Enrollment and School Health Care Provider Responsibilities - FAQ

School health care providers must enroll in NC Medicaid through NCTracks because federal law now requires it. 

The 21st Century Cures Act requires state Medicaid programs to enroll all providers who order, refer, render, or prescribe Medicaid services — not just the entities that bill. NC Medicaid previously allowed Local Education Agencies (LEAs) to bill for services without each individual provider being separately enrolled.

Under the Cures Act screening mandate, the person who delivers the service must be enrolled and screened (e.g., checked against federal exclusion lists) and their National Provider Identifier (NPI) must appear on the claim as the rendering provider. This is a nationwide program-integrity / identification requirement.

No, the rendering provider is not responsible for the claim itself. Two different NPIs play two different roles:

For clarity: If the provider’s documentation accurately reflects a service provided within their scope of practice, and the LEA then submits a claim that doesn’t match that documentation (incorrect code, incorrect units, billing something not documented), the denial or recoupment for that claim sits with the billing entity that submitted it, not with the person who provided the service. The servicing provider’s signature/NPI attests to the service and the record, upon which the LEA builds the claim.

Rendering school health care providers must adhere to their individual licensure requirements and are responible for the following:

• Practicing within the scope of licensure. Providing only services the provider is licensed and qualified to provide, consistent with their practice act.
• Accurate, compliant documentation.  Documenting services performed, when, and for whom — meeting the licensure board’s documentation standards and the service/medical-necessity and compliance requirements in NC Medicaid Clinical Coverage Policy 10C.
• Truthful enrollment information. Upon enrollment, an Individual Provider Agreement is signed, attesting that the information in the application is accurate and that the provider’s record will be kept current. This attestation pertains to the provider’s credentials and responses, not to any specific claim.

These requirements, obligations, and professional liability are applicable, regardless of the requirement to enroll in NC Medicaid.

No. The Office Administrator (OA) is an administrative system-access role in NCTracks[AS1] . Every NPI enrolled in NCTracks must have one OA. Providers have the opportunity to assign a back-up OA.

NC Medicaid  requires the OA to be either the service provider, a managing employee, or an owner of the organization. For school-based providers who are employees of an LEA, it is typical and permitted for an LEA staff member to serve as the OA.

What the OA can do: 

• Maintain the electronic record 
• Initiate enrollment, re-certify, manage change requests,
• Assign user roles, and 
• Submit updates (such as Electronic FundTransfer/payment details for the LEA’s record). 

What the OA cannot do: 

Change or edit clinical documentation.

The risks are practical and administrative, not a change to professional liability. Because the OA controls the NCTracks record, consider the following:

• Control of your record. The OA can submit changes and updates to the provider record. Make sure the person/office serving as OA is trustworthy and that updates made are accurate.
• Visibility. Ask to be able to review what’s submitted under your NPI (affiliations, effective dates, re-verification). The provider remains responsible for the accuracy of their own enrollment information.
• Moving employers.  If a provider changes employers, the OA role and the NPI’s affiliation must be updated. The provider may become their own OA or transition to the new employer’s OA via the OA Change Process, which requires an NCID and the NPI’s authorization code. A former employer should not remain listed as the OA indefinitely.
• Affiliation ≠ endorsement of claims. Being affiliated to the LEA’s record  for billing purposes does not make the provider the biller. The affiliation simply links  the rendering NPI to the organization; the LEA  retains ownership of any claim it submits.

Alternatively, a provider can be their own OA, or have a trusted back-up (“Managing Relationship”) user on  record. The OA arrangement does not increase liability for providers. Rather, it determines who maintains the electronic file.

Audits look at whether the service was provided and that the documentation supports the services billed, as well as claim compliance.

The provider’s obligation is to ensure that their documentation is accurate, complete and within their scope of practice. Recoupment for a billing error, such as wrong code, duplicate claiming, units that don’t match the documentation, claiming a non-covered or non-medically necessary service, is the responsibility of the entity that submitted the claim (the LEA).

No. Enrollment is a federal identification and screening requirement. Your professional and legal responsibilities remain unchanged by enrollment in NC Medicaid.