NC Medicaid Managed Care Provider Update – June 29, 2021
Frequently Asked Questions for NC Medicaid Managed Care

Frequently Asked Questions for NC Medicaid Managed Care

Note: Information under "What member ID should be used when submitting claims?" has been updated for AmeriHealth Caritas as of July 15, 2021.

What is the NC Medicaid Help Center?

The NC Medicaid Help Center is an online source of information about NC Medicaid 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.

How do I find the status of my provider enrollment application? 

To check the status of a provider enrollment application please contact NCTracks at 800-688-6696 or visit the NCTracks secure Provider Portal.

How do I contract with the health plans?

It is the responsibility of the provider to contract with health plans - if providers would like to contract with the NC Managed Care Plans, please use the contact information found at the Health Plans page. Once the contracting process is complete and the health plan has all the required demographic information from the provider, it typically takes at least two to three weeks to load a provider into the health plan's system and begin showing as an in-network provider. A provider can help expedite this process beginning to share physician roster information with the health plans in advance of finalizing their contract. This allows the health plans to begin processing this information and be prepared to enroll a provider most quickly. For more information, visit the Provider Contracting with Health Plans page.  

When will the Advanced Medical Home (AMH)/Primary Care Provider (PCP) enrollee report include patient health plan assignment?

The Enrollee Report offers managed care assignment information for the current month. The June 25, 2021 report contains health plan assignment information for managed care eligible beneficiaries and is a supplement to the earlier June report that had only NC Medicaid Direct members. The combined report will be available in the next July release of the report. Providers can also see health plan assignment at the individual level through the Recipient Eligibility Verification function in NCTracks. In addition, prepaid health plans (PHPs) sent AMH Tier 3 providers or their Clinically Integrated Network partners the beneficiary assignment file which includes their panel assignments. If you are an AMH Tier 3 and a member of a CIN but have not received their report, please contact your CIN as they may have your panel information. For more information, view the Panel Management Fact Sheet on the Provider Playbook Fact Sheet page

What if a member has private insurance and Medicaid? How should I bill?

Medicaid is generally the “payer of last resort”. Any other coverage you have will need to be filed as primary and Medicaid will need to be filed last. If there are claims for dates of service prior to July 1, 2021, claims should be submitted as they are today, through NCTracks or local management entities/managed care organizations (LME/MCOs).

For dates of service beginning July 1, 2021, claims routing depends on a beneficiary's enrollment at time of service and the service provided. Claims for beneficiaries enrolled in NC Medicaid Direct should continue to be submitted to NCTracks. Claims for members enrolled in NC Medicaid Managed Care should be submitted to the assigned health plan as shown on their member ID card and validated through the NCTracks Recipient Eligibility Verification methods outlined below, unless the service provided is a carved-out service.

If you have additional questions, please contact the Local DSS Directory for further assistance. For more information, view the Managed Care Claims and Prior Authorizations Submission: What Providers Need to Know - Part 1 Fact Sheet on the Provider Playbook Fact Sheet page.       

How does a provider bill Standard Plans instead of traditional Medicaid?

NC Medicaid has quick reference guides on the Provider Playbook Fact Sheet page under the Health Plan Resources heading. It contains detailed information about billing for each health plan. Additionally, that information should be included in any contract providers sign with a health plan as well as in their provider manual or through provider portals.  

Will managed care plans require referrals for patients to see a specialist?

NC Medicaid Managed Care is designed for members to access services through a network of providers contracted with their PHP. If a member chooses a PHP based on her primary care provider (i.e. the PCP is in-network for the chosen PHP), but other providers are not in-network, then the member will need to move to specialists who are in-network with her PHP. Note that periods of transition of care will permit a member to continue to see an out-of-network provider for a specific period of time until they transition to an in-network provider. Additional transition of care-specific guidance will become available at:

  • For the first 60 days, referrals for care are not needed, as all Medicaid enrolled providers are able to see patients regardless of being in-network or out of network with the provider.
  • After the first 60 days, referrals for care are only needed when a member is seeing a provider who is not an in-network provider with the PHP, with whom the beneficiary is enrolled.
  • All providers should confirm with the PHP, with whom the beneficiary is enrolled, if the service that they are providing requires PA prior to performing the service. 

Each health plan will have their own processes for how these referrals will be managed – we recommend reviewing the provider manual from your contracted health plan to verify this information. Contact information and links to the health plan provider manuals can be found on the NC Medicaid website at:

What are the prompt payment requirements?

Health plans are responsible for claims processing and timely payments to providers for claims submitted within 180 days of the date of service. Health plans must, within 18 calendar days of receiving the Medical claim, notify the provider whether the claim is clean or request all additional information needed to timely process the claim. If the claim is clean, the health plan must pay or deny within 30 days of receipt.

Health plans will be required to act on additional information that is submitted by a provider within the required timeframe. Health plans that do not pay claims within the required timeframe according to prompt pay requirements will bear interest at the annual rate of 18 percent beginning on the date following the day on which the claim should have been paid or was underpaid. In addition to interest, a health plan shall pay the provider a penalty equal to one percent of the claim per day. Providers do not have to make separate requests to the health plan for interest or penalty payments and are not required to submit another claim to collect the interest and penalty. For more information, view the Prompt Payment Fact Sheet on the Provider Playbook Fact Sheet page.  

What ID is listed on my patient’s ID Card?

Health plans are required to generate an identification card for each Member enrolled in their health plan that contains the Member’s North Carolina Medicaid or NC Health Choice Identification number. Some health plans also include their health plan member ID as well.

What member ID can I use to search for my patients in the health plan portals?

Health plans are required to allow providers to use the Member’s North Carolina Medicaid or NC Health Choice Identification number to search in their health plan provider portals. Some health plans also allow providers to search by their patient’s health plan member ID as well.

What member ID should be used when submitting claims?

This varies by health plan:

AmeriHealth Caritas North Carolina

Providers may submit authorizations and claims with either the NC Medicaid ID, NC Health Choice ID, or the AmeriHealth Caritas NC Member ID.

Carolina Complete Health

Prior authorizations and claims do not require the use of a separate PHP ID, rather a NC Medicaid or NC Health Choice ID.

Healthy Blue (Blue Cross Blue Shield)

For prior authorizations and claims, providers can use either the NC Medicaid or NC Health Choice ID or our system generated Subscriber ID.

WellCare of North Carolina

Providers are able to submit authorizations and claims with either the NC Medicaid or NC Health Choice ID or the WellCare member ID.

United Healthcare Community Plan of North Carolina

Claims expects to receive the PHP ID on the claim submission, but there is member pick logic set in the system to select the appropriate member based on either the NC Medicaid or NC Health Choice ID, or the Name and Date of Birth if the PHP ID is not available.

What if I have questions?

For Additional resources for providers on the transition to managed care can be found in the NC Medicaid Help Center, the Provider Playbook and on the Medicaid Transformation website.    

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) 

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