A delay in identifying individuals in NCTracks as dually eligible for Medicare and Medicaid has been discovered. If an individual is enrolled in a prepaid health plan (PHP) and Medicare data is delayed, submission of Medicare evidence will trigger automatic retro disenrollment of the member back to the first day of the month of Medicare effective date. This retroactive disenrollment can span back several months and, in some cases, back to the NC Medicaid Managed Care Go-Live of July 1, 2021.
The enrollment change will trigger a recoup of payments made to the PHP by the Department, and the PHP will in turn recoup any claims paid for the period while the individual was in managed care. To ensure the provider is paid for recouped services rendered due to no fault of the provider, the provider agency should submit claims to NCTracks for the dates of service that now fall in NC Medicaid Direct.
For example, a member is enrolled in PHP1 beginning July 1, 2021, and is receiving personal care services (PCS). They became dually eligible on Feb. 1, 2022, but the system does not show the Medicare information until June 15, 2022.
- NCTracks will update the enrollment segment retroactively to reflect the PHP1 effective disenrollment date to align with an NC Medicaid Direct effective date of Feb. 1, 2022.
- In this example, the provider should submit claims to NCTracks for services rendered for dates of service between Feb. 1, 2022, to June 15, 2022.
The provider should check NCTracks for appropriate PAs and submit claims to NCTracks. If the provider receives a denial of those claims or experiences other difficulties submitting these claims to NCTracks, the provider should contact the NC Medicaid Managed Care Provider Ombudsman at 866-304-7062 or Medicaid.ProviderOmbudsman@dhhs.nc.gov to generate a ticket for claim reprocessing.
The provider should include the following information:
- Subject: Retro Disenrollment Claims Issue
- Provider Name and NPI:
- Previous PHP Name:
- MID:
- Service Provided:
- Dates of Service:
- EVV provider, if applicable:
- Copies of PHP PAs, if applicable:
- Evidence documenting recoup of PHP claims
These tickets and the claims they represent will be given high priority.
Contact
NCTracks Call Center: 800-688-6696