MedicaidAdministrativeHigh impact
Claim submission process when eligibility is retroactively updated
NC Medicaid - NCDHHS·NC·Claims & Billing
We identified it
Aug 11, 2026
Summary
NC Medicaid has updated claim submission procedures when patient eligibility is retroactively changed between plans. Providers must contact the new NC Medicaid Managed Care plan directly to determine submission procedures, and when claims are recouped back to NC Medicaid Direct, must resubmit within 180 days with proof of recoupment and timely original submission.
Action Required
Within 180 days of any recoupment from NC Medicaid Managed Care to NC Medicaid Direct: Billing team must resubmit affected claims to NC Medicaid Direct in NCTracks using the 'Provider Adjustments, Time Limit Overrides, and Medicare Overrides' job aid. All resubmissions must include documentation of: (1) proof of recoupment from the NC Medicaid Managed Care plan, and (2) verification that the original claim was submitted timely. For retroactive eligibility changes to NC Medicaid Managed Care plans, billing team must proactively contact the new health plan BEFORE resubmitting claims to determine their specific submission requirements. Failure to resubmit within 180 days will result in claim denial. Update billing team workflows to flag accounts with retroactive eligibility changes and implement tracking procedures for recoupment dates.