NC Medicaid Managed Care Provider Update

Key Milestone Dates for NC Medicaid Managed Care

Provider Playbook Updates

The Provider Playbook is a collection of information and tools specifically designed to assist providers transitioning to NC Medicaid Managed Care. New resources added to the fact sheet page include:

• Managed Care Claims and Prior Authorizations Submission - Part 1 (Updated) -- This fact sheet contains references to resources each Prepaid Health Plan (PHP) has created to inform both in-network and out-of-network providers about their claims submission process and their billing guidelines, and also includes details on where providers should route their claims.
• Managed Care Claims and Prior Authorizations Submission - Part 2 (Updated) – An overview of frequently asked questions regarding providers and PHPs during the claims and prior authorization submission process. ***Now includes provider payment schedule from July to October 2021***
• What Providers Need to Know After Managed Care Launch (Updated) – An overview of key dates, reminders and links to assist providers and their beneficiaries after Managed Care launch on July 1, 2021. 
• Combined PHP Quick Reference Guide (Updated) –  A quick reference guide (QRG), with updated contact numbers,  designed for providers to use beginning on day one of NC Medicaid Managed Care go-live. This QRG gives providers access to the information they will most frequently use such as contact numbers, email addresses, as well as prior authorizations and claims information for each of the health plans. ***New contact numbers for PHPs and NEMT/NEAT services*** 
• Panel Management (Updated) – An overview of how providers can manage their NC Medicaid Direct panels, as well as their panels with each of the health plans. Provides a detailed summary of how to verify member eligibility and enrollment within NCTracks.  *** Revised links and additional information on searching patients in health plan portals***
• Protections for Pregnant Women and Newborns – An overview of NC Medicaid established safeguards specific to pregnant women and newborns receiving care, particularly from out-of-network (OON) providers.

New resources will be added to the Provider Playbook as they become available.

Provider Prior Authorizations

If a prior authorization was previously obtained by your practice for Medicaid members prior to the go-live of July 1, 2021, the prior authorization has been sent from the State to your health plan and no further action is needed.

Health plans are receiving prior authorization requests that were previously submitted and approved by the DHHS. Please do NOT submit a prior authorization if one was already approved by the State. If a practice wants to verify a health plan has received a prior authorization, please contact the health plan provider relations team directly at:

• AmeriHealth Caritas:  Provider Services: 888-738-0004 
• Carolina Complete:  Provider Services: 833-552-3876 
• Healthy Blue: Provider Services: 844-594-5072 
• United Healthcare: Provider Services: 800-638-3302 
• WellCare: Provider Services: 866-799-5318 

For more information about prior authorization, see the Managed Care Claims and Prior Authorization Submission fact sheets under Programs and Services.

Provider Contracting Reminders

Although NC Medicaid beneficiaries have transitioned to managed care, providers are reminded that contracting is an ongoing process. Uncontracted providers may begin the process at any time understanding that health plans need sufficient processing time to complete the process and add the provider to their network.

Through Sept. 30, 2021, beneficiaries can contact the Enrollment Broker to change their health plan for any reason. After the 90-day choice period, beneficiaries can change their health plan at the time of their Medicaid recertification. Health plan changes outside of the 90-day choice period are allowed “with cause,” and can be requested by contacting the Enrollment Broker and submitting the Health Plan Change Request form.

Beneficiaries are able to change their assigned PCP/AMH for up to 30 days after they receive notice from the health plan of their initial PCP/AMH assignment, which was issued on or before  June 12, 2021. After their initial PCP/AMH assignment beneficiaries can change their PCP/AMH only one time each year or “with cause”.  Beneficiaries must contact their assigned health plan to request a change of their PCP.

Newly eligible NC Medicaid beneficiaries  required to enroll in a health plan may choose a health plan and/or a PCP/AMH at the time of application. Beneficiaries that do not choose a health plan will be auto-enrolled in a health plan. Beneficiaries will have 90 days from their Medicaid effective date to change their health plan for any reason. Health plan enrollments, whether selected by the beneficiary or through auto-enrollment, will be processed nightly. If the newly eligible beneficiary does not select a primary care provider, the health plan will auto-assign to a PCP/AMH within 24 hours of assignment to the health plan.

See the Member Enrollment fact sheets for more information.

Provider Ombudsman

NC Medicaid offers a Provider Ombudsman to assist providers  by receiving and responding to inquiries, concerns and complaints regarding health plans. This service is intended to represent the interests of the provider community, provide supportive resources and assist with issues through resolution.

The Ombudsman will also investigate and address complaints of alleged maladministration or violations of rights against the health plans. Health plans are expected to resolve complaints promptly and furnish a summary of final resolution to NC Medicaid.

Inquiries may be submitted to Medicaid.ProviderOmbudsman@dhhs.nc.gov or the Medicaid Managed Care Provider Ombudsman at 866-304-7062 (NEW NUMBER). Likewise, responses may also be delivered through either email or by phone. The Provider Ombudsman contact information can be found in each health plan’s Provider Manual linked on the Health Plan Contacts and Resources Page.

The Ombudsman service is separate and apart from the Health Plans’ Provider Grievances and Appeals process. Each health plan has a grievance and appeal process for providers, separate from the process for beneficiaries, which can be found in each health plan’s Provider Manual, linked on the Health Plan Contacts and Resources Page.

NC Medicaid Managed Care Hot Topics Webinar Series on the first and third Thursday of the Month for Medicaid providers and practice managers:   

The Medicaid webinars on the first and third Thursday of each month are dedicated to bringing you late breaking information/guidance on NC Medicaid’s transition to NC Medicaid Managed Care. Topics will vary, but each session will include an open question and answer period. 

Upcoming topics will include transition highs and lows, and more. To register to attend, visit the AHEC Medicaid Managed Care website. 

     Upcoming Webinars:

     Thursday, July 15, 2021 | Managed Care Transition Highs and Lows

The latest schedule, registration and information about previous webinars are available on the AHEC Medicaid Managed Care website. 

Virtual Office Hours

NC Medicaid and NC AHEC are  continuing a series of virtual office hours for providers the fourth Thursday of each month. These sessions offer an interactive format to answer provider questions.

     Upcoming Virtual Office Hours:

     Thursday, July 22, 2021 | Medicaid Managed Care Provider Hot Topics

Providers are encouraged to submit questions in advance. Virtual Office Hours will cover a range of NC Medicaid Managed Care topics. For the most up-to-date schedule, visit the AHEC Medicaid Managed Care webpage.

Health Plan Virtual Meet and Greet Sessions

Although no Virtual meet and greet sessions are scheduled at this time, recordings of previous sessions are available on the AHEC Medicaid Managed Care webpage.  These sessions were structured as conversations between providers and health plan staff to address concerns and questions about the transition to NC Medicaid Managed Care.

Ensure Your Information Displays Correctly in NC’s Provider Directory – Medicaid and NC Health Choice Provider and Health Plan Look-Up Tool

Reports are  available on the Managed Care Provider Playbook Resources page to assist providers in verifying their records. The Provider Directory Listing Report, as well as the Provider Affiliation Report, is available to ALL actively enrolled Medicaid and NC Health Choice providers. In combination, these reports allow all providers to confirm the information visible to NC Medicaid beneficiaries as each utilize the Medicaid and NC Health Choice Provider and Health Plan Look-up Tool to find participating provider information, and if applicable, enroll in NC Medicaid Managed