Upcoming Key Milestone Dates for NC Medicaid Managed Care
|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 primary care provider (PCP) or Advanced Medical Home (AMH). Beneficiaries shall be allowed to change their AMH/PCP for any reason (without cause) up to one time per year thereafter.|
Provider Playbook Updates
The Provider Playbook is a collection of information and tools specifically designed to assist providers transitioning to NC Medicaid Managed Care.
Request to Move to NC Medicaid Direct Process
While physical health services are the same for all individuals with Medicaid, some services for people with an intellectual/developmental disability (I/DD), mental illness, traumatic brain injury (TBI), or substance use disorder are only available in NC Medicaid Direct and/or through the LME/MCOs.
The Request to Move to NC Medicaid Direct process is used for beneficiaries who have a Managed Care Status of Mandatory, therefore they are enrolled in an NC Managed Care Standard Plan, and need services only available through the NC Medicaid Direct and/or the LME/MCOs. The Request to Move to NC Medicaid Direct (fee-for-service) or LME/MCO: Provider form can be submitted digitally via the website www.ncmedicaidplans.gov or by calling the Enrollment Broker at 833-870-5500 to request a downloadable form version that can be mailed or faxed.
There are two types of submissions: Service Associated Request, and the Non-Service Associated Request.
- Service Associated Requests
- A request that must be submitted by a Provider with the Beneficiary’s consent using the Request to Move to NC Medicaid Direct (Fee for Service) or LME/MCO: Provider Form
- It is required for this request type that a Service Authorization Request (SAR) or Treatment Authorization Request (TAR) and necessary documentation are submitted with the Provider form
- It is required that a Service Authorization Request (SAR) or Treatment Authorization Request (TAR) and necessary documentation are submitted with the Request to Move to NC Medicaid Direct (Fee for Service) or LME-MCO: Provider form
- Non-Service Associated Request
- This request may be submitted by a Provider with the Beneficiary’s consent using the Request to Move to NC Medicaid Direct (Fee for Service) or LME/MCO: Provider Form or by a beneficiary using the Request to Move to NC Medicaid Direct (Fee for Service) or LME/MCO: Beneficiary Form
- Non-service associate requests take five business days to process for Provider forms and eight days for beneficiary forms
- If the Request is approved, the individual is enrolled in NC Medicaid Direct effective the first of the following month
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.
Nov. 30, 2021 is the last day NC Medicaid will require that health plans pay claims and authorize services for Medicaid-enrolled out-of-network providers equal to that of in-network providers. If a contract is not in place by Dec. 1, 2021, and the provider has not engaged in good faith negotiations as defined in the PHP’s Good Faith Contract Policy, Medicaid-enrolled out-of-network providers are at risk for being reimbursed at 90% of the current Medicaid fee-for-service rate and subject to additional prior authorizations. For more information on contracting with the health plan, contact the health plan.
Information for each health plan is available at: https://medicaid.ncdhhs.gov/providers/provider-contracting-health-plans.
Beneficiaries are able to change their assigned PCP/AMH until Nov. 30, 2021 “without cause”. 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.
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 Provider 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 by calling the NC Medicaid Managed Care Provider Ombudsman at 866-304-7062.
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 Provider 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
The latest schedule, registration and information on previous webinars, including the recording, slides, and transcript are available on the AHEC Medicaid Managed Care website.
Tailored Care Management 101 Webinar Series
The Tailored Care Management 101 webinar series was designed to help develop a shared understanding of the model across the North Carolina provider community (including advanced medical homes and behavioral health, I/DD, and TBI providers) and anyone else who is interested.
The webinar series will run from October through mid-December, on Fridays from 12 to 1 PM, and cover various topics.
Upcoming Tailor Care Management 101 Webinars:
Friday, Nov. 5, 2021 | Transitional Care Management and Community Inclusion Activities
Friday, Nov. 19, 2021 | Conflict-Free Care Management and Additional Care Coordination Functions for Members Enrolled in the Innovations or TBI Waiver
Friday, Dec. 3, 2021 | Billing
Friday, Dec. 10, 2021 | Oversight and Quality Measurement/Improvement
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
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:
- Go to NC Medicaid Help Center
- Type a topic or key words into the search bar
- 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.
NCTracks Call Center: 800-688-6696