Guidance to Pharmacies Supporting Beneficiaries Transitioning to NC Medicaid Direct
Guidance to pharmacies on prior authorizations that transfer from a health plan to NC Medicaid Direct

Guidance to pharmacies on prior authorizations that transfer from a health plan to NC Medicaid Direct.

This bulletin provides guidance to pharmacies on prior authorizations (PAs) that transfer from a Standard Plan Prepaid Health Plan (PHP). Please also review Prior Authorizations Covered When a Beneficiary Transitions to NC Medicaid Direct for additional information.

Background

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. A list of exempted/carved-out populations can be found here. 

Consistent with the Department’s vision to ensure beneficiary continuity of care and minimize provider administrative burden through this transition process, the beneficiary’s PHP will transfer most PAs it authorized that extend beyond the beneficiary’s transition date to NCTracks. For PA types covered in this bulletin, NCTracks will accept this PA and the PA will remain in effect upon the beneficiary’s transition to NC Medicaid Direct.

Mitigation Effort to Minimize Disruption Due to Technical Errors File Transfer

As noted in Prior Authorizations Covered When a Beneficiary Transitions to NC Medicaid Direct.

When a Transferred PHP-Generated PA is in Reject Status

  • A PHP-generated inbound PA that does not yet meet the technical requirements to be accepted into NCTracks will appear as “Rejected” in the Approval PA Inquiry page. 
  • PHPs are required to correct these rejected PAs and resubmit until errors are addressed. 
  • The PHP, NCTracks and State team will be monitoring all rejected records daily to ensure prompt correction.
  • Claims will deny if billing for a service that has a PA in rejected status.
  • Providers are encouraged to monitor the status of applicable PAs closely.

Instructions to Pharmacies

  • If the pharmacy receives a denied claim due to technical issues with the file transfer, please help ensure the Beneficiary does not experience a lapse in medication.
  • As noted above, if a claim is submitted against a PA in Reject Status, the claim will deny with a message that the beneficiary requires a PA. To ensure beneficiary continuity of care, the pharmacy is encouraged to notify the prescriber to resubmit a PA. The prescriber should re-submit a new PA for date of service (DOS) on or after the beneficiary’s transition date to NCTracks.
    • The pharmacy should submit 72-hour emergency fill request using the published guidance:
      • A “3” in the Level of Service field (418-DI) should be used to indicate that the transaction is an emergency fill. 

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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