Prior Approval

Prior approval (PA) is required for many DHB services. The preferred method to submit PA requests is online via the NCTracks Provider Portal.

However, providers can also submit some paper forms via mail or fax. The links below reference the latest PA forms for submission to NCTracks. This list is the definitive source for DHB PA forms.

For a list of services that require PA, see the DHB policy specific to the services to be rendered.

For additional information about how PA works in NCTracks, see the Prior Approval Fact Sheet on the Fact Sheet page of the Provider Portal.

 

Prior Approval Requests

The recommended method for submitting a PA request is to key it directly into the secure Provider Portal. If you must mail or fax a PA request, use the form below that pertains to the service being requested. See the DHB Clinical Coverage Policy Website for additional information. The below forms must be sent as the top page with any attachments behind it.

Prior Approval Attachments

The below forms should be sent in to accompany a PA request. These forms will NOT create a PA request. They must be sent in with one of the forms listed above. If not, your PA request may be delayed or not received at all.

School Reimbursement Form (DHB-3514) (replaced PDN Verification of School Nursing Form (DMA-3171))*

*Note: Providers are instructed to use the attachments in the current PDN 3G-2 Clinical Policy for Beneficiaries under 21 for each form (pages 25-35) until the 3G-2 policy is amended, at which time both policies will use the new forms located on the PDN webpage.

When either of the following forms are used, they should be uploaded as attachments to the PA request that has been keyed into the secure NCTracks Provider Portal. Neither of these forms can be used to create a PA request.

Long Term Care FL2 Form (372-124)

 

 

Cell & Gene Therapy Prior Approval (PA) Criteria

Review Clinical Coverage Policy 1S-13 Cell & Gene Therapies prior to submitting a prior approval (PA).

DO NOT use a Drug Request Form to submit prior approval (PA) for Cell & Gene Therapies. Use the NCTracks Secure Provider Portal to submit a Medical PA for Cell & Gene Therapies using PA Type TRANSPLANT. Use the most appropriate procedure code for the specific Cell & Gene Therapy you are requesting. Attach any supporting documentation when required.

If the request is for a Cell & Gene Therapy that is provided outside the state of North Carolina, please review Clinical Coverage Policy 2A-3 Out-of-State Services prior to submitting PA. Use the NCTracks Secure Provider Portal to submit an OUT OF STA (OUT OF STATE) PA for Cell & Gene Therapies. Attach any supporting documentation when required.

NCTracks serves as the primary point of contact for inquiries related to cell and gene therapy (CGT) services, including prior authorization, provider enrollment, and questions related to single case agreements. NCTracks can assist with guidance, intake, and routing of CGT related inquiries. If an issue cannot be resolved through NCTracks, providers may escalate the inquiry to the State as the secondary point of contact by emailing Medicaid.NCSelectDrugList@dhhs.nc.gov.

PA criteria for individual cell and gene therapies will be posted here.

Physician Administered Drug Program (PADP) Prior Approval

*** Coming Soon---Please refer to each individual health plan for more details. ***

Outpatient Hospital Drug Prior Approval

*** Coming Soon---Please refer to each individual health plan for more details. ***

 

 

Prior Approval Announcements

All Announcements