Medicaid Managed Care Provider Update

<p>The latest information providers need to know about the transition to Medicaid Managed Care. Update includes the Provider Directory and Health Plan Look-Up Tool, contracting reminders, Provider Playbook updates, upcoming webinars and more.</p>

Please note this bulletin was updated on June 17, 2021, to add the new phone number for the Provider Ombudsman.

Key Dates for Transitioning to Medicaid Managed Care

  • March 15, 2021 – Beneficiary Open Enrollment begins
  • April 12, 2021 – Provider contracting deadline for inclusion in Primary Care Provider (PCP) Auto Enrollment
  • May 14, 2021 – Beneficiary 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

LIVE NOW: NC’s Provider Directory – Medicaid and NC Health Choice Provider and Health Plan Look-Up Tool

The Medicaid and NC Health Choice Provider and Health Plan Lookup Tool is now available at The provider directory contains all active Medicaid and NC Health Choice providers, including primary care providers, specialists, hospitals and organizations.

For more information, please visit NC Provider Directory – Medicaid and NC Health Choice Provider and Health Plan Look Up Tool Now Available.

In addition to the Lookup Tool, interim reports are available on the Managed Care Provider Playbook Resources page to assist providers in verifying their records. These reports, the Provider Directory Listing Report and the Provider Affiliation Report, are updated every two weeks with information about all actively enrolled Medicaid and NC Health Choice providers.   

Enrolled providers should utilize these resources now to thoroughly review and confirm the accuracy of their individual and organization provider information as well as their accepted health plans, and to submit changes prior to the Beneficiary Open Enrollment period. More information is available here.

Provider Contracting Reminders

In order to be included in the Medicaid and NC Health Choice Provider and Health Plan Look-up Tool, as well as the health plan provider directories used by beneficiaries as open enrollment begins (March 15, 2021), the Department recommended providers submit signed contracts to health plans by Feb. 1, 2021; of course, providers can still negotiate and execute contracts with health plans even after this date. In order for a provider’s information to be used in auto-enrollment (May 16, 2021), the Department recommends contracts be signed and submitted to health plans by April 12, 2021.

This allows sufficient time for signed contracts to be returned to the provider and for the health plan to process those contracts. Providers should contract with health plans in a timely fashion to avoid losing patients when health plans assign beneficiaries to in-network providers. More information is available here.

Provider Playbook Updates

The Department of Health and Human Services (DHHS) recently re-launched the online “Provider Playbook” as part of its commitment to ensure providers have resources to help Medicaid beneficiaries transition smoothly to Medicaid Managed Care. The Provider Playbook is a collection of information and tools specifically tailored to providers. New resources to the Readiness page include:

  • Member Enrollment Part 1 - Health Plan Auto-Enrollment Overview of health plan auto enrollment including information on how beneficiaries can select and change their health plan.
  • Member Enrollment: Part 2 - Primary Care Provider (PCP)/Advanced Medical Home (AMH) Auto-Assignment How the PCP/AMH auto assignment will work and how beneficiaries will experience this process. This includes information on how providers can verify auto assignment information, how providers can help educate their patients, and who to contact if you have questions.
  • Managed Care Eligibility for Newborns - A detailed look at the eligibility requirements for newborns and how this process will work as the Department transitions to Managed Care.

New resources will be added to the Provider Playbook as they become available.

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) have partnered to host a series of webinars on the first and third Thursdays of each month to increase engagement with providers, practice managers and quality managers. Upcoming webinars are shown below. The latest schedule, registration and information about previous webinars is available here.

Upcoming Medicaid Managed Care Fireside Chat Webinar Series

  • Thursday, March 4, 2021 | Policy Approvals, Process Changes, and Appeals
  • Thursday, April 1, 2021 | Value Based Payment/Advanced Payment Models

Upcoming Clinical Quality Webinar Series

  • Thursday, Feb. 18, 2021 | COVID 19 Vaccine Administration

Upcoming Clinical Quality Webinar Series

  • Thursday, Feb. 11, 2021 | AMH Glide Path
  • Thursday, March 11, 2021 | Know your population: Data, Empanelment, Quality Measures
  • Thursday, April 8, 2021 | Care Management (Resources, CMARC/CMHRP, NCCARE360)

Additional Practice Support

Additionally, during the months of January 2021 – June 2021 AHEC will host health plan and EBCI Tribal Option Provider Meet-N-Greets, Webinars, and Virtual Office Hours sessions on behalf of NC Medicaid Provider Operations with a focus on Medicaid Managed Care readiness. More details to come.

Provider Ombudsman

The NC Medicaid Provider Ombudsman represents the interests of the provider community by offering supportive resources and assistance in resolution of provider inquiries, concerns, and complaints regarding health plans.

Separate from the health plan’s Provider Grievance and Appeals process in which health plans are expected to resolve complaints and provide a summary of final resolution to NC Medicaid, the Provider Ombudsman will investigate and address complaints of alleged maladministration or violations of rights against the health plans when problems persist after following the health plan’s process.

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

Inquiries may be submitted by:

The Provider Ombudsman contact information, as well as the health plan’s Provider Grievance and Appeal Process, can also be found in each health plan’s Provider Manual linked on the Health Plan Contacts and Resources Page.

Tailored Care Management Certification

Providers must be certified as an Advanced Medical Home Plus (AMH+) practice or Care Management Agency (CMA) to perform Tailored Care Management for Members of Behavior Health Intellectual/Developmental Disability (I/DD) Tailored Plans.  

Behavioral Health I/DD Tailored Plans will launch in July 2022 and will serve Medicaid beneficiaries with serious mental illnesses, serious emotional disturbances, severe substance use disorders, intellectual or developmental disabilities, or traumatic brain injuries (TBI).

DHHS is accepting applications now from existing AMH Tier 3 practices, as well as from Behavioral Health, IDD, or TBI providers who wish to be considered for approval as an AMH+ or CMA to provide this new health home care management function starting in July 2022. The certification process will take place in three rounds. Applications for the first round of certification will be due on March 1, 2021. More information is available here.

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