Medicaid Providers

Medicaid Cover Letter

North Carolina Medicaid Cover Letter

• English

Medicaid Participating Provider Agreement

North Carolina Medicaid Participating Provider Agreement

• English

W-9 Form

W-9 Form

• English

Medicaid Instructions Guide

North Carolina Medicaid Instructions Guide

• English

Medicaid Ancillary Profile Sheet

North Carolina Medicaid Ancillary Profile Sheet

• English

Provider Incident Report Form

This report is to be completed for ALL injuries occurring within a facility. Report is to be printed and submitted to Risk Management within 24 hours of occurrence. Fax to:

• English

• English

Medicaid Drug Coverage Request Form

Please use this form to request coverage of a drug that we would not usually cover or would restrict in some way.

• English

• English

Medicaid Prior Authorization Request

Authorization approves the medical necessity of the requested service only. It does not guarantee payment, nor does it guarantee that the amount billed will be the amount reimbursed.

• English

Value-Added Benefit Referral Form

Clinical information and supportive documentation should consist of current physician order, notes and recent diagnostics. Notification is required for any date of service change.

• English

Antihistamines

Prior Authorization Form

• English

Botox, Dysport, Myobloc, and Xeomin

Prior Authorization Form

• English

Continuous Glucose Monitors

Prior Authorization Form

• English

Crohn’s Disease (Cimzia and Humira)

Prior Authorization Form

• English

Cystic Fibrosis Medications

Prior Authorization Form

• English

Dupixent for Atopic Dermatitis

Prior Authorization Form

• English

Emflaza

Prior Authorization Form

• English

Eucrisa (Temporary Request Form)

Prior Authorization Form

• English

Fasenra

Prior Authorization Form

• English

Growth Hormone (Children Less than 21 Years of Age)

Prior Authorization Form

• English

Immunomodulators: Cytokine Release Syndrome (Actemra Infusion and Actemra SQ)

Prior Authorization Form

• English

Ingrezza

Prior Authorization Form

• English

Juxtapid and Kynamro

Prior Authorization Form

• English

Lupus Medications

Prior Authorization Form

• English

Mavyret (Initial)

Prior Authorization Form

• English

Monoclonal Antibody Therapy (Xolair)

Prior Authorization Form

• English

Non-Covered Request Form for Recipients under 21 Years Old

Prior Authorization Form

• English

Opioid Analgesic (Long-Acting)

Prior Authorization Form

• English

Opioid Dependence Therapy Agents

Prior Authorization Form

• English

Plaque Psoriasis (Otezla, Cosentyx, and Taltz)

Prior Authorization Form

• English

Procrit, Epogen, and Aranesp

Prior Authorization Form

• English

Psoriatic Arthritis (Enbrel, Humira, and Simponi)

Prior Authorization Form

• English

Rheumatoid Arthritis (Enbrel, Humira, Cimzia, Kineret, Orencia SQ, Xeljanz, Actemra and Simponi)

Prior Authorization Form

• English

Standard Drug Request

Prior Authorization Form

• English

Topical Anti-Inflammatory Medications

Prior Authorization Form

• English

Triptans

Prior Authorization Form

• English

Vosevi

Prior Authorization Form

• English

Zepatier (Continuation)

Prior Authorization Form

• English