This bulletin article applies to NC Medicaid Direct.
As part of NC Medicaid's commitment to ensuring compliance with federal regulations, we are implementing updates to NCTracks Third Party Liability (TPL) process for NC Medicaid Direct. These updates will impact claims submitted for certain services when a member has other third-party insurance coverage listed in their eligibility record.
What This Means for Providers
- Claims for the following services will be denied if third-party insurance is detected in the member’s eligibility record:
- Hospice
- Private Duty Nursing
- Home Infusion Therapy
- Local Health Department (LHD)
- Therapy Services
- Institutional Ambulance
- Hearing Aid
- Independent Diagnostic Testing Facility/Portable X-ray
- Providers are required to submit these claims to the member’s primary insurer before billing Medicaid.
What Providers Need to do to Avoid Claim Denials
- Check Member Eligibility Before Billing: Always verify member eligibility and third-party insurance information in NCTracks prior to submitting claims.
- Submit Claims to Primary Insurance First: Ensure claims for the affected services are submitted to any identified third-party insurance before sending them to NC Medicaid.
- Maintain Documentation: Keep Explanation of Benefits (EOB) records from the primary insurers for audit and resubmission purposes.
Claims submitted prior to Dec. 31, 2024, will not be affected. These updates align with NC Medicaid Direct federally mandated role as the payer of last resort.
Contact
Third Party Recovery; 919-527-7690