Personal Care Services Beneficiary Managed Care Disenrollment Process and Updated Referral Form

Effective July 1, 2021, some Medicaid beneficiaries receiving Personal Care Services (PCS) transitioned from NC Medicaid Direct to receiving services through an NC Medicaid Managed Care health plan.

Effective July 1, 2021, some Medicaid beneficiaries receiving Personal Care Services (PCS) transitioned from NC Medicaid Direct to receiving services through an NC Medicaid Managed Care health plan.   

A Medicaid beneficiary who later becomes dually eligible for both Medicaid and Medicare services will be disenrolled from their managed care health plan and will receive services through NC Medicaid Direct.   

To ensure a PCS beneficiary appropriately transitions from managed care back to NC Medicaid Direct when they are disenrolled, the PCS Referral Form – Request for Independent Assessment for Personal Care Services Attestation of Medical Need (DHB 3051) must be submitted to the PCS Independent Assessment Entity, Liberty Healthcare of North Carolina.      

When a beneficiary is disenrolling from NC Medicaid Managed Care, the health plan will notify the provider of the anticipated disenrollment, providing guidance and current prior authorization status, as well as the point of contact for the NC Medicaid Direct PCS Independent Assessment Entity.  

  • Once the PCS provider is notified, the PCS provider is required to coordinate the completion of the DHB 3051 form with the beneficiary’s primary care physician (PCP) or treating physician.   
  • Once the DHB 3051 form is completed and signed by the physician, the PCS provider submits the 3051 to Liberty Healthcare of North Carolina.   
  • PCS providers should ensure the DHB 3051 form is sent to Liberty timely before the disenrollment date to ensure no delays in payment or services.      

Medicaid has revised the DHB 3051 form to include an additional request type: Managed Care Disenrollment and the Managed Care Disenrollment Section that is to be completed by the current PCS provider of record prior to sending to the physician for completion of pages one and two of the 3051. The revised DHB 3051 form and instructions are available on the NC Medicaid PCS Webpage under Resources>Personal Care Services Forms.

Providers who have questions on the managed care disenrollment process for their PCS beneficiaries may email

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