Nc Dma Carolina Access Override Request Form printable pdf download

NC DMA Carolina ACCESS Override Request Form

DMA-0010 V1.0

Recipient Information

Recipient ID #: ___________________________________________________________________________

Last Name: _________________________________ First Name:___________________________________

Date of Birth: ______________ Gender: _____ Date(s) of Service: _________________________________

Requesting Provider’s Information

Requesting Provider’s NPI #:_________________________________________________________________________

Requesting Provider’s Name of Practice: _______________________________________________________________

Site Address: _____________________________________________________________________________________

City: ______________________________ State: __________________ 9 Digit Zip Code: ______________________

CCNC /CA PCP Information

Verified name of the PCP on record on the Date(s) of Service per the EVS or AVR:

________________________________________________________________________________________________

Person contacted at PCP’s Office: ___________________________________ Date contacted: ___________________

Reason the PCP stated he/she would not authorize treatment: ____________________________________________

________________________________________________________________________________________________

Reason recipient did not go to the PCP on record: ______________________________________________________

________________________________________________________________________________________________

Reason services were provided prior to receiving PCP authorization or requesting an Override: ___________________

________________________________________________________________________________________________

Diagnosis or presenting symptoms: ___________________________________________________________________

________________________________________________________________________________________________

Override Information

I am requesting an override due to:

Enrollee linked incorrectly to PCP. Please explain: ___________________________________________________

________________________________________________________________________________________________

Who is the correct PCP? ____________________________________________________________________________

Child has been placed in foster care in another area: _________________________________________________

Recipient has moved to another county: ___________________________________________________________

An inpatient admission from the Emergency Dept.

Recipient’s condition is catastrophic. Please explain: _________________________________________________

________________________________________________________________________________________________

Unable to contact PCP. Please explain: _____________________________________________________________

Recipient is in a course of treatment. Please explain: _________________________________________________

Other. Please explain: ___________________________________________________________________________

________________________________________________________________________________________________

Complete this form to request a Carolina ACCESS override when you have received a denial for EOB 270 or 286 or the

Primary Care Provider (PCP) has refused to authorize treatment for past date(s) of service. The request must be

submitted within six months of the date(s) of service. Overrides will not be considered unless the PCP has been contacted

and refused to authorized treatment.

Requestor’s Name _______________________________ Phone Number: __________________Ext_______

Requestor’s Signature:_____________________________________________ Date:_____________________

Fax this form to CSC at: (855) 710-1964

Nc Dma Carolina Access Override Request Form