Chapter 108C

This Chapter applies to providers enrolled in Medicaid. (2011-399, s. 1; 2022-74, s. 9D.15(z).)

(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 …

(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 sp…

(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 …

(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 copayments owed by Medicaid recipients with the intent to induce recipients to purchase, lease, or order items or services from the permitted provider. For enforce…

(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 H…

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…

(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 shal…

(a) Provider Screening. - The Department shall conduct provider screening of Medicaid 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, i…

(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%)…

(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 provi…

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…

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 implement…

(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 b…

The Department shall not pursue recovery of Medicaid 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…

(a) Applicants who submit an initial application for enrollment in North Carolina Medicaid 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 me…