Frequently Asked Questions and Answers - Medicaid Providers

North Carolina has suspended the transition of Medicaid to managed care. Medicaid beneficiaries will get health services as they do now from the state. Beneficiaries do not need to choose a health plan. Behavioral health services will continue to be provided by Local Management Entities – Managed Care Organizations. All health providers enrolled in Medicaid are still part of the program and will continue to bill the state through NCTracks. Timelines noted within Medicaid Transformation policy papers, fact sheets and other communications will not apply.

Please call the Medicaid Contact Center at 888-245-0179 if you have questions.  

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Published August 28, 2019

How can I get fee schedules for all 5 Prepaid Health Plans (PHPs) before contracting?   
Providers may negotiate reimbursement arrangements with each PHP. Contact each PHP to discuss contracting and reimbursement. Please reference the Medicaid provider page for a list of PHP contacts.

Will each PHP have their own prior authorization process?  
PHPs must establish and maintain a referral and prior authorization process with the Advanced Medical Home (AMH) at its center. Providers will request prior authorization as required by the PHP with which the beneficiary is enrolled. To reduce administrative burden, the Department has standardized prior authorization request forms to be used with all PHPs, and requires PHPs to cover benefits in an amount, duration, and scope no less than those covered under current clinical coverage policies. In addition, the PHP must honor existing and active prior authorizations on file with the North Carolina Medicaid or NC Health Choice for the first ninety (90) days after implementation to ensure continuity of care for members. For more information, see Contract #30-190029-DHB Prepaid Health Plan Services.

Do I need to be credentialed with each plan?    
To reduce the administrative burden and maximize efficiency as we transition to managed care, providers will continue to use a single, centralized credentialing process, available through NCTracks. Enrolled providers will also continue to maintain their provider record in NCTracks. PHPs will contract with Medicaid enrolled providers for billing and payment. Providers may initiate PHP contracting by contacting PHPs directly. Please reference the Medicaid provider page for a list of PHP contacts.

Will request for payment for services/ claims still be forwarded to NCTracks?   
Medicaid/NC Health Choice beneficiary assignment determines claims submission requirements. Claims for beneficiaries enrolled with a PHP will be submitted to the PHP. If the beneficiary is not enrolled with a PHP, then the beneficiary is in the fee-for-service program, or Medicaid Direct, and claims would be submitted to NCTracks.     

Will there be a set number of providers per region?      
No, there are no limitations on the number of providers a PHP may contract with in a region.      

Do I have to contract with all PHPs?      
PHPs must contract with any willing and qualified provider. Although providers are not required to contract with every PHP, you are encouraged to explore contracting options with each PHP.                

Will ALL providers who want to provide services be accepted into NC Medicaid Managed Care?               
Yes. To comply with the any willing provider requirement, PHPs must contract with providers willing to accept reimbursement at or above the rate floor (or an alternative, mutually agreed upon payment arrangement) unless the provider does not meet “objective quality” standards. In addition, there are specific requirements for PHPs to include all essential providers (i.e., federally qualified health centers, rural health centers, local health departments, veterans’ homes and charitable/free clinics) in their provider networks. For more information about contracting requirements, see Contract #30-190029-DHB Prepaid Health Plan Services.

Can a PHP decline an agreement for a willing provider?
Yes. A PHP may decline a provider if that provider will not accept reimbursement at or above the applicable rate floor (or an alternative mutually agreed upon payment arrangement) or the provider does not meet “objective quality” standards. Objective quality concerns may include a history of malpractice concerns or fraud, waste and abuse enforcement actions. Providers denied participation with a PHP will be given opportunity to appeal the decision per the instructions in the denial notification.            

Can credentialing be done through CAQH?       
No. Credentialing will be done through the state’s centralized credentialing process.    

Will pharmacists be credentialed?         
Provider types eligible to enroll in Medicaid are identified on the NCTracks Provider Permission Matrix. Pharmacies may credential, as well as Clinical Pharmacists. Once credentialed by Medicaid, PHPs must abide by the any willing and qualified provider standard for contracting.         

Where can I locate the credentialing information?         
Medicaid provider enrollment and credentialing information is available on the NCTracks Provider Enrollment webpage. Once enrolled, a provider may use the Health Plan Contracting List on the the Medicaid provider page to explore contracting options with each PHP.    

