Policy Clarification for Out of State Providers

Out of State providers, including border-area providers, must be enrolled in Medicare or their home-state Medicaid program in order to enroll in NC Medicaid and Health Choice.   If Medicare participation cannot be verified, GDIT will contact the home-state Medicaid program for verification.

If Medicare participation is required based on taxonomy, it will be verified and home-state Medicaid participation will not be required.

To successfully administer screenings, application fees and revalidation requirements, as specified in Federal Regulations at 42CFR 455.410, 42 CFR 455. 414, 42 CFR 455.450 and 42CFR 455.460, States must validate Medicare enrollment and, for out of state providers, proof of home state Medicaid participation. This is important since States can rely on the results of other States’ screenings, thus eliminating additional costs and burdens to State Medicaid programs and providers.

Although this is not a new policy, the Provider Permission Matrix will be updated to reflect this requirement.  A Provider Enrollment FAQ has been posted as well.