Reminders About Required Provider Disclosures

Exclusion Sanction questions must be accurately answered on applications and new adverse actions must be reported to the Department.

This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care.

Enrollment and Reverification Requirements

At time of Initial enrollment, re-enrollment or re-verification providers must:

  • Accurately answer all Exclusion Sanction questions for all individuals listed on the application, including managing employees, owners or agents. It must be answered accurately for anyone listed on the application, and regardless of the length of time since the infraction occurred.
  • Failure to disclose required information to NC Medicaid through an affirmative response on the Exclusion Sanction page of the application will result in automatic denial of the application.
  • Depending on the type of application submitted, such as a re-verification application, additional adverse action can occur up to and including termination of the NCTracks provider record.
  • New initial enrollment applications cannot be edited, they must be withdrawn and submitted, and the North Carolina application fee must be paid again.

Currently enrolled providers

As contractually required in Section 4 of the NCDHHS Provider Administrative Participation Agreement, enrolled providers must:

Notify the Department within 30 calendar days of learning of any adverse action initiated against any required license, certification, registration, accreditation and/or endorsement of the Provider or any of its officers, agents, or employees.

Providers can report changes through the submission of a Manage Change Request (MCR) on the NCTracks portal by:

  • Accurately answer the appropriate Exclusion Sanction question is answered affirmatively.
  • Upload the required supplemental documentation, either at the time of submission or after submission through the upload link associated with the pending MCR on the NCTracks Provider Portal Status and Management page.

In addition, providers must disclose changes to the criminal convictions of anyone listed on the provider enrollment record to comply with the Department’s review of criminal history as defined in NC Gen Stat 108C-4, and Section 8 of the NCDHHS Provider Administrative Participation Agreement.
Failure of provider to disclose adverse actions within 30 days as contractually required will result in termination of their NCTracks provider record.

Additional Required Disclosures

In addition to the above referenced adverse actions, providers are contractually required to maintain the accuracy of their provider data. The following excerpts from the NCDHHS Provider Administrative Participation Agreement highlight some important required disclosures. This is not an exhaustive list of requirements but is shared for illustrative purposes. Like adverse actions, providers notify the Department of changes through the submission of an MCR unless otherwise noted.

Section 5: Billing and Payment

Providers will notify the Department of any change in ownership as defined under N.C.G.S. 108C-10(a) no later than 30 days before effective date of the change in ownership and shall submit a completed Provider Change of Ownership Disclosure Form. This indicates whether the new owner/entity has agreed to assignment of this Provider Agreement including assumption of liability or has agreed in writing to assume all liability, including but not limited to cost report settlements, health care assessment settlements or recoupment actions that have arisen or that may arise in connection with claims billed by Provider.

Provider agrees that if the new owner/entity has not agreed in writing to assignment of this Provider Agreement or assumption of liability arising in connection with claims billed by Provider, the Provider will remain directly liable for repayment of any liabilities incurred based on services furnished prior to the change of ownership.

Section 6: Disclosure

b. The Provider agrees to provide written notification to the Department through the Department’s agents, vendors, or contractors, their successors or assigns in the manner determined by the Department of any material and/or substantial change in information contained in the enrollment application given to the Department by the Provider within thirty (30) calendar days of an event triggering the reporting obligation. Material and/or substantial change includes, but is not limited to, a change in:

  • i.    licensure;
  • ii.   federal tax identification number;
  • iii.  National Provider Identifier (NPI), including the addition of a new NPI or change to the NPI under which the Provider previously enrolled with the Department;
  • iv.  bankruptcy;
  • v.   additions, deletions, or replacements in group membership; and
  • vi.  any change in address, telephone number, or email.

Section 8: Termination also advises that the provider is subject to applicable provision of Controlling Authority:

a.  The Department may summarily terminate this Agreement without giving 30 days written notice under the following circumstances:

  • i.  The Provider does not meet conditions for participation, including necessary licensure, certification, or endorsement requirements or other terms and conditions stated in this Agreement; or
  • ii.  Any person with ownership or controlling interest in the Provider, or agent, or managing employee of the Provider, has been convicted of a criminal offense set forth in 42 CFR §1001.101 or 42 CFR §1001.201; or
  • iii.  The Provider, any person with ownership or controlling interest in the Provider, operator, agent, or managing employee of the Provider, has been convicted of a criminal offense relating to fraud, theft, embezzlement, breach of fiduciary responsibility or other financial misconduct, or crime of moral turpitude, or any criminal offense specified in N.C.G.S. §108C-4; or
  • iv.  The Provider fails to disclose information required under 42 CFR §1002.3; or
  • v.  Any person with ownership or controlling interest in the Provider, or an agent as that term is defined in accordance with 42 CFR §455.101 or managing employee of the Provider, has been excluded by the United States Department of Health and Human Services from participation in the Medicare, Medicaid, or other federal health care programs; or
  • vi.  The Provider poses an imminent health or safety risk to a patient; or
  • vii.  The Provider has been found by the Department to be in breach or violation of any law, rule, or policy for which summary termination is authorized by Controlling Authority or by a rule authorized by and consistent with the Controlling Authority and adopted pursuant to Chapter 150B of the General Statutes.

Providers are encouraged to read the full NCDHHS Provider Administrative Participation Agreement to ensure complete understanding of the requirements for participation with NCDHHS programs.

Additional information is available on the Exclusion Sanction Questions FAQs page.

Contact

  • NCTracks Call Center: 800-688-6696
  • Provider Ombudsman: 866-304-7062

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