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Division of Medical Assistance Health Insurance Information Referral Form Recipient Name Recipient ID No Date of Birth Health Ins. Co. Name 1 Policy/Cert No* 2 Policy/Cert No* Reason For Referral 1. Recipient never covered by or added to above policy s EOB attached Recipient s insurance coverage terminated EOB attached New policy not indicated on Medicaid ID card EOB or copy of insurance card attached Indicate type coverage Do not include Medicare Major Medical Dental Indemnity Hosp/Surgical Cancer Nursing Home Basic Hospital Accident Attach original claim a copy of the EOB or a copy of the insurance card and submit to DMA - TPR 2508 Mail Service Center Raleigh North Carolina 27699-2508. The Third Party Recovery TPR Section will update the system and forward claims to EDS within 10 working days after receipt. Provider Name Provider Number Submitted By Date Submitted Telephone Number DMA 2057 Revised January 2003. Name 1 Policy/Cert No* 2 Policy/Cert No* Reason For Referral 1. Recipient....

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NC Medicaid Ombudsman: 877-201-3750 Stay in touch!

Starting July 1, 2021, most Medicaid beneficiaries began receiving the same Medicaid services in a new way. Called "NC Medicaid Managed Care," beneficiaries choose a health plan and get care through a health plan's network of doctors.

Filing Claims The North Carolina Medicaid program requires providers to file claims electronically (with some exceptions) using the NCTracks claims processing and provider enrollment system.

Click the one called "Medicaid" for Medicaid providers and the one called "Health Choice" for NC Health Choice providers. You need a referral from your Primary Care Provider (PCP) to see a specialist. Only your PCP can refer you to another doctor.

If you don't receive your Medicaid card, or if you lose your card, call Member Services at 1-855-375-8811 (TTY 1-866-209-6421)....Your Medicaid card will have: Your primary care provider's (PCP's) name and phone number. Your Medicaid identification number. Information on how you can contact us if you have any questions.

North Carolina did transition to NC Managed Medicaid Care on July 1, 2021.

No paper submission is required - secondary claims can be billed electronically to NCTracks, either on the portal or as a batch electronic claims transaction.

Prior approval (PA) may be required for some services, products or procedures to verify documentation of medical necessity. Prior approval is for medical approval only and must be obtained before rendering a service, product or procedure that requires prior approval.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232