North Carolina Medicaid Denied? Appeal Through NCDHHS and Tailored Care Plans

North Carolina has undergone a major transformation of its Medicaid system in recent years, transitioning most beneficiaries from a fee-for-service model to managed care. The NC Department of Health and Human Services (NCDHHS) administers the program, which now delivers benefits through two tracks: NC Medicaid Direct (fee-for-service for certain populations) and Medicaid Managed Care through PHP (Prepaid Health Plan) and Tailored Plan contractors.

If your North Carolina Medicaid claim was denied, understanding which program you're in is the first step to mounting a successful appeal.

How North Carolina Medicaid Is Structured

North Carolina's Medicaid system includes:

Standard Plans (Prepaid Health Plans): Cover most Medicaid enrollees for physical health and some behavioral health services. Current contractors include:

• Aetna Better Health of North Carolina
• Blue Cross NC (NC Medicaid)
• Healthy Blue (Centene)
• United Healthcare Community Plan
• WellCare of North Carolina

Tailored Plans: Cover individuals with significant behavioral health needs, intellectual or developmental disabilities, or traumatic brain injuries. Tailored Plans are operated by the state's Local Management Entities/Managed Care Organizations (LME/MCOs).

NC Medicaid Direct: A fee-for-service track for beneficiaries who are not enrolled in managed care, including some individuals with complex needs during transition periods.

North Carolina expanded Medicaid in late 2023, opening coverage to hundreds of thousands of previously uninsured adults.

Why North Carolina Medicaid Claims Are Denied

Common denial reasons in NC include:

• Medical necessity: The PHP or Tailored Plan determines the service does not meet clinical criteria
• Prior Authorization Denied: How to Appeal" class="auto-link">Prior authorization not obtained: Required preapproval was not secured before service
• Out-of-network provider: Service received from a non-participating provider
• Documentation gaps: Provider records insufficient to support the service
• Covered benefit not available in plan: The plan excludes the service
• Eligibility issues: Coverage gap during redetermination or enrollment transition

Step 1 — File a Grievance or Appeal With Your Plan

When your Prepaid Health Plan or Tailored Plan denies a service, you receive an Adverse Benefit Determination (ABD) notice. You have 60 days to file an internal appeal.

File your appeal in writing and include:

• The denial letter
• Medical records and clinical notes supporting your need
• A physician's letter of medical necessity
• Relevant clinical guidelines

Request an expedited appeal for urgent situations — plans must respond within 72 hours.

Standard appeals must be resolved within 30 days. If the plan upholds the denial, you can request a state fair hearing.

Step 2 — Request a Medicaid Fair Hearing

North Carolina Medicaid beneficiaries have the right to a State Fair Hearing before the Office of Administrative Hearings (OAH). You can request a hearing if your plan or NCDHHS denied, reduced, or terminated benefits.

To request a hearing:

• Contact NCDHHS Medicaid Operations at 1-800-662-7030
• Or submit a written request online at oah.nc.gov

You must file within 60 days of the adverse action notice. If your benefits are being reduced or terminated, file within 10 days of the notice to request continuation of benefits pending the outcome.

OAH administrative law judges conduct these proceedings. You can bring a representative. If you disagree with the OAH decision, you can appeal to Superior Court.

Step 3 — Escalate to NCDHHS Ombudsman

NCDHHS operates a Managed Care Ombudsman program to help beneficiaries navigate managed care disputes. Contact the Medicaid Ombudsman at 1-877-201-3750. The ombudsman can help you understand your rights, file complaints, and escalate unresolved issues.

Special Situations in North Carolina

Tailored Plans and behavioral health: If your mental health, substance use, or I/DD services were denied through a Tailored Plan or LME/MCO, the appeals process runs through that organization's grievance system and then to OAH. Behavioral health denials are common and frequently overturned on appeal.

NC Medicaid expansion enrollees: Adults newly covered under the 2023 expansion have the same appeal rights as other Medicaid enrollees. If you were denied coverage or enrollment in the expansion, contact NCDHHS immediately.

EPSDT: Children under 21 in NC Medicaid are entitled to EPSDT services — meaning any medically necessary care must be covered even if not in the standard benefit package. Cite EPSDT when appealing pediatric denials.

Transition period confusion: NC's transition from fee-for-service to managed care has created confusion about which entity is responsible for certain services. If you receive a denial claiming you're in the wrong program or your plan doesn't cover the service, contact the NCDHHS Ombudsman to help clarify responsibility.

Fight Back With ClaimBack

North Carolina's evolving Medicaid system adds complexity to an already difficult appeals process. ClaimBack helps you navigate which plan is responsible, build your clinical argument, and draft an appeal that meets OAH standards.

Start your North Carolina Medicaid appeal with ClaimBack

Related Reading

• Common Reasons Insurance Claims Are Denied
• How to Write an Insurance Appeal Letter
• Internal vs. External Insurance Appeal: Which Should You File?