The North Carolina Department of Health and Human Services (DHHS) and Prepaid Health Plans (PHPs) continue their commitment to support providers a year after the transition to managed care. We stand by the day one goal to ensure providers are paid for services they provide. While progress has been made to timely reimburse claims, DHHS recognizes that some claims continue to be incorrectly paid and/or denied.
If a provider is unable to resolve claim payment issues through contacting the PHPs, they should contact the Provider Ombudsman at Medicaid.ProviderOmbudsman@dhhs.nc.gov or 866-304-7062 and provide a detailed description of the issue at hand, the PHP(s) involved, and claim examples.
Providers who are at risk of not meeting financial obligations because of PHP claim processing issues may request a hardship advance to offset the business cost due to pended or denied claims. To request a hardship advance, send an email to the Provider Ombudsman. Please include:
- Financial obligations the provider is unable to meet
- Estimated total monetary impact to the provider of unpaid managed care claims
- The NPI number of the provider who will receive the advance
- A list of the unpaid managed care claims, the associated PHP and the reason the claim has not paid (i.e., denial reason)
- Name, telephone number and email address of the provider’s contact person
DHHS and PHPs will respond to the completed hardship advance request by contacting the provider to resolve any claim payment issues and sending a hardship agreement, if necessary. If advances are issued, they will be recouped from future payments.
For fact sheets and additional resources, please visit the NC Medicaid Provider Playbook for Medicaid Managed Care fact sheet webpage.
Thank you for your patience and cooperation as we work to resolve claims payment issues.