Prepaid Health Plan Flexibility for Prior Authorizations During First 60 days after Managed Care Launch

Additional information on prior authorization is available.

Note: This bulletin replaces the July 1, 2021 bulletin Hospital Procedure Continuity at NC Medicaid Managed Care Launch.

NCDHHS continued to receive feedback from NC Medicaid providers indicating confusion about prior authorization requirements during the state’s transition to NC Medicaid Managed Care. The Department shared this feedback with the prepaid health plans (PHPs). In response to these concerns, the PHPs will implement the following solution during the first 60 days after managed care launch to ensure beneficiaries continue to have access to services during this transition without unnecessary interruption. 

  1. Between July 1 and Aug. 30, 2021, medically necessary services that normally require prior authorization will still be reimbursed at 100% of the NC Medicaid fee-for-service rate for both in- and out-of-network providers.  To ensure that providers fully understand each PHP’s prior authorization requirements during the transition, the PHPs will still process and pay for these services if:

    • a provider fails to submit prior authorization prior to the service being provided and submits prior authorization after the date of service, or 
    • a provider submits for retroactive prior authorizations. 
      This exception does not apply to concurrent reviews for inpatient hospitalizations which should still occur during this time period.
  2. Beginning Aug. 31, 2021, the PHP may deny payment for services that require prior authorization.  For in-network providers this will apply to those services that normally require prior authorization. Out-of-network providers will need to seek authorizations for all services. 
  3. The Department expects all providers to maintain scheduled medical care for beneficiaries through this transition.
  4. The Department expects the PHPs and providers to continue to work to resolve any outstanding contracting barriers during this time to mitigate out-of-network challenges. 

Additional details about each PHP’s required authorizations are available here:

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