December 01, 2023

North Carolina Medicaid: Pending claims prior to PML determination

Skilled nursing facility claims that were denied due to delayed patient monthly liability (PML) determination will be reprocessed

The North Carolina Department of Health and Human Services (DHHS) provided directives to Prepaid Health Plans (PHPs) to pend skilled nursing facility (SNF) claims submitted prior to patient monthly liability (PML) determination. PML is determined by the Department of Social Services (DSS) for North Carolina Medicaid.

Directives for processing claims

Claims received by United Healthcare prior to PML determination will pend as an unclean claim for 90 calendar days. If the claim is clean as cited in section 3.41 of Managed Care Billing Guidance to Health Plans, version 24 and the PML is received within the 90 calendar days, we will pay the claim. If the PML is not received within 90 calendar days of receipt of the claim, we will deny the claim as consistent with North Carolina General Statute § 58-3-225(d). If the missing additional information (i.e., the PML) is received within 1 year after the date of the denial notice closing the claim, United Healthcare is required to reopen and process the claim in accordance with North Carolina General Statute § 58-3-225(d).

Further, as required by North Carolina General Statute § 58-3-225(d), United Healthcare will inform providers in the denial notice that the claim will be reopened if the PML is received within 1 year of the date of the denial notice closing the claim.

Reprocessing denied claims

DHHS requires PHPs to reprocess claims with dates of service from July 1, 2021, to present day that were previously denied for timely filing where the PML was delayed by DSS.

What this means for you

There’s nothing you need to do for us to reopen and process claims from this timeline. We’ll notify you of any affected claims.


Chat with a live advocate 7 a.m.–7 p.m. CT from the UnitedHealthcare Provider Portal or contact your provider advocate. 


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