Important Information About Sterilization Claims

Electronic Sterilization Claims for Undocumented Aliens -

Inpatient delivery claims, for "Undocumented Aliens" who had a non-covered sterilization provided during the stay, can be submitted electronically via the NCTracks provider portal with the non-covered charges listed in the non-covered column. To meet documentation requirements found in sterilization policy 1E-3 a printed version of the UB claim with the sterilization charges moved to the non-covered column and a statement in the remarks field indicating charges for sterilization were entered in the non-covered column must also be uploaded in the provider portal with the electronic claim submission.

Electronic Sterilization Claims for Non-Covered Sterilization Claims -

Inpatient delivery claims which include non-covered sterilization services not related to "Undocumented Aliens" should be submitted electronically. The claim will be denied with EOB 00041 (Federal Sterilization Consent Form Required). After receiving a denial providers should submit a paper adjustment request form with supporting documentation. The adjustment request should include a UB claim form with the sterilization charges in the non-covered column and a statement in the remarks field indicating non-covered charges are for sterilization. Adjustment instructions and documentation requirements can be found on the NCTracks provider portal.

This is based on Clinical Coverage Policy 1E-3 Medicaid and Health Choice Sterilization Procedures, which can be found on the N.C. Division of Medical Assistance (DMA) website. (See link below.) Note: Failure to complete both the Non-Covered column and the Remarks field will result in denial.