Key Milestone Dates for NC Medicaid Managed Care
July 1, 2021 |
NC Medicaid Managed Care Launch |
Aug. 1, 2021 |
Last date for most beneficiaries to change their Primary Care Provider (PCP)/Advanced Medical Home (AMH) for any reason |
Aug. 30, 2021 |
Last date by which the health plan will pay claims and authorize services for Medicaid-enrolled out-of-network providers equal to that of in-network providers (or until end of episode of care, whichever is less) |
Sept. 29, 2021 |
Last date by which the health plan must honor existing and active prior authorizations on file with the North Carolina Medicaid or NC Health Choice program (or until the end of the authorization period, whichever occurs first) |
Sept. 30, 2021 |
End of beneficiary choice period |
Provider Playbook Updates
The Provider Playbook is a collection of information and tools specifically designed to assist providers transitioning to NC Medicaid Managed Care. New resources added to the fact sheet page includes:
- Request to Move to NC Medicaid Direct Process – Details the process for beneficiaries currently enrolled in a health plan with NC Medicaid Managed Care who need services only available through NC Medicaid Direct and/or through the LME-MCOs, e.g., intellectual/developmental disability, mental illness, traumatic brain injury or substance use disorder.
Provider Prior Authorizations
If a prior authorization (PA) was previously obtained by your practice for Medicaid members prior to managed care go-live on July 1, 2021, the PA has been sent from the State to your health plan and no further action is needed.
Health plans are receiving PA requests that were previously submitted and approved by NC Medicaid. Please do NOT submit a PA if one was already approved by the State. If a practice wants to verify a health plan has received a PA, please contact the health plan provider relations team directly at:
- AmeriHealth Caritas: Provider Services: 888-738-0004
- Carolina Complete: Provider Services: 833-552-3876
- Healthy Blue: Provider Services: 844-594-5072
- United Healthcare: Provider Services: 800-638-3302
- WellCare: Provider Services: 866-799-5318
For more information about PAs, see the Managed Care Claims and Prior Authorization Submission fact sheets under Programs and Services.
Provider Frequently Asked Questions
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 includes 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 or 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 an 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. |
Provider Contracting Reminders
Although NC Medicaid beneficiaries have transitioned to managed care, providers are reminded that contracting is an ongoing process. Uncontracted providers may begin the process at any time, understanding that health plans need sufficient processing time to complete the process and add the provider to their network.
Through Sept. 30, 2021, beneficiaries can contact the Enrollment Broker to change their health plan for any reason. After Sept. 30, 2021, beneficiaries can change their health plan at the time of their Medicaid recertification. Health plan changes outside of the 90-day choice period (July 1 – Sept. 30, 2021) are allowed “with cause,” and can be requested by contacting the Enrollment Broker and submitting the Health Plan Change Request form.
Beneficiaries are able to change their assigned PCP/AMH for up to 30 days after they receive notice from the health plan of their initial PCP/AMH assignment, which was issued on or before June 12, 2021. After their initial PCP/AMH assignment, beneficiaries can change their PCP/AMH only one time each year or “with cause.” Beneficiaries must contact their assigned health plan to request a change of their PCP.
Newly eligible NC Medicaid beneficiaries required to enroll in a health plan may choose a health plan and/or a PCP/AMH at the time of application. Beneficiaries who do not choose a health plan will be auto-enrolled in a health plan. Beneficiaries will have 90 days from their Medicaid effective date to change their health plan for any reason. Health plan enrollments, whether selected by the beneficiary or through auto-enrollment, will be processed nightly. If the newly eligible beneficiary does not select a primary care provider, the health plan will auto-assign to a PCP/AMH within 24 hours of assignment to the health plan.
See the Member Enrollment fact sheets for more information.
Provider Ombudsman
NC Medicaid offers a Provider Ombudsman to assist providers by receiving and responding to inquiries, concerns and complaints regarding health plans. This service is intended to represent the interests of the provider community, provide supportive resources and assist with issues through resolution.
The Ombudsman will also investigate and address complaints of alleged maladministration or violations of rights against the health plans. Health plans are expected to resolve complaints promptly and furnish a summary of final resolution to NC Medicaid.
Inquiries may be submitted to Medicaid.ProviderOmbudsman@dhhs.nc.gov or the NC Medicaid Managed Care Provider Ombudsman at 866-304-7062 (NEW NUMBER). Responses may also be delivered through email or by phone. The Provider Ombudsman contact information can be found in each health plan’s Provider Manual linked on the Health Plan Contacts and Resources Page.
