NC Medicaid Managed Care Provider Update – June 16, 2021

Key Milestone Dates for NC Medicaid Managed Care

• July 1, 2021 – NC Medicaid Managed Care launch 
• Aug. 1, 2021 – Beneficiaries have 30 days from the effective date of the AMH assignment (regardless of the notification date) to change their AMH/PCP without cause (1st instance) and shall be allowed to change their AMH/PCP without cause up to one time per year thereafter (2nd instance). In addition, Members shall be allowed to change their AMH/PCP with cause at any time. In year one, most beneficiaries will have until Aug. 1, 2021 to change their PCP/AMH for any reason.
• Aug. 30, 2021 – Last date by which the health plan will pay claims and authorize services for Medicaid-enrolled out-of-network providers equal to that of in-network providers (or until end of episode of care, whichever is less) 
• Sept. 29, 2021 – Last date by which the health plan must honor existing and active prior authorizations on file with the North Carolina Medicaid or NC Health Choice program (or until the end of the authorization period, whichever occurs first) 
• Sept. 30, 2021 – End of beneficiary choice period.

Where to Turn for Help

There is an abundance of resources provided by DHHS and the health plans for providers to get help with an issue or for information around a particular question or concern.   

For Providers:

• Check NCTracks for the Beneficiary’s enrollment (Standard Plan or NC Medicaid Direct) and health plan.
  • NCTracks Call Center: 800-688-6696
• Call the health plan for coverage, benefits and payment questions. 
  • AmeriHealth Caritas: 888-738-0004
  • Carolina Complete: 833-522-3876
  • Healthy Blue: 844-594-5072
  • United Healthcare: 800-638-3302
  • WellCare: 866-799-5318
• Contact the provider Ombudsman on unresolved problems or concerns.
  • Provider Ombudsman: 866-304-7062 (NEW NUMBER) or at Medicaid.ProviderOmbudsman@dhhs.nc.gov 

For Beneficiaries: 

• Check their health plan. If they don’t know their health plan, they should contact the Enrollment Broker. 
  • Enrollment Broker: 833-870-5500
• Call their health plan for coverage, benefits and payment questions.
  • WellCare:
    • Phone Number: 866-799-5318
    • Website: www.wellcare.com/nc
  • UnitedHealthcare:
    • Phone Number: 800-349-1855
    • Website: www.uhccommunityplan.com/nc
  • HealthyBlue:
    • Phone Number: 844-594-5070
    • Website: www.healthybluenc.com
  • AmeriHealth Caritas:
    • Phone Number: 855-375-8811
    • Website: www.amerihealthcaritasnc.com
  • Carolina complete Health:
    • Phone Number: 833-552-3876
    • Website: www.carolinacompletehealth.com  
• Contact the member Ombudsman on unresolved problems or concerns
  • NC Medicaid Ombudsman: 877-201-3750 or at info@ncmedicaidombudsman.org

Provider Playbook

DHHS has created a comprehensive list of fact sheets to guide providers through Managed Care go-live in the Provider Playbook as part of its commitment to ensure resources are available to help providers and Medicaid beneficiaries transition smoothly to NC Medicaid Managed Care. Although there are many available, the following fact sheets will be most useful for Managed Care go-live and can be found on the Fact Sheet page:

• What Providers need to know after Managed Care Launch – An overview of key dates, reminders and links to assist providers and their beneficiaries after Managed Care launch on July 1, 2021.
• Combined PHP Quick Reference Guide – A quick reference guide (QRG) designed for providers to use on day one of NC Medicaid Managed Care go-live. This QRG gives providers access to the information they will most frequently use such as contact numbers, email addresses, as well as prior authorizations and claims information for each of the health plans.
• Provider Payment – An overview of the requirements providers and health plans must follow regarding pharmacy claims, payment by electronic fund transfers and appeals to ensure payments are made in a reasonable time frame.
• Transition of Care for beneficiaries receiving long-term services and supports – An overview of how NC Medicaid Managed Care impacts beneficiaries with disabilities and older adults who are receiving Long-Term Services and Supports (LTSS). 
• Panel Management – An overview of how providers can manage their NC Medicaid Direct panels, as well as their panels with each of the health plans. Provides a detailed summary of how to verify member eligibility and enrollment within NCTracks. 
• Advanced Medical Home (AMH) Program – A detailed look at how the Advanced Medical Home (AMH) program will serve as the primary vehicle for delivering local care management as the state transitions to Medicaid Managed Care. 
• Eastern Band of Cherokee Indians (EBCI) Tribal Option – a detailed look at the health care option managed by the Cherokee Indian Hospital Authority (CIHA) to meet the primary care coordination needs of federally-recognized tribal members and others eligible for services through Indian Health Service (IHS). 
• Managed Care Claims Part 1 – An overview of claims guidelines and resources to inform both in-network and out-of-network providers about their claims submission process and their billing guidelines. 
• Managed Care Claims Part 2 – An overview of frequently asked questions regarding providers and PHPs during the claims and submission process.  
• 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.  
• Early Intervention Services in Medicaid Managed Care – An overview of how the transition to Managed Care impacts Medicaid services to infants and toddlers with disabilities and/or developmental delays provided by Children’s Developmental Services Agencies (CDSAs). 

PHP Quick Reference Guides

In addition to the DHHS Combined PHP Quick Reference Guide, 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.

NC Medicaid Managed Care Hot Topics and Virtual Office Hours

The Medicaid webinars and virtual office hours give providers a chance to hear information and guidance on NC Medicaid’s transition to Managed Care. A wide variety of topics have been covered with sessions including an open question and answer period. 

Topics covered: pharmacy and durable medical equipment, behavioral health, transitions of care, specialized therapies, quality measures, network adequacy, provider directory, billing, incentive payments, clinical coverage policy updates, and more. To view recordings, slides and Q&A, visit the AHEC Medicaid Managed Care website at: https://www.ncahec.net/medicaid-managed-care. Below are some of the sessions most helpful for Managed Care launch.

Upcoming Webinar:

June 17, 2021 | Hot Topics with health plan Chief Medical Officers

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 Trending Topics 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 managed change request (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.

Additional information on updating an NCTracks provider record can be found at: https://www.nctracks.nc.gov/content/public/providers/provider-user-guides-and-training/fact-sheets.html. Providers needing additional assistance with updating the information on their NCTracks provider record may contact the NCTracks Contact Center at 800-688-6696.

Help Center for Providers to Find Information

The NC Medicaid Help Center is an online source of information about Managed Care, COVID-19 and Medicaid and behavioral health services, and is also used to view answers to questions from the NC Medicaid Help Center mailbox, webinars and other sources. To use this new tool:

1. Go to NC Medicaid Help Center
2. Type a topic or key words into the search bar
3. Select a topic from the available list of Categories

More information about the NC Medicaid Help Center is available here.

If, after using the NC Medicaid Help Center, the inquiry remains unresolved, use the below table to direct the question appropriately:

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 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 (NEW NUMBER). 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.

The Ombudsman service is separate and apart from the Health Plan 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.