Durable Medical Equipment and Orthotic and Prosthetic Manually Priced Procedure Codes - Prior Authorization Update

A new prior authorization is required for beneficiaries returning to NC Medicaid Direct

A Medicaid beneficiary enrolled in a health plan may be later identified as a member of a Medicaid population that is exempt or excluded from NC Medicaid Managed Care enrollment. This will result in a beneficiary’s disenrollment from the health plan and return to NC Medicaid Direct. 

Most managed care prior authorizations (PAs) transfer to NC Medicaid Direct for impacted beneficiaries. However, the Department has identified system and process differences that exist between NC Medicaid Direct and the health plans that resulted in PAs with manually priced Durable Medical Equipment (DME) and Orthotic and Prosthetic (O&P) procedure codes transferring to NCTracks with insufficient information for use during claim adjudication. 


  • Due to the system differences, health plans are asked not to return PAs with manually priced DME and O&P codes to NCTracks. 
  • PAs with manually priced procedure codes sent to NC Medicaid Direct by health plans will be rejected.  

Note: This change applies only to manually priced procedure codes. DME and O&P codes that are not manually priced will continue to transfer back to NCTracks when a beneficiary returns to NC Medicaid Direct.

Guidance to Providers

Effective April 1, 2023, DME and O&P providers must submit a new PA request to NCTracks when a beneficiary transitions back to NC Medicaid Direct from a health plan. The specific manually priced items listed are on the DME and O&P fee schedules on the NC Medicaid Fee Schedule and Covered Code site. Specifically: 

  • A new PA for these items is required for all beneficiaries returning to NC Medicaid Direct regardless of previous managed care PA status.   
  • PAs for unlisted nationally recognized HCPCS codes that are manually priced, such as B9998, E0986, E1012, E1399 and K0108, will also be rejected.  

New PA requests must be submitted for all beneficiaries returning from NC Medicaid Direct regardless of previous managed care PA status for unlisted codes as well. To support providers through this process, the Department will allow retroactive review of PA requests for beneficiaries who transition back to NC Medicaid Direct from a health plan.

Retroactive Prior Authorization Request

For beneficiaries who return to NC Medicaid Direct on or after April 1, 2023, retroactive requests must be submitted within 90 days of the effective date of return to NC Medicaid Direct. The "effective date" is the latter of: 

  • the date coverage begins under NC Medicaid Direct, 
  • or the date the coverage was issued. 

Providers should check NCTracks for appropriate prior authorizations and submit claims to NCTracks. If the dates of service are outside the 90-day window, or the provider experiences other difficulties submitting a retro prior authorization request or affiliated claims to NCTracks, the provider should contact the NC Medicaid Managed Care Provider Ombudsman at 866-304-7062 or Medicaid.ProviderOmbudsman@dhhs.nc.gov to generate a ticket for claim reprocessing. 

The provider should include: 

  • Subject: Retro Disenrollment Claims Issue
  • Provider Name and NPI:
  • Previous PHP Name:
  • MID:
  • Service Provided (include procedure codes):
  • Dates of Service or Date of Dispensing:

Documentation Requirement

For all retroactive PA requests, the health plan PA history must be documented with a copy of the health plan PA submitted, if one was issued. 


Providers should always check the beneficiary’s current NC Medicaid eligibility and managed care enrollment status and available PAs in NCTracks prior to submitting a PA or providing services. 



LTSS, Medicaid.DMErequest@dhhs.nc.gov

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