Reimbursement

 

North Carolina insurance law was amended in 1993 to mandate reimbursement by indemnity plans for any service delivered by nurse practitioners, certified nurse midwives and psychiatric-mental health clinical nurse specialists that is covered  by a patient’s insurance plan, within theses APRNs scope of practice, and reimbursable to other providers.

 In 2001, NC Session Law 1001-446 (aka the Managed Care Patient’s Bill of Rights) made it illegal to prohibit any provider from submitting an application for inclusion in managed care networks based on their education, certification or licensure. It also required the inclusion of nurse practitioners, certified nurse midwives and psychiatric-mental health clinical nurse specialists in managed care network provider directories when requested by the employing physician.

Despite this law, some NPs are still denied the opportunity to apply for inclusion in managed care network or out-of-network panels.  If you have been denied this opportunity, please notify use by sending an email to NCNA.

 

Medicare

Medicare has directly reimbursed NPs since passage of the 1997 Balanced Budget Act. NPs are reimbursed at 85% of physician fee schedule for a covered service. NPs must have a Medicare provider number to bill Medicare directly.

Cigna is the Medicare carrier for North Carolina. To obtain a Medicare Provider Number, contact Cigna at the regional office in Tennessee (1-615-782-4509).

Medicare may also be billed for NP services that are provided to patients ‘incident to’ the plan of care initiated by a physician. Services billed ‘incident to’ must meet specific requirements and are reimbursable at 100% of the physician fee schedule. 

 

Medicaid

Medicaid directly reimburses North Carolina NPs at 100% of the physician fee schedule if they are self-employed.

To obtain a Medicaid Provider Number, contact the NC Medicaid Provider Enrollment Section of the Division of Medical Assistance at 919-855-4057.