States must revalidate the enrollment of all providers at least every five years to ensure the information on record is accurate and current.

 

Pursuant to 42 CFR 455.414, Medicaid states must revalidate the enrollment of all providers at least every five years to ensure the information on record for each provider is accurate and current. As part of this process, the provider’s credentials and qualifications are evaluated to ensure they meet the ongoing conditions of participation. The re-credentialing process also includes a criminal background check on all owners and managing relationships associated with the provider record.

When reverification is due, providers receive a reverification notice in their Message Center Inbox on the secure NCTracks Provider Portal. Due dates for reverification are specific to each provider; therefore, not all providers will receive notices simultaneously.

  • The initial reverification notification instructs the provider to complete the federally mandated reverification by a specific date, which is 70 days from the date of the notice to avoid suspension and possibly termination.
  • The requirement is to complete the reverification process, so providers are encouraged to watch for notices in their message center inbox and act promptly upon receipt of the initial notification in order to avoid suspension of claims and termination from the Medicaid program.
  • Suspension and termination are automated NCTracks system actions which allow for no intervention.

A review of reverification history to date reveals that many providers take no action until after they learn their claims have been suspended and they are unable to receive payment. These are non-compliant providers who place themselves at risk. The Division of Health Benefits finds that most reverification failures that result in a provider’s termination from NC Medicaid apply to non-compliant providers. Once a suspension is in place, two scenarios are possible:

  1. An application can be submitted (lifting the suspension) and processed through the system to completion with no errors, resulting in a successful reverification; or,
  2. An application can be submitted (lifting the suspension), but errors or omissions cause delays that result in the reverification being abandoned, withdrawn, or denied, ultimately resulting in termination.

With respect to processing time frames referenced in Medicaid Bulletin articles and NCTracks Provider announcements, there are references to 70-day and 50-day requirements. (For example: (https://www.nctracks.nc.gov/content/public/providers/provider-recredentialing.htm). Information can also be found on NCTracks to assist providers with the recredentialing/reverification process (Provider Re-credentialing/Re-verification – Provider Re-credentialing/Re-verification (nc.gov))

The 70-day timeframe referenced in publications applies to all providers and is the date by which reverification is to be completed by the provider, which is 70 days from the date of the initial notification.

The 50-day timeframe, which allows for an additional 50 days from the date claims are suspended to submit a reverification application, is applicable to non-responsive providers. Non-responsive providers are providers who take no action whatsoever to initiate the reverification process. This is not applied in the same manner to providers who submit delinquently.

In the case of a delinquent submission, the NCTracks system enforces the due date on the initial Reverification Notice. This is because the system voids the 50-day extension immediately upon the submission of a reverification application, regardless of whether the submission is timely or not. A provider who is delinquent in submitting their reverification is considered a non-compliant provider, that is, one who fails to act in accordance with a requirement. This is not the same as “taking no action.” A delinquent submission meets the definition of “taking action;” however, it is non-compliant in that required deadlines have not been met.

More information about reverification can be found on the NCTracks Provider Re-credentialing/Re-verification webpage.

For additional question, contact [email protected] or 800-688-6696