10A NCAC 45A .0303       PAYMENT LIMITATIONS

(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.

History Note:        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 4C .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.