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Third Party Insurance Forms

  • Third Party Liability Billing Manual (DMA-2046) - June 15, 2022
  • Online Submission for Health Insurance Information Referrals (2057 Referral Form)
  • Third Party Recovery (TPR) Health and Accident Resources (DMA-2041-ia)
  • Insurance Company Code Request Form (DHB-2043)
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  • Third Party Recovery (TPR) Accident Information Report (DHB-2043)
    • Instructions for Third Party Recovery (TPR) Accident Information Report (DHB-2043-i)
       
  • Medicaid Credit Balance Report (DHB-2044-ia)
    • Instructions for Completing Medicaid Credit Balance Report (DHB-2045)

This page was last modified on 04/05/2024

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Contact Information

NC Medicaid, Division of Health Benefits
2501 Mail Service Center
Raleigh, NC 27699-2501

NC Medicaid Contact Center
Phone: 888-245-0179
Monday-Friday 8 a.m. to 5 p.m.
Closed on State holidays.
 
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