Instructions for DHB-7063 – Medicaid/NC Health Choice Beneficiary Profile Request
1. Fill in the name and title of the worker requesting profiles.
2. Select your county number and name. (Ex: 01 Alamance).
3. Fill in the date of the initial profile request unless this is a follow-up request.
4. Fill in the follow-up profile request date unless this is the initial request.
5. Enter the Case Head Name.
6. Enter the NC Fast Medicaid PDC # used to create the PI referral (Insurance Affordability, Income Support or the EIS Case ID for benefits issued prior to NC
Fast).
7. Enter the NC Fast MEDICAID Referral ID #. THIS IS REQUIRED. NO REQUEST WILL BE PROCESSED WITHOUT THIS NUMBER.
8. Indicate whether the period(s) of ineligibility is due to a transfer of assets sanction and, if yes, check the recipient’s living arrangement during the sanction period.
Living arrangement determines which claims are considered non-covered during a transfer of assets sanction.
9. Indicate whether this request is for FPP claims. If “YES”, check “FPP” by through date. DO NOT CHECK IF PROGRAM CODE IS MAFD.
NOTE: The Family Planning Waiver (FPW) coverage was in effect from 10/01/05 to 09/30/2014. The Family Planning Program (FPP) began 10/01/2014.
10. For each ineligible beneficiary fill in the information as follows in the spaces provided:
▪ Beneficiary Name
▪ Beneficiary’s CNDS ID #
▪ From and Through Dates for each Overpayment Period for which Medicaid Profiles are requested. Use MM/DD/CCYY format.
If all ineligible periods are consecutive use one line. If there is a break in overpayment periods put each separate period on a separate line.
▪ The Medicaid program and classification for each overpayment period requested. Note: NCHC claims are only available beginning 7/01/2010.
11. Continue to fill out the information required for each ineligible beneficiary for that NC Fast Case ID. Use a second DHB-7063, if needed.
12. Mail or fax the completed DHB-7063, Medicaid Beneficiary Profile Request Sheet to:
Division of Health Benefits
Quality Assurance Section - 18
2501 Mail Service Center
Raleigh, NC 27699-2501
Fax: 919-800-3186
Note: Allow three weeks for processing and availability in NC Tracks. If profiles are not available within three weeks of the original request date, please do not
send a 2nd request until you have verified whether DHB received your original DHB-7063.
To check the status of your original request, send an email to your Program Integrity Fraud Consultant with the following information: referral number,
the fax submission date and date(s) requested. You may also call DHB’s Office of Compliance and Program Integrity at 919-527-7700 and ask to speak with a
Program Integrity (Beneficiary) Fraud Consultant.
If your original request was not received, you will be asked to re-fax or mail a copy of the original DHB-7063. Please write 2nd Request in bold on the fax cover
letter.
If you have questions regarding how to interpret the Medicaid Profiles or how to determine the amount of the overpayment, please contact your Program Integrity
Beneficiary Fraud Consultant.
Division of Health Benefits
Quality Assurance Section
DHB-7063
Revised 01
-2021
