Provider/Stakeholder Request for Coverage Form
Providers and external stakeholders may formally submit a request for coverage of a procedure(s), product(s) and/or service(s) through the NC Medicaid website.
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 any supporting documentation embedded within. Submissions will only be processed if all required information is completed.