The North Carolina Department of Health and Human Services (NCDHHS), through General Dynamics Information Technology, Inc. (GDIT), will establish a Credentialing Committee to review and determine if healthcare providers’ qualifications meet required NC Medicaid and National Committee for Quality Assurance (NCQA) standards for participation in the NC Medicaid program. Operating under its charter and bylaws, the Committee will help maintain a network of qualified, ethical, and competent healthcare providers for the benefit of NC Medicaid beneficiaries.
A stakeholder teleconference to kick off the discussion will be held April 30, 2025, from 2-3 p.m.
This forum offers stakeholders the opportunity to engage in meaningful dialogue about the committee’s role in making final determinations regarding evidence of compliance and regulatory requirements by NC Medicaid provider applicants. NC Medicaid will also share additional updates related to the National Committee for Quality Assurance (NCQA) - driven provider application changes. The meeting will be recorded.
April 30, 2025, from 2-3 p.m.
Join the meeting now
Meeting ID: 265 111 852 194
Passcode: 8Lg9PF9r
Dial in by phone: +1 984-204-1487, 919093346# United States, Raleigh
Find a local number
Phone conference ID: 919 093 346#
Join on a video conferencing device
Tenant key: ncgov@m.webex.com
Video ID: 119 592 920 7
More info
The Committee will meet weekly to make quality determinations on provider records containing issue findings from primary source verifications, provider disclosures, National Practitioner Data Bank (NPDB) queries, and ongoing oversight by the Department. Applications found to have no issues or findings will be formally approved and ratified by the committee.
The following application types are subject to the Committee’s review:
- Initial enrollment
- Re-enrollment
- Manage Change Request (when the provider adds a credential, criminal disclosure, service location, or other event applicable to the credentialing process.)
- Recredentialing
The Credentialing Committee will be comprised of voting and non-voting members. The voting members may include:
- One Medical Director (employed by GDIT)
- Two representatives from NC Medicaid
- At least one representative from each managed care health plan
- Representative(s) from other NCDHHS payors, including: Division of Mental Health, Developmental Disabilities and Substance Use Services, Division of Public Health and Office of Rural Health
Non-voting members may include a Credentialing Coordinator, Peer Expert Specialists and Peer Expert Non-Physician Practitioners, as needed.
Review by the Credentialing Committee will apply to any enrolling or actively participating NCDHHS provider, making it vital for all providers to proactively prepare for the transition to the new process:
- Maintain an accurate provider record. Reviewing each provider record and correcting outdated information is essential to ensuring the integrity of provider data.
- Stay informed. Review the NC Medicaid Provider webpage often and read all new Medicaid bulletins and communications.
- Participate in educational opportunities. Respond to notifications of engagement, participating in webinars and other events meant to fully engage providers and stakeholders.
- Regularly review the secure NCTracks Provider Message Inbox. Provider outreach and notification is primarily offered through this Inbox and the email address associated with the provider record. Review often.
- Hearings and Appeals. Providers may exercise their right to appeal adverse decisions made by the committee which allows for the committee’s decision to be reviewed and reconsidered. The filing of an appeal results in a hearing. For reconsideration of the decision, providers may submit a request within 30 business days from the date of the denial or termination letter. The letter will offer additional details about the reconsideration process, including the option for a contested case hearing if the provider disagrees with the reconsideration review decision.
For more information, please see the NC Medicaid Provider Credentialing web page.
Contact
Medicaid.credcommittee.stakeholders@dhhs.nc.gov
Provider Ombudsman: 866-304-7062