Get Nc Medicaid Carolina Access Override Request Form

This guide provides clear and detailed instructions for users seeking to fill out the Nc Medicaid Carolina Access Override Request Form online. Completing this form is essential for requesting an override when treatment authorization has been denied.

Follow the steps to successfully complete the override request form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the recipient MID number and the recipient's name as they appear on the Medicaid card.
3. Fill in the date of birth and the date(s) of service for which you are requesting the override.
4. Indicate if the claim is due to an inpatient admission, an inpatient admission via the ER, or a current condition. Check the appropriate box.
5. Provide the name of the primary care provider (PCP) listed on the recipient’s Medicaid card.
6. Enter the name of the person contacted at the PCP’s office and the date of contact.
7. Detail the reason provided by the PCP for not authorizing treatment in the designated section.
8. Explain why the recipient did not see the PCP listed on their Medicaid card.
9. Select the reason for requesting an override by checking the appropriate box and providing additional explanations as necessary.
10. Complete the provider's name, provider number, and contact information, including telephone and fax numbers.
11. After filling out all sections, review the information for accuracy before saving or submitting the form. Users can then choose to save changes, download, print, or share the form.

Start filling out the Nc Medicaid Carolina Access Override Request Form online today.