The Ombudsman service is separate from the Health Plans’ Provider Grievances and Appeals process. Each health plan has a grievance and appeal process for providers, separate from the process for beneficiaries, which can be found in each health plan’s Provider Manual, linked on the Health Plan Contacts and Resources Page.
NC Medicaid Managed Care Hot Topics Webinar Series on the first and third Thursday of the Month - for Medicaid providers and practice managers:
PLEASE NOTE CHANGE: The Medicaid webinars on the first and third Thursday of each month are dedicated to bringing you late-breaking information/guidance on NC Medicaid’s transition to NC Medicaid Managed Care. Based on recent provider feedback, we will have one webinar each month on the third Thursday until March 2022, when we will add back the first Thursday webinar for Behavioral Health and Intellectual/Developmental Disability (I/DD) Tailored Plan launch updates.
Topics will vary, but each session will include an open question and answer period. In addition, so that the NC Medicaid team can address what providers are most concerned about, providers are able to submit questions to the NC Medicaid team when they register for the webinar.
To register to attend, visit the AHEC Medicaid Managed Care website.
Upcoming Webinars:
Thursday, Aug. 19, 2021 | Medicaid Managed Care Hot Topics with Health Plan Chief Medical Officers (CMOs)
Thursday, Sept. 16, 2021 | Medicaid Managed Care Hot Topics with Health Plan CMOs
The latest schedule, registration and information on previous webinars, including the recording, slides, transcript and Q/A are available on the AHEC Medicaid Managed Care website.
Virtual Office Hours
NC Medicaid and NC AHEC are continuing a series of virtual office hours for providers the fourth Thursday of each month. These sessions offer an interactive format to answer provider questions.
Upcoming Virtual Office Hours:
Thursday, Aug. 26, 2021 | Transition of Care
Thursday, Sept. 23, 2021 | TBD
Providers are encouraged to submit questions in advance. Virtual Office Hours will cover a range of NC Medicaid Managed Care topics. For the most up-to-date schedule, visit the AHEC Medicaid Managed Care website.
Ensure Your Information Displays Correctly in NC’s Provider Directory – Medicaid and NC Health Choice Provider and Health Plan Look-Up Tool
Reports are available on the Managed Care Provider Playbook Resources page to assist providers in verifying their records. The Provider Directory Listing Report, as well as the Provider Affiliation Report, is available to ALL actively enrolled Medicaid and NC Health Choice providers. In combination, these reports allow all providers to confirm the information visible to NC Medicaid beneficiaries as each utilize the Medicaid and NC Health Choice Provider and Health Plan Look-up Tool to find participating provider information, and if applicable, enroll in NC Medicaid Managed Care.
- Providers may use the NCTracks MCR process, available in the Secure NCTracks Provider Portal, to modify any provider record or service location information as well as individual to organization affiliations.
- If the Provider Affiliation information is incorrect, the affiliated individual provider or the office administrator for the affiliated individual provider must update the group affiliation.
- Providers unable to find their practice associated with the correct health plans should reach out directly to the health plan to discuss contracting options. If contracting with health plans through a Clinically Integrated Network (CIN), providers should reach out to their CIN to resolve.
Participating providers are contractually obligated to maintain their NCTracks provider record, which serves as the source of truth for managed care entities. It is vital for enrolled providers to use these resources to thoroughly and regularly review their individual and organization provider enrollment information and submit changes as needed using the Manage Change Request process.
More information about this tool is available in a Medicaid Bulletin posted on Sept. 25, 2020.
PHP Quick Reference Guides Created
NC Medicaid’s Managed Care Prepaid Health Plans (PHPs) created quick reference guides to include the most current and comprehensive information for providers.
The PHP quick reference guides are available on the Provider Playbook Fact Sheet webpage under the Health Plan Resources section. Links to the health plan training webpages have also been added on the Provider Playbook Training Courses webpage.
Help Center Available for Providers to Find Information
The NC Medicaid Help Center is an online source of information about 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. To use this new tool:
- Go to NC Medicaid Help Center
- Type a topic or key words into the search bar
- Select a topic from the available list of categories
Detailed information about the NC Medicaid Help Center is available in a Medicaid Bulletin updated on June 17, 2021.
Contact:
NCTracks Call Center: 800-688-6696