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 NC Medicaid Managed Care
May 21, 2021 – Open Enrollment ended
May 22, 2021 – Auto Enrollment ended for beneficiaries who did not select a health plan
May 22, 2021 (approximate) – Transition of Care information was sent to each health plan for beneficiaries assigned to that health plan
July 1, 2021 – NC Medicaid Managed Care launch
Provider Contracting Reminders
Although the initial contracting milestones previously identified by the NC Department of Health and Human Services (DHHS) have passed, that should not deter uncontracted providers from quickly beginning that process to best ensure participation in a health plan’s network at managed care launch (July 1, 2021).
In order for a provider to be included in a health plan’s network at managed care launch, contracts should be executed with health plans as early as possible. Health plans need sufficient time for signed contracts to be returned and to process those contracts. Typically, health plan processing time is two to three weeks, but may take longer. Providers need to contract with health plans in a timely fashion to avoid losing patients or otherwise disrupting the provider’s Medicaid business.
Beneficiaries who did not choose a health plan before May 21 were auto-enrolled to ensure continuous coverage of Medicaid health services. Once the health plan receives the beneficiary information, the health plan will auto-assign a PCP/AMH to the beneficiary.
Within the first 90 days of Managed Care Launch (through Sept. 30, 2021), beneficiaries can contact the Enrollment Broker to change health plan for any reason. After the 90-day choice period, beneficiaries can change their health plan at their Medicaid recertification date. Health plan changes outside of the 90-day choice period are allowed “with cause,” and can be requested by contacting the Enrollment Broker and submitting the Health Plan Change Request form. Beneficiaries will be able to change their assigned PCP/AMH up to 30 days after they receive notice from the health plan of their initial PCP/AMH assignment, which will be received no later than June 12, 2021. After that, they can change their PCP/AMH only one time each year.
After open enrollment, newly eligible Medicaid beneficiaries who are required to enroll in a health plan may choose a heath plan and/or a PCP/AMH at the time of application. If beneficiaries do not choose a health plan, they will be auto-enrolled in a health plan. Beneficiaries will have 90 days from their Medicaid effective date to change their health plan for any reason. Health plan enrollments, whether selected by the beneficiary or through auto-enrollment, will be processed nightly. If the newly eligible beneficiary does not select a primary care provider, then the health plan will auto-assign to a PCP/AMH within 24 hours.
See the Member Enrollment fact sheets for more information.
Provider Ombudsman
NC Medicaid offers a Provider Ombudsman to assist providers transitioning to NC Medicaid Managed Care by receiving and responding to inquiries, concerns and complaints regarding health plans. This service is intended to represent the interests of the provider community, provide supportive resources and assist with issues through resolution.
The Ombudsman will also investigate and address complaints of alleged maladministration or violations of rights against the health plans. Health plans are expected to resolve complaints promptly and furnish a summary of the final resolution to NC Medicaid. Inquiries may be submitted to Medicaid.ProviderOmbudsman@dhhs.nc.gov or the Medicaid Managed Care Provider Ombudsman at 866-304-7062. Likewise, responses may also be delivered through either email or by phone. The Provider Ombudsman contact information can be found in each health plan’s Provider Manual linked on the Health Plan Contacts and Resources Page.
Additionally, the Ombudsman will assist providers with Health Information Exchange (HIE) inquiries related to NC HealthConnex connectivity compliance and the HIE Hardship Extension process.
The Ombudsman service is separate and apart from the Health Plans Provider Grievances and Appeals process. Each health plan has a grievance and appeal process for providers, separate from the process for beneficiaries, which can be found in each health plan’s Provider Manual, linked on the Health Plan Contacts and Resources Page.
Provider Playbook Updates
The Provider Playbook is a collection of information and tools specifically designed to providers transition to NC Medicaid Managed Care. New resources to the fact sheet page include:
- Provider Directory (Updated) – A detailed look at the Medicaid and NC Health Choice Provider and Health Plan Lookup Tool. The fact sheet enables providers to understand the information contained in the tool, how to ensure accurate information and where to turn for answers to questions.
- Transition of Care for Beneficiaries Receiving Long-term Services and Supports (Updated) – An overview of how NC Medicaid Managed Care impacts beneficiaries with disabilities and older adults who are receiving Long-Term Services and Supports (LTSS).
- What Providers Need to Know After Managed Care Launch (Updated) – An overview of key dates, reminders and links to assist providers and their beneficiaries after Managed Care launch on July 1, 2021.
- Managed Care Claims and Prior Authorizations Submission Part 2 (Updated) – An overview of frequently asked questions regarding providers and PHPs during the claims and submission process.
- Introduction to Medicaid Transformation Part 2: Enrollment and Timelines (Updated) – An overview of the Medicaid transformation and Enrollment along with important dates and information for beneficiaries to be aware of.
- Managed Care Eligibility for Newborns: What Providers Need to Know (Updated) – A detailed look at newborn health coverage through Medicaid. This fact sheet gives providers the information they need to submit payments for newborns, understand newborn eligibility, determine what transition of care may be required and where to turn to for questions.
- Managed Care Populations: Do I Need to Choose a Health Plan? – This fact sheet for beneficiaries outlines who must choose a health plan, who may choose a health plan, and who cannot choose a health plan.
