Medicaid and prepaid health plans (PHPs) have identified a trend in claim denials related to taxonomy enrollment and credentialing. As a reminder, the taxonomy submitted on a claim for billing, rendering and attending providers must be a taxonomy for which the provider is enrolled with NC Medicaid. There are three levels of taxonomies:
- Level 1 is the practitioner type (not used on claims),
- Level 2 is Classification, and
- Level 3 is the Area of Specialization.
Providers enrolling with NC Medicaid select the appropriate taxonomy to the specificity desired for services rendered and must use that approved taxonomy on their claim. See the Provider Permission Matrix for taxonomies accepted for NC Medicaid.
For example, if a provider is approved for Level 3 taxonomy 1041C0700X - Clinical, but uses the Level 2 taxonomy 104100000X – Social Worker on the claim, the claim will be denied. The provider must use the taxonomy approved on their NC Medicaid provider record.
- All levels of taxonomies are visible in NCTracks but the selected taxonomy is the one displayed as indicated below (I.e. 282N00000X and 3112A0620X). If active, this is the taxonomy that should be used on claims.
- Expanding the taxonomy information using the “+” sign will also show all levels of taxonomies based on the provider selection. If these do not appear on the Taxonomy Classification screen without expanding, the provider should not use them on a claim as it will cause claims to deny.
- The taxonomy must be active on the date of service for a claim to be paid. See the Status field as displayed above.
- Taxonomies will be suspended when providers fail to update expiring credentials as described in the June 29, 2021 Update Expiring Credentials to Avoid Claims Suspension bulletin. Provider participation will be suspended when providers fail to complete revalidation. If no action is taken during suspension, the taxonomy and/or health plan will terminate.
- Claims will pend when a taxonomy or health plan is suspended and deny when participation is terminated.
- If terminated, providers will need to resubmit any denied claims upon re-enrollment.
- When submitting claims to PHPs, providers should continue to submit the appropriate billing provider taxonomy which is expected to be consistent with the taxonomy on the NCTracks provider record and valid for the service rendered. As noted in the August 27, 2021 Claims Denied – Taxonomy Codes Missing, Incorrect, or Inactive bulletin, Clearinghouses may be updating taxonomy information submitted by providers. It is important that providers work with their clearinghouse to ensure valid taxonomy data is submitted to the PHPs on their claims.
- Taxonomies on the NC Medicaid provider record may be modified using the Manage Change Request process.
For help, please refer to the following NCTracks user guides:
- How to view and update Taxonomy on the Provider Profile in NCTracks User Guide
- How to Add or Update Licensing and Accreditation on the Provider Profile
NCTracks Call Center: 800-688-6696