MedicaidAdministrativeHigh impact
Provider Categorical Risk Level Adjustment
NC Medicaid - NCDHHS·NC·Provider Bulletin
Effective date
Aug 11, 2026
We identified it
Aug 12, 2026
Summary
North Carolina Medicaid has implemented a Provider Categorical Risk Level Adjustment policy that automatically escalates providers from Limited or Moderate risk to High risk based on specific triggering events (fraud allegations, OIG exclusions, outstanding overpayments, conviction exemptions, etc.). Providers bumped to High risk must complete site visits and fingerprinting within specified timeframes or face termination from all NCDHHS programs. An off-cycle revalidation is required two years after the bump-up, then providers return to the standard five-year revalidation cycle.
Action Required
Immediately: Billing and administrative teams must: (1) Review your practice's current Medicaid risk categorization status through NCTracks portal or contact NCDHHS; (2) Establish internal monitoring for any triggering events listed in the policy (payment suspensions, OIG exclusions, outstanding overpayments >$1500, etc.); (3) If your practice receives a Bump-Up notice from NC Medicaid, immediately initiate the fingerprinting process per instructions and coordinate with Public Consulting Group (PCG) to schedule required site visit—failure to complete both screenings by the specified due date will result in automatic termination from all NC Medicaid and NCDHHS programs; (4) Calendar the two-year off-cycle revalidation deadline after initial bump-up; (5) Contact NCTracks Call Center (800-688-6696) or Provider Ombudsman (866-304-7062) if your practice has questions about current risk status or receives a bump-up notice; (6) Ensure all providers, owners, operators, and managing employees are aware that OIG exclusions, disqualifying convictions, and fraud allegations trigger this escalation. Do not delay—this policy is effective immediately and applies to all current and future provider applications.