Sterilization Consent Form Status and Denial Reasons Accessible to Facility Providers

Facility providers can access Sterilization Consent Form status including denial reasons, on the secure NCTracks Provider Portal, if the sterilization consent form has been properly completed.

Once the beneficiary has had the sterilization procedure and before submitting the completed sterilization consent form to the NCDHHS fiscal contractor, the following is required:

• Surgeon’s NPI must be added to the top left of the consent form.
• Beneficiary’s identification number must be added to the top right of the Sterilization Consent Form.
• The NPI of the facility in which the sterilization procedure was performed may be added to the top center of the consent. The facility NPI field must be populated upon initial submission of the consent form to DHHS fiscal contractor, to ensure that the facility in which the procedure was performed can make inquiries concerning the sterilization consent form status. The service facility NPI cannot be added after the sterilization consent form is in an approved or permanently denied status. The service facility may inquire on the status of the sterilization consent and shall have access to any documents, including the denial letter, associated with the record.

The following providers may receive consent form status from the NCTracks call center: rendering provider, service facility provider, rendering provider’s office administrator or service facility’s office administrator. The caller’s NPI must match one of the NPI’s submitted on the sterilization consent form.

The NCTracks call center shall provide the following status of the consent form review:

• If the consent has been approved
• If the consent has been denied
• The reason for the denial

Mail completed sterilization consents to:

GDIT P.O. Box 30968 Raleigh, NC 27622

For more information, providers should refer to the Clinical Coverage Policy 1E-3, Sterilization Procedures.