How to Fill Out and Submit the NC Medicaid Resolution Inquiry Form

The NC Medicaid Resolution Inquiry Form is a one-page document providers use to request a claim override from NCTracks when a Medicaid claim cannot be processed through normal channels. It covers two situations only: Medicare overrides and time limit overrides. You complete the form, attach the claim and supporting documents, and send the packet to the claims contractor (CSRA) by mail, fax, or upload through the NCTracks Provider Portal. There is no filing fee.¹

When the Form Is Required

The form itself states in bold: “PLEASE USE THIS FORM FOR OVERRIDES ONLY.”¹ Use it for anything else and the request will not be processed.

For Medicare overrides, the paper form is still required. Overrides will not be issued on claims submitted without it. For time limit overrides alone, the form is no longer required if you submit the claim electronically through the NCTracks Provider Portal or a batch X12 transaction with the appropriate delay reason code in the designated field.² The two accepted delay reason codes are:

Code 7, for a third-party processing delay.
Code 9, when the original claim was rejected or denied for a reason unrelated to the billing limitation rules.

Providing “other payer” information, including CARC details, directly on an electronic claim can also replace the paper Medicare override in some situations. The Job Aid presents this as a more efficient alternative rather than a blanket replacement for the form.²

Pick the Right Override Type

The form has five checkboxes at the top. Mark one, and only one.¹

Medicare Override, when Medicare denied the service as non-covered and you believe Medicaid should pay as primary.
Time Limit Override, when a claim missed the standard 365-day filing window and you can document a timely original submission or an accepted delay reason.
Time Limit Override with Medicare, when the claim is late and involves a Medicare crossover.
Time Limit Override with TPL, when the claim is late and involves a third-party liability payer such as commercial insurance.
Time Limit Override with Medicare and TPL, when the claim is late and involves both Medicare and another insurer.

Checking the wrong box routes the file to the wrong queue. Before you mark anything, confirm whether Medicare or any other insurer touched the claim.

Each override request requires its own separate form. Three claims that need overrides means three forms.²

Filling In Each Field

Download the PDF from the NCTracks Providers page.¹ Every entry must match the original claim exactly. The fields are:

Type: an “X” in one of the five override categories.
National Provider Identifier: your 10-digit NPI from the National Plan and Provider Enumeration System.
Provider Name and Address: the billing provider’s name and address as registered in NCTracks.
Patient’s Name: the Medicaid recipient who received the service.
Recipient ID: the recipient’s Medicaid identification number.
Date of Service: the “From” and “To” dates on the original claim.
Claim Number: the number NCTracks assigned when the original claim was processed or denied. Not your internal billing system number.
Billed Amount: the dollar amount on the original claim.
Paid Amount: what NCTracks actually paid. Enter zero if the claim was denied entirely.
RA Date: the date on the Remittance Advice reporting the payment or denial.
Comments: a brief explanation of why the override is needed. Reference specific denial codes, note what changed, or explain the delay.
Signature, Date, and Phone Number: the authorized person signs, dates the form, and provides a callback number.

What to Attach

The form alone is not enough. The instructions require you to attach the claim, copies of any related Remittance Advice documents, and any other supporting information. The contractor scans all incoming documents, so send single-sided pages only. Double-sided pages will not scan correctly and the back side will be lost.²

What you add beyond that depends on which box you checked.

For a Medicare override, attach the section of the Medicare or other third-party EOB showing the Claim Adjustment Reason Codes. The CARC detail is what proves Medicare denied the service as non-covered, which is the basis for asking Medicaid to pay instead.²

For a time limit override, you must prove the original claim was submitted within the initial 365-day window. Acceptable proof includes dated correspondence from the Division of Health Benefits or the claims contractor about the specific claim received within 365 days of the date of service, a primary insurance EOB dated within 180 days of the Medicaid claim submission, or a copy of the Remittance Advice showing the original timely submission.² Without that proof, the override cannot be approved regardless of the merits.

If your records include clinical documentation supporting medical necessity, add it. Federal law requires Medicaid providers to maintain records that fully disclose the extent of services furnished and support the claims billed, and entries must be legible, signed, and dated.³

Where to Send It

You have three options.

Upload the completed form and attachments through the secure NCTracks Provider Portal.

Fax the packet to 855-710-1965.⁴

Mail the physical packet to:

CSRA
PO Box 300009
Raleigh, NC 27622¹

For certified or overnight mail, use the physical street address: CSRA, 5444 Wade Park Ave., Wade IV, Raleigh, NC 27607.⁴ A trackable shipping method or fax confirmation gives you proof of the date the contractor received the paperwork, which matters if the timeliness of the request itself is ever questioned.

What Happens After You Submit

The file enters a queue for manual review. The contractor may contact you if the documentation is insufficient, so responding quickly to any request for additional information keeps the inquiry from being closed without a resolution. The form does not specify a guaranteed processing timeline, and publicly available NCTracks materials do not publish a standard turnaround window. If the inquiry seems stalled, the NCTracks Call Center at 800-688-6696 (Monday through Friday, 8:00 a.m. to 5:00 p.m., excluding state holidays) can provide a status update.⁴

You will receive written notification of the result. Either the override is approved and the claim is reprocessed for payment, or the override is denied and the original claim decision stands.

Common Mistakes That Delay Processing

Wrong override type selected. Marking “Time Limit Override” when the claim actually involves a Medicare crossover routes it to the wrong reviewer.
Missing or mismatched claim number. The claim number must match the one NCTracks assigned. Transposed digits or an internal billing number prevent the reviewer from locating the claim.
No proof of timely original submission on a time limit override. Without that evidence the override cannot be approved on the merits.
Double-sided attachments. The scanner captures only the front, so the back side is lost from your file.²
Missing Remittance Advice. The instructions require RA copies. Submitting without them is the fastest way to trigger a request for additional information.¹

If the Override Is Denied

A denial is not the end of the road. For claim-level disputes, the Division of Health Benefits has a provider reconsideration process. A reconsideration request must include the provider name, address, telephone number, and a specific statement about what you disagree with. Incomplete requests will not be processed.⁵ The NC Department of Health and Human Services Hearing Office handles informal reconsideration reviews for other adverse determinations, including recoupment amounts and provider enrollment denials or terminations.⁶

1
NCTracks. Medicaid Resolution Inquiry Form
2
NCTracks. Provider Adjustments, Time Limit Overrides, and Medicare Override Job Aid
3
Centers for Medicare & Medicaid Services (CMS). Medicaid Documentation for Medical Professionals
4
NCTracks. Contact Us
5
North Carolina Department of Health and Human Services. Provider Reconsideration Process for Claim Denials
6
NC Medicaid. Appeals