Quarterly Provider Update – Summer 2025

Information on Provider Ombudsman, Children and Families Specialty Plan and Upcoming Credentialing Changes.

Children and Families Specialty Plan Launching Later this Year

The Children and Families Specialty Plan (CFSP) is a first-of-its-kind statewide health plan to ensure access to comprehensive physical and behavioral health services for NC Medicaid-enrolled children, youth and families served by the child welfare system (e.g. foster care) with seamless, integrated and coordinated care. The CFSP contract was awarded to Blue Cross Blue Shield NC after a competitive selection process, and the term will last four years. The plan, named Healthy Blue Care Together (HBCT), will go live on Dec. 1, 2025.

Providers should review the What Providers Need to Know Before Children and Families Specialty Plan Launch (Part 1) fact sheet for more information about impacted NC Medicaid beneficiaries, key dates and contracting. HBCT has their own provider contract template and process, making it imperative for providers serving impacted beneficiaries to initiate contact.  For additional information about CFSP, please visit the Children and Families Specialty Plan webpage.

Maintain Eligibility Reminders

As a reminder, the quarterly Maintain Eligibility process through NCTracks identifies enrolled providers with no claim activity within the past 12 months. NCTracks notifies the provider by a Notification of Inactivity Letter posted to the secure NCTracks Provider Portal Message Inbox.

When a provider is identified as having no claims activity in 12 months, a Maintain Eligibility Due Date will be set. If the provider does not submit the application by the due date, the provider’s participation in the NC Medicaid and other North Carolina Department of Health and Human Services (NCDHHS) programs will be end dated and a Provider Termination Letter will be sent by certified mail. There is no suspension period. Providers terminated through this process may submit a re-enrollment application as needed, selecting an effective date of up to 365 days retroactive to fill any gap in participation.

The Maintain Eligibility Process helps prevent fraud, waste and abuse in the NC Medicaid programs. For more information, please see the Information on Maintaining Eligibility announcement.

Site Visit Guidance for Physical Therapists

Physical Therapists who are enrolling with NC Medicaid are categorized as moderate risk, which generally requires a site visit. However, there are special provisions for a Physical Therapist enrolling as an individual and affiliated with an organization billing on their behalf. In the NCTracks application, Physical Therapists must answer questions regarding site visits. When prompted, those enrolling with Taxonomy 225100000X are advised to answer No for "Have you completed the Federal site visit for this site to NC Medicaid, another state or Medicare?" when the application includes an affiliation to an organization. This will cause a manual review and will prompt a site visit only when deemed necessary. This instruction is only applicable to a Physical Therapist enrolling with an Individual enrollment type.

Healthy Opportunities Pilots Update

Budget proposals from both chambers of the North Carolina General Assembly currently do not include funding for Healthy Opportunities Pilots (HOP) services beyond June 30, 2025, and for the State Fiscal Years 2026 - 2027. In alignment with contractual obligations to health plans and in an effort to remain fiscally responsible with available resources, the Department is preparing to stop HOP services beginning July 1, 2025, until further notice and final budget decisions are made. As of June 2, 2025, health plans were permitted to stop new service authorizations. More information can be found on the recently published Healthy Opportunities Pilots Update bulletin.

Care Management Rate Assumptions Memo for SFY 2026

NC Medicaid has finalized a memo on NC managed care capitation rates for 2025-2026. The memo provides information on the assumptions underlying the care management component of capitation payments to Standard Plans for the upcoming contract year. The memo is published here on the NC Medicaid website.

NC Medicaid Help Center & Provider Ombudsman

The Provider Ombudsman is separate from the managed care health plans’ issue resolution processes and should be used only after contacting the health plan(s) or seeking information and guidance through the NC Medicaid Help Center. 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. Inquiries may be submitted to Medicaid.ProviderOmbudsman@dhhs.nc.gov or by calling the Provider Ombudsman at 1-866-304-7062.

Credentialing Committee Planned for Fall 2025

A Credentialing Committee will be established to review NC Medicaid provider files that have flagged items that impact the disposition of their NCTracks enrollment, reenrollment or reverification applications, as well as issues discovered through ongoing monitoring.

The committee will make quality determinations on provider files with issue findings from primary source verifications, disclosures, National Practitioner Data Bank queries (NPDB) and ongoing monitoring. Led by a Medical Director, voting and non-voting members from NC Medicaid payers and managed care health plans will make up the Credentialing Committee, which will meet weekly. The tentative launch date of the Credentialing Committee is early October 2025.

NC Medicaid, in collaboration with NC Area Health Education Centers (AHEC), is conducting monthly stakeholder engagement sessions, as follows, until the project implementation. These sessions are intended to be interactive as the Department values input from partnering stakeholders:

  • July 30, 2025
  • Aug. 27, 2025
  • Sept. 24, 2025

More information can be found on the Credentialing Committee webpage. Providers are encouraged to submit your related questions and comments for targeted open discussion at the meetings to Medicaid.credcommittee.stakeholders@dhhs.nc.gov.

Delegated Credentialing Planned for Spring 2026

The NC Medicaid Provider Operations team is working to establish and implement a Delegated Enrollment and Credentialing process through the NCTracks system. Delegated Credentialing allows NC Medicaid to delegate credentialing to major hospitals and large health care systems who will use National Committee for Quality Assurance (NCQA), federal and State guidelines to perform credentialing activities for their health care practitioners. This allows for a more streamlined process for large systems to credential their individual practitioners. Delegated Credentialing is tentatively scheduled to launch by March 2026.

The NC Medicaid Provider Operations team will continue to share updates about this initiative and upcoming stakeholder engagement opportunities. Questions can be emailed to medicaid.delegatedcredentialing.stakeholders@dhhs.nc.gov.

Recent Provider Communications

Providers are encouraged to review the following content which has been recently created or refreshed.

NC Medicaid Provider Bulletins

NCTracks Provider Announcements

Updated NC Medicaid Fact Sheets are in the NC Medicaid Managed Care Provider Playbook:

Updated NCTracks Provider FAQs:

NC Medicaid Webinars

Attending webinars co-hosted by NC AHEC in partnership with NC Medicaid can help providers to stay informed about program initiatives and updates.

  • Dr. Janelle White, Chief Medical Officer of NC Medicaid, will host an upcoming Back Porch Chat on July 31, 2025. This webinar will primarily focus on the CFSP.
  • NC Medicaid’s Provider Operations unit will host a Virtual Office Hours webinar on Sept. 4, 2025, from 12-1 p.m. These quarterly sessions offer an interactive format for providers to ask questions on a variety of topics, including NC Medicaid Managed Care and provider enrollment.

Visit the NC AHEC Medicaid Managed Care Trainings webpage to register for upcoming sessions. Recordings, presentation slides and transcripts from previous webinars are available.

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