Durable Medical Equipment Coverage
Durable Medical Equipment (DME) is covered under NC Medicaid Managed Care for beneficiaries enrolled in a managed care plan and under NC Medicaid Direct for those beneficiaries who remain in NC Medicaid Direct. DME is NOT carved out of managed care. Pharmacies and other providers that provide DME to NC Medicaid Managed Care beneficiaries should contract with or update contracts with health plans to include a DME agreement to be able to bill DME products, which are a DME benefit, for NC Medicaid Managed Care beneficiaries. For beneficiaries enrolled in NC Medicaid Direct, providers can continue to submit claims through NCTracks. For beneficiaries enrolled in managed care plans, please contact the plan directly for more information.
DME pharmacies and providers can access the Managed Care Claims and Prior Authorization Submission: Frequently Asked Questions - Part 2 fact sheet on the NC Medicaid Managed Care Provider Playbook Fact Sheets webpage for information on how to submit claims to PHPs for services/supplies provided to managed care enrolled beneficiaries. The NC Medicaid Managed Care Provider Playbook has the latest information, tools and other resources to help providers with the transition to managed care.
DME pharmacies should also be actively working to contract with PHPs so they can continue to provide DME supplies for beneficiaries enrolled in managed care plans. Please reference NC Medicaid’s Health Plan Contracting Information webpage and reach out to the PHP contacts listed to contract with the PHPs.
For beneficiaries enrolled in NC Medicaid Direct, please contact NCTracks Call Center: 800-688-6696 for more information.
Contact information for all of the PHPs, including the provider portal and provider service line, is available in the Day One Provider Quick Reference Guide linked in the NC Medicaid Managed Care Provider Playbook Fact Sheets.