North Carolina Governor Roy Cooper issued Executive Order 311 on Aug. 5, 2024, which declared a State of Emergency for North Carolina in anticipation of potential severe weather caused by the approach of Tropical Storm Debby.
NC Medicaid is committed to North Carolina's response to and recovery from Tropical Storm Debby. We are working with county and federal partners to make it faster and easier for beneficiaries to receive — and for health care professionals to provide— Medicaid care and services.
This bulletin describes flexibilities effective Aug. 6, 2024, to Aug. 20, 2024 (unless otherwise communicated by DHHS), for the NC Medicaid program including NC Medicaid Direct and NC Medicaid Managed Care, as indicated below. Updates will be provided as they become available.
Flexibilities for both NC Medicaid Direct and NC Medicaid Managed Care
Reimbursement for medically necessary services during Tropical Storm Debby
NC Medicaid Direct and NC Medicaid Managed Care will reimburse providers for medically necessary drugs and services, and equipment and supplies, provided during the Tropical Storm Debby emergency without prior approval (PA) starting Aug. 6, 2024, through Aug. 20, 2024 (unless otherwise communicated by DHHS).
Medical documentation must support medical necessity. In addition, beneficiaries who have been evacuated out-of-state (OOS), voluntarily or involuntarily, can receive medically necessary services care if needed and NC Medicaid Direct and NC Medicaid Managed Care will reimburse the OOS provider without PA. OOS providers must enroll as NC Medicaid providers in an abbreviated, expedited process on the NCTracks Provider Enrollment webpage.
Providers are encouraged to obtain a PA if it is possible to do so (and normally required for the service). All claims are subject to audit.
Medication Prior Approval Overrides due to Tropical Storm Debby
The potential for severe weather conditions may present situations where NC Medicaid beneficiaries in impacted areas may have difficulty obtaining necessary prior approval for certain medications. Therefore, NC Medicaid enrolled pharmacy providers have been approved to override prior approval requirements starting Aug. 6, 2024, through Aug. 20, 2024 (unless otherwise communicated by DHHS). This override of prior approval is being allowed while the Governor’s State of Emergency order remains in place to ensure that all NC Medicaid beneficiaries have access to necessary medications.
For NC Medicaid Direct, NC Medicaid enrolled pharmacy providers should resubmit these claims with “09” (Emergency Preparedness) in the PA Type Code field to override a denial for prior approval required. Do not place any values in the Submission Clarification Code field. Additional questions can be directed to the NCTracks service line at 800-688-6696.
For NC Medicaid Managed Care, providers should contact the pharmacy service line (numbers below) to confirm if additional documentation or processes need to be completed to allow for prior authorization overrides due to Tropical Storm Debby.
Standard Plans
- AmeriHealth: 1-866-885-1406
- Healthy Blue: 1-833-434-1212
- Carolina Complete: 1-833-992-2785
- United Healthcare: 1-855-258-1593
- Wellcare: 1-866-799-5318, option 3
Tailored Plans
- Alliance Health: 1-855-759-9300
- Partners: 1-866-453-7196
- Trillium: 1-866-245-4954
- Vaya Health: 1-800-540-6083
Early Prescription Refills during Governor’s State of Emergency Declaration
The potential for severe weather conditions may present situations where NC Medicaid beneficiaries in impacted areas may require an early refill of their medications. NC Medicaid enrolled pharmacy providers have been approved to early fill these prescriptions and will follow applicable co-pay requirements. Effective Aug. 6, 2024, through Aug. 20, 2024 (unless otherwise communicated by DHHS), the early refill is being allowed while the Governor’s State of Emergency order remains in place to ensure that all Medicaid beneficiaries have access to necessary medications.
For NC Medicaid Direct, NC Medicaid enrolled pharmacy providers should resubmit these claims with “09” (Emergency Preparedness) in the PA Type Code field and a valid value for an E.R. override in the Reason for Service, Professional Service and Result of Service fields to override a denial for an early refill. Do not place any values in the Submission Clarification Code field. This allows the beneficiaries to receive their medication during an emergency without using either of their limited-use Submission Clarification Code overrides. Additional questions can be directed to the NCTracks service line (800-688-6696).
For NC Medicaid Managed Care, providers should contact the pharmacy service line (numbers below) to confirm if additional documentation or processes need to be completed to allow for emergency prescription refills effective due to Tropical Storm Debby.
Standard Plans
- AmeriHealth: 1-866-885-1406
- Healthy Blue: 1-833-434-1212
- Carolina Complete: 1-833-992-2785
- United Healthcare: 1-855-258-1593
- Wellcare: 1-866-799-5318, option 3
Tailored Plans
- Alliance Health: 1-855-759-9300
- Partners: 1-866-453-7196
- Trillium: 1-866-245-4954
- Vaya Health: 1-800-540-6083
Flexibilities for NC Medicaid Direct Only
Community Alternatives Program for Children (CAP/C) and Community Alternatives Program for Disabled Adults (CAP/DA)
A critical role for case management entities serving CAP/C and CAP/DA beneficiaries is to provide support to ensure the health, safety and well-being of all CAP beneficiaries in the preparation for, during and immediately after, a natural disaster. To fulfill this requirement, NC CAP case management entities are directed to assist their assigned CAP beneficiaries in activating their emergency and disaster plans in preparation for the unknown impact of Tropical Storm Debby.
When helping CAP beneficiaries activate their plans, it is imperative to emphasize checking and updating disaster kits. Ready NC is a valuable resource to use for additional information and assistance to prepare for a tropical storm. Encourage beneficiaries to register with their special needs’ registry in their county.
It is our utmost concern that not only are our beneficiaries safe and accounted for during times of disaster, but that case management entities are equipped to communicate with staff and beneficiaries effectively as well as take the appropriate steps to remain safe. Please coordinate with local county emergency management departments if assistance is needed.
NC Medicaid gave notification to CAP case management entities that if the state is impacted by Tropical Storm Debby, and to coordinate resources, Medicaid will request from case management entities an assessment of the health and well-being status of each CAP beneficiary. Case management entities will be required to complete in the eCAP systems the Disaster Wellness Check Documentation related to the health and well-being status of the CAP beneficiaries they serve. Below is the information that must be included in the Disaster Wellness report.
- Name of contact person for questions regarding the report
- Status of beneficiary (safe, sustained impact, unknown)
- Beneficiary current location (home, shelter, facility, relative – in/out of county/state)
- Beneficiary contact information, if displaced from home
- Documentation if the current service plan meets the needs of the beneficiary as a result of Tropical Storm Debby
- If it does not, specify what additional or replacement services are needed through a plan revision.
To seek technical assistance in managing a waiver beneficiary’s recovery from Tropical Storm Debby, contact the CAP unit at medicaid.capc@dhhs.nc.gov or medicaid.capda@dhhs.nc.gov.