New Living Arrangement Code

Effective November 1, 2016, NCTracks begins recognizing living arrangement code 19 for recipients who are incarcerated at a county or local jail, meanwhile continuing to recognize living arrangement code 16, which identifies a recipient under state incarceration. Living arrangement code 19 will be considered during the processing of enrollment records, management fee claims, capitation claims, Buy-In records, Point-of-Sale claims and eligibility verification responses.

Recipients who have a living arrangement code of 19 will not be assigned to a Primary Care Physician (PCP); in turn management fee claims will not be generated since they are based off claims where a PCP is assigned. If a recipient is assigned living arrangement code 16 or 19 retroactively, previously paid capitation claims will be voided or recouped. These same recipients will be excluded from Medicare Buy-In and other Medicare Modernization Act (MMA) processes.

Note: Pharmacies will recognize both living arrangement codes during claim adjudication resulting in one of the EOB's listed below. Pharmacy claims with the payer Department of Public Health (DPH) will not be affected.

In order to recognize living arrangement code 19 during claim adjudication, a new Edit/EOB will be created, which is not applicable to DPH claims:

  • EOB 01796 - BENEFICIARY'S ELIGIBILTY IS LIMITED TO INPATIENT HOSPITAL STAY SERVICES

The current Edit/EOB being used for living arrangement code 16 (state incarceration) will remain

  • EOB 01797- BENEFICIARY'S ELIGIBILTY IS LIMITED TO INPATIENT HOSPITAL STAY SERVICES

Specific messages will be given to providers when verifying eligibility on the Provider Portal and by telephone.

  1. On the Provider portal, providers will receive RESTRICTIVE COVERAGE, INPATIENT SERVICES AT A HOSPITAL ONLY.
  2. Providers utilizing the Automated Voice Response System (AVRS) will hear "This is a restrictive coverage category. Recipient is eligible for Medicaid covered services while inpatient in a hospital."