- Panel Management – A detailed look at panel management for providers that delves into panel size, updates, and patient eligibility.
New resources will be added to the Provider Playbook as they become available.
Provider Outreach to Patient Panels
Some providers are encouraging patients to sign up for NC Medicaid Managed Care and listing the health plans they have contracted with to help patients with health plan selection. We welcome this engagement from our providers, but please note that not all Medicaid beneficiaries are moving to managed care. Receiving blanket letters sent to all Medicaid beneficiaries is causing some confusion for beneficiaries who are not required to sign up at this time.
If your practice is conducting outreach, we encourage providers to include the following language in any communication to patients about your contracted health plans and signing up for NC Medicaid Managed Care:
This letter is not an official enrollment notice. Depending on your current eligibility, you may not be required to enroll with a health plan. Please call the Enrollment Broker at 833-870-5500 (TTY: 833-870-5588) for assistance.
See the Member Enrollment Managed Care Populations fact sheet for more information about beneficiary transition requirements.
Webinar Series for Medicaid Providers and Practice Leaders
NC Medicaid Managed Care Hot Topics Webinar Series on the first and third Thursday of the Month:
The Medicaid webinars on the first and third Thursday of the month are dedicated to bringing you late-breaking information/guidance on NC Medicaid’s transition to NC Medicaid Managed Care. Topics will vary, but each session will include an open question and answer period.
Upcoming topics will include: transitions of care, hot topics with health plan chief medical officers (CMOs), transition highs and lows, and more. To register to attend visit the AHEC Medicaid Managed Care webpage.
Upcoming Webinars:
Thursday, June 3, 2021 | Transitions of Care
Thursday, June 17, 2021 | Hot Topics with Health Plan CMOs
Thursday, July 15, 2021 | Managed Care Transition Highs and Lows
The latest schedule, registration and information about previous webinars is available here.
Virtual Office Hours
NC Medicaid and NC AHEC are conducting a series of virtual office hours for providers which began in March 2021. These sessions offer an interactive format for providers to have their questions answered.
Upcoming Virtual Office Hours:
Thursday, June 24, 2021 | Hearing Aid and Auditory Implant Parts
Providers are encouraged to submit questions in advance. Virtual Office Hours will cover a range of NC Medicaid Managed Care topics. For the most up-to-date schedule, visit the AHEC Medicaid Managed Care webpage.
Health Plan Virtual Meet and Greet Sessions
Virtual meet and greet sessions are structured as conversations between providers and health plan staff to address concerns and questions about the transition from Medicaid fee-for-service to NC Medicaid Managed Care. Sessions are delivered live with a recording and transcript made available after each event. No additional sessions are scheduled at this time. Recordings from previous sessions are available on the AHEC Medicaid Managed Care webpage.
Ensure Your Information Displays Correctly in NC’s Provider Directory – Medicaid and NC Health Choice Provider and Health Plan Look-Up Tool
Interim reports are temporarily available on the Managed Care Provider Playbook Resources page to assist providers in verifying their records. The Provider Directory Listing Report, as well as the Provider Affiliation Report, is available to all actively enrolled Medicaid and NC Health Choice providers. In combination, these reports allow all providers to confirm the information visible to NC Medicaid beneficiaries as each utilize the “Medicaid and NC Health Choice Provider and Health Plan Look-up Tool” to find participating provider information, and if applicable, enroll in NC Medicaid Managed Care.
- Providers may use the NCTracks MCR process, available in the Secure NCTracks Provider Portal, to modify any provider record or service location information as well as individual to organization affiliations.
- If the Provider Affiliation information is incorrect, the affiliated individual provider or the Office Administrator for the affiliated individual provider must update the group affiliation.
- Providers unable to find their practice associated with the correct health plans should reach out directly to the health plan to discuss contracting options. If contracting with health plans through a Clinically Integrated Network (CIN), providers should reach out to their CIN to resolve.
As NC Medicaid moves forward with the implementation of NC Medicaid Managed Care, it is important enrolled providers use these resources to thoroughly review their individual and organization provider enrollment information and submit changes as needed using the Manage Change Request process.
More information is available here.
PHP Quick Reference Guides Created
NC Medicaid’s Managed Care Prepaid Health Plans (PHPs) created quick reference guides to include the most current and comprehensive information for providers.
The PHP quick reference guides are available on the Provider Playbook Fact Sheet webpage under the Health Plan Resources section. Links to the Health Plan training webpages have also been added on the Provider Playbook Training Courses webpage.
Help Center Now Available for Providers to Find Information
The NC Medicaid Help Center is an online source of information about NC Medicaid Managed Care, COVID-19, Medicaid and behavioral health services. It is also used to view answers to questions from the NC Medicaid Help Center mailbox, webinars and other sources. To use this new tool:
- Go to NC Medicaid Help Center
- Type a topic or key words into the search bar
- Select a topic from the available list of Categories
More information about the NC Medicaid Help Center is available here.
Tailored Care Management Certification
To continue supporting providers interested in obtaining certification as an Advanced Medical Home Plus (AMH+) practice or Care Management Agency (CMA), the Department extended the Round 1 application deadline from March 1, 2021 to June 1, 2021. More information is available here.