This bulletin applies to NC Medicaid Managed Care.
Since the July 1, 2024, launch of Behavioral Health and Intellectual/Developmental Disability Tailored Plans (Tailored Plans), NC Medicaid has become aware of claim denials due to missing or invalid taxonomy codes.
Taxonomy codes must be included when submitting claims to a Tailored Plan or their contracted partners, whether the claim comes from the individual provider or through a clearinghouse.
Tailored Plans are encountering billing issues on professional and institutional Electronic Data Interchange (EDI) claims (ASC X12 837-P and ASC X12 837-I) with missing or invalid Provider Taxonomy Code (non-provider taxonomy values or non-enrolled provider taxonomy codes) billing provider, rendering provider, and/or attending provider taxonomy codes.
All Tailored Plan systems require provider taxonomy codes to be submitted on all claim types except pharmacy point of sale claims. Submission of claims with missing or incorrect provider taxonomy codes will cause the claims to deny and delay provider payments. For more information, see Section 3.22 of the NC Medicaid Managed Care Billing Guidance for Health Plans.
When submitting claims to Tailored Plans, it is important to submit the appropriate billing and, when applicable, rendering/attending taxonomy code which is expected to be consistent with the provider taxonomy on the NCTracks provider record based on the service rendered and the rendering/attending provider location.
- Providers should verify that the submitted provider taxonomy code on the claim matches one of the active provider taxonomy codes listed on the NCTracks provider record and is appropriate for the claim being billed.
- Providers should validate the configuration of their own billing systems to ensure provider taxonomy codes are included when submitting claims to the Tailored Plans.
- To validate provider taxonomy code(s), please use the NCTracks How to view and update Taxonomy on the Provider Profile in NCTracks User Guide.
Clearinghouses may be updating provider taxonomy information submitted by providers; therefore, so it is important that providers work with their clearinghouse to ensure valid provider taxonomy data is submitted to the Tailored Plans on their claims.
If a clearinghouse does not submit a provider taxonomy code or if the provider taxonomy is incorrect, these errors may increase the provider’s claim denials with the Tailored Plans to which they submit claims.
For claims that have been submitted to Tailored Plans and denied for invalid billing, rendering, or attending provider taxonomy codes, please immediately resubmit the denied claims with the corrected data. For additional assistance, please follow up with the Tailored Plan.
Contact
- For questions related to NCTracks provider information, contact the NCTracks Call Center at 800-688-6696.
- For all other questions, contact the NC Medicaid Contact Center at 888-245-0179
- Providers should route payment concerns to their health plans’ appeals and grievances processes which can be found in the health plan’s Provider Manual, linked on the Health Plan Contacts and Resources page. Providers can escalate to the Medicaid Provider Ombudsman at 866-304-7062 or Medicaid.ProviderOmbudsman@dhhs.nc.gov.