Note: This bulletin has been replaced by Prepaid Health Plan Flexibility for Prior Authorizations During First 60 days after Managed Care Launch
published on July 7, 2021.
NC Medicaid wants to ensure that during the transition to NC Medicaid Managed Care that Medicaid beneficiaries receive the care they need as scheduled prior to July 1. This includes confirming that procedures for care scheduled prior to July 1 continue without interruption.
The Department and the health plans want to give providers the information they need to provide care to beneficiaries and receive reimbursement for the care that is provided. To support this effort, the Department is compiling the following information for hospitals/facilities and providers to make sure that they have the information to maintain their scheduled procedures.
It is critical for hospitals and health systems to share this information broadly and to include their care teams at all levels of the organization, including outpatient facilities and clinics, schedulers, phone centers and individual departments.
The health plans provide information on how they are handling prior authorizations on their website and Quick Reference Guides. Please see the below links and bullets on how you can find out more information. Additionally, hospitals/facilities can access the NC Medicaid Managed Care Provider Playbook for the latest information, tools and other resources to help with the transition to managed care.
- AmeriHealth Caritas North Carolina: To allow providers time to learn prior authorization processes and to avoid disruption of care for members, AmeriHealth Caritas North Carolina will temporarily allow retroactive submission of prior authorizations during the first 60 days following managed care launch.
- Quick Reference Guide: https://www.amerihealthcaritasnc.com/assets/pdf/provider/provider-reference-guide.pdf
- Carolina Complete Health: Carolina Complete Health has built in flexibilities to limit the negative impact of a missed authorization in first 60 days. Amongst those flexibilities will include waiving prior authorization for covered dental anesthesia procedures for at least the first 60 days.
- More information is provided on their prior authorization website: https://network.carolinacompletehealth.com/resources/prior-authorization.html
- Quick Reference Guide: https://network.carolinacompletehealth.com/content/dam/centene/carolinacompletehealth/pdfs/CCHN-Current-PDF-QRG-Form.pdf
- Healthy Blue: Healthy Blue’s policy with out of network providers is to require prior authorization for all services both in situations where the provider requesting the authorization is out of network and for in network providers when they are referring to an out of network provider when not part of a transition of care situation. Transition of care would apply to authorizations and episodes of care that predate the enrollment of the Member with the health plan and go through the end of the authorization, episode of care, or 60 days, whichever is less. Healthy Blue recognizes that there will be a period of time where Member access to care is pivotal and for that reason will offer forbearance on claim denials because of no authorization for a period of time. That period of time is fluid and will be based on the needs of our Members, not any one out of network provider.
- Information can be found on their website: https://provider.healthybluenc.com/north-carolina-provider/prior-authorization
- Quick Reference Guide: https://provider.healthybluenc.com/docs/gpp/NC_CAID_QuickReferenceGuide.pdf
- United Health Care: United Health Care is committed to supporting providers during the transition to Medicaid Managed Care and will provide flexibilities in the first 30 days for services that require prior authorization. To simplify the prior authorization process, providers utilizing the Provider Portal will be able to receive real-time authorization for certain services and procedures.
- Quick Reference Guide: https://www.uhcprovider.com/content/dam/provider/docs/public/commplan/nc/training/NC-Medicaid-QRG.pdf
- Additional information can be found on their website: https://www.uhcprovider.com/content/provider/en/prior-auth-advance-notification.html
- WellCare: WellCare is waiving many prior authorizations for the first 90 days.
- This notice and additional specific information for providers regarding which prior authorizations are waived can be found on their Transition of Care Authorization website: https://www.wellcare.com/North-Carolina/Providers/Bulletins/Transition-of-Care-Authorization-Info
- Quick Reference Guide: https://www.wellcare.com/North-Carolina/Providers/Medicaid
To further guarantee that providers and hospitals have confidence in their ability to receive payment for services rendered, the Department will monitor authorization and claims data from the health plans to verify that they are following the above described prior authorization waivers.
We remain committed to working with our provider and health plan partners to verify services are paid for without undue burden to our beneficiaries during this transition. If providers experience issues during this transition period, they can reach out to the Medicaid Provider Ombudsman at Medicaid.ProviderOmbudsman@dhhs.nc.gov or 919-527-6666.
- AmeriHealth Caritas:
- Provider Portal: https://navinet.navimedix.com
- Provider Services: 888-738-0004
- Carolina Complete Health:
- Provider Portal: https://network.carolinacompletehealth.com
- Provider Services: 833-552-3876
- Healthy Blue:
- United Healthcare:
- Provider Portal: https://www.uhcprovider.com
- Provider Services: 800-638-3302
- Provider Portal: https://provider.wellcare.com
- Provider Services: 866-799-5318