Provider Requirements related to Billing Medicaid Beneficiaries
This bulletin restates the Medicaid Provider Participation requirement that providers shall not bill an NC Medicaid beneficiary for services furnished to a beneficiary who the provider has accepted as a Medicaid patient in accordance with 10A NCAC 22J .0106 and the NC Medicaid Provider Participation Agreement.
A provider who has filed a claim with NC Medicaid for services or supplies provided to a Medicaid beneficiary is deemed to have accepted a patient as a Medicaid patient pursuant to 10A NCAC 22J .0106(b). Accordingly, when a provider files a Medicaid claim for services or supplies provided to a Medicaid patient, the provider shall not bill the Medicaid patient for those services or supplies for which it receives no reimbursement from Medicaid except as set forth in 10A NCAC 22J .0106(c).
Rule 10A NCAC 22J .0106(a) further states that a provider may bill a Medicaid beneficiary as a private pay patient “only if the provider informs the patient that the provider will not bill Medicaid for any services or supplies but will charge the patient for all services or supplies provided.”
The provider shall inform a patient if they refuse to accept the patient as a Medicaid patient before providing any services or supplies except as required by 42 U.S.C. 1395dd. Providers should maintain documentation to reflect that the Medicaid beneficiary was informed in writing in advance of services or supplies being furnished that the Medicaid beneficiary was not accepted as a Medicaid patient or the requested service or supply is not covered by Medicaid, and that the beneficiary will be billed for all services and supplies provided.
Providers are reminded that 10A NCAC 22J .0106 is controlling authority under the NC Medicaid Provider Participation Agreement (“Agreement”) Section 3.d. All NC Medicaid enrolled providers sign the Agreement at the time of enrollment and re-verification in accordance with 42 C.F.R. 431.107(b). Providers should ensure that billing practices comply with provider billing requirements under section 5 of the Agreement.
NC Medicaid Contact Center: 888-245-0179