NC Medicaid Clinical Policy Revision Request Form

Providers and external stakeholders may submit requests to revise NC Medicaid Clinical Coverage Policies for consideration of statewide policy changes.

Important Note

This form is not used for individual member requests, prior authorization (PA) requests, claim issues or other patient-specific matters. Prior authorization requests must be submitted through the appropriate service vendor. For individual member or provider issues, please visit the NC Medicaid Contacts page.

The Process

The requestor may fill out the below form and email it to: medicaid.policy.revision.request@dhhs.nc.gov as a single file in PDF format with supporting documentation embedded within. Submissions will only be processed if all required information is completed.

Note: When submitting the request, please include in the email subject line, “Policy Revision Request” along with the Clinical Coverage Policy (CCP) number and name.

Please check your Spam folder for any responses related to your submission, which will be sent from the medicaid.policy.revision.request@dhhs.nc.gov email address.

When submitting the Clinical Policy Revision Request form, please ensure your submission has sufficient evidence to support the request. NC Medicaid wants to ensure that we are providing the best evidence-based care for our beneficiaries, and there needs to be solid clinical evidence to support coverage of procedure(s), product(s) and/or service(s).

NC Medicaid Clinical Policy Revision Request Form

Notes about Requests

• To complete the fillable PDF form, you may need to download and save the form to your computer before entering information.
• Submission of a request does not guarantee NC Medicaid coverage or policy modification.

Process Timeline

If you decide to submit a policy revision request, please note the typical review cadence that is listed below; however, our timeline may be delayed as NC Medicaid works on time-sensitive legislative and department initiatives.  

The NC Medicaid team has established the following estimated timeframes for review of submissions:

Initial Review (up to 8 weeks)

• NC Medicaid will review the submitted request to determine whether the requested policy revision is appropriate for further evaluation and whether sufficient supporting information has been provided.
• Requests may be evaluated for alignment with existing Medicaid authorities, federal and state requirements, operational considerations, and current NC Medicaid policy structure.

Detailed Review (up to 16 weeks)

If the request passes the initial review, NC Medicaid will conduct a more comprehensive review of the request, which may include evaluation of supporting literature, stakeholder impact, operational feasibility and policy approaches utilized by other states or payers.

Further Consideration of Policy (up to 14 months)

If the request advances beyond detailed review, NC Medicaid may initiate the formal policy modification process. Pending legal review, fiscal analysis, governance review, operational feasibility and any required approvals pursuant to NCGS §108A-54.2, policy changes may be implemented.