Prior Authorizations Covered When a Beneficiary Transitions to NC Medicaid Direct

Note: Specialized Therapies was removed from the table "PA Types Within the Scope of this Bulletin" on May 24, 2022. For more information, please see Outpatient Specialized Therapies Prior Authorization (PA) Update.

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 prior authorizations (PA) 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.

Scope

• This bulletin applies to medical, pharmacy and behavioral health PAs for PA types listed below, that are adjudicated by NCTracks and related utilization (UM) vendors.
• Additional instructions for Pharmacy PAs are communicated in Guidance to Pharmacies Supporting Beneficiaries Transitioning to NC Medicaid Direct.   
• While Personal Care Services (PCS) are included in the scope of this bulletin, please also see Personal Care Services Beneficiary Managed Care Disenrollment Process and Updated Referral Form on July 17, 2021 for supplemental guidance on how the PA process will be managed.
• Long-term care PAs are outside the scope of this bulletin. Please see Nursing Facilities Supporting NC Medicaid Only Residents Enrolled in NC Medicaid Managed Care: Prior Authorizations on June 29, 2021, for instruction.
• PAs for Eyeglasses (covered under PA Type A36) are outside the scope of this bulletin and are addressed in Eyeglasses Prior Approval and Dispensing Fee Claims Submission When a Beneficiary Transitions to NC Medicaid Direct. 
• PAs for Medically Necessary Contact Lenses (covered under PA Type A36) are outside the scope of this bulletin and are addressed in Prior Authorizations for Medically Necessary Contact Lenses When a Beneficiary Transitions NC Medicaid Direct.   
• PHPs will submit Behavioral Health PAs managed by an LME/MCO directly to the transitioned beneficiary’s LME/MCO. This process is outside the scope of this bulletin.

Key Points

• This bulletin’s information only applies when a beneficiary is enrolled in a PHP and then transitions to NC Medicaid Direct (fee-for-service).
• This bulletin only covers PAs for services listed below. 
• If a beneficiary was enrolled in a PHP and then transitions to NC Medicaid Direct, the beneficiary’s PHP will transfer prior authorizations that extend beyond the beneficiary’s transition date back to NCTracks. 
• That “transferred PHP-generated PA” will remain in effect for the beneficiary and the applicable provider until the end of the authorization or until otherwise terminated. 

PA Types Within the Scope of this Bulletin

Providers Will Not be Required to Resubmit Applicable PAs to NCTracks

• Providers should check NCTracks to confirm a beneficiary’s eligibility and NC Medicaid Managed Care status before submitting any PA request. 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.
• If a beneficiary has transitioned to NC Medicaid Direct, the provider will not be required to submit a new request for transferred PAs already authorized by the beneficiary’s PHP under the Service Types listed previously, unless instructed to do so by the State.   

Locating the Provider’s Transferred PHP-generated PA in NCTracks

A provider’s approved “transferred PHP-generated PA” will display in the Approval PA Inquiry page of the NCTracks Provider Portal, along with any other active PAs the provider has for that beneficiary.  

Provider May Submit Claims through NCTracks for Transferred PHP-Generated PAs in “Approved” Status

• Once the PHP-generated PA is successfully received into NCTracks, the PHP-generated PA will be reflected as “Approved” in the Approval PA Inquiry page.
• Once this PA is in approved status, the provider may submit claims against this PHP-generated PA through NCTracks for Dates of Service (DOS) the beneficiary is in NC Medicaid Direct, not otherwise covered by non-per diem Diagnostic Related Grouping (DRG) payments.

When a Transferred PHP-Generated PA is in Reject Status

• An approved 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 teams will be monitoring all rejected records on a daily basis to ensure prompt correction.
• A provider’s claims may deny when billing for a service that has a PA in rejected status.
• Providers are strongly encouraged to hold their claims until the PHP PA is not in rejected status. However, the Department will explore the option of reprocessing impacted claims and will communicate any decision to do so in future communications. Providers are encouraged to monitor the status of applicable PAs closely.

New PAs for Beneficiary Disenrolling from NC Medicaid Direct

If a beneficiary who has transitioned from a PHP to NC Medicaid Direct requires a new PA to request or continue services not otherwise covered by the PHP-generated PA after the transition date, the provider will submit the request to NCTracks or the applicable Medicaid Direct UM vendor as usual.

Special Scenarios for Transferring PAs Covered by this Bulletin

If a PHP transfers an authorization for a service that does not require a PA in NC Medicaid Direct.

• In this scenario, the transferred PHP-generated PA will be irrelevant and not required in order for applicable claims to pay. 
• The provider will not be required to resubmit an authorization. 

If a PHP has authorized a service for more units than allowed under the applicable Clinical Coverage Policy.

• NCTracks claim edits will only allow payment up to the limit under the applicable Clinical Coverage policy. 

If a PHP transfers PA for a service not covered under NC Medicaid Direct.

• A beneficiary will not receive this service in NC Medicaid Direct, unless the non-covered service is approved for beneficiaries under the age of 21 under the EPSDT benefit or per the Home Health Final Rule at 42CFR, part 440.70.
• Fee-for-service claims submitted for a service authorized by a PHP but not covered under NC Medicaid Direct will deny, unless the corresponding PA has been authorized under the EPSDT benefit or per the Home Health Final Rule at 42CFR, part 440.70.

Provider appropriately submits a PA request to a beneficiary’s PHP before the beneficiary’s disenrollment date to NC Medicaid Direct. PA determination has not been rendered by disenrollment date.

• A PHP is required to review any PA request that it receives prior to a beneficiary’s disenrollment date.
• If clinically indicated, the PHP will approve the PA request and the PA will transfer the PA to NCTracks. This PA, assuming otherwise allowable under NC Medicaid Direct and this bulletin, will be available in NCTracks. 

If a provider is submitting a retroactive PA for a beneficiary who has recently disenrolled from a PHP to NC Medicaid Direct.

• Unless otherwise managed under an applicable non-per diem DRG reimbursement arrangement, a retroactive PA should be submitted to the entity responsible for the beneficiary during the applicable date of service (DOS). PHPs will only be able to process retroactive requests for DOS for which the beneficiary was enrolled. 
• For example, if a provider needs to submit a retroactive PA request for DOS July 25, 2021 to Jan. 25, 2022, on Aug. 2, 2021, and the beneficiary transitions to NC Medicaid Direct on Aug. 1, 2021, the provider should submit DOS July 25, 2021 to July 31, 2021, to the beneficiary’s PHP and will submit a new PA to the applicable NC Medicaid Direct UM vendor for DOS beginning Aug. 1, 2021. 

Appeals in Effect at Disenrollment

• If a beneficiary has an open appeal with the PHP for an initial service request at the time of the disenrollment, the beneficiary/provider will resubmit the PA request to the appropriate NC Medicaid Direct UM Vendor. 
• If a beneficiary is under Maintenance of Service (MOS) at the time of disenrollment, the beneficiary’s MOS will be in effect upon transitioning back to NC Medicaid Direct.

Program Integrity Considerations

• A provider is responsible for ensuring it does not submit duplicate claims for a DOS authorized by the PHP and now available in NCTracks.    

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.
• The Department will announce additional training opportunities through subsequent provider updates.