This bulletin replaces the bulletin posted on May 24, 2022 regarding prior authorizations. Updates were made to provider notifications in the Scope (third bullet) and the NOTE at the end of the bulletin regarding PA requests.
When a beneficiary enrolled in Medicaid Direct transitions to NC Medicaid Managed Care, NC Medicaid will transfer authorized prior authorizations (PA) that extend beyond the beneficiary’s transition date, to the appropriate Prepaid Health Plan (PHP). This allows the beneficiary to continue services using the same PA while in Managed Care.
If an individual disenrolls from NC Medicaid Managed Care and returns to Medicaid Direct, the PHP will transfer most authorized PAs that extend beyond the beneficiary’s transition date to NCTracks. See Notes below for exceptions to this process.
Effective June 26, 2022, Medicaid Direct PA effective begin and end dates will be modified to align with the individual’s eligibility segment. This change is necessary to avoid PA duplication caused by re-ingesting PA records into NCTracks for beneficiaries returning to Medicaid Direct.
Scope
- After sending a PA to the PHP, NCTracks will end date PAs for beneficiaries moving from Medicaid Direct to Managed Care. The end date will align with the last day of the beneficiary’s enrollment in Medicaid Direct.
- The PA in NCTracks will be updated to a Terminated status. This PA remains useable for dates of service aligning with dates the beneficiary was in Medicaid Direct.
- A notification will be issued to the billing provider associated with the end-dated PA via the provider message center. Because billing provider information on PHP pharmacy PAs is optional, provider notification will only be issued for PHP generated Pharmacy PAs with modified end dates that include the billing provider information.
- The effective begin date on approved PAs received from the PHP for beneficiaries transitioning from Managed Care to Medicaid Direct will be modified to align with the beneficiary’s first day of Medicaid Direct enrollment.
- NCTracks plans a one-time clean-up of PAs for beneficiaries who have previously transitioned to Managed Care. This is expected to generate higher than normal notifications to the billing provider’s message center.
Provider Next Steps
If a provider receives a notification in the provider message center, the recommended next steps include:
- Identify the PHP in which this beneficiary is enrolled by reviewing the Managing Entity information on the beneficiary’s record.
- Verify the PHP has received previously issued Medicaid Direct PAs and that there are remaining units/visit of service available. If no current PA is available, then the provider should submit new authorizations for Managed Care covered services to the beneficiary’s identified PHP.
- Submit claims for dates of service that align with the beneficiary’s eligibility in Managed Care to the beneficiary’s identified PHP; submit claims for dates of service that align with the beneficiary’s eligibility in Medicaid Direct to NCTracks.
NOTE: PA Types that do not transfer back to NCTracks include Outpatient Specialized Therapies (PA Type A45), PAs for contact lenses and Long-Term Care (PA Type A11 and A12). Providers are advised to submit a new PA request to the Carolinas Center for Medical Excellence (CCME) for Outpatient Specialized Therapies, and to NCTracks for Long-Term Care and contact lenses when the beneficiary returns to NC Medicaid Direct.