NC Medicaid Credentialing Committee Questions and Answers

NC Medicaid Credentialing Committee Questions and Answers

Tab/Accordion Items

Providers will have full appeals rights for adverse decisions, just as they do today.

The OA must direct the attestation to be sent to the provider to attest. An NCID is not required. The provider will receive an email to complete the attestation. Once the provider completes the attestation, a notice will be sent to the OA to submit the application. If the provider does not sign the application, the OA will receive a notice once the application is rejected.

Due to the volume of files and to avoid holding up approvals, the committee will meet weekly, if only to ratify clean applications.

Applications with no adverse actions will be signed off by the Medical Director from our Fiscal Agent, General Dynamics Information Technology (GDIT,) and shared as a list to the Credentialing Committee to be ratified officially. They will not be up for discussion at the Credentialing Committee.

Yes, the Credentialing Committee will be held to NCQA standards.

Delays in transmission of provider enrollment file data are not expected.

No changes will be made to current provider enrollment files.

The criteria for the Provider Penalty Tracking Database will not change and will be written into the bylaws for review at a future meeting.

Not at this time. Currently, the department has a waiver to keep reverification at every five years.

Yes, before files reach the Credentialing Committee they will be sent out for review. As we are still structuring the Credentialing Committee, it is not yet known if the file will be historically available or no longer available after a decision is made.

GDIT is creating a portal for Credentialing Committee members to access, as well as training materials for the portal. More information will become available as this is developed and will be shared in upcoming stakeholder meetings.

Current processing times for clean applications can be found on the NC Medicaid Provider Enrollment web page. The Department does not anticipate a significant change to current processing times, as clean files will only be subject to weekly ratification by the committee.

The Credentialing Committee will review applications for every type of provider.

The PDM/CVO implementation has been paused. Please stay tuned for communication updates pertaining to the continuation of PDM/CVO.

For more information, visit the Provider Data Management/Credentialing Verification Organization web page.

GDIT performs Primary Source Verification but NCTracks requires providers to complete an MCR to upload the necessary information unless there is a feed from the board, such as the medical board, to process. This will be noted as an enhancement for the PDM/CVO system.

The process of becoming a peer reviewer is still in development. More information to come soon.

There is more information to come soon on this topic. Charter and bylaws are still in development.

Quality of care data from the plans will not be a factor in enrollment decisions unless performance of care issues (quality of care) are directly reflected in any adverse actions or criminal background findings flagged for a provider to be reviewed by the committee.

Not currently.

Not currently.

Not currently.

NC Medicaid is open to having conversations in our stakeholder meetings about who will represent each plan in the Credentialing Committee. No, the participating Tailored Plan committee representative is not required to be a Medical Director. There will be a Medical Director from GDIT serving on the committee.

NC Medicaid is open to feedback on health plan representatives, as roles for these representatives have not been mandated.

NC Medicaid and the Prepaid Health Plans are currently operating under NCQA waivers and will continue to do so when the Credentialing Committee is implemented. At some point, the waivers may be revisited.

No, the PDM/CVO solution that was previously announced has been postponed. More information on that initiative will be announced later.

One representative from DMH, DPH, and ORH is the recommendation with additional staff identified to serve as their proxy in the event they are unable to attend the meeting. Please offer feedback on this recommendation as deemed appropriate.

Positions on the Credentialing Committee are volunteer.

Yes, the committee includes a diverse representation of provider specialties. While the core voting members include representatives from NC Medicaid, managed care plans, and other state divisions, the non-voting participants may include peer reviewers.

Credentialing and recredentialing standards are not changing and are based on current NCQA, Federal and State guidelines.

Yes, Non-Physician Practitioners (i.e. Nurse Practitioners, Physician Assistants, other provider types that enroll with NC Medicaid) will serve on the Credentialing Committee, as needed.

No. The Credentialing Committee is not going to introduce changes to requirements for becoming an NC Medicaid Provider.

All clean applications will be formally approved or ratified by the committee. Applications with adverse findings will be assessed by the Committee for individual and organizational providers. Persons, other than the provider applicant, that appear on the application will be subject to background checks, just as they are today.

North Carolina Medicaid is committed to a diverse and inclusive committee. The process for becoming a Credentialing Committee member is still in development. More information will be shared soon.

The process for becoming a Credentialing Committee member is still in development. More information will be shared soon.

NC Medicaid, in its provider enrollment and credentialing processes, complies with and follows the requirements outlined in 42 CFR Part 455, Subpart E -- Provider Screening and Enrollment. Credentialing Committee members will be expected to adhere to NCQA, Federal, and State requirements as stated in the bylaws.

NC Medicaid's hearings and appeals process will apply, just as it does today.

Provider organizations, including hospitals, will follow the same enrollment process as they do today.

The Fiscal Agent will continue to perform credentialing functions.

Please refer to the NCQA website for more information regarding NCQA requirements for health plans. Current requirements implemented by NC Medicaid for provider enrollment will continue to be subject to NCQA, Federal and State guidelines.

The Office Administrator (OA) must initiate the process by directing the attestation to the provider. The provider does not need an NCID; instead, they will receive an email with a link to complete the attestation. Once the provider completes and signs it, the OA will receive a notice to submit the application. If the provider does not sign, the OA will be notified when the application is rejected.

For more information on the new attestation process and other important provider application changes, see the Upcoming Provider Application Changes Medicaid bulletin. 

Yes, the Credentialing Committee will review applications for every type of provider.

NC AHEC maintains a web page with resources for providers. You can access this information on the Medicaid Managed Care Trainings webpage. 

Yes, future stakeholder meetings regarding the Credentialing Committee initiative are scheduled for the last Wednesday of each month through September 2025. You can get more information on these upcoming meetings on the New Webinar Series: NC Medicaid Provider Enrollment webpage. 

The number of members on the Credentialing Committee will be determined in the bylaws.

Yes.

Yes.

NPDB applies to individual practitioners.