Specialty Care Referrals in NC Medicaid – 2025 Update

This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care.

Prior to Nov. 2016, NC Medicaid beneficiaries enrolled in Carolina Access (CA) and assigned a primary care provider (PCP) were required to obtain a primary care provider (PCP) referral before seeking specialty care. The specialty provider was then required to add the Carolina Access provider’s National Provider Identifier (NPI) to receive reimbursement.

Although referrals are no longer required, PCPs are encouraged to coordinate and document referrals for medically necessary health care services. It is important for the provider to remain at the forefront of care coordination for their beneficiaries. Some specialists may still request a PCP referral from the assigned PCP prior to treating a member. However, NC Medicaid does not require a PCP referral for claims payment.

Guidelines for Specialty Care Access

• NC Medicaid Direct: Specialists may provide office visits (evaluation and management services) without barriers to beneficiaries when the provider is enrolled with NC Medicaid.
• NC Medicaid Managed Care: Specialists may provide office visits (evaluation and management services) to members when the specialist provider is enrolled with NC Medicaid and contracted with the members’ assigned health plan.
  • Out-Of-Network (OON) Providers: If the member is enrolled with a NC Medicaid Managed Care plan and the provider is not in the members’ assigned health plan’s prior authorization may be required. All OON providers (primary care and specialists) should check with the members’ assigned health plan prior to seeing the patient.
  • Prior Authorization for Services: Providers should consult with the NC Medicaid Managed Care health plan to assure if prior authorizations for certain tests or imaging services are required prior to rendering these services.

Health Plan Resources for Referrals and OON Requirements

Standard Plans:

• AmeriHealth Caritas Provider Manual
  • See Section V. Utilization Management > Referrals
  • For OON:
    • See Section V. Utilization Management > Prior Authorization Policy and Procedure
    • See Section XI. Claims Submission Protocols and Standards > Claims Submission
    • See Section XI. Claims Submission Protocols and Standards > General Procedures for Claim Submission
• Carolina Complete Provider Manual
  • See Guidelines for Providers > Referrals (this contains information on OON providers)
  • See Guidelines for Providers > Specialist Responsibilities
• Healthy Blue Provider Manual
  • See Section 2.9 Role and Responsibilities of Specialty Care Providers
  • See Section 5.6 Prior authorization/Notification Coverage Guidelines > Out-of-area/ out-of-network care
• United Healthcare
  • PA for OON Requirements
    • See General information
  • Provider Manual
    • See Chapter 2: Care Provider Standards and Policies > Specialist responsibilities
    • See Chapter 4: Medical Management > Referral guidelines
• WellCare Provider Manual
  • See Section 4: Utilization Management (UM), Care Management (CM) and Disease managed (DM) > Utilization Management > Utilization Management Process > Referrals
  • See Section 4: Utilization Management (UM), Care Management (CM) and Disease managed (DM) > Utilization Management > Authorization Request Forms 

Tailored Plans:

• Alliance Health Provider Manual
  • See Section F: Provider Responsibilities > Advanced Medical Home Program
  • For OON:
    • alliancehealthplan.org/out-of-network-authorizations/
    • alliancehealthplan.org/providers/tp/submission-processes/pa-submission-process/
• Partners Health Management
  • For physical health OON providers: partners-physical-health-oon-provider-guidance.pdf
• Trillium Health Resources
  • For Physical Health services, Trillium partners with Carolina Complete Health to manage referrals and authorizations. Please refer to the guidelines in the Carolina Complete Provider Manual.
    • See Guidelines for Providers > Referrals (this contains information on OON providers)
    • See Guidelines for Providers > Specialist Responsibilities
  • For Behavioral Health Services, please refer to the Contracting with Trillium webpage: trilliumhealthresources.org/contracting-trillium
  • All OON services require prior authorization inclusive of observation stays. To verify whether a prior authorization is necessary, please refer to and utilize Trillium’s Prior Authorization Look-Up Tools located on Trilliums’ website: trilliumhealthresources.org/for-providers/benefit-plans-service-definitions
• Vaya Health
  • Information on OON requirements (all enrollment scenarios) can be found here: providers.vayahealth.com/provider-enrollment/
  • Vaya does not have a specific contact for referrals, but providers can reach out to providerinfo@vayahealth.com for non-clinical questions and network assistance.

Summary

NC Medicaid Direct and NC Medicaid Managed Care health plans do not require PCP referrals for specialty care.

• Some specialists may still require a referral from the PCP to see the patient.
• NC Medicaid and the NC Medicaid Managed Care health plans encourage coordination of care between specialists and the member’s PCP to enhance patient outcomes.

Provider Reverification Reminder

Provider re-credentialing/reverification is an evaluation of a provider’s ongoing eligibility for continued participation in NC Medicaid.  This is conducted every five years as mandated 42 CFR 455.414. Reverification is required for continued participation with NC Medicaid programs.

NC Medicaid has published bulletins to aid providers in the successful and timely completion of the reverification process:

• Provider Reverification Reminders
• Reverification Timeliness and Requirements Clarification
• Refresher: Be Sure to Disclose on Provider Application Exclusion Sanction Questions.

Additional resources are also available on the NCTracks Provider Re-credentialing/Re-verification webpage.

Contact

NCTracks Call Center: 800-688-6696