New Edit for Emergency Hemodialysis

Effective February 1, 2016, new restrictions will be in place in NCTracks to limit services for certain undocumented aliens to dialysis services only. Providers will see RESTRICTIVE COVERAGE, EMERGENCY HEMODIALYSIS SERVICES ONLY when inquiring about eligibility information.

Federal law restricts coverage of services for undocumented aliens to those services that have been determined to treat an emergency condition as defined in 42 CFR 440.255. Previously, providers may have been reimbursed for non-emergency services provided on the same day for which eligibility was determined due to the need for hemodialysis. Now, a new edit will be applied to Medicaid claims for services provided that do not fit the criteria for hemodialysis. The EOB 00246 - SERVICE NOT ALLOWED FOR UNDOCUMENTED ALIENS will post to denied claims.

All Medicaid claims adjudicated after February 1 are subject to the new edit, regardless of dates of service. No claims reprocessing is scheduled to occur.

Eligibility does not guarantee claims payment. Claims for dialysis are still subject to Medicaid dialysis policy, which can be found on the Division of Medical Assistance (DMA) website at http://dma.ncdhhs.gov/providers/programs-services/medical/end-stage-renal-disease.

This new edit only applies to beneficiaries authorized because they need dialysis. Claims for services that are provided to undocumented aliens that are deemed eligible due to conditions unrelated to dialysis will not be impacted by this edit.