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Medical Billing Services in North Carolina

North Carolina Medicaid now runs on three tracks: managed care Standard Plans for most beneficiaries, Tailored Plans for people with significant behavioral health or developmental needs, and NC Medicaid Direct for those outside managed care. Expansion has added adult members, and workers' comp is priced against an Industrial Commission schedule. We bill remotely for North Carolina practices.

  • Standard Plan, Tailored Plan and NC Medicaid Direct claims routed correctly
  • Workers' comp priced against the Industrial Commission's Medical Fee Schedule
  • Support for practices serving rural communities
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Standard Plans, Tailored Plans and NC Medicaid Direct

NC Medicaid is run by the Division of Health Benefits within the NC Department of Health and Human Services. Most beneficiaries must get care through a managed care Standard Plan, people with serious behavioral health needs, intellectual and developmental disabilities or traumatic brain injury may be in a Tailored Plan, and beneficiaries not enrolled in managed care are covered by NC Medicaid Direct.

North Carolina has also expanded Medicaid to cover adults ages 19 through 64 who meet the income limit. For practices, that means more adult patients whose coverage must be checked for which of the three tracks applies.

Official sources: NCDHHS: divisions and programmatic offices (external site), NC Medicaid: health plans and programs (external site), NC Medicaid: North Carolina expands Medicaid (external site)

How remote billing works for practices in North Carolina

We work remotely in your systems and the plan portals. Your team decides what access we have and can revoke it at any time.

  1. Step 1: Identify the Medicaid track

    Each Medicaid patient is marked Standard Plan, Tailored Plan or NC Medicaid Direct, with the specific plan recorded.

  2. Step 2: Re-check expansion adults

    Adult members covered under expansion are verified at each visit, like every other Medicaid patient.

  3. Step 3: Use the current fee schedule

    Workers' comp bills are priced against the Industrial Commission's Medical Fee Schedule in force on the date of service.

  4. Step 4: Take fee disputes to the Commission

    Disputed workers' comp payments are prepared for the Medical Fees Section's dispute process.

Commercial insurers and workers' comp in North Carolina

The NC Department of Insurance monitors the market conduct of insurers in the state, including life and health companies, HMOs and PPOs, under Chapter 58 of the General Statutes.

The Workers' Compensation Act, Chapter 97 of the General Statutes, governs workers' comp claims in North Carolina, and the Industrial Commission adopts the rules that apply. The Commission's Medical Fees Section reviews medical bills for workers' comp claims, helps settle fee disagreements and issues a yearly update of the Medical Fee Schedule. We price claims against the current schedule rather than any fixed figure.

Official sources: NC Department of Insurance: market regulation (external site), North Carolina Industrial Commission (external site), NC Industrial Commission: Medical Fees Section (external site)

Practices we typically see in North Carolina

North Carolina practices that see Medicaid patients bill across three tracks, Standard Plans, Tailored Plans and NC Medicaid Direct, and many also bill workers' comp claims priced under the Industrial Commission's Medical Fee Schedule.

Rural health care in North Carolina

The NCDHHS Office of Rural Health supports the state's Critical Access Hospitals and small rural hospitals through its Rural Hospital Program. For practices that work alongside these hospitals, the same careful coverage checks apply as anywhere else in the state.

Official source: NCDHHS Office of Rural Health: Rural Hospital Program (external site)

Official sources for North Carolina

Rules change. These are the agencies and contractors we check for the current requirements.

Frequently asked questions

Who is the Medicare contractor for North Carolina?

Palmetto GBA, the Medicare Administrative Contractor for Jurisdiction M, which also covers South Carolina, Virginia and West Virginia.

Official source: CMS: A/B MAC Jurisdiction M (Palmetto GBA) (external site)

How do we know whether a patient is in a Standard Plan or a Tailored Plan?

Check eligibility for each visit. Most beneficiaries are in Standard Plans, while people with serious behavioral health needs, intellectual or developmental disabilities or traumatic brain injury may be in Tailored Plans, and some remain in NC Medicaid Direct.

Official source: NC Medicaid: health plans and programs (external site)

Who sets workers' comp payment rules in North Carolina?

The North Carolina Industrial Commission, under the Workers' Compensation Act. Its Medical Fees Section reviews bills and revises the Medical Fee Schedule each year.

Official source: NC Industrial Commission: Medical Fees Section (external site)

Did Medicaid expansion change who we bill?

It added adult members ages 19 through 64 who meet the income limit, who are billed through the Medicaid track their coverage falls under.

Official source: NC Medicaid: North Carolina expands Medicaid (external site)

Can you bill for a rural practice in North Carolina remotely?

Yes. Claims and follow-up are handled electronically, wherever the practice is. Our remote team supports practices in rural and urban areas alike.

Related services and nearby states

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Get your North Carolina Medicaid tracks in order

A free audit shows how your claims split across Standard Plans, Tailored Plans and Medicaid Direct, and where denials cluster.

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