NC Medicaid Managed Care Provider Update – April 21, 2023

Provider Reverification

The federal PHE is expected to end on May 11, 2023. The Centers for Medicare and Medicaid Services (CMS) allows all providers whose reverification was delayed due to the federal PHE a specified period to complete reverification.  

Once the federal PHE ends on May 11, 2023, reverification is not optional. To avoid a potential increased administrative burden, and to benefit from the $100 NC Application Fee Waiver which expires June 30, 2023, providers in receipt of the Voluntary Reverification Program notification are encouraged to take advantage of this unique time-limited opportunity.

• Notifications to impacted providers were distributed through March 31, 2023. 
• Providers have 30 days to respond. No adverse action will occur if a provider chooses to not submit a voluntary application. 

For more information, see the Voluntary Reverification bulletin article.

Reverification notifications received beginning in May, at the end of the federal PHE, represent the required reverification process. Providers must respond to avoid adverse action to their NC Medicaid participation status. More information is forthcoming about the end of the federal PHE.

Implementation of Tailored Plans Delayed -- Start Date Oct. 1, 2023

The Oct. 1, 2023, start date allows Tailored Plans to contract with more providers to support member choice and to validate that data systems are working appropriately. For more information, please see Medicaid bulletin article NCDHHS Delays Implementation of the NC Medicaid Managed Care Behavioral Health and I/DD Tailored Plans.

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. Providers are encouraged to regularly review each section for the latest information.

NC Health Choice Move to Medicaid 

NC Health Choice moved to Medicaid on April 1, 2023.

On March 31, 2023, the NC Health Choice health plan end-dated on all NCTracks provider records with an effective date of April 1, 2023, with one exception:  

• Providers with a suspended status or a pending application will see no change to the NC Health Choice health plan until the resolution of that pending action. 
• Upon completion, GDIT will automatically take additional action to end-date the NC Health Choice health plan.

General information can be found on the NC Health Choice Move to Medicaid webpage. In addition to the fact sheets, bulletins, and frequently asked questions posted on this page, see Timeline for Claims Adjudication and Process for Prior Approvals for more information.

Billing Requirement Modifications Effective May 12, 2023

As a result of the end of the federal PHE, beginning with date of service May 12, 2023, NC Medicaid will end the temporary emergency flexibilities implemented for the disposition of three claims processing edits:

• Edit 02437 and 02425 – Service Facility Provider Invalid or Not Active.  
• Edit 07025 – Rendering Provider Not Affiliated with Billing Provider.

These claim edits will change from “pay and report” to “deny.” To resolve the denials, providers must ensure that the Service Facility NPI on the claim is actively enrolled or that the individual rendering NPI on the claim is actively affiliated with the billing NPI on the claim as appropriate.  

Keep NCTracks Provider Records Current

NC Medicaid recently announced a Provider Data Management/Credentialing Verification Organization Solution Coming in 2024. It is essential for providers to ensure all data in each active NCTracks provider record is accurate so when it is transmitted to the new vendor, it is correct.  

To assist with this effort and allow for the organization and basic review of multiple records concurrently, the Department continues to offer Provider Directory Listing and Affiliation Reports for Standard Plans and Tailored Plans in the Provider Playbook.  These reports are updated regularly and also serve as a resource for verifying the contract status with health plans.

When using these reports, providers may filter to review information about multiple records simultaneously. A “Field Description” tab is available on the report that allows you to connect the section of the “Manage Change Request” (MCR) to the field in the report displaying the information. To review the NCTracks provider record in its entirety, providers may use the full MCR process in the NCTracks Secure Provider Portal. If outdated or erroneous information is found using either resource, the Office Administrator must submit the MCR to report the change.

The ongoing accuracy of provider enrollment information is not only contractually required of providers, but also vital to the successful sharing of data among health plans and the incorporation into new solutions. For additional information, see the related bulletin article Ensure Your Information Displays Correctly in NC’s Provider Directory Tool – Provider & Health Plan Look-Up.  

Provider Ombudsman

Each health plan has a grievance and appeal process for providers, separate from the process for beneficiaries, which can be found in the 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. 

Responses to inquiries are autogenerated from ServiceNow and sent directly to the inquirer's email address. The subject line will read “NC Medicaid Inquiry COM00XXXXX Has Been Closed” and be sent from this email address: IT Service Desk Medicaid.HelpCenter@dhhs.nc.gov.

Help Center Available for Providers to Find Information

The NC Medicaid Help Center is an online source of information about NC Medicaid Managed Care, COVID-19, Medicaid and behavioral health services, and is used to view answers to questions from the NC Medicaid Help Center mailbox, webinars and other sources. To use this tool:

1. Go to the 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. 

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
• Provider Ombudsman: 866-304-7062