NC Medicaid Managed Care Provider Update – Sept. 15, 2021

Topics include key dates, playbook updates, prior authorization, FAQs, contracting, ombudsman, webinars and more.

Key Milestone Dates for NC Medicaid Managed Care

July 1, 2021

NC Medicaid Managed Care Launch

Sept. 29, 2021

Last date by which the health plan must honor existing and active prior authorizations, for members with a July 1, 2021, Managed Care effective date, on file with the North Carolina Medicaid or NC Health Choice program (or until the end of the authorization period, whichever occurs first)

Sept. 30, 2021

End of beneficiary choice period to change health plan. *Exempt beneficiaries can change their health plan at any time. They can request to be moved to NC Medicaid Direct at any time. *Beneficiaries can change their health plan at any time if they have a special (with cause) reason.

Nov. 30, 2021

Last date by which the health plan will pay claims and authorize services for Medicaid-enrolled out-of-network providers equal to that of in-network providers (or until end of episode of care, whichever is less)

Nov. 30, 2021

End of beneficiary choice period to change PCP. Beneficiaries shall be allowed to change their AMH/PCP for any reason (without cause) up to one time per year thereafter (second change of AMH/PCP).

Provider Playbook Updates

The Provider Playbook is a collection of information and tools specifically designed to assist providers transitioning to NC Medicaid Managed Care. New resources added to the fact sheet page include:

  • Managed Care Claims and Prior Authorizations Submission - Part 2 (Updated) – An overview of frequently asked questions regarding providers and PHPs during the claims and prior authorization submission process. 
  • What Providers Need to Know After Managed Care Launch (Updated) – An overview of key dates, reminders and links to assist providers and their beneficiaries after Managed Care launch on July 1, 2021. 

Provider Prior Authorizations

If a prior authorization (PA) was previously obtained by your practice for Medicaid members prior to managed care go-live on July 1, 2021, the PA has been sent from the State to your health plan and no further action is needed. 

Health plans are receiving PA requests that were previously submitted and approved by NC Medicaid. Please do NOT submit a PA if one was already approved by the State. If a practice wants to verify a health plan has received a PA, please contact the health plan provider relations team directly at:

  • AmeriHealth Caritas: Provider Services: 888-738-0004 
  • Carolina Complete: Provider Services: 833-552-3876 
  • Healthy Blue: Provider Services: 844-594-5072 
  • United Healthcare: Provider Services: 800-638-3302 
  • WellCare: Provider Services: 866-799-5318 

For more information about PAs, see the Managed Care Claims and Prior Authorization Submission fact sheets under Programs and Services.

Provider Frequently Asked Questions

What ID is listed on my patient’s ID Card?

Health plans are required to generate an identification card for each member enrolled in their health plan that includes the member’s North Carolina Medicaid or NC Health Choice Identification number. Some health plans also include their health plan member ID as well.

What member ID can I use to search for my patients in the health plan portals?

Health plans are required to allow providers to use the member’s North Carolina Medicaid or NC Health Choice Identification number to search in their health plan provider portals. Some health plans also allow providers to search by their patient’s health plan member ID as well.

What member ID should be used when submitting claims?

This varies by health plan:

AmeriHealth Caritas North Carolina

 

Providers may submit authorizations and claims with either the NC Medicaid ID or NC Health Choice ID or the AmeriHealth Caritas NC Member ID.

 

Carolina Complete Health

 

Prior authorizations and claims do not require the use of a separate PHP ID, rather an NC Medicaid or NC Health Choice ID.

 

Healthy Blue (Blue Cross Blue Shield)

 

For prior authorizations and claims, providers can use either the NC Medicaid or NC Health Choice ID or our system-generated Subscriber ID.

 

WellCare of North Carolina

 

Providers are able to submit authorizations and claims with either the NC Medicaid or NC Health Choice ID or the WellCare member ID.

 

United Healthcare Community Plan of North Carolina

 

Claims expects to receive the PHP ID on the claim submission, but there is member pick logic set in the system to select the appropriate member based on either the NC Medicaid or NC Health Choice ID, or the Name and Date of Birth if the PHP ID is not available.

 

Provider Contracting Reminders

Although NC Medicaid beneficiaries have transitioned to managed care, providers are reminded that contracting is an ongoing process. Uncontracted providers may begin the process at any time, understanding that health plans need sufficient processing time to complete the process and add the provider to their network. 

Through Sept. 30, 2021, beneficiaries can contact the Enrollment Broker to change their health plan for any reason. After Sept. 30, 2021, beneficiaries can change their health plan at the time of their Medicaid recertification. Health plan changes outside of the 90-day choice period (July 1 – Sept. 30, 2021) are allowed “with cause,” and can be requested by contacting the Enrollment Broker and submitting the Health Plan Change Request form. 

Beneficiaries are able to change their assigned PCP/AMH for up to 30 days after they receive notice from the health plan of their initial PCP/AMH assignment, which was issued on or before June 12, 2021. After their initial PCP/AMH assignment, beneficiaries can change their PCP/AMH only one time each year or “with cause.” Beneficiaries must contact their assigned health plan to request a change of their PCP.

See the Member Enrollment fact sheets for more information.

Provider Ombudsman

NC Medicaid offers a Provider Ombudsman to assist providers by receiving and responding to inquiries, concerns and complaints regarding health plans. This service is intended to represent the interests of the provider community, provide supportive resources and assist with issues through resolution. 

The Ombudsman will also investigate and address complaints of alleged maladministration or violations of rights against the health plans. Health plans are expected to resolve complaints promptly and furnish a summary of final resolution to NC Medicaid. 

