This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care.
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, NC Medicaid is making changes to the Nursing Facility process to ensure that providers can receive prompt payment for nursing facility claims in alignment with federal regulations.
Changes for Modified Adjusted Gross Income (MAGI) Members who are Admitted to a Nursing Facility
Effective Sept. 1, 2025, NC Medicaid will no longer require any action by the local Department of Social Services (DSS) in the member’s county prior to the provider being able to bill for nursing facility services. Providers still must submit the PHP Notification of Nursing Facility Level of Care Form (DHB-2039) (for members in NC Medicaid Managed Care) or the FL-2 (for NC Medicaid Direct Members).
This will enable providers to submit claims and receive payment for nursing facility claims for MAGI members immediately upon admission into the Nursing facility. The PML determination is no longer required for MAGI members.
Changes for All Members who are Admitted to a Nursing Facility
Effective Sept. 1, 2025, NC Medicaid will no longer require DSS to complete the transfer of assets evaluation prior to nursing facility providers receiving payment for members who are admitted into a nursing facility. This change will also reduce the time frame between admission and when providers can receive payment for claims.
This will enable providers to submit claims and receive payment for nursing facility claims for non-MAGI members after the PML has been determined, prior to the completion of the transfer of assets evaluation.
Additionally, if there are any sanctions that result from the transfer of assets evaluation, those sanctions are effective the date indicated on the DSS-8110 “Your Medical Assistance Benefits Are Continuing, Changing, or Terminating” notice. This termination date for nursing facility claims will always be the last day of the month.
What is Remaining the Same in Financial Eligibility and Transfer of Assets Evaluation Processes for Members who are Admitted to a Nursing Facility
While there are some aspects of the nursing facility process which are changing, there are many aspects of the process which will remain the same.
- Nursing Facilities must continue to receive clinical authorization for the nursing facility admission through the health plan (by submitting a prior authorization) or through NCTracks (by submitting an FL-2).
- For Managed Care members, nursing facilities must continue to send the PHP Notification of Nursing Facility Level of Care Form (DHB-2039) to the county to complete the financial eligibility steps.
- For non-MAGI members, the member must have a PML entered by the county for the provider to receive payment for the member’s admission.
- Note: While this is still required due to the changes in the transfer of assets process, this should allow counties to complete this action in a shorter time frame.
- For non-MAGI member nursing facility claims:
- Health plans will pend nursing facility claims prior to the PML determination.
- NCTracks will deny nursing facility claims submitted without the PML determination.
- Counties will still complete a transfer of assets evaluation for all members who are admitted into a nursing facility, but the results of that evaluation will no longer prevent initial payment for nursing facility claims.
Contact
NC Medicaid Contact Center: 1-888-245-0179
Contact information for health plans can be found on the Health Plan Contacts and Resources page.