North Carolina Medicaid Provider Enrollment Disaster Relief

Department of Health & Human Services
Centers for Medicare & Medicaid Services
Division of Medicaid & Children’s Health Operations
Atlanta Regional Office
61 Forsyth Street, Suite 4T20
Atlanta, Georgia 30303

September 13, 2018

Mr. Dave Richard
Deputy Secretary for Medical Assistance
North Carolina Department of Health and Human Services
1985 Umstead Drive
Raleigh, NC 27699-2501

Re: North Carolina Medicaid Provider Enrollment Disaster Relief

Dear Mr. Richard:

The President declared a state of emergency for North Carolina and the HHS Secretary declared a Public Health Emergency for North Carolina which allows for CMS programmatic waivers based on Section 1135 of the Social Security Act.

North Carolina Medicaid currently has the authority to rely upon screening that is performed by other SMAs and/or Medicare. North Carolina is not required to create a temporary provisional enrollment for providers who are enrolled with another SMA or Medicare.

With respect to providers not already enrolled with another SMA or Medicare, CMS will waive the following screening requirements so the state/territory may provisionally, temporarily, enroll the providers:

1. Payment of the application fee - 42 C.F.R 455.460
2. Criminal background checks associated with FCBC- 42 C.F.R Section 455.434
3. Site visits - 42 C.F.R Section 455.432
4. In-state/territory licensure requirements - 42 C.F.R Section 455.412; 

For those providers located out of state/territory and from which North Carolina Medicaid participants seek care, enrollment is not necessary if the following criteria are met.¹

1. The item or service is furnished by an institutional provider, individual practitioner, or pharmacy at an out-of-state/territory practice location– i.e., located outside the geographical boundaries of the reimbursing state/territory’s Medicaid plan,
2. The NPI of the furnishing provider is represented on the claim,
3. The furnishing provider is enrolled and in an “approved” status in Medicare or in another state/territory’s Medicaid plan,
4. The claim represents services furnished, and;
5. The claim represents either:
   • A single instance of care furnished over a 180 day period, or
   • Multiple instances of care furnished to a single participant, over a 180 day period

If the Medicaid participant is enrolled with the Medicaid program from the disaster designated state, the final two criterion will be waived. Therefore, there is no limit to the instances of care furnished or to how many participants in a 180 day period.

In the instance that a certified provider is enrolled in Medicare or with a state/territory’s Medicaid program other than North Carolina, North Carolina may perform an expedited enrollment, as described above, of an out-of-state/territory facility in order to accommodate participants who were displaced by the disaster.

CMS is granting waiver authority to allow North Carolina to enroll providers who are not currently enrolled by meeting the following minimum requirements:

1. Must collect minimum data requirements in order to file claims and process, including, but not limited to NPI
2. Must collect SSN/EIN/TIN in order to perform the following screening requirements:
   • OIG exclusion list
   • State/territory licensure – provider must be licensed, and legally authorized, in any state/territory to practice or deliver the services for which they intend to file claims
3. North Carolina may grant a provisional temporary enrollment that meets the following requirements:
   • Must cease approving temporary provisional enrollments no later than the date that the disaster designation is lifted
   • Must cease payment to providers who are temporarily enrolled within six months from the date that the disaster designation is lifted, unless a provider has submitted an application that meets all requirements for Medicaid participation and that application was subsequently reviewed and approved by North Carolina
   • North Carolina must allow a retroactive effective date for provisional temporary enrollments that is no earlier than September 7, 2018.

North Carolina may temporarily cease revalidation of providers who are located in North Carolina or are otherwise directly impacted by the disaster.

If you have any questions or concerns with information outlined in this letter, please contact Trina Roberts at 404-562-7418 or Shantrina.Roberts@cms.hhs.gov.

Sincerely,

Shantrina D. Roberts, MSN
Associate Regional Administrator
Division of Medicaid & Children’s Health Operations

¹Medicaid Provider Enrollment Compendium