Inquiries may be submitted to Medicaid.ProviderOmbudsman@dhhs.nc.gov or the NC Medicaid Managed Care Provider Ombudsman at 866-304-7062 (NEW NUMBER). Responses may also be delivered through email or by phone. The Provider Ombudsman contact information can be found in each health plan’s Provider Manual linked on the Health Plan Contacts and Resources Page.

The Ombudsman service is separate from the Health Plans’ Provider Grievances and Appeals process. Each health plan has a grievance and appeal process for providers, separate from the process for beneficiaries, which can be found in each health plan’s Provider Manual, linked on the Health Plan Contacts and Resources Page.

Upcoming NC Medicaid Managed Care Webinars

Back Porch Chat: Medicaid Managed Care Hot Topics
Thursday, Sept. 16 | 5:30 to 6:30 p.m. Register
Join us for important Medicaid updates at the next Back Porch Chat on Medicaid Managed Care Hot Topics scheduled for Thursday, September 16 from 5:30-6:30 PM. Carrie Brown, MD, MPH Chief Medical Officer for Behavioral Health & Intellectual and Developmental Disabilities, NC Department of Health and Human Services will host the event, which will include Q/A and presentations on:

  • Quick Updates on Hot Topics

    • Hope4Healers
    • Standard Plan Claims & Taxonomy
    • COVID-19
    • Advanced Medical Home (AMH) vs AMH+
  • Medicaid Managed Care & Behavioral Health and Intellectual/Developmental Disability (I/DD) Tailored Plan Overview
  • Tailored Care Management (TCM)
  • Request to Move to TP or NC Medicaid Direct
     

The latest schedule, registration and information on previous webinars, including the recording, slides, and transcript are available on the AHEC Medicaid Managed Care website

Virtual Office Hours

NC Medicaid and NC AHEC are continuing a series of virtual office hours for providers the fourth Thursday of each month. These sessions offer an interactive format to answer provider questions. 

Upcoming Virtual Office Hours:
Thursday, Sept. 23, 2021 | Provider Hot Topics  Register

Providers are encouraged to submit questions in advance. For the most up-to-date schedule, visit the AHEC Medicaid Managed Care webpage.

Ensure Your Information Displays Correctly in NC’s Provider Directory – Medicaid and NC Health Choice Provider and Health Plan Look-Up Tool

Reports are  available on the Managed Care Provider Playbook Resources page to assist providers in verifying their records. The Provider Directory Listing Report, as well as the Provider Affiliation Report, is available to ALL actively enrolled Medicaid and NC Health Choice providers. In combination, these reports allow all providers to confirm the information visible to NC Medicaid beneficiaries as each utilize the Medicaid and NC Health Choice Provider and Health Plan Look-up Tool.

Participating providers are contractually obligated to maintain their NCTracks provider record, which serves as the source of truth for managed care entities. It is vital for enrolled providers to use these resources, as well as the NCTracks Manage Change Request process, to thoroughly and regularly review their individual and organization provider enrollment information and submit changes as needed.

Providers should pay particular attention to the following sections, which commonly contain outdated information:

  • Health Benefit Plan Selection: Confirm that the health plans in which participation is intended are selected (i.e. Medicaid, NC Health Choice).   
  • Service Location Address and Taxonomy Classification:  
    • Add all service locations intended to be displayed in the results of a search in the provider Look-up Tool.  For example, add any missing affiliated organization address as a service location on the individual provider’s NCTracks record to ensure it displays in the Look-up Tool. When entering the service location, match the address character for character, so both the individual and organization’s address is the exactly the same.  
    • Verify that each physical service location address meets USPS standards, is not duplicative of another service location, and that active taxonomies associated with each location are accurate. Select ‘Verify Address’ while in the Addresses section of the Manage Change Request to confirm that the address is found in the USPS database.
  • Accreditation: Update expiring licenses, certifications and accreditations.  
  • Hours of Operation: Confirm that the hours of availability to provide care are accurate.
  • Services: Ensure that the Physically Handicapped and other Special Needs indicators are correct, as well as the Languages Supported in Office, Accepting New Patients, Accepting Siblings, and Gender and Age Served. 
  • Affiliated Provider Information: Confirm that individual providers are correctly affiliated to organizations billing on their behalf and to each appropriate location within that organization. 

For assistance with completing an NCTracks Manage Change Request, providers should reference the NCTracks Provider User Guides and Training tools located at: https://www.nctracks.nc.gov/content/public/providers/provider-user-guides-and-training/fact-sheets.html.

Health Plan Office Hours for Providers

The most up-to-date information on health plan office hours is available on the Provider Playbook Training Courses webpage.

PHP Quick Reference Guides Created

NC Medicaid’s Managed Care Prepaid Health Plans (PHPs) created quick reference guides to include the most current and comprehensive information for providers.

The PHP quick reference guides are available on the Provider Playbook Fact Sheet webpage under the Health Plan Resources section. Links to the health plan training webpages have also been added on the Provider Playbook Training Courses webpage.

Help Center Available for Providers to Find Information

The NC Medicaid Help Center is an online source of information about Managed Care, COVID-19 and Medicaid and behavioral health services, and is also used to view answers to questions from the NC Medicaid Help Center mailbox, webinars and other sources. To use this new tool:

  1. Go to NC Medicaid Help Center
  2. Type a topic or key words into the search bar
  3. Select a topic from the available list of  categories

Detailed information about the NC Medicaid Help Center is available in a Medicaid Bulletin updated on June 17, 2021.

Contact:

NCTracks Call Center: 800-688-6696

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