Accepting and Billing Medicaid Beneficiaries

Wednesday, April 18, 2018

In accordance with 10A NCAC 22J .0106, a provider may refuse to accept a patient as a Medicaid patient and bill the patient as a private pay patient only if the provider informs the patient that the provider will not bill Medicaid for any services, but will charge the patient for all services provided. Acceptance of a patient as a Medicaid patient by a provider includes, but is not limited to, entering the patient's Medicaid number or card into any sort of patient record or general record-keeping system, obtaining other proof of Medicaid eligibility, or filing a Medicaid claim for services provided to a patient.

A provider who accepts a patient as a Medicaid patient shall agree to accept Medicaid payment plus any authorized deductible, co-insurance, co-payment and third-party payment as payment in full for all Medicaid covered services provided, except that a provider shall not deny services to any Medicaid patient on account of the individual's inability to pay a deductible, co-insurance or co-payment amount.

Providers may bill a patient accepted as a Medicaid patient only in the following situations:

  • For allowable deductibles, co-insurance, or co-payments;
  • Before the service is provided the provider has informed the patient that the patient may be billed for a service that is not one covered by Medicaid regardless of the type of provider or is beyond the limits on Medicaid services;
  • The patient is 65 years of age or older and is enrolled in the Medicare program at the time services are received but has failed to supply a Medicare number as proof of coverage; or
  • The patient is no longer eligible for Medicaid as defined in 10A NCAC 21B.

When a provider files a Medicaid claim for services provided to a Medicaid patient, the provider shall not bill the Medicaid patient for Medicaid services for which it receives no reimbursement from Medicaid when:

  • The provider failed to follow program regulations; or
  • The Division denied the claim on the basis of a lack of medical necessity; or
  • The provider is attempting to bill the Medicaid patient beyond the situations stated in Paragraph (c) of 10A NCAC 22J.0106.

Annual Office Visit Limit for Mandatory Services

North Carolina Medicaid has an annual office visit limit of 22 visits per beneficiary for mandatory services. Prior approval (PA) may be requested for additional office visits beyond the legislative limit. Approval must be received before the service is rendered. If a PA is not obtained, a provider may privately bill beneficiaries for visits more than the legislative annual visit limit, but only if beneficiaries were notified, either orally or in writing, in advance of each office visit that Medicaid will not be billed and they will be financially responsible.

If the service has already been rendered and the claim is denied due to exceeding the annual visit limit, the provider may complete a Medicaid Claim Adjustment Request Form. Optional services (podiatry, optometry and chiropractic) have different limits. Refer to Medicaid’s Annual Visit web page for more information.

For more information, refer to 10A NCAC 22J .0106 or Medicaid’s Annual Visit web page.

Under federal Early Periodic Screening, Diagnostic, and Treatment (EPSDT) law, some limits and restrictions do not apply to recipients under the age of 21. Refer to Medicaid’s EPSDT web page for more information.

Clinical Policy and Programs
DMA, 919-855-4320

Clinical Policy and Programs