During the beneficiary choice period (Jan. 15 through Feb. 14, 2023), Tailored Plan beneficiaries can choose a primary care provider (PCP) by contacting their Tailored Plan. Beneficiaries who do not make a choice will be automatically assigned a PCP starting Feb. 15, 2023.
To be included in the first day of the beneficiary choice period and in auto-assignment, PCP provider contracts should be signed and returned to the Behavioral Health and Intellectual/Developmental Disability (I/DD) Tailored Plans by:
- Jan. 5, 2023 – Last day for PCPs to have fully executed contracts with Tailored Plans to be included in the first day of the beneficiary choice period.
- Jan. 15, 2023 – Last day for PCPs to have fully executed contracts with Tailored Plans for inclusion in PCP auto-assignment.
Loading a contract into health plan systems typically takes at least two to three weeks but could take longer. The PCP provider contracting deadlines allow health plans time to process PCP contracts and ensure that PCP records are loaded correctly and transmitted to the Department. The information is used by the Enrollment Broker to populate its directory and by the Department in auto-assignment.
Tailored Plan network files are transmitted daily to the Department; therefore, if contracting does not occur by Jan. 5, 2023, providers still can appear in future directories and be included in PCP auto-assignment.
PCPs that do not contract with Tailored Plans by the deadlines risk losing patients, as beneficiaries will choose a PCP from the assigned Tailored Plan’s in-network providers. Beneficiaries will be automatically assigned to only in-network providers.
If a contract is not in place by April 1, 2023, and the provider has not engaged in good faith negotiations, the provider is at risk for being reimbursed at 90% of the current NC Medicaid Direct (fee-for-service) rate and subject to additional prior authorizations.
The Department expects Tailored Plans to negotiate with any willing physical health services or pharmacy services provider in good faith.
- Tailored Plans may exclude eligible providers from their physical health services or pharmacy services networks only if the provider refuses to accept network rates.
- Tailored Plans have the authority to maintain a closed network for behavioral health, I/DD and traumatic brain injury (TBI) services, and may exclude such providers from their behavioral health, I/DD or TBI networks if they have a sufficient network of providers of that type.
Health systems and providers are strongly encouraged to continue contract negotiations with Tailored Plans and finalize contracts as soon as possible. Once contracts are executed and health plan systems are updated, providers (including health system providers) become in-network providers with that Tailored Plan.
Contact the Tailored Plan directly for more information on contracting. Contact information is on the health plan page of the NC Medicaid website.
Questions and answers relating to provider contracting deadlines are in the Contracting with Tailored Plans fact sheet and on the Provider Contracting with Health Plans webpage.
As NC Medicaid moves toward the Tailored Plan launch on April 1, please keep sharing with the Department what is working and what is not. Submit questions or comments at 866-304-7062 or Medicaid.ProviderOmbudsman@dhhs.nc.gov.
Contact
- Provider Ombudsman: 866-304-7062
- NCTracks Call Center: 800-688-6696
- NC Medicaid Contact Center: 888-245-0179