10A NCAC 22J .0101        PURPOSE AND SCOPE

The purpose of these regulations is to specify the rights of providers to appeal reimbursement rates, payment denials, disallowances, payment adjustments and cost settlement disallowances and adjustments.  Provider appeals for program integrity action are specified in 10A NCAC 22F.


History Note:        Authority G.S. 108A‑25(b); 108A‑54; 150B‑11; 42 U.S.C. 1396(b);

Eff. January 1, 1988;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.


(a)  A provider may request a reconsideration review within 30 calendar days from receipt of final notification of payment, payment denial, disallowances, payment adjustment, notice of program reimbursement and adjustments and within 60 calendar days from receipt of notice of an institutional reimbursement rate.  Final notification of payment, payment denial, disallowances and payment adjustment means that all administrative actions necessary to have a claim paid correctly have been taken by the provider and DMA or the fiscal agent has issued a final adjudication.  If no request is received within the respective 30 or 60 day periods, the state agency's action shall become final.

(b)  A request for reconsideration review must be in writing and signed by the provider and contain the provider's name, address and telephone number.  It must state the specific dissatisfaction with DMA's action and should be mailed to:  Appeals, Division of Medical Assistance at the Division's current address.

(c)  The provider may appoint another individual to represent him.  A written statement setting forth the name, address and telephone number of the representative so designated shall be sent to the above address.  The representative may exercise any and all rights given the provider in the review process.  Notice of meeting dates, requests for information, hearing decisions, etc. will be sent to the authorized representative.  Copies of such documents will be sent to the petitioner only if a written request is made.


History Note:        Authority G.S. 108A‑25(b); 108A‑54; 150B‑11; 42 U.S.C. 1396(b);

Eff. January 1, 1988.



(a)  Upon receipt of a timely request for a reconsideration review, the Deputy Director shall appoint a reviewer or panel to conduct the review.  DMA will arrange with the provider a time and date of the hearing.  The provider must reduce his arguments to writing and submit them to DMA no later than 14 calendar days prior to the review.  Failure to submit written arguments within this time frame shall be grounds for dismissal of the reconsideration, unless the Division within the 14 calendar day period agrees to a delay.

(b)  The provider will be entitled to a personal review meeting unless the provider agrees to a review of documents only or a discussion by telephone.

(c)  Following the review, DMA shall, within 30 calendar days or such additional time thereafter as specified in writing during the 30 day period, render a decision in writing and send it by certified mail to the provider or his representative.


History Note:        Authority G.S. 108A‑25(b); 108A‑54; 150B‑11; 42 U.S.C. 1396(b);

Eff. January 1, 1988;

Pursuant to G.S. 150B-33(b)(9), Administrative Law Judge Augustus B. Elkins, II declared this rule void as applied in Psychiatric Solutions, Inc., d/b/a/ Holly Hill Hospital v. Division of Medical Assistance, North Carolina Department of Health and Human Services (02 DHR 1499).



If the provider disagrees with the reconsideration review decision he may request a contested case hearing in accordance with 10A NCAC 01.


History Note:        Authority G.S. 108A‑25(b); 108A‑54; 150B‑11; 42 U.S.C. 1396(b);

Eff. January 1, 1988.


10a NCAC 22J .0105        PAYMENT STATUS

Once a final overpayment or final erroneous payment is determined by DMA to exist, action will be taken immediately to recover such overpayment or erroneous payment.  If the provider's appeal is successful, repayment will be made to the provider.


History Note:        Authority G.S. 108A‑25(b); 108A‑54; 150B‑11; 42 U.S.C. 1396(b)(d)(2);

Eff. January 1, 1988.



(a)  A provider may refuse to accept a patient as a Medicaid patient and bill the patient as a private pay patient only if the provider informs the patient that the provider will not bill Medicaid for any services but will charge the patient for all services provided. 

(b)  Acceptance of a patient as a Medicaid patient by a provider includes, but is not limited to, entering the patient's Medicaid number or card into any sort of patient record or general record-keeping system, obtaining other proof of Medicaid eligibility, or filing a Medicaid claim for services provided to a patient.  A patient, or a patient's representative, must request acceptance as a Medicaid patient by:

(1)           presenting the patient's Medicaid card or presenting a Medicaid number either orally or in writing; or

(2)           stating either orally or in writing that the patient has Medicaid coverage; or

(3)           requesting acceptance of Medicaid upon approval of a pending application or a review of continuing eligibility.

(c)  Providers may bill a patient accepted as a Medicaid patient only in the following situations:

(1)           for allowable deductibles, co-insurance, or co-payments as specified in 10A NCAC 22C .0102; or

(2)           before the service is provided the provider has informed the patient that the patient may be billed for a service that is not one covered by Medicaid regardless of the type of provider or is beyond the limits on Medicaid services as specified under 10A NCAC 22B, 10A NCAC 22C, and 10A NCAC 22D; or

(3)           the patient is 65 years of age or older and is enrolled in the Medicare program at the time services are received but has failed to supply a Medicare number as proof of coverage; or

(4)           the patient is no longer eligible for Medicaid as defined in 10A NCAC 21B.

(d)  When a provider files a Medicaid claim for services provided to a Medicaid patient, the provider shall not bill the Medicaid patient for Medicaid services for which it receives no reimbursement from Medicaid when:

(1)           the provider failed to follow program regulations; or

(2)           the agency denied the claim on the basis of a lack of medical necessity; or

(3)           the provider is attempting to bill the Medicaid patient beyond the situations stated in Paragraph (c) of this Rule.

(e)  A provider who accepts a patient as a Medicaid patient shall agree to accept Medicaid payment plus any authorized deductible, co-insurance, co-payment and third party payment as payment in full for all Medicaid covered services provided, except that a provider may not deny services to any Medicaid patient on account of the individual's inability to pay a deductible, co-insurance or co-payment amount as specified in 10A NCAC 22C .0102.  An individual's inability to pay shall not eliminate his or her liability for the cost sharing charge.  Notwithstanding anything contained in this Paragraph, a provider may actively pursue recovery of third party funds that are primary to Medicaid.

(f)  When a provider accepts a private patient, bills the private patient personally for Medicaid services covered under Medicaid for Medicaid recipients, and the patient is later found to be retroactively eligible for Medicaid, the provider may file for reimbursement with Medicaid. Upon receipt of Medicaid reimbursement, the provider shall refund to the patient all money paid by the patient for the services covered by Medicaid with the exception of any third party payments or cost sharing amounts as described in 10A NCAC 22C .0102.


History Note:        Authority G.S. 108A‑25(b); 108A‑54; 150B‑11; 42 C.F.R. 447.15;

Eff. January 1, 1988;

Amended Eff. February 1, 1996; October 1, 1994.