Try for free

NC Medicaid-3402 EPSDT Non-Covered Services Request

North Carolina Medicaid uses form 3402 to ask for EPSDT coverage of a service, product or procedure that the State Medicaid Plan does not cover, for a recipient under 21. Treating physicians and other licensed clinicians meet it when a child needs something outside standard coverage. The form is an attachment: it must accompany a prior approval request, and it asks how the service will correct or ameliorate the child's condition.

Who completes it

A physician, licensed clinician or other provider completes the whole form: recipient information, requester and provider NPIs, the requested service with CPT or HCPCS code, and the medical necessity questions, then signs with credentials.

Submitting and payment

How to submit it
Upload the form to the prior approval request in NCTracks, or send it with the request by fax or mail; NCTracks prefers online submission. Sent alone, it creates no request and is not processed.

Good to know

  • Describe how the service will correct or ameliorate the condition: improve or maintain health, compensate for a health problem, prevent worsening or prevent additional problems.
  • Answer whether the request is experimental or investigational (with protocol), whether it is safe and effective, and whether cheaper, similarly effective alternatives exist.
  • Attach medical records supporting medical necessity, and include evidence-based literature if available; additional sheets are allowed.
  • Federal definitions of Medicaid services are in 42 CFR 440.1 to 440.170. The current form is dated 1.2019.

Get the official form

Download the current version from the source each time; forms change without notice.

Non-Covered State Medicaid Plan Services Request Form for Recipients under 21 Years Old

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

See how Vero Documents works

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Can I send NC Medicaid-3402 by itself?

No. The form must accompany a prior approval request for EPSDT consideration. NCTracks lists it as an attachment form that does not create a PA request on its own, and the form warns it will not be processed without a prior approval request.

What questions does NC Medicaid-3402 ask the clinician?

It asks how long and in what capacity you have treated the child, health history, recent diagnoses with onset and status, treatments given and the response, how the requested service will correct or ameliorate the condition, safety, effectiveness, cheaper alternatives, and expected duration of treatment.