A Medicaid or NC Health Choice beneficiary enrolled in a Prepaid Health Plan (PHP) may be later identified as a member of a Medicaid population that is exempt or excluded from managed care enrollment. This will result in a beneficiary’s disenrollment from the PHP and return to NC Medicaid Direct.
The Department’s long-term design was intended to transfer most managed care prior authorizations (PAs) to NC Medicaid Direct for impacted beneficiaries. However, the Department has identified system and process differences that exist between NC Medicaid Direct and the PHPs, which have resulted in many of the Outpatient Specialized Therapy (OST) PAs transferring to NCTracks with information that is insufficient for use during claim adjudication. Due to the system differences, PHPs will no longer return OST PAs to NCTracks.
Guidance to Providers
Effective July 1, 2022, OST providers must submit a new PA request to the Carolinas Center for Medical Excellence (CCME) when a beneficiary transitions back to NC Medicaid Direct from a PHP. The new PA is required for all beneficiaries returning from NC Medicaid Managed Care regardless of previous CCME or managed care PA status.
To support providers through this process, the Department will allow retroactive review of PA requests for beneficiaries who transition back to NC Medicaid Direct from a PHP.
Retroactive Prior Authorization Request
For beneficiaries who return to NC Medicaid Direct on or after July 1, 2022, retroactive requests must be submitted no later than the last day of the month following the month of the beneficiary’s effective enrollment date in NC Medicaid Direct. The “effective date” is the later of the date coverage begins under NC Medicaid Direct or the date this coverage was issued.
For beneficiaries who returned to NC Medicaid Direct prior to July 1, 2022, and claims were denied in NCTracks for lack of PA, retroactive requests must be submitted no later than Aug. 31, 2022.
Documentation Requirement
For all retroactive PA requests, the PHP PA history must be documented. For beneficiaries who returned to NC Medicaid Direct prior to July 1, 2022, a copy of the PHP-issued PA must also be submitted to CCME if a PA was issued.
Reminder
Providers are reminded to always check the beneficiary’s current Medicaid eligibility and NC Medicaid Managed Care status in NCTracks before submitting a PA or providing services.
Resources
- 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 health plan to the applicable health plan. Contact information for each health plan 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.