NC Medicaid Managed Care Provider Update – Aug. 4, 2022

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.

• Tailored Plan Enrollment and Timeline - June 29, 2022
• Medicaid and NC Health Choice Provider and Health Plan Lookup Tool - June 24, 2022

Verifying NC Medicaid Eligibility for Beneficiaries

Providers are reminded to verify eligibility, health plan and primary care provider enrollment as beneficiaries present at the office for care and prior to rendering services using the NCTracks Recipient Eligibility Verification/Response. Member ID cards are not required to provide services, including pharmacies, so members should not be turned away due to the lack of a Member ID card in their possession. Upon discovery that a beneficiary is not eligible for Medicaid, the practice should refer the beneficiary to the county DSS agency for assistance.

For more information, see the fact sheet What Providers Need to Know: Part 2 – After Managed Care Launch or the Confirming Medicaid Coverage for Beneficiaries bulletin.

Provider Reverification

As the federal Public Health Emergency (PHE) comes to an end, 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.

IMPORTANT: Verify 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.

Providers may review the information on their NCTracks record by initiating a Manage Change Request from the Status and Management page of the secure Provider Portal. For assistance with reporting changes through the NCTracks Manage Change Request, providers should reference the NCTracks Provider User Guides and Training tools, or contact the NCTracks Call Center at 800-688-6696.

Behavioral Health Services to 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 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 Behavioral Health and I/DD Tailored Plan (Tailored Plan) benefit packages.    

Beneficiaries who are excluded from enrolling in a Standard Plan or Tailored Plan will continue to receive services through NC Medicaid Direct with the PIHPs managing their Behavioral Health services and their physical health services being provided through NC Medicaid Direct.
 
DHHS also currently covers a subset of Behavioral Health services under its 1915(b) waiver [(b)(3) services], 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 a 1915(i) authority which will be managed by the Tailored Plans and the PIHPs. Information on the 1915(i) services is available in the NC Medicaid Transition of 1915(b)(3) Benefits to 1915(i) Authority white paper. 

REMINDER: Coverage for Pregnant Beneficiaries Extended to 12 Months

As of April 1, 2022, NC Medicaid coverage for pregnant beneficiaries is extended 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 is available in Medicaid bulletin article Medicaid for Pregnant Beneficiaries Extended to 12 Months After Birth.

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.

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.

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