As a result of NC Medicaid's ongoing effort to resolve issues related to nursing facility payments due to delays in patient monthly liability (PML) determination, effective Dec. 11, 2023, health plans are required to update systems and processes to pend nursing facility claims submitted prior to the PML determination up to 90 days and process them when the PML has been provided to the health plan.
Health plans will be expected to pend nursing facility claims submitted prior to PML determination as unclean claims until the lesser of 90 calendar days of receipt of the claim or the PML is received.
Health plans must reprocess previously denied claims with dates of service beginning July 1, 2021, where the PML was delayed and did not meet the timely filing deadline.
Providers are reminded to submit the DHB-2039 (PHP Notification of Nursing Facility Level of Care) form to the local division of social services (DSS) within five business days of receipt.
Providers should continue to submit claims in accordance with billing guidance.
- If a claim is submitted to the health plan for payment before the PML has been received, the claim will be pended by the health plan for up to 90 calendar days from receipt.
- If the PML is not received within 90 days from the date that the health plan pended the claim, the health plan will deny the claim. However, pursuant to NCGS 58-3-225, if the PML is received within one year of the claim denial, the health plan is required to reopen and process the claim.
- Nursing facilities may follow-up with the health plan upon receipt of a PML if the claim was denied due to not having the PML.
For more information on the nursing facility process in NC Medicaid Managed Care, please see the NC Medicaid Managed Care/Nursing Facility Provider fact sheet.
Contact
NC Medicaid Contact Center, 888-245-0179
Contact information for health plans can be found on the Health Plan Contacts and Resources page.