NCTracks to Verify Active Home State Medicaid Participation for Border and Out-of-State Locations

Effective April 25, 2021, in accordance with Code of Federal Regulations 42 CFR 455.410, 42 CFR 455.414, 42 CFR 455.450 and 42 CFR 455.460, NCTracks will verify active Medicare* or home state Medicaid participation for all border and out-of-state service locations submitted on Initial, Re-Enrollment, Re-Verification and Manage Change Request Applications (MCRs), including backdated applications. 

The following consequences will apply for providers with out-of-state/border service locations if not enrolled in Medicare or home state Medicaid:

  • Enrollment/Re-enrollment Applications will be denied (or one of the service locations will be denied, as applicable) if the provider is not active in Medicare or home state Medicaid program for the location(s) listed on the application.
  • MCR Applications will be denied (or one of the service locations will be denied, as applicable) if the provider is not active in Medicare or the home state Medicaid program for the location(s) added or reinstated on the application.
  • Back-Dating MCR Applications will be denied if the provider is not active in Medicare or the home state Medicaid program or if the provider is not active for the requested effective date for any of the out-of-state service location(s).
  • Re-verification Applications will be denied (or one of the service locations, as applicable) will be denied if the provider is not active in Medicare or the home state Medicaid program for the location(s). Upon denial, the system will automatically terminate the provider at the location or health plan level.

*Verification of Medicare-approved enrollment status may be used in lieu of home state verification.

The following denial reasons may be posted in the denial letter sent to the provider if NCTracks cannot verify Medicare or home state Medicaid participation for the application:

  • TERM-OOS, NOT ACTIVE IN MEDICARE OR HOME STATE MEDICAID
  • OUT OF STATE MEDICAID PROVIDER NOT ACTIVE IN MEDICARE OR HOME STATE FOR REQUESTED EFFECTIVE DATE

Medical and pharmacy claims will also deny with edit 00046 – BILLING/RENDERING PROVIDER TERMINATED if submitted for a billing/rendering provider that was terminated for not having active Medicare or home state Medicaid participation.

If a border or out-of-state provider is terminated for lack of Medicare or home state Medicaid participation, they may reinstate the terminated taxonomy by completing another application once enrolled in Medicare or home state Medicaid.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M21084-R-2401