Emergency Department Claims from Out-of-Network Hospitals
Claims from out-of-network hospitals for services provided in the emergency department to Sandhills Center Medicaid members can be billed directly. Hospitals will need to complete an ED Reimbursement Request Form, a Trading Partner Agreement and a copy of their W-9.
- Emergency Department Cover Letter
- Emergency Department Reimbursement Request Form
- Trading Partner Agreement
- W-9 Form
Please submit the forms by email, fax or mail.
Email Address: email@example.com
Fax Number: (910) 673-0904
Attn: Karen Nall Dunn, Network Management
P.O. Box 9 West End, NC 27376
Once your reimbursement request form (application) has been reviewed, you will be enrolled as a provider of Emergency Department services and will be eligible for billing options as outlined on the form. For inquiries regarding this reimbursement/application process or status, please contact Karen Nall Dunn at (910) 673-7515 or via email at firstname.lastname@example.org.