NCTracks
Recipient Eligibility Inquiry FAQs
This list reflects answers to frequently asked questions regarding provider inquiry on recipient eligibility, including changes made for CAQH CORE.
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1. What is CAQH CORE?
The Council for Affordable Quality Healthcare (CAQH) is a nonprofit alliance of health plans and trade associations. The Committee on Operating Rules for information Exchange (CORE) is an initiative through CAQH to promote streamlining and ease of use for physicians and hospitals to access eligibility, benefits and claim information for their patients at the point of care. Implementation of the CAQH CORE operating rules is a mandate of the Affordable Care Act.
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2. Will CAP/DA be added to the Service Item List?
CAP/DA is a benefit plan not a service type. If a recipient has benefit plan CAP/DA, the response screen displays it in the Recipient Information section of the screen, under Health Plan: Medicaid.
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3. Will Health Choice be added to the Service Item List?
Health Choice is a health plan and benefit plan, not a service type. If a recipient has Health Choice, the response screen displays it in the Recipient Information section of the screen, under Health Plan: Health Choice.
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4. Will Orthodontic be added to the Service Item List?
Orthodontics is not one of the CAQH CORE mandated service types.
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5. Why is Dental and Oral Surgery listed separately in the Service Item List?
The service type codes are mandated by CAQH CORE. See www.caqh.org for the complete list of service type codes. This list is a subset of the complete list noted in the 270/271 TR3.
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6. Will the copay for third party payers be included with the response to recipient eligibility inquiry?
No. This is not in scope for CAQH CORE. The service types and copays are for DHB and DPH eligibility only.
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7. If a recipient says they have Other Insurance, but none is listed, then what does the provider do?
The provider completes the NC Provider 2057 Referral Form at https://ncprovider.hms.com/. Please submit this form to submit changes to recipient information. All requests will be completed within 3 business days.
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8. If a recipient used to have Other Insurance, but now they don’t, how long does it take Medicaid to update to display no Other Insurance?
The provider completes the NC Provider 2057 Referral Form. Please use this form to submit changes to recipient information. All requests will be completed within 48 business hours.
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9. Is there a way to save the Eligibility Response page without printing it all out?
Currently, there is no way to do this in NCTracks. There are third party software applications to do screen captures.
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10. Where is the information on payment for services?
The following statement appears over the Service Limits section of the Eligibility Response screen: “Information regarding these services is provided for informational purposes only and is not a guarantee of payment. Payment for services is subject to criteria and limitations documented in the applicable Medicaid policy manual. Please refer to your NC Medicaid policy manual.”