Note: This bulletin is replaced by NC Health Choice Move to Medicaid: Timeline for Claims Adjudication and Process for Prior Approvals. This bulletin has been updated to adjust the table under “Managed Care Prior Approval Summary.”
North Carolina Session Law 2022-74 directs the NC Department of Health and Human Services to combine the NC Health Choice Program with the NC Medicaid benefit plan.
As of April 1, 2023, all NC Health Choice beneficiaries with active eligibility will be moved to Medicaid, providing them access to Medicaid services that are not currently covered under NC Health Choice.
Additional benefits include enhanced behavioral health services, Early Periodic Screening, Diagnosis and Treatment (EPSDT) services, and non-emergency medical transportation (NEMT).
Once children in NC Health Choice are enrolled in Medicaid, they will no longer be subject to cost sharing.
Providers must check eligibility in NCTracks prior to the beneficiary visit, even if the beneficiary presents with a Medicaid ID or Medicaid Managed Care health plan card to determine which health benefit the beneficiary is enrolled in and whether their eligibility remains current.
Claims can be submitted for eligible NC Health Choice beneficiaries who are not enrolled in Standard Plans for up to 365 days after the date of service. The timeframe for adjustments will remain 18 months.
Standard Plans have their own timeline and process for adjudicating claims, and their guidelines can be found in their Provider Handbook/ Provider Manual. Please review the Standard Plans Provider Handbooks to ensure awareness of their process and to avoid any issues with the payment of claims.
Managed Care Prompt Pay Quick Reference Summary
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Medical Claims |
Pharmacy Claims |
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Timely Filing |
Within 180 calendar days of covered service or discharge |
Within 365 calendar days of date of provision of care |
|
Timely Filing for Retroactive Enrollees |
180 calendar days of the approved enrollment |
365 calendar days of the approved enrollment |
|
Notify providers of Clean/Pend Claim |
18 calendar days of receiving claims |
14 calendar days of receiving claims |
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Pay/Deny claims upon clean submission/or becomes clean |
Within 30 calendar days of clean submission / becoming clean |
Within 14 calendar days of clean submission / becoming clean |
|
Deny claims if no additional information provided from the provider |
90 days of the date the additional information was requested |
90 days of the date the additional information was requested |
Active NC Health Choice prior approvals will remain active and transition to NC Medicaid as of April 1, 2023. All other criteria within the prior approval will remain the same, but the health benefit will change to NC Medicaid.
For NC Medicaid Direct prior approvals submitted after April 1, 2023, please make sure to change the health plan to NC Medicaid. A prior approval with NC Health Choice as the health plan may be rejected.
For the Standard Plans, active NC Health Choice prior approvals will remain active and transition to NC Medicaid as of April 1, 2023. All other criteria within the prior approval will remain the same, but the health benefit will change to NC Medicaid.
Managed Care Prior Approval Summary
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Medical Claims |
Pharmacy Claims |
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Timely Filing |
Non-Urgent Pre-Service- no longer than 14 days after request received Urgent or Expedited Pre-Service- within 72 hours of receipt Concurrent Review- within 24 hours of receipt of following business day |
Within 24 hours after receiving all pertinent clinical information, no longer than 72 hours |
|
Timely Filing for Retroactive Enrollees |
Within 30 days of receiving all pertinent medical information |
Within 24 hours after provider submission |
|
Notification of Approval or Denial |
Non-Urgent Pre-Service- no longer than 14 days after request received Urgent or Expedited Pre-Service- within 72 hours of receipt Concurrent Review- within 24 hours of receipt of following business day |
Within 24 hours after receiving all pertinent clinical information, no longer than 72 hours |
|
Deny Prior Approval if no additional information provided from the provider |
Non-Urgent Pre-Service- no longer than 14 days after request received Urgent or Expedited Pre-Service- within 72 hours of receipt Concurrent Review- within 24 hours of receipt of following business day |
Within 24 hours after receiving all pertinent clinical information, no longer than 72 hours |
No action is required for providers enrolled in both the Medicaid and NC Health Choice health plans. Providers currently enrolled in only the NC Health Choice health plan risk termination effective April 1, 2023, when the NC Health Choice benefit is end-dated. To avoid a terminated provider status and to continue rendering services to transitioning NC Health Choice patients, please enroll with Medicaid before April 1, 2023.
Contact
NCTracks Call Center: 800-688-6696