NC MEDICAID NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF HEALTH BENEFITS
LOCATION: 1915 Health Services Way, Raleigh NC 27607
MAILING ADDRESS: 2501 Mail Service Center, Raleigh NC 27699-2501
medicaid.ncdhhs.gov • TEL: 919-855-4100 • FAX: 919-733-6608
AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER
NC Medicaid New Coverage/Service Request
Provider and Request Details
Field
Response
Date:
Provider’s Name:
NPI #:
Address:
City, State & Zip Code:
Is Request Disaster Related (Yes/No)
The North Carolina Medicaid Program provides payment for a variety of procedures, products and services for categorically needy and medically needy residents of the State. The requestor is requesting clinical policy consideration for INSERT TITLE OF COVERAGE REQUEST HERE.
All procedures, products and services must be medically necessary and may not be considered solely cosmetic, experimental or part of a clinical trial.
Please provide the following information to expedite review of the request for flexible coverage. Indicate N/A if an item does not apply.
Name of procedure, product or service (provide a brief description) for which coverage is being requested or where change or flexibility is being requested.
Enter response here
Does this request replace an existing coverage, change or add flexibility (PA waiver, telehealth, etc.) to an existing coverage? Explain in detail what replacement or flexibilities are being requested.
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Has the request been mandated through federal or state legislation?
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Does this request appear to have a potential cost savings to the Medicaid program? If yes, explain.
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Please provide details around the types of providers and beneficiaries whose quality of care will be enhanced due to this request.
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Indications, limitations and restrictions for use.
Diagnostic indication(s) [ICD-10 CM code(s)].
Proposed advantages of the new product, procedures or service.
Duration and frequency of use.
Gender restrictions.
Age restrictions.
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Procedure (CPT or HCPCS) or revenue codes to be used or impacted by the request
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Recommended place of service.
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FDA approval status (attach copy of approval letter/documents to the email).
Supporting data from research studies, peer review journals etc. (attach copy of approval letter/documents to the email)
Extent to which the requested coverage/flexibility request is currently in use in North Carolina.
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Is coverage/flexibility supported by other state Medicaid programs (List states or entity, if known, and a contact person with telephone number or email address.)
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Does Medicare and/or other insurance company cover this request? (Attach policy, if available).
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Please submit the information requested above within this document to the following inbox in PDF Format:
