Provider appeal rights defined in the Standard Plan Contract Section V.D.5 Provider Grievances and Appeals, and the appeal processes outlined in the Prompt Payment Fact Sheet, include deadlines to submit appeals which may vary by Standard Plans, from 30 days to 365 days after the decision giving rise to the right to appeal.
The Department shared concerns from providers about these deadlines with the Standard Plans. In response, Standard Plans will temporarily extend the following minimum appeal timeframes to support the transition to NC Medicaid Managed Care:
| Appeal Submission Date | Minimum Appeal Timeframe |
| Through Jan. 31, 2022 | 90 calendar days from the decision giving rise to the right to appeal |
| Feb. 1, 2022 through March 31, 2022 | 60 calendar days from the decision giving rise to the right to appeal |
| April 1, 2022 and later | 30 calendar days from the decision giving rise to the right to appeal |
Standard Plans are required to correct all claims that are incorrectly adjudicated regardless of an appeal or the timing of the claim adjudication and decision.
Providers are encouraged to submit appeals for claims they feel have been incorrectly adjudicated to maintain their appeal rights. Sending issues to the NC Medicaid Provider Ombudsman does not replace the need to file an appeal or extend the deadline for providers submitting appeals.
Provider Appeal references:
- Standard Plan Contract section V.D.5 Provider Grievances and Appeals
- Standard Plan Contract Attachment I. Provider Appeals
- Prompt Payment Fact Sheet
- Health Plan Provider Manuals
Contact
NC Medicaid Contact Center, 888-245-0179