Confirming Medicaid Coverage for Beneficiaries
Providers and pharmacies should always use NCTracks to confirm eligibility

Providers and pharmacies should always use NCTracks to confirm eligibility.

NC Medicaid has received reports of confusion in the field by providers and pharmacies when members do not present an ID card or when presented with a Medicaid member ID card that differs from the data shown in the NCTracks system. 

To mitigate any confusion associated with newly issued Medicaid Managed Care member ID cards, providers and pharmacies should always use NCTracks Recipient Eligibility Verification/Response to confirm eligibility and not rely solely on the information shown on a Member ID Card. 

Health plans are required to generate an identification card for each Member enrolled in their health plan that contains the Member’s North Carolina Medicaid or NC Health Choice Identification number. Some health plans also include their health plan member ID as well. However, member ID cards are not required to provide service, and this includes pharmacies as well. Therefore, members should not be turned away due to the lack of a Member ID card in their possession.

Follow these steps when an NC Medicaid or NC Health Choice member presents at your office:

  • Verify eligibility, health plan and primary care provider enrollment using the NCTracks Recipient Eligibility Verification/Response or calling the NCTracks Call Center for more information: 800-688-6696
  • Confirm that your office participates with the member’s assigned health plan and obtain the appropriate health plan member ID as needed to file claims.  
  • If you are not the assigned Primary Care Practice for the member but are in-network for the health plan, you can render and be paid for Primary Care Services. 
  • If the member would like to have you as their assigned Primary Care Practice, they should call their health plan to be reassigned to you. 
  • If you are a non-participating provider for the member’s Medicaid health plan, you may still render services. Special protection is afforded to out-of-network providers. If a good-faith contracting effort has been made by the health plan and you declined to participate, then you are subject to receiving 90% of the Medicaid fee-for-service rate. If no good-faith contracting effort has occurred, or if it is in progress, then you are subject to receiving 100% of the Medicaid fee-for-service rate until the contracting effort has been resolved. 

Additionally, the health plan will honor existing and active prior authorizations on file with the North Carolina Medicaid or NC Health Choice program for services covered by the health plan for the first 90 days after launch (until Sept. 29, 2021) or until the end of the authorization period, whichever occurs first. 

  • For the first 60 days after Launch (until Aug. 30, 2021), the health plan will pay claims and authorize services for Medicaid enrolled out-of-network providers equal to that of in-network providers until the end of the episode of care or for 60 days, whichever is less (extended transition periods may apply for circumstances covered in N.C. Gen. Stat. § 58-67-88(d), (e), (f), and (g).). 
  • If a member transitions between health plans after July 1, 2021, a prior authorization authorized by their original health plan will be honored for the life of the authorization by their new health plan.

Additional resources for providers can be found in the NC Medicaid Help Center, the Provider Playbook and on the Medicaid Transformation website. Additional resources for providers can be found in the NC Medicaid Help Center, the Provider Playbook and on the Medicaid Transformation website

For general provider inquiries and complaints regarding health plans, contact the Provider Ombudsman at Medicaid.ProviderOmbudsman@dhhs.nc.gov, or 866-304-7062. The Provider Ombudsman contact information is also published in each health plan’s provider manual. 

For questions related to your NCTracks provider information, please contact the NCTracks Call Center at 800-688-6696. To update your information, please log into the NCTracks provider portal to verify your information and submit a Manage Change Request. For all other questions, please contact the NC Medicaid Contact Center at 888-245-0179.
 

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