Eyeglasses Prior Approval and Dispensing Fee Claims Submission When a Beneficiary Transitions to NC Medicaid Direct – Aug. 30, 2021

This replaces the bulletin, published on Aug. 4, 2021

This replaces the bulletin, published on Aug. 4, 2021: Eyeglasses Prior Approval and Dispensing Fee Claims Submission When a Beneficiary Transitions to NC Medicaid Direct.

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. 

Providers may check NCTracks to confirm a beneficiary’s eligibility and NC Medicaid Managed Care status. 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. 

NC Medicaid (NC Medicaid and NC Health Choice) eyeglasses fabrication, frames and lenses are carved out of NC Medicaid Managed Care, but the eyeglasses dispensing fee is carved in. Therefore, providers submit ALL eyeglasses prior approval (PA) requests for NC Medicaid Direct beneficiaries and PHP members to NCTracks. 

Obtaining an Eyeglasses PA for a PHP Member

To obtain eyeglasses prior approval for a health plan member, click the “OK” button in the lower right-hand corner of the new informational message that appears in the NCTracks Visual Aid Prior Approval Portal that reads:  

NOTICE: This recipient is currently enrolled in a health plan under NC Medicaid Managed Care. Prior Authorizations for services managed by the PHP, must be submitted directly to the PHP. NCTracks will process Medicaid services that remain in fee-for-service (NC Medicaid Direct). NCTracks will process retroactive services up to the recipient’s NC Medicaid Managed Care effective date.  

Clicking on the “OK” button will move the provider forward to the familiar eyeglasses PA entry portal.

Provider’s Next Steps When a Beneficiary Transitions to NC Medicaid Direct

  1. If the provider obtained eyeglasses PA in NCTracks before the member transitioned from the PHP back to NC Medicaid Direct, the provider does not need to submit a new or retroactive eyeglasses PA.
  2. If the beneficiary is a PHP member on the date the eyeglasses are dispensed – submit the eyeglasses dispensing fee claim to the PHP or their third-party vision vendor (Envolve, EyeMed, or March Vision).
  3. If the beneficiary is in NC Medicaid Direct on the date the eyeglasses are dispensed, submit the eyeglasses dispensing fee claim to NC Medicaid Direct through NCTracks. Again, the provider does not need to submit a new or retroactive eyeglasses PA when PA was already obtained in NCTracks prior to the beneficiary transitioning back to NC Medicaid Direct.   

Resources

  • Please direct additional questions about NCTracks 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. All Plan information is compiled in the NC Medicaid Managed Care: Day One Provider Quick Reference Guide.
  • Other questions may be directed to NC Medicaid Contact Center: 888-245-0179.
     

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