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NC Medicaid - NCDHHSMedicaid · Administrative · Provider Bulletin · NCHigh impact

Provider Categorical Risk Level Adjustment

Act
immediately
Effective date
Aug 11, 2026
Identified
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.

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What to do

immediately · 8 steps
01Billing and administrative teams must.
02Review your practice's current Medicaid risk categorization status through NCTracks portal or contact NCDHHS.
03Establish internal monitoring for any triggering events listed in the policy (payment suspensions, OIG exclusions, outstanding overpayments >$1500, etc.).
04If 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.
05Calendar the two-year off-cycle revalidation deadline after initial bump-up.
06Contact 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.
07Ensure all providers, owners, operators, and managing employees are aware that OIG exclusions, disqualifying convictions, and fraud allegations trigger this escalation.
08Do not delay—this policy is effective immediately and applies to all current and future provider applications.

Original notice

Provider Categorical Risk Level Adjustment
medicaid.ncdhhs.gov · Always check the source before changing claims.
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