NC Medicaid Managed Care Provider Update – April 6

Upcoming Key Milestone Dates for NC Medicaid Managed Care

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 resources are added to the fact sheet page.

Behavioral Health Services Transition to Tailored Plans or Prepaid Inpatient Health Plans (PIHP) in December 2022

With NC Medicaid’s transformation to managed care, DHHS will continue to offer to Medicaid beneficiaries a comprehensive array of behavioral health, intellectual/developmental disability (I/DD) and traumatic brain injury (TBI) services.

In previous guidance, including the Behavioral Health and Intellectual/Development Disability Tailored Plan Final Policy Guidance and Behavioral Health and Intellectual/Development Disability Tailored Plan Request for Applications, NCDHHS released detailed information about the Standard Plan and future Tailored Plan benefit packages. 

DHHS also currently covers a subset of Behavioral Health services under its 1915(b)(3) waiver, which will sunset upon Tailored Plan launch in December 2022. DHHS is seeking authority to cover most of the current 1915(b)(3) services through the 1915(i) authority (Tailored Plans), including services traditionally covered under the fee-for-service Prepaid Inpatient Health Plans (PIHP) - also known as LME-MCO. Information on the 1915(i) services is available in the NC Medicaid Transition of 1915(b)(3) Benefits to 1915(i) Authority white paper.

Behavioral Health and I/DD services for individuals who remain in NC Medicaid Direct after the launch of Tailored Plans will continue to receive those services through the PIHP.

Provider Reverification

As the federal Public Health Emergency (PHE) comes to an end, so does the suspension of reverification for providers enrolled in NC Medicaid. Beginning Summer of 2022, providers will begin receiving reverification notices again. These notices will be sent to providers with approaching reverification due dates, as well as those whose reverification was suspended during the PHE. For more information see Provider Reverification Requirements to be Reinstated.

Taxonomy Reminders

Health plans have identified a trend in claims denials related to the taxonomy used on the claim as well as suspended providers. Providers are reminded:

1. The taxonomy submitted on a claim for billing, rendering and attending providers must be a taxonomy for which the provider is enrolled with NC Medicaid.  
2. Licensing information must remain current to avoid suspension and termination of the taxonomy. Providers receive multiple notifications for expiring credentials and are encouraged to respond quickly to ensure their license is renewed as appropriate and updated on their NC Medicaid provider record.  

Additional information is available in the Taxonomy Enrollment Requirement Reminders for Claim Payment, and the NCTracks Changes to Provider Verification Process bulletins.

IMPORTANT: Verify that Your NCTracks Provider Record is Current

Providers are contractually obligated to maintain their NCTracks provider enrollment information. This includes ensuring that the designated Office Administrator and all email addresses on the provider record remain current so designated personnel may receive and respond to notifications.

Reports are also available on the Managed Care Provider Playbook Resources page to assist providers in verifying information from their records. The Provider Directory Listing Report, as well as the Provider Affiliation Report, is available to display all actively enrolled Medicaid and NC Health Choice providers. In combination, these reports allow all providers to confirm the information transmitted daily to managed care plans as well as made available on the Enrollment Broker and PHP provider directories. 

For assistance with reporting changes through the 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.

NC Medicaid Coverage for Pregnant Beneficiaries Extended to 12 Months

Effective April 1, 2022, NC Medicaid coverage for pregnant beneficiaries will extend to the last day of the month in which the 12-month postpartum period ends. The change is made pursuant to NC Senate Bill 105 Session Law 2021-180 Section 9D.13 and the American Rescue Plan Act of 2021. These laws are in effect through March 31, 2027.

Detailed information about the 12-month postpartum extension is available in a Feb. 22, 2022, Medicaid bulletin.

COVID-19 Vaccine Incentive Program

A fact sheet covering the Vaccine Incentive Program has been posted to the NC Medicaid COVID-19 Guidance and Resources Page. The fact sheet provides a summary of each Standard Plan COVID-19 Member Incentive Program and links to more detailed information on the Standard Plan member incentives. 

Provider Prior Authorizations

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 Ombudsman

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.

The Provider Ombudsman service is separate from the Health Plans’ Provider Grievances and Appeals process and should be used as an escalation after contacting Health Plans and searching the NC Medicaid Help Center (see below). 

Inquiries may be submitted to Medicaid.ProviderOmbudsman@dhhs.nc.gov or by calling the NC Medicaid Managed Care Provider Ombudsman at 866-304-7062. 

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.

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.

Upcoming NC Medicaid Managed Care Webinars

Visit the AHEC Medicaid Managed Care webpage for additional information and registration for upcoming webinars, as well as recordings, slides and transcripts from previous webinars.

Contact

NCTracks Call Center: 800-688-6696