Nc Medicaid Credit Balance Report Form – Fill Out and Use This PDF

The NC Medicaid Credit Balance Report form is a crucial document designed to detail any outstanding credit balances that Medicaid providers may have. By requiring information such as the facility's full name, Medicaid provider number, and specifics of the Medicaid recipient's service dates and payments, this form ensures a transparent and accurate accounting process. Providers are guided to list credit balances, accompanied by their reasons, to aid in the recovery process.

This meticulously detailed form plays a pivotal role in maintaining the integrity of Medicaid’s financial records, ensuring that any excess payments are properly accounted for and returned. It's an essential step for facilities to stay compliant with Medicaid regulations and facilitate the smooth functioning of healthcare financial operations.

To maintain compliance and streamline your Medicaid financial reporting, ensure this form is completed with precision and submitted in a timely manner. Click the button below to start filling out your form.

Get Form Now Download PDF

Nc Medicaid Credit Balance Report Form PDF Details

In the realm of healthcare finance management, the NC Medicaid Credit Balance Report form is a pivotal tool, utilized by facilities to report any credit balances owed to Medicaid. These instances occur when the amount reimbursed by Medicaid exceeds the cost of the services provided, necessitating a refund. The form requires detailed information, including the full name of the facility as registered on Medicaid records, the facility's Medicaid provider number(s), and the comprehensive contact information of the individual completing the report. Each entry must outline the Medicaid recipient's name and identification number, service dates, payment dates, Medicaid claim numbers, and the precise amount that constitutes the credit balance. Moreover, the form mandates an explanation for the origin of each credit, categorizing them into payments received from Medicare, health, casualty insurance, or other sources, providing clarity and ensuring accountability. Once filled, this document, acting as a cornerstone for financial integrity, must then be dispatched to Third Party Recovery at DMA, reinforcing the transparent and judicious management of Medicaid funds. This procedure not only helps in maintaining accurate financial records but also strengthens the trust in healthcare administration by ensuring that funds are appropriated correctly and efficiently.

Question	Answer
Form Name	Nc Medicaid Credit Balance Report Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	ICN, medicaid credit balance report, Raleigh, nc medicaid credit balance report

Form Preview Example

Instructions for Completing Medicaid Credit Balance Report

Complete the “Medicaid Credit Balance Report” as follows:

•Full name of facility as it appears on the Medicaid Records

•The facility’s Medicaid provider number. If the facility has more than one provider number, use a separate sheet for each number.

DO NOT MIX

•Circle the date quarter end

•Enter year

•The name and telephone number of the person completing the report. This is needed in the event DMA has any questions regarding some

item in the report

Complete the date fields for each Medicaid balance by providing the following information:

Column 1 – The last name and first name of the Medicaid recipient (e.g., Doe, Jane)

Column 2 – The individual Medicaid identification (MID) number

Column 3 – The month, day, and year of beginning service (e.g., 12/05/03)

Column 4 – The month, day, and year of ending service (e.g., 12/10/03)

Column 5 – The R/A date of Medicaid payment (not your posting date)

Column 6 – The Medicaid ICN (claim) number

Column 7 – The amount of the credit balance (not the amount your facility billed or the amount Medicaid paid)

Column 8 – The reason for the credit balance by entering: “81” if it is a result of a Medicare payment; “83” if it is the result of a health insurance payment; “84” if it is the result of a casualty insurance/attorney payment or “00” if it is for another reason. Please explain “00” credit balances on the back of the form.

After this report is completed, total column 7 and mail to Third Party Recovery, DMA, 2508 Mail Service Center, Raleigh, NC 27699-2508.

MEDICAID CREDIT BALANCE REPORT

PROVIDER NAME:__________________________ CONTACT PERSON: ___________________________________

PROVIDER NUMBER: _______________________ TELEPHONE NUMBER: _________________________________

QUARTER ENDING: (Circle one) 3/31 6/30			9/30 12/31	YEAR: _________________
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)
RECIPIENT’S	MEDICAID	FROM DATE	TO DATE	DATE	MEDICAID	AMOUNT OF	REASON
NAME	NUMBER	OF	OF SERVICE	MEDICAID	ICN	CREDIT	FOR CREDIT
		SERVICE		PAID		BALANCE	BALANCE

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Circle one:	Refund	Adjustment			Return form to:	Third Party Recovery
						DMA

2508 Mail Service Center

Raleigh, NC 27699-2508

Revised 10/07

Nc Medicaid Credit Balance Report Form – Fill Out and Use This PDF

Nc Medicaid Credit Balance Report Form PDF Details

Form Preview Example

Nc Medicaid Credit Balance Report Form isn’t the one you’re looking for?

Related Documents