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.
Prior authorizations (PA) for medically necessary contact lenses authorized by the PHP that extend beyond the beneficiary’s transition date will not transfer to NCTracks. Providers must submit a contact lens prior approval request to NCTracks for any contact lens service for a beneficiary who has transferred back to NC Medicaid Direct.
Providers must check NCTracks to confirm a beneficiary’s eligibility and NC Medicaid Managed Care status before dispensing any contact lenses. 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.
Only contact lens services covered under the following NC Medicaid and NC Health Choice Clinical Coverage Policies (CCP) shall be considered for approval in NC Medicaid Direct:
- Policies 6A, Routine Eye Exam and Visual Aids for Beneficiaries Under 21 Years of Age
- 6B, Routine Eye Exam and Visual Aids for Beneficiaries 21 and Older
- A beneficiary under 21 years of age may receive approval for medically necessary services that are not covered in CCP 6A under the EPSDT benefit
Contact Lenses - Dispensed on or before the Beneficiary Disenrolled from a Health Plan
If a beneficiary has disenrolled from a health plan and transitioned to NC Medicaid Direct and the contact lenses were dispensed prior to the transition to NC Medicaid Direct, submit the contact lens claim to the PHP. No contact lens prior approval submission to NCTracks is required.
Contact Lenses on Order or in Office - Not Dispensed
If a beneficiary has disenrolled from a health plan and transitioned to NC Medicaid Direct and the contact lenses have not yet been dispensed, submit a contact lens PA to NCTracks and wait for approval before dispensing the contact lenses.
Contact Lens Claims
Claims for contact lens services that are dispensed without confirmed eligibility and NC Medicaid Managed Care status and prior approval in NCTracks are subject to denial.
Appeals in Effect at Disenrollment
If a beneficiary has an open appeal with the PHP for an initial contact lens service request at the time of the disenrollment, the provider will resubmit the PA request to the appropriate NCTracks.
Program Integrity Considerations
A provider is responsible for ensuring it does not submit duplicate claims for a date of service (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.