North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 45 - GENERAL PROCEDURES FOR PUBLIC HEALTH PROGRAMS › Subchapter A - PAYMENT PROGRAMS › Section .0300 - ELIGIBILITY PROCEDURES › Section 45A .0303 - PAYMENT LIMITATIONS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Payment program
				  payments shall be made for authorized services only when funds are
				  available.
(b) During the last six
				  months of the fiscal year, the State Health Director may limit payment program
				  payments that can be authorized when the total amount of outstanding
				  authorizations, plus the estimated authorizations for the remainder of the
				  fiscal year, less estimated cancellations, exceeds 100 percent of the program's
				  cash balance. The State Health Director shall rescind the limitations at the
				  end of the fiscal year, or prior to the end of the fiscal year if sufficient
				  funds become available to authorize full program benefits for the remainder of
				  the fiscal year.
(c) Payment
				  program benefits shall be available only for services or appliances which are
				  not covered by another third party payor or which cannot be paid for out of
				  funds received in settlement of a civil claim. Patients shall be advised to
				  apply for Medicaid or Medicare benefits to which they may be entitled. However,
				  Early Intervention Program payment shall be available for services based on
				  Title 34, Code of Federal Regulations, Part 303.520, which is hereby
				  incorporated by reference along with all subsequent amendments and editions. A
				  copy of 34 C.F.R. Part 303.520 is available for inspection at the Department of
				  Health and Human Services, Division of Public Health, Women's and Children's
				  Health Section, Early Intervention Branch, 5605 Six Forks Road, Raleigh, North
				  Carolina. Copies of 34 C.F.R. Part 303.520 may be downloaded and printed from
				  the Internet at
http://www.gpo.gov/fdsys/pkg/FR-2011-09-28/pdf/2011-22783.pdf
Providers shall take reasonable measures to collect other third party
				  payments.
(d) The Department shall
				  not pay Medicaid co-payments or in any other way supplement Medicaid payments
				  for the services governed by this Subchapter.
(e) If prior to the Department's payment for
				  particular services or appliances, the provider, the patient, or a person
				  responsible for the patient receives partial or total payment for the services
				  or appliances from a third party payor, or receives funds in settlement of a
				  civil claim, the Department shall pay only the amount, if any, by which the
				  Department's payment rate exceeds the amount received by the person. For the
				  purpose of this Rule the Department's payment rate means the rate of
				  reimbursement established in
				  10A NCAC
				  45A .0400.
(f) If after the Department makes payment for
				  particular services or appliances, the provider, the patient, or a person
				  responsible for the patient receives partial or total payment for the services
				  or appliances from a third party payor, or receives funds in settlement of a
				  civil claim which are available to pay for the services or appliances, the
				  person receiving the payment shall reimburse the Department to the extent of
				  the amount received by the person without exceeding the amount of the
				  Department's prior payment to the provider. This reimbursement shall be made to
				  the Department within 45 days after receipt of the third party
				  payment.
(g) If the Department
				  requests a refund of a payment made to a provider, the refund shall be made to
				  the Department within 45 days after the date of the refund request.
Authority
					 G.S.
					 130A-5(3);
					 130A-27;
					 130A-124;
					 130A-127;
					 130A-129;
					 130A-205;
Eff. July
					 1, 1981;
Amended Eff. February 1, 1990; September 1, 1989; March 1,
					 1989;
Transferred and Recodified from
					 10 NCAC
					 04C .0303 Eff. April 4, 1990;
Amended Eff. January 1, 2014; June 1, 2004; April 1, 1992; February 1, 1992;
					 May 1, 1991; February 1, 1991;
Pursuant to
					 G.S.
					 150B-21.3A, rule is necessary without
					 substantive public interest Eff. January 13,
					 2015.