The Department of Health and Human Services (DHHS) recently published the following fact sheets related to managed care. Providers are encouraged to reference them as guidelines and resources.
- Prompt Payment
- Provider Payment and Reimbursement
- Managed Care Claims Submission: What Providers Need to Know – Part 1
- Tailored Plan Managed Care Claims and Prior Authorizations Submission: Frequently Asked Questions – Part 2
Prompt Payment --contains important information about provider rights to timely payment and outlines the responsibilities of health care providers. In this fact sheet, providers will be able to find relevant information about timely filing, clean claims, interest and penalties, and recoupment.
Provider Payment and Reimbursement-- provides guidance on the reimbursement payment process for providers. This fact sheet covers information related to claim payments, medical home payments, care management payments and directed payments. The claim payments section includes rate floor and non-rate floor payments, out-of-network claim payments, and member payments.
The medical home payments section provides information about Primary Care Medical Home Payments in which health plans are required to pay a per member per month (PMPM) payment to providers, which will be equal to the payments under the Carolina ACCESS program.
The care management payment section covers information for Tailored Care Management (TCM) and Local Health Departments (LHD).
- TCM providers will receive a monthly standard rate between Dec. 1, 2022, and Sept. 30, 2023, when providing TCM to assigned members, and will submit a TCM claim for the first contact of each month.
- From Oct. 1, 2023, TCM providers will be paid a monthly acuity-based payment, based on the beneficiary's assigned acuity tier, and will submit a TCM claim for the first contact of each month to their respective Tailored Plan.
Standard Plans will continue to pay LHDs the same PMPM payments they currently receive for providing Care Management for High-Risk Pregnancy (CMHRP) and Care Management for At-Risk Children until 2024. Tailored Plans will also pay LHDs at a rate no less than the current PMPM payments for CMHRP until 2024.
Managed Care Claims Submission: What Providers Need to Know – Part 1-- provides important information related to health plans claims submission. DHHS partners with health plans to provide Medicaid services to our clients. It is important for providers to understand the process for submitting claims to health plans for reimbursement.
Providers must follow each health plan specific claim submission procedure, including submitting claims within the designated timeframe. This fact sheet also covers important information if providers experience claims payment issues.
Tailored Plan Managed Care Claims and Prior Authorizations Submission: Frequently Asked Questions – Part 2-- provides a list of frequently asked questions for providers to reference on different topics related to claims processing. This list includes specific information and responses from each health plan, ensuring you have the necessary references.
We hope this comprehensive list of frequently asked questions and their respective responses from each health plan will provide you with the guidance needed for smooth claims processing and prior authorizations.
Provider Ombudsman inquiries, concerns, or complaints can be submitted to Medicaid.ProviderOmbudsman@dhhs.nc.gov, or received through the Provider Ombudsman line at 919-527-6666. The Provider Ombudsman contact information is also published in each health plan’s provider manual. For all other questions, please contact the NC Medicaid Help Center at 888-245-0179 or email at Medicaid.HelpCenter@dhhs.nc.gov.