Interim Process for Submitting Prior Authorization Requests for Beneficiaries Disenrolled to NC Medicaid Direct Providers are encouraged to confirm which PA types are included in this long-term design.
In its Aug. 4, 2021, Medicaid bulletin, Prior Authorizations Covered When a Beneficiary Transitions to NC Medicaid Direct, the Department outlined its intended long-term design to transfer most Standard Plan prior authorizations (PA) to NC Medicaid Direct for impacted beneficiaries. Providers are encouraged to review this Bulletin to confirm which PA types are included in this long-term design.
A Medicaid beneficiary enrolled in a Standard Plan Prepaid Health Plan (PHP) may be later identified as a member of a Medicaid population that is exempt or excluded from Standard Plan enrollment. This will result in a beneficiary’s disenrollment from the PHP and return to NC Medicaid Direct.
A PHP may be currently waiving PA requirements for some or all of its covered services. If a PHP member is moved back to NC Medicaid Direct, the beneficiary may not have a PA transferred for a service that requires an authorization in NC Medicaid Direct. The absence of a PA may result in service disruption upon a beneficiary’s return to NC Medicaid Direct.
Time-Limited Requirement and Related State Flexibility
To ensure beneficiaries and providers do not experience service disruption in the scenario previously outlined, a provider may be required to submit a prior authorization request to the applicable NC Medicaid Direct vendor in order to continue services to the beneficiary.
To support providers through this process, the Department will allow retroactive review of prior authorization requests for beneficiaries who have been moved back to NC Medicaid Direct from a Standard Plan. '
A provider may submit a PA request for a beneficiary up to the last day of the month following the month of the beneficiary’s NC Medicaid Direct effective date (see example below).
The PA request will only be reviewed for the dates of service in which the beneficiary is enrolled in NC Medicaid Direct.
July 1, 2021: A beneficiary transitions to the Standard Plan. The Standard Plan has established time-limited PA flexibilities to support members and providers.
Sept. 1, 2021: The beneficiary is moved back to NC Medicaid Direct due to their excluded status. Due to Plan’s flexibility, there was no PA for the needed service to transfer.
Sept. 15, 2021: The provider doesn’t realize the beneficiary has transitioned to NC Medicaid Direct and needs to submit a PA for dates of service while the beneficiary is in NC Medicaid Direct, back to Sept. 1, 2021. The provider may submit a PA request with an effective date back to Sept. 1, 2021, if otherwise appropriate (and would be authorized to submit for this retro review until Oct. 31, 2021).
This flexibility only applies to beneficiaries who are moved from a Standard Plan back to NC Medicaid Direct.
Additional Guidance to Providers
Other PA review requirements, such as medical necessity review criteria, are not modified by this flexibility.
This flexibility will remain in place until communicated by NC Medicaid with 30 days advance notice.
Providers are reminded to always check the beneficiary’s current eligibility and NC Medicaid Managed Care status in NC Tracks before submitting a PA.
Providers should also review NCTracks to determine if a PA has transferred or is otherwise available. There will be circumstances when the beneficiary's new status renders the current PA irrelevant (e.g. Medicare becomes primary payer). The provider should be aware of how a beneficiary’s status change impacts the applicability of existing PAs.
- For related training, please see the Supporting Members Transitioning to Medicaid Direct provided on NC AHEC’s Virtual Office Hours for Providers Aug. 26, 2021 Session. Materials and recordings are available on the NC AHEC Medicaid Managed Care Website.
- 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 PHP to the applicable PHP. Contact information for each PHP 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.