This bulletin applies to NC Medicaid Managed Care and NC Medicaid Direct.
Effective April 17, 2025, for beneficiaries enrolled in both Medicare and Medicaid (dually-eligible beneficiaries) assigned to a NC Medicaid Managed Care plan, NCTracks will automatically route the claims processed by Centers for Medicare & Medicaid Services (CMS) Medicare Administrative Contractor (MAC) to the corresponding Behavioral Health Intellectual/Developmental Disabilities Tailored Plans and Prepaid Inpatient Health Plans (PIHPs) to allow the Tailored Plan or PIHP to process the claim as the secondary payor. Providers will no longer have to wait for the CMS MAC to complete processing of the Medicare claim and to submit a secondary claim with the Explanation of Medicare Benefits (EOMB) to the appropriate Tailored Plan or PIHP for determination of the NC Medicaid benefit.
There are some situations in which the billing format used by the primary payor differs from Medicaid. For example, with Federally Qualified Health Centers (FQHC)/Rural Health Clinic (RHC) claims, Medicare requires a UB/837I format and Medicaid requires a CMS1500/837P format. In those cases, the claim will not crossover from Medicare and the provider will need to bill a secondary claim to the NC Medicaid designated coverage (PIHP, Tailored Plan or NC Medicaid Direct).
Providers will continue to receive their EOMB and now the respective Explanation of Benefit (EOB) from the designated NC Medicaid Managed Care health plan.
If providers have questions or experience issues regarding the adjudication of the Medicare Crossover claim, they should contact the designated NC Medicaid Managed Care health plan or NC Medicaid Direct.
For more information on Claims Submission to the Tailored Plan and PIHP, refer to the following fact sheet:
Managed Care Claims Submission: What Providers Need to Know – Part 1
For provider submitted Medicare secondary claims to NC Medicaid Direct, there is no change. Refer to the NCTracks Secondary Claims webpage for additional guidance on submitting secondary claims to NC Medicaid Direct.
Contact
For questions, contact the NC Medicaid Help Center at 1-888-245-0179 or email at Medicaid.HelpCenter@dhhs.nc.gov.