SPECIAL BULLETIN: Provider Data Contractor for Medicaid Managed Care: Guidance for Providers

<p>To minimize the administrative burden on providers as NC Medicaid transitions to managed care, the Provider Data Contractor (PDC) will supplement the state&rsquo;s existing provider credentialing data to the Prepaid Health Plans (PHPs). This will support the PHP&rsquo;s ability to make quality determinations during Medicaid Managed Care provider network contracting activities. The PHPs will make their quality determination policy public once approved by NC Medicaid.</p>

Author: NC Medicaid Provider Contracts, (919) 527-7021

To minimize the administrative burden on providers as NC Medicaid transitions to managed care, the Provider Data Contractor (PDC) will supplement the state’s existing provider credentialing data to the Prepaid Health Plans (PHPs). This will support the PHP’s ability to make quality determinations during Medicaid Managed Care provider network contracting activities. The PHPs will make their quality determination policy public once approved by NC Medicaid.
Wipro Infocrossing, the PDC, will assist the NC Medicaid Managed Care program to identify the credentialing status of providers contracting with PHPs. This streamlined process will facilitate providers enrolling with a PHP.

  • The PDC will be responsible for obtaining the primary source-verified credentialing data for North Carolina Medicaid and NC Health Choice enrolled providers (see FAQ for more information).

o For Individual Providers, the PDC will provide the following:

  1. Education and training (highest level)
  2. Board certification (current board status)
  3. Malpractice history/liability insurance (past 5 years)
  4. Work history (past 5 years)
  5. DEA or CDS certification
  6. Licensure
  7. State licensing board sanctions (past 5 years)
  8. Medicare/Medicaid sanctions (past 5 years)

o For Facility Providers, the PDC will provide the following:

  1. Liability insurance (verification of effective and expiration dates and coverage amounts)
  2. Evidence of accreditation from the Joint Commission or other appropriate accrediting body

o For Facility Providers without accrediting bodies, the PDC may provide the following:

  1. Information on quality management program
  2. Reports on disciplinary action from the last 5 years
  3. Letters of recommendation attesting to quality or cost effectiveness of care
  4. Documented policies for coverage arrangements or onsite quality assessment on quality management program
  • The PDC will not be permitted to update information on the providers’ behalf; this will need to be updated through the methods identified in the FAQ document, on NCTracks, or other sources. Providers are encouraged to keep their credentialing information up to date.
  • To ensure that PHPs have access to information from a credentialing process that is held to consistent, current standards, the credentialing data will be primary source-verified under the standards of NCQA.
  • PHPs will be required to accept verified information from the PDC and will not be permitted to require additional credentialing information from a provider to make their quality determination.

Providers should call the PDC helpdesk at 877-236-3198 or email NCProviderData.HelpDesk@wipro.com to inquire about data provided to the PHPs. Be sure to have your NPI and other identifying information ready when calling, as this is needed to verify your information. Primarily, this will fall into one of the areas below:

  • A dispute on the information that was provided
  • Assistance on correction of data that was provided
  • Assistance on providing data for missing information
  • Verifying that the key identifiers used to obtain information were correct
  • Guiding the provider on how to provide additional or updated information

As noted in a previous article, /documents/files/medicaid-bulletin-2018-10/download, Medicaid providers are encouraged to update their enrollment records in the NCTracks provider portal.
Providers should:

  • Review affiliations by location for accuracy
  • End-date any affiliations that are not current
  • Make sure physical addresses are correct with the accurate taxonomies
  • Review license, certification and accreditation information
  • If necessary, begin the Managed Change Request process to make necessary corrections and updates.

A list of Frequently Asked Questions (FAQs) has been posted at:  https://www.nctracks.nc.gov/content/public/providers/faq-main-page/

For assistance, please reference the NCTracks Provider User Guides and Training, Provider Record Maintenance. Contact the GDIT call center with any questions at 800-688-6696, 855-710-1965 (fax) or NCTracksProvider@nctracks.com.

Detailed information about the design of North Carolina’s implementation of Medicaid Managed Care is available at https://medicaid.ncdhhs.gov/transformation.

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