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 as a single file in PDF format with supporting documentation embedded within. Submissions will only be processed if all required information is completed.  

Please check your Spam folder for any responses related to your submission, which will be sent from the 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

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 will take up to nine weeks. The 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 impact and other components as required by NCGS §108A-54.2, coverage may be implemented.