NCTracks
DHB to Assess Out-of-State Enrollment Applications for Certain DME Taxonomies
Effective Oct. 23, 2022, NCTracks will send all out-of-state (OOS) Durable Medical Equipment (DME) provider enrollment requests for taxonomy codes 332BC3200X, 332BD1200X, 332BP3500X and 332BX2000X to Division of Health Benefits (DHB) for review.
Provider OOS enrollment requests for these taxonomies will be reviewed by DHB to screen for the applicable criteria. Per Durable Medical Equipment, Prosthetics/Orthotics and Supply (DMEPOS) policies 5A-1, 5A-2, 5A-3, and 5B, subsection 6.0 (Provider(s) Eligible to Bill for the Procedure, Product, or Service), DMEPOS providers/suppliers without a physical presence within the boundaries of North Carolina or the 40-mile border area of a contiguous state may be enrolled only when one of the following three circumstances applies:
- Access: The medically necessary product the provider supplies or manufactures is not reasonably available through an enrolled provider located within the boundaries of North Carolina or the 40-mile border area of a contiguous state.
- Medicare Crossovers: The provider is enrolled with Medicare and seeks to serve beneficiaries dually eligible for Medicare and North Carolina Medicaid. In this case, the provider shall be enrolled only for secondary crossover claims payments.
- Medicare Competitive Bid-winner: The provider is a Medicare competitive bid-winner in at least one of four competitive bidding areas of North Carolina, and then only for the items included in their winning bid.
In addition to meeting clinical coverage policy criteria, providers must upload a completed Out-of-State Durable Medical Equipment (DME) Provider Form with their application. This form will be available on the Provider Policies, Manuals, Guidelines and Forms page of NCTracks under Provider Forms. The NCTracks Provider Enrollment staff will ensure the provider has uploaded the form, which is required for application approval. If the form is not uploaded, the application will be returned to the provider.
A member from the North Carolina Medicaid DME team will review the request and decide if the provider meets the North Carolina Medicaid clinical coverage criteria for OOS providers. The DME reviewer will then recommend to NCTracks whether to approve or deny the provider’s participation as an OOS DME provider. Providers will still receive an approval or denial letter from NCTracks.
If applicable the following denial reason will be included in the denial letter: YOUR REQUEST TO ENROLL AS A NC MEDICAID DURABLE MEDICAL EQUIPMENT (DME) PROVIDER HAS BEEN DENIED, AS YOUR ENROLLMENT REQUEST DOES NOT MEET THE NC MEDICAID OUT-OF-STATE DME PROVIDER REQUIREMENTS.
OOS providers seeking to apply with one of these taxonomy codes are encouraged to review the applicable clinical coverage criteria for enrollment when submitting their application.
CC22264-R-2584