Author: NC Medicaid Provider Services, (919) 855-4050
Enrollment applications submitted with incorrect data including name, Social Security number (SSN) and date of birth (DOB) result in application denials and withdrawals. As a result, providers must submit new applications and pay any applicable fees. This delay can impact the fingerprint processing and may put providers at risk of suspension or termination for failure to complete the recredentialing/reverification process by the due date.
Providers, Office Administrators and Enrollment Specialists must ensure the data entered on an application is correct. Name, SSN and DOB should match the data on government-issued identification documents such as a driver’s license or Social Security card.
Errors in the provider name, SSN, DOB or Employer Identification Number (EIN) cannot be corrected within an application. Instead, providers must submit a request to NCTracks asking for corrections to be made. Correction requests may be submitted by email to NCTracksprovider@nctracks.com. Any required documentation must be included in the submission (see chart below).
Once corrections have been made in NCTracks, providers may resume submission of any enrollment-related documents. Note: Although providers are also permitted to submit documents by fax or mail, these methods can delay processing.
Fax: (855) 710-1965
Mail: GDIT, Provider EVC Unit, P.O. Box 300020, Raleigh, NC 27622-8020
| Type of Change | Required Documentation |
|
Individual Legal Name |
|
|
Organization/Group Legal Name |
|
|
Employer Identification Number (EIN) |
Copy of IRS letter reflecting the correct EIN. Note: The IRS letter only needs to be submitted if the EIN change is NOT due to a Change of Ownership (CHOW). If the EIN change is due to a CHOW, the provider should terminate the current record with the CHOW reason and then enroll the new record with the new EIN. |
|
Date of Birth (DOB) |
Copy of birth certificate, driver’s license, passport or other form of legal identification reflecting the correct DOB. Note: If the DOB is incorrect for a Managing Employee or Owner, it can be changed through an MCR by end-dating the incorrect information. Credentialing may be required. |
|
Gender |
Copy of birth certificate or driver’s license indicating the correct gender. |
|
Social Security Number (SSN) |
Copy of Social Security card representing the correct SSN. Note: If the SSN is incorrect for a Managing Employee or Owner, it can be changed through an MCR by end-dating the incorrect information. Credentialing may be required. |