Eyeglasses Prior Approval and Dispensing Fee Claims Submission When a Beneficiary Transitions to NC Medicaid Direct
Providers must submit ALL eyeglasses prior approval requests for NC Medicaid Direct beneficiaries and health plan members to NCTracks

Providers must submit ALL eyeglasses prior approval requests for NC Medicaid Direct beneficiaries and health plan members to NCTracks.

This bulletin has been replaced by Eyeglasses Prior Approval and Dispensing Fee Claims Submission When a Beneficiary Transitions to NC Medicaid Direct – Aug. 30, 2021.

When a beneficiary enrolled in NC Medicaid Managed Care becomes part of a population exempted or excluded from NC Medicaid Managed Care enrollment, the beneficiary will disenroll from the Standard Plan Prepaid Health Plan (PHP) and transition to NC Medicaid Direct (fee-for-service). A list of exempted/carved out populations can be found here. 

Providers may check NCTracks to confirm a beneficiary’s eligibility and NC Medicaid Managed Care status. If a beneficiary has transitioned to NC Medicaid Direct, the Benefit Plan field in the Provider Portal will display “Medicaid-FFS” and the Managing Entity field will be blank. 

NC Medicaid (NC Medicaid and NC Health Choice) eyeglasses fabrication, frames and lenses are carved out of managed care but the eyeglasses dispensing fee is carved in. Therefore, providers submit ALL eyeglasses prior approval (PA) requests for NC Medicaid Direct beneficiaries and health plan members to NCTracks. 

Obtaining PA for a Health Plan Member

To obtain eyeglasses prior approval for a health plan member, click the OK BUTTON in the lower right-hand corner of the new informational message that appears in the NCTracks Visual Aid Prior Approval Portal that reads:  

NOTICE: This recipient is currently enrolled in a health plan under NC Medicaid Managed Care. Prior Authorizations for services managed by the PHP, must be submitted directly to the PHP. NCTracks will process Medicaid services that remain in fee-for-service (NC Medicaid Direct). NCTracks will process retroactive services up to the recipient’s NC Medicaid Managed Care effective date.  

Your Next Steps

  1. Identify the health plan in which this recipient is enrolled by reviewing the Managing Entity information on the recipient’s record;
  2. Submit retroactive PA requests covering date on or after the recipient enrolled into NC Medicaid Managed Care directly to the recipient's PHP; and
  3. Visit https://medicaid.ncdhhs.gov/providers for links to each PHP's PA submission portal and additional instructions. 

Providers should apply the following guidelines when submitting claims for eyeglasses dispensing fees:

  • If the beneficiary is a health plan member on the date the eyeglasses are dispensed – submit the eyeglasses dispensing fee claim to the PHP or the PHP’s third-party vision vendor (Envolve, EyeMed, or March Vision).
  • If the beneficiary is in NC Medicaid Direct on the date the eyeglasses are dispensed, submit the eyeglasses dispensing fee claim to NC Medicaid Direct.  

Resources

  • Please direct additional questions about NCTracks’ functionality to the NCTracks Call Center: 800-688-6696
  • Please direct additional questions about PAs currently authorized by a beneficiary’s health plan to the applicable health plan. Contact information for each health plan is compiled in the NC Medicaid Managed Care: Day One Provider Quick Reference Guide.
  • Other questions may be directed to the NC Medicaid Contact Center: 888-245-0179.

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