Upcoming Key Milestone Dates for NC Medicaid Managed Care
| Dec. 1, 2022 | NC Medicaid Behavioral Health and Intellectual/Developmental Disability (I/DD) Tailored Plans launch. |
Provider Playbook Updates
The Provider Playbook is a collection of information and tools specifically designed to assist providers transitioning to NC Medicaid Managed Care.
The latest resource added under the Quick links heading is National Committee for Quality Assurance Kidney Health Toolkit.
The National Committee for Quality Assurance (NCQA) has developed a Kidney Health Toolkit to help patients and provider care teams navigate Chronic Kidney Disease (CKD) diagnosis monitoring and management, which is related to conditions including diabetes and cardiovascular disease.
NC Medicaid Direct vs. Traditional Medicaid
The Department and Enrollment Broker have received numerous inquiries from NC Medicaid Direct beneficiaries being denied services, stating the provider does not accept NC Medicaid Direct. Please remember that NC Medicaid Direct is a new name for the traditional fee-for-service Medicaid program.
Approximately 700,000 beneficiaries remain in NC Medicaid Direct. Services rendered to beneficiaries in the NC Medicaid Direct program are billed through NCTracks using the same rules and processes known to providers prior to NC Medicaid Managed Care launch. For more information, see the Medicaid Transformation Fact Sheets.
Fabrication of Eyeglasses
The fabrication of eyeglasses, including complete eyeglasses, lenses and frames, is carved out of managed care, but the dispensing for these glasses is carved into managed care. What does this mean for providers who render eyeglasses services to managed care members?
- Providers obtain prior approval for all Medicaid and NC Health Choice eyeglasses through NCTracks regardless of NC Medicaid Direct or managed care health plan enrollment
- The eyeglasses will be fabricated by Nash Optical Plant and shipped to the provider’s office
- The State pays Nash Optical Plant for the frames, lenses, and eyeglasses fabrication
- This is the part of the eyeglasses process that is carved out of managed care, making the State responsible for prior approval and claims payment
- After the eyeglasses are dispensed to the beneficiary/member, the provider will submit the eyeglasses dispensing fee claim to the managed care health plan that the member is enrolled with at the time the eyeglasses are dispensed
- Medicaid beneficiaries ages 0 through 20, are eligible for eyeglasses once every 365 days (every year)
- NC Health Choice beneficiaries ages 6 through 18 are eligible for eyeglasses once every 365 days (every year)
- Beneficiaries 21 years of age and older are eligible for eyeglasses once every 740 days (every two years)
- Providers may submit prior approval requests for medically necessary replacement eyeglasses and Rx or frame change.
In summary, providers obtain all Medicaid and NC Health Choice eyeglasses through NCTracks and from Nash Optical Plant. The only step in the process that has changed is that the provider submits the dispensing fee claim to the entity with which the beneficiary/member is enrolled (NC Medicaid Direct or a managed care health plan).
Managed Care Eligibility for Newborn Policy: Parity for Out-of-Network Providers
As established in the NC Medicaid Fact Sheet, “Managed Care Eligibility for Newborns: What Providers Need to Know,” Standard Plans will treat all out-of-network (OON) providers the same as in-network providers for purposes of prior authorization and will pay OON providers the fee-for-service rate for services rendered through the earlier of:
- 90 days from the Newborn’s birth or
- The date the health plan is engaged* and has transitioned the child to an in-network PCP or other provider.
*In the above, “engaged” means that the PHP has assigned the newborn to an in-network PCP and the newborn has visited that in-network PCP. Once the newborn visits their in-network PCP, this provision would end, even if that visit occurs prior to 90 days from the newborn’s birth date.
This provision covers all medically necessary care provided by any health care provider, not just primary care providers, which includes hospitals and/or facilities. When a child is enrolled in a health plan, that health plan will be visible to providers when they confirm the child’s eligibility. Providers should bill the health plan the child is enrolled in, regardless of whether they are in-network or out-of-network. Providers can bill all health plans regardless of contracting status during the first 90 days of a newborn’s life or the date the health plan engaged, whichever is earlier. Providers should know they may initially get a denial, but most health plans have an extenuating circumstances review that will allow payment. Providers should work with health plans to ensure payment.
For additional information please refer to the NC Medicaid Fact Sheet, “Ensuring Continuity of Care for Medicaid Beneficiaries: Protections for Pregnant Women and Newborns.”
“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 currently only available in the NC Medicaid Direct program and/or through the LME/MCOs.
The Request to Move to NC Medicaid Direct process may be used for beneficiaries who have a Managed Care Status of Mandatory and are therefore enrolled in a NC Managed Care Standard Plan, but 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
- This request is used for a beneficiary that develops behavioral health, substance use disorder, I/DD or TBI support needs not available in the Standard Plans
- Request 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 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
- Service associated requests are sent to the LME/MCO within 24 hours for review, and if approved, the individual is moved within one business day retroactively to the date of the request.
- Non-Service Associated Request
- This request may be submitted by a provider with the beneficiary’s consent, or by the beneficiary using the appropriate applicable 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
* A webinar on the “Request to Move to NC Medicaid Direct” process was presented on Sept. 16, 2021. The slides and recording can be found here.
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 was sent from the State to the appropriate health plan.
Health plans were required to honor existing and active prior authorizations on file until Oct. 1, 2021, or until the end of the authorization period, whichever occurred first to ensure continuity of care. If a provider needs to verify the status of a PA request, 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 Question
What member ID should be used for PA requests or 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 require the use of 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. |
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 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.
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
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 to 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.
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.
Contact
NCTracks Call Center: 800-688-6696