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Division of Medical Assistance Health Insurance Information Referral Form Recipient Name Recipient ID No Date of Birth Health Ins. Co. Name 1 Policy/Cert No* 2 Policy/Cert No* Reason For Referral 1. Recipient never covered by or added to above policy s EOB attached Recipient s insurance coverage terminated EOB attached New policy not indicated on Medicaid ID card EOB or copy of insurance card attached Indicate type coverage Do not include Medicare Major Medical Dental Indemnity Hosp/Surgical...

People Also Ask about

Are you dual eligible for Medicaid in NC?

Beneficiaries receiving both Medicare and Medicaid are sometimes called “duals” because they are dually eligible for both programs. Beneficiaries who receive both Medicare and Medicaid are temporarily excluded and will remain in NC Medicaid Direct at this time.

What is the secondary insurance?

Secondary insurance is health insurance that pays after primary insurance on a claim for medical or hospital care. It usually pays for some or all of the costs left after the primary insurer has paid (e.g., deductibles, copayments, coinsurances).

Can you have Medicaid and private insurance in NC?

Yes. A provider can refuse to accept Medicaid for beneficiaries who also have third-party coverage, even though they accept Medicaid for beneficiaries who do not have third-party coverage. However, providers must advise the beneficiary of the responsibility for payment before the services are rendered.

What are the different types of Medicaid in NC?

Health Plans NC Medicaid Managed Care Health Plans. Behavioral Health I/DD Tailored Plans. EBCI Tribal Option. Health Plan Contracts.

What is the maximum income to qualify for Medicaid in NC?

Who is eligible for North Carolina Medicaid Program? Household Size*Maximum Income Level (Per Year)1$19,3922$26,2283$33,0644$39,9004 more rows

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What is dma 2057 form?

The dma 2057 form is a document used for reporting financial information to the relevant authorities.

Who is required to file dma 2057 form?

Any individual or organization who meets the criteria set by the authorities must file the dma 2057 form.

How to fill out dma 2057 form?

To fill out the dma 2057 form, you need to provide accurate and complete financial information as per the instructions provided in the form.

What is the purpose of dma 2057 form?

The purpose of the dma 2057 form is to collect financial data for regulatory or compliance purposes.

What information must be reported on dma 2057 form?

The dma 2057 form typically requires information such as income, expenses, assets, liabilities, and any other relevant financial information.