolina law requires that providers pay a $100 fee for Medicaid recredentialing.

Note that recredentialing does not apply to time-limited enrolled providers, such as out-of-state providers. Out-of-state providers must complete the enrollment process every 365 days.

Out-of-State Provider Enrollment

Out-of-state (OOS) providers are required to adhere to all North Carolina rules, regulations, laws, and statutes governing healthcare delivery under the N.C. Medicaid and the N.C. Health Choice (NCHC) programs.  They are only eligible for enrollment under the following conditions:

  • For the reimbursement of services rendered to N.C. Medicaid or NCHC beneficiaries in response to emergencies or if travel back to North Carolina would endanger the health of the eligible beneficiaries
  • For reimbursement of a prior-approved non-emergency service, or,
  • For reimbursement of medical equipment and devices that are not available through an enrolled provider located within North Carolina or in the 40-mile border area

Effective Oct. 29, 2017, OOS providers who are seeking to enroll with N.C. Medicaid or the Children's Health Insurance Program (CHIP) – also known as NCHC – will have the option to enroll using a full-enrollment application or a lite-enrollment application.

If an out of state provider chooses to enroll using the lite-enrollment application the following will apply:

  • The provider will complete an abbreviated application
  • Enrollment is limited to one year
  • Credentialing and background checks will be required
  • Fingerprint-based criminal background checks, if applicable
  • There is no application fee for lite-enrollment

If an OOS provider chooses to enroll using the full-enrollment application the following will apply:

  • The provider will complete a full-enrollment application
  • The provider is required to complete re-verification every five years
  • Credentialing and background checks will be required
  • Fingerprint-based criminal background checks, if applicable
  • The provider will be required to pay the $100 N.C. application fee during enrollment and re-verification

Note: A provider has the option to change from lite enrollment to full enrollment by submitting a Manage Change Request (MCR). The provider will be required to pay the $100 N.C. application fee.

Providers with questions about the NCTracks online enrollment application can contact the CSRA Call Center at 1-800-688-6696 (phone); 919-851-4014 (fax) or NCTracksprovider@nctracks.com (email).

Ordering, Prescribing and Referring (OPR) Lite Enrollment

Effective Oct. 29, 2017, an abbreviated enrollment application will be available for ordering, prescribing and referring (OPR) practitioners. As required by 42 CFR 455.410, physician and non-physician practitioners who solely order, refer, or prescribe items for N.C. Medicaid or N.C. Health Choice (NCHC) beneficiaries must enroll in the Medicaid program. Physician and non-physician practitioners may elect to enroll as OPR-only providers (OPR lite). Billing providers will use the National Provider Identifier (NPI) of the OPR lite provider on their claims when OPR providers order or refer items or services. NCTracks will not reimburse OPR lite providers when their NPI is used as “rendering” or “attending” on a claim.

Starting Nov. 1, 2017, residents and interns licensed through the N.C. Medical Board with a resident in training license (RTL) will also be able to enroll as OPR lite providers via the abbreviated application. These practitioners will use the taxonomy 390200000X, Student Health Care, when enrolling as an OPR lite provider.

The services of residents or interns are not billable to Medicaid in the teaching setting. Therefore, residents and interns who order services, prescribe medications or services, or make referrals must provide their NPI (if appropriate) or their supervising physician’s NPI to the provider submitting claims for service reimbursement. The supervising physician may bill for the services they personally provided during the patient encounter.

Note: On April 30, 2018, the use of the NPI exemption list for residents and interns will cease. The exemption from the provider enrollment requirement does not include an exemption from the U.S. Drug Enforcement Administration (DEA) registration required for controlled substances.

The following enrollment requirements will apply to OPR lite providers:

  • $100 application fee
  • Credentialing and Background Checks including fingerprinting, if applicable
  • Manage Change Request (MCR) submission to update or end date the provider record
  • Revalidate every five years
  • MCR to change from an OPR lite enrollment provider to a fully enrolled provider if they are to be reimbursed for claims.

OPR lite providers may request a retroactive effective date up to 365 days preceding the date of application.