The PDM/CVO solution will consolidate provider data management and coordinate provider enrollment, credentialing, and ongoing data maintenance. To allow for additional time to test the system and ensure that providers and NCDHHS payers experience a seamless transition to the new solution, the PDM/CVO launch is now anticipated in 2026.
To read more about the new solution and how providers can prepare for the transition, see Provider Data Management / Credentialing Verification Organization Solution New Launch Date of 2026. Additional resources are available on the NC Medicaid Provider Data Management / Credentialing Verification Organization webpage.
Healthy Opportunities Pilots at Work
On May 15, 2024, the Healthy Opportunities Pilot (HOP) program expanded eligibility to include a subset of members living in Pilot regions who are enrolled in NC Medicaid Direct. Members who are eligible to receive Tailored Care Management and receive services from a Local Management Entity/Managed Care Organizations (LME/MCO), may now also qualify for HOP services. This will address the non-medical needs of approximately 14,000 additional members. Since March 2022, NC Medicaid has set a national precedent by reimbursing for evidence-based, non-medical services to address whole-person health through HOP.
Providers play an essential role in helping to identify Medicaid members that can benefit from NC HOP services—including identifying physical or behavioral health conditions or non-medical needs that may qualify someone for the Pilots.
A provider may connect a member to their health plan by calling the health plan’s Member Services Line and making a warm handoff or by using NCCARE360’s “Benefits Eligibility Screening” referral to indicate that a member is interested in, and may be eligible for, Healthy Opportunities Pilot services. The member’s health plan will assess if the member is eligible for NC HOP services and connect the member to services that meet their needs.
Read real life stories and get data on the impact of Healthy Opportunities on the lives of North Carolinians on the Healthy Opportunities Pilots at Work page.
Updated Provider Fact Sheets
NCDHHS updated Fact Sheets in the NC Medicaid Managed Care Provider Playbook to reflect the
July 1, 2024, launch of Tailored Plans.
- What Providers Need to Know After Tailored Plan Launch
- Tailored Plan Member Enrollment: PCP Auto-assignment
- Tailored Plan Auto-Enrollment & Opt-In Scenarios
- Tailored Plan Managed Care Claims and Prior Authorizations Submission:
Frequently Asked Questions – Part 2 - Managed Care Claims and Prior Authorization Submission: Frequently Asked Questions - Part 2
Reverification Updates
A new bulletin article is now available to give insight into the reverification process and clarify questions around timelines for this requirement. Providers are reminded to check their message center inbox frequently and act promptly upon receipt of the initial notification to complete the reverification process. Delinquent submissions result in suspension of claims and potential termination from the Medicaid program. The full bulletin article is posted on the NC Medicaid provider website.
Effective May 19, 2024, an update was made to the NCTracks reverification process. When a provider’s Medicaid health plan is terminated during the reverification process, their Division of Mental Health, Developmental Disabilities and Substance Use Services Health Plans (DMH/DD/SUS) health plans will also terminate. Providers will be required to submit a re-enrollment application to continue to render services to NC Medicaid or State-funded beneficiaries. The full announcement available on the public facing NCTracks provider page.
NC Health Choice Removed from NCTracks Provider Portal; Draft Applications will be Deleted
Beginning April 1, 2023, NC Health Choice was automatically transitioned to the Medicaid program. At that time, the NC Health Choice health plan was end-dated on existing provider records, but non-enrolled providers retained the ability to apply for the program retroactively. However, effective May 5, 2024, providers were no longer able to retroactively enroll in NC Health Choice. In addition, NC Health Choice was removed from the following areas of the NCTracks portal: Provider application pages including initial enrollment, re-enrollment, Manage Change Request (MCR), and re-verification. The full announcement is available on the public facing NCTracks provider page.
Provider Enrollment Terms and Conditions Updated
The NCDHHS Provider Administrative Participation Agreement, Consent to Release Information, EFT Attestation, the NCDHHS OPR Provider Participation Agreement, and the NCDHHS Out or State Lite Provider Participation Agreement have been updated in the NCTracks Provider Portal. Providers are encouraged to read each term and condition requiring their signature prior to submission of their application. All terms and conditions of provider enrollment are available on the public-facing NCTracks Provider Enrollment webpage.
License Accreditation Certification
An NCTracks automated process scans each record for an expiring credential (license, accreditation, certification) and initiates letters to providers 60 days prior to expiration. Although NC Medicaid has established a relationship with several credentialing entities to receive files and automatically update applicable credentials, it is ultimately the responsibility of the provider to ensure credentials are updated prior to expiration.
If no action is taken to update the credential, and the system cannot automatically update the expiration, the associated taxonomy code(s) will be suspended. A suspension letter is generated and sent to the provider’s Message Center Inbox with the subject Recertify Suspension Letter. The suspension will remain in place for another 60 calendar days unless the credential is renewed, which will lift the suspension.
Note: Suspension means the claims will pend and will not continue adjudicating until the suspension is lifted. See NCTracks License and Accreditation FAQs for additional information.
NC Medicaid Managed Care Information and Resources
Providers are encouraged to remain informed of NC Medicaid Managed Care Transformation through the following resources:
- Medicaid Managed Care Provider Playbook
- Health Plans webpage – Contact information for all health plans, as well as health plan contract requirements and information.
- Contains a variety of dashboards and reports related to NC Medicaid activities.
Provider Ombudsman
The health plan grievance and appeal process for providers 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’ process and should be used only as an escalation after contacting the health plan(s) and seeking guidance through 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 may be autogenerated from ServiceNow to the inquirer’s email or received from a Provider Ombudsman team member assigned to help resolve the inquiry. When the inquiry is considered resolved and closed, a final email with subject line “NC Medicaid Inquiry COM00XXXXX Has Been Closed” will be sent from Medicaid.HelpCenter@dhhs.nc.gov.
NC Medicaid Webinars
Visit the NC AHEC Medicaid Managed Care webpage for additional information and registration for upcoming webinars and Virtual Office Hour sessions. Webinars inform providers of program initiatives and updates within NC Medicaid. Attendance is vital to staying informed. Recordings, presentation slides and transcripts from previous webinars are available.
Contacts
NCTracks Call Center: 800-688-6696
Provider Ombudsman: 866-304-7062 or Medicaid.ProviderOmbudsman@dhhs.nc.gov