NC Medicaid New Coverage/Service Request Form

Providers and external stakeholders may submit requests for NC Medicaid coverage of procedures, products and services.

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 webpage.

The Process

The requestor may fill out the below form and email it to medicaid.coverage.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.

When submitting the request, please include in the email subject line “New Coverage/Service Request” along with the service being requested (for example: CPT code, test name, or procedure).

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

When submitting the Coverage 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).

Request for Coverage 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 coverage 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 team will review to confirm coverage of the submitted procedure/product/service for other Medicaid programs, commercial payers and Medicare.
• Note: If the submitted procedure/product/service is not covered by other payers, it is unlikely that NC Medicaid will cover this product.

Detailed Review (up to 16 weeks)

If the request passes the initial review, the NC Medicaid team will review associated literature and consider coverage in other states.

Further Consideration to Policy (up to 14 months)

If the request passes the detailed review, then the NC Medicaid team will initiate the formal policy modification process. Pending legal review, fiscal analysis, governance review, and operational feasibility, as required by NCGS §108A-54.2, coverage may be implemented.