Health Plan Billing Guidance

The Department’s NC Medicaid Managed Care Billing Guidance to Prepaid Health Plans is designed to: 

• Supplement clinical policies and Medicaid bulletins 
• Reduce provider administrative burden, 
• Ensure consistency in provider billing practices for key Medicaid services, and 
• Allow for accurate and complete NC Medicaid and Centers for Medicare and Medicaid (CMS) reporting.

Health Plan Billing Guide - Version 28 - Nov. 25, 2024

The Billing Guide references requirements to adhere to NC Medicaid and NC Health Choice Direct clinical coverage policies which reference NCTracks or GDIT (the Department’s fiscal agent). Unless specifically noted within this billing guide, the health plan should not interpret this requirement as requiring the health plan or provider to submit information through NCTracks, but rather to provide direction for how providers should submit to the health plan claims platform. 

Any reference to adhere to an NC Medicaid Direct clinical coverage policy does not alleviate the health plan’s responsibility to accept and adjudicate all NC Medicaid Managed Care claims for their enrolled members. 

The billing guidance may be updated by the Department to include additional requirements based on feedback from health plans, providers, or other stakeholders. 

Health plans should refer to and comply with their contract for billing requirements.