Skip all navigation Skip to page navigation

DHHS Home | A-Z Site Map | Divisions | About Us | Contacts | En Español

NC Department of Health and Human Services
NC Division of
Medical Assistance
 
 

Recipient Eligibility Verification

What Needs to be Verified

A recipient's eligibility status may change from month to month if financial and household circumstances change. For this reason, at each visit a provider must verify the cardholder's

  • identity (if an adult)
  • current eligibility
  • Medicaid program (benefit category)
  • CCNC/CA primary care provider information
  • other insurance information

Methods of Verification

Real Time Eligibility Verification (270/271 Transaction)

Providers may choose to process a real-time electronic eligibility inquiry transaction (270/271 transaction) for a single Medicaid recipient through the Eligibility Verification System (EVS). Real-time transactions are only supported through Value Added Networks (VANs) with whom HP Enterprise Services and DMA have agreements. There is a charge from HP Enterprise Services to the provider of $0.08 per transaction and applicable contract charges by the provider's VAN may also apply.

Refer to Section 8 of the Basic Medicaid Billing Guide for information on contacting an approved VAN.

Batch Eligibility Verification (270/271 Transaction)

The 270/271 transaction set is also available in batch mode, allowing trading partners to submit an eligibility request for multiple recipients at the same time. Trading partners can submit batch transactions directly to HP Enterprise Services (without using a VAN) using a vendor-created software program. There is no charge from HP Enterprise Services to the provider to submit batch 270/271 transactions.

Refer to the HIPAA Companion Guides for information on all HIPAA-approved transactions.

Automated Voice Response System 1-800-723-4337, option 6

Providers may choose to utilize the Automated Voice Response (AVR) System to verify a recipient's eligibility. The AVR System gives providers eligibility information in a verbal format.

For step-by-step instructions on using the AVR System to verify recipient eligibility, refer to Appendix F of the Basic Medicaid Billing Guide.

NC Electronic Claims Submission/Recipient Eligibility Verification Web Tool

The NC Electronic Claims Submission/Recipient Eligibility Verification Web Tool includes a recipient eligibility verification component, which allows providers to verify a recipient's

  • current eligibility
  • Medicaid program (benefit category)
  • CCNC/CA primary care provider information
  • Medicare participation
  • other insurance information
  • transfer of asset information

Providers must have an Electronic Claims Submission Agreement on file with N.C. Medicaid and must obtain a logon ID and password in order to access the eligibility information.

For step-by-step instructions on using the Web Tool, refer to the September 2009 Special Bulletin, North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool Instructions Guide.

Note: The Web Tool is only available through Internet Explorer.

DMA Claims Analysis

To verify eligibility for dates of service over 12 months old, contact DMA Claims Analysis at 919-855-4045.

For More Information