§ 108C-1 – (Effective until contingency met see note) Scope; applicability of this Chapter.
108C-1. Scope; applicability of this Chapter. This Chapter applies to providers enrolled in Medicaid or Health Choice. (2011-399, s. 1.)
§ 108C-10 – Change of ownership and successor liability.
108C-10. Change of ownership and successor liability. (a) For providers subject to this Chapter, any of the following occurrences shall constitute a change of ownership: (1) In the case of a partnership, the removal, addition, or substitution of a partner, unless the partners expressly agree otherwise, as permitted by Chapter 59 of the General Statutes. […]
§ 108C-11 – Cooperation with investigations and audits.
108C-11. Cooperation with investigations and audits. (a) Providers shall cooperate with all announced and unannounced site visits, audits, investigations, post-payment reviews, or other program integrity activities conducted by the Department. Providers who fail to grant prompt and reasonable access or who fail to timely provide specifically designated documentation to the Department may be terminated from […]
§ 108C-12 – Appeals by Medicaid providers and applicants.
108C-12. Appeals by Medicaid providers and applicants. (a) General Rule. – Notwithstanding any provision of State law or rules to the contrary, this section shall govern the process used by a Medicaid provider or applicant to appeal an adverse determination made by the Department. (b) Appeals. – Except as provided by this section, a request […]
§ 108C-13 – (Effective until contingency met see note) Certain waivers of Medicaid and Health Choice co-payments prohibited.
108C-13. Certain waivers of Medicaid and Health Choice co-payments prohibited. (a) No provider that has obtained a permit pursuant to G.S. 90-85.21 or G.S. 90-85-21A shall waive the collection of co-payments owed by recipients of Medicaid and Health Choice, as required by the respective program, with the intent to induce recipients to purchase, lease, or […]
§ 108C-14 – Provider performance bonds.
108C-14. Provider performance bonds. (a) Subject to the provisions of this section, the Department may require Medicaid-enrolled providers to purchase a performance bond in an amount not to exceed one hundred thousand dollars ($100,000) naming as beneficiary the Department of Health and Human Services, Division of Health Benefits, or provide to the Department a validly […]
§ 108C-2 – (Effective until contingency met see note) Definitions.
108C-2. Definitions. The following definitions apply in this Chapter: (1) Adverse determination. – A final decision by the Department to deny, terminate, suspend, reduce, or recoup a Medicaid payment or to deny, terminate, or suspend a provider’s or applicant’s participation in the Medical Assistance Program. (2) Applicant. – An individual, partnership, group, association, corporation, institution, […]
§ 108C-2.1 – Provider application and revalidation fee.
108C-2.1. Provider application and revalidation fee. (a) Each provider that submits an application to enroll in the Medicaid program shall submit an application fee. The application fee shall be the sum of the amount federally required and one hundred dollars ($100.00). (b) The fee required under subsection (a) of this section shall be charged to […]
§ 108C-3 – (Effective until contingency met see note) Medicaid and Health Choice provider screening.
108C-3. Medicaid and Health Choice provider screening. (a) Provider Screening. – The Department shall conduct provider screening of Medicaid and Health Choice providers in accordance with applicable State or federal law or regulation. (b) Enrollment Screening. – The Department must screen all initial provider applications for enrollment in Medicaid and Health Choice, including applications for […]
§ 108C-4 – (Effective until contingency met see note) Criminal history record checks for certain providers.
108C-4. Criminal history record checks for certain providers. (a) The Department shall conduct criminal history records checks of provider applicants and enrolled providers in accordance with federal law and regulation. (b) The Division shall deny enrollment or terminate the enrollment of a provider where any person with a five percent (5%) or greater direct or […]
§ 108C-5 – Payment suspension and audits utilizing extrapolation.
108C-5. Payment suspension and audits utilizing extrapolation. (a) The Department may suspend payments to a provider in accordance with the requirements and procedures set forth in 42 C.F.R. 455.23. (b) In addition to the procedures for suspending payment set forth at 42 C.F.R. 455.23, the Department may also suspend payment to any provider that (i) […]
§ 108C-5.1 – Post-payment review and recovery audit contracts.
108C-5.1. Post-payment review and recovery audit contracts. The Department shall not pay contingent fees pursuant to any contract with an entity conducting Medicaid post-payment reviews or Recovery Audit Contractor (RAC) audits before all appeal rights have been exhausted. Any contingent fee for Medicaid post-payment reviews or RAC audits shall be calculated as a percentage of […]
§ 108C-6 – Agents, clearinghouses, and alternate payees; registration required.
108C-6. Agents, clearinghouses, and alternate payees; registration required. The Department is authorized to establish a registry of billing agents, clearinghouses, and/or alternate payees that submit claims on behalf of providers and to charge a fee to recover the costs of maintaining the registry in accordance with 42 U.S.C. 1396a(a)(79) and implementing regulations. All billing agents, […]
§ 108C-7 – Prepayment claims review.
108C-7. Prepayment claims review. (a) In order to ensure that claims presented by a provider for payment by the Department meet the requirements of federal and State laws and regulations and medical necessity criteria, a provider may be required to undergo prepayment claims review by the Department. Grounds for being placed on prepayment claims review […]
§ 108C-8 – (Effective until contingency met see note) Threshold recovery amount.
108C-8. Threshold recovery amount. The Department shall not pursue recovery of Medicaid or Health Choice overpayments owed to the State for any total amount less than one hundred fifty dollars ($150.00) unless directed to do so by the Centers for Medicare and Medicaid Services or unless such recovery would be cost-effective and in the best […]
§ 108C-9 – (Effective until contingency met see note) Provider enrollment criteria.
108C-9. Provider enrollment criteria. (a) Applicants who submit an initial application for enrollment in North Carolina Medicaid or North Carolina Health Choice shall be required to submit an attestation and complete trainings prior to being enrolled. (b) The applicant’s attestation shall contain a statement that the applicant’s organization has met the minimum business requirements necessary […]