Medicaid Managed Care Provider Update

<p>Key dates, webinar series, Provider Directory tool, Provider Ombudsman and PHP manuals updated.</p>

On July 1, 2021, an estimated 1.6 to 1.8 million Medicaid and NC Health Choice beneficiaries will transition to Medicaid Managed Care. Beneficiaries will be able to choose from five Prepaid Health Plans (PHPs) or the Eastern Band of Cherokee Indians (EBCI) Tribal Option. Some beneficiaries will stay in fee-for-service known as NC Medicaid Direct.

Key Dates for Transitioning to Medicaid Managed Care

March 15, 2021 – Open Enrollment begins
May 14, 2021 – Open Enrollment ends
May 15, 2021 – Auto Enrollment for beneficiaries who have not selected a health plan
May 22, 2021 (approximate) – Transition of Care information is sent to each health plan for beneficiaries assigned to that health plan
July 1, 2021 – Medicaid Managed Care launch

Webinar Series for Medicaid Providers and Practice Leaders

The North Carolina Department of Health and Human Services (NCDHHS) and North Carolina Area Health Education Centers (AHEC) are offering two monthly evening webinar series to increase engagement with providers, practice managers and quality managers. One series is specifically focused on the transition to Medicaid Managed Care, and the second is focused on Quality and Performance on clinical criteria. More information is available here.

Ensure Your Information Displays Correctly in NC’s Provider Directory Tool – Medicaid and NC Health Choice Provider and Health Plan Look-Up

As NC Medicaid moves forward with the implementation of Medicaid Managed Care, it is important for enrolled providers to act now to thoroughly review their individual and organization provider enrollment record in NCTracks. Take the time now to review your provider records in NCTracks, now, and submit changes.

Not only is ensuring accuracy a requirement in the legal and binding NCDHHS Provider Administrative Participation Agreement, but correct information on the NCTracks provider record will assist beneficiaries with the search for primary care providers in the new Medicaid and NC Health Choice Provider and Health Plan Look-Up tool. 

Every page of the NCTracks provider record should be assessed for accuracy. More information is available here.

Provider Ombudsman

As part of NC Medicaid’s continued move forward with the implementation of Medicaid Managed Care, the Division of Health Benefits (DHB) has created a Provider Ombudsman who will represent the interests of the provider community by receiving and responding to inquiries and complaints regarding PHPs. The Ombudsman will provide resources and assist providers with issues through resolution.

Additionally, the Ombudsman will assist providers with Health Information Exchange (HIE) inquires related to NC HealthConnex connectivity compliance and the HIE Hardship Extension process.

Provider Ombudsman inquiries, concerns or complaints can be directed to the email distribution listserv address, or providers may utilize the Medicaid Manage Care Provider Ombudsman line at 919-527-6666. The Provider Ombudsman contact information will also be published in each PHP provider manual.

PHP Provider Manuals Updated

NC Medicaid’s Managed Care PHPs have finalized and the Department has approved all 5 PHP provider manuals to include the most current and comprehensive information for providers. Each manual covers, in part: 

  • Clinical practice standards and utilization management programs;
  • Covered services, additional benefits and carved-out services (services that will remain fee for service, or Medicaid Direct;
  • Provider responsibilities;
  • Primary care provider responsibilities;
  • Network requirements, including nondiscrimination, on-call coverage, credentialing, re-credentialing, access requirements, no-reject requirements, notification of changes in address, licensure requirements, insurance requirements, and required availability;
  • Telemedicine guidelines;
  • Network adequacy and access standards;
  • Billing, claim editing, Strategic National Implementation Process (SNIP) editing and clearinghouse requirements;
  • Cultural competency and accessibility requirements;
  • Authorization, utilization review and care management requirements;
  • Care coordination and discharge planning requirements;
  • Department-required documentation requirements;
  • Provider appeals and grievance processes;
  • Complaint or grievance investigation and resolution procedures;
  • Notification of the availability of the NCDHHS’s Provider Ombudsman where a provider may submit a complaint about a PHP. The manual shall include instructions on how to submit the complaint;
  • Performance improvement procedures including member satisfaction surveys, clinical studies, incident reporting, and outcomes requirements;
  • Compensation and claims processing requirements, including required electronic formats, mandated timelines, transition of care obligations, and coordination of benefits requirements;
  • Interest and penalty provisions for late or under-payment by the PHP;
  • NC Medicaid payer of last resort requirements;
  • Member rights and responsibilities;
  • Member cost sharing requirements; and
  • Provider program integrity requirements that address how to report suspected fraud, waste and abuse, and other federal and state requirements. 

The PHP provider manual must also include the provider’s obligations to:

  • Monitor and audit the provider’s own activities to ensure compliance and prevent and detect fraud, waste and abuse;
  • Monitor and report on provider preventable conditions;
  • Retain patient records for the mandated period;
  • Ensure that all documentation regarding services provided is timely, accurate, and complete;
  • Ensure PHP is the payer of last resort; and
  • To report and promptly return overpayments within sixty (60) days of identifying the overpayment.

PHPs are contractually obligated to maintain the content of the manual to offer providers the tools and resources necessary for the delivery of quality care and services to Medicaid and NC Health Choice beneficiaries. Likewise, providers must use the manual for each contracted PHP as a means of remaining current on PHP policies which will reflect any changes in state and federal regulations. 

The Department-approved PHP provider manuals are available on the Medicaid Health Plan Contacts and Resources webpage

Each update will illustrate what has changed from the previous version. Manuals will be updated annually on July 1. Quarterly updates will be made for time sensitive changes.
Stay tuned to the Medicaid Bulletin for additional updates on Medicaid Managed Care. 


NC Medicaid Contact Center, 888-245-0179

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