This bulletin applies to LME/MCO services in NC Medicaid Direct and NC Medicaid Managed Care health plans.
NOTE: This bulletin replaces the Sept. 16, 2021, Prepaid Health Plan Interest and Penalties for Provider Claims bulletin.
In accordance with Section V. H.1.d of the NC PHP Contract, Section V. B.6.i.iv, Behavioral Health and Intellectual/Developmental Disabilities (I/DD) Tailored Plan contract, and Section IV.J.1.d. of the NC Medicaid Direct Prepaid Inpatient Health Plan Contract, health plans are required to pay interest to providers if the health plan fails to accurately pay or inappropriately denies a clean claim within 30 calendar days of receipt of medical claims or within 14 calendar days of receipt for pharmacy claims.
- This includes incorrect denials and under or partial payments that are identified and paid on reprocessed claims.
- It is the health plan’s responsibility to issue interest payments to providers when applicable.
A clean claim is a claim for services submitted to a health plan by an NC Medicaid medical or pharmacy service provider which can be processed without obtaining additional information from the submitter to adjudicate the claim.
If the health plan fails to implement fee schedule changes and reprocess impacted claims with the correct rates within 45 calendar days of notification of a fee schedule change from NC Medicaid, the health plan must pay interest on the adjusted amount.
Fee Schedule Health Plan Policies
As stated in Section V.H.1.d.iv.d of the NC PHP Contract, Section V. B.6.i.iv,d of the Behavioral Health and I/DD Tailored Plan contract, and Section IV.J.1.d.iv of the NC Medicaid Direct Prepaid Inpatient Health Plan contract, health plans are required to implement fee schedule changes and reprocess all impacted claims (claims with dates of services from the effective date of the NC Medicaid fee schedule change) with correct rates within 45 calendar days of notification from NC Medicaid. This standard is only applicable for NC Medicaid rate floor programs. Failure to implement fee schedule changes within the required timeframe will result in interest payments to providers beginning on the 46th calendar day after the health plan received notification from NC Medicaid.
A select number of fee schedules can be found on the Fee Schedule page of the NC Medicaid website. Effective dates are reflected in the fee schedule header and/or body.
Updates to fee schedules not published on the NC Medicaid website will be communicated to impacted provider associations via email and/or rate letters from the Department.
Fee schedule updates are uploaded to the Fee Schedule and Covered Code Portal. Health plans have been advised to regularly check the portal for the latest fee schedules.
Providers should route payment concerns to their health plan’s appeals and grievances processes. Providers can escalate to the Medicaid Provider Ombudsman at Medicaid.ProviderOmbudsman@dhhs.nc.gov, if necessary.
Health plans are required to promptly pay clean claims, update rate floor program fee schedules, and reprocess impacted claims in conjunction with one another. In cases where a provider submits claims with dates of service after the fee schedule effective date, health plans shall adhere to both prompt pay and fee schedule implementation deadlines.
Guidance scenarios can be found here.
Contact
NC Medicaid Contact Center, 888-245-0179