What is PDM/CVO?       
An independent, third party, nationally recognized Credentials Verification Organization (CVO) and provider data management (PDM) solution. When the integrated PDM/CVO solution is available, providers will initiate a single online application for Medicaid enrollment and re-enrollment and will submit documentation for initial credentialing and recredentialing (e.g., certifications, insurance) through the PDM/CVO provider portal. The PDM/CVO will verify all provider information against primary sources, as required by national accrediting entities, federal requirements and the Department. Primary sources will include national databases, state and federal sources, information collected by national health plans and proprietary or licensed databases. Once the CVO has collected documentation and verification is completed, the provider will be enrolled in Medicaid fee-for-service and will be able to receive reimbursement for covered services provided to fee-for-service beneficiaries. PHPs will have access to credentialed information through the PDM/CVO about Medicaid-eligible providers to use in building their networks. Additional information on the integrated PDM/CVO solution can be found in the Supporting Provider Transition to Medicaid Managed Care policy paper and the Centralized Credentialing and Provider Enrollment proposed concept paper.

What are the reimbursement guidelines for PHP and FFS? Where will claim go and who will reimburse?
Medicaid/NC Health Choice beneficiary assignment determines claims submission and reimbursement. If the beneficiary is not enrolled with a PHP, then the beneficiary is in Medicaid Direct, and claims would be submitted to NCTracks. Medicaid Direct reimbursement will follow the fee schedules published on the Medicaid Provider webpage. Claims for beneficiaries enrolled with a PHP will be submitted to the PHP. Providers will be reimbursed according to their PHP contract (e.g., value-based payments, negotiated rates, or other incentive arrangements) as well as any applicable state provider rate floors.            

When will providers need to start contracting with PHPs?          
Now. PHPs have already started contracting with providers to build their networks. Providers interested in contracting may use the Health Plan Contracting List on the the Medicaid provider page to explore contracting options with each PHP.                 

Wipro Infocrossing is the selected centralized credentialing vendor. When do we start the credentialing process? And do we contact Wipro directly?
NC Medicaid will continue to use a centralized enrollment and credentialing process through NCTracks. A file with actively enrolled Medicaid providers is automatically transmitted to Wipro Processing to undergo supplemental credentialing and is then sent to the PHPs to be used in contracting. Providers should continue to maintain their NCTracks provider record to ensure the accuracy of information used in the credentialing process.            

Will NCTracks continue to be used after February 2020?      
Yes. NCTracks will maintain its current functionality for Medicaid Direct beneficiaries. In addition, NCTracks will continue to be the primary source for provider enrollment, credentialing and provider record maintenance.        

Will there be provider led PHPs?             
Yes. There is currently one regional Provider-Led Entity (PLE), Carolina Complete Health, available to beneficiaries and providers in region 3 and 5.   

What is an example of an excluded population that will continue under Medicaid fee-for-service?
An example of a population excluded from Medicaid Managed Care enrollment is beneficiaries enrolled in Family Planning Medicaid. For a complete understanding of beneficiaries who are mandatory, excluded, exempt or delayed from participating in NC Medicaid managed care, see the Beneficiaries in Medicaid Managed Care policy paper or the Beneficiary Policy (MCT 105) recorded webinar.              

Will there be a way to cap the number of Medicaid Managed Care patients per provider?
Providers may address preferred restrictions with the PHP(s) during contracting discussions.

When will the list of the approved PHP's be available to practitioners?
The awarded PHPs are listed at:

How many Managed Care Organizations will there be in the state and when can providers apply?
There are four statewide PHP contracts and one PLE operating in regions 3 and 5. Providers interested in contracting may use the Health Plan Contracting List on the the Medicaid provider page to explore contracting options with each PHP.                

Will a beneficiary have to select a primary care provider (PCP) when selecting a PHP? If so, can the beneficiary see any credentialed provider within the practice? 
Although not required, the Enrollment Broker will provide beneficiaries with information and assistance in selecting their AMH/PCP at the time of PHP enrollment. Beneficiaries that do not select an AMH/PCP with the enrollment broker will be automatically enrolled with one by their assigned PHP.

Will the NC Medicaid Managed Care Prepaid Health Plan Contract Awards document be made available in multiple languages for those Medicaid families whose first language is not English?         
The PHP contract is posted at Contract #30-190029-DHB Prepaid Health Plan Services. The Enrollment Broker is required to provide unbiased, culturally competent choice counseling services to beneficiaries. The PHPs shall ensure all contacts with members/authorized representatives are culturally competent and provides effective communication in the method requested by the member.     

How will the standard plan regions impact the future of the LME/MCOs?
For Medicaid Direct beneficiaries, LME/MCOs will continue to provide applicable services to beneficiaries in their current region. For Standard Plan Medicaid Managed Care enrollees, PHPs will offer most behavioral health services according to managed care regions. For more information about behavioral health services, see the Behavioral Health Services (MCT 106) recorded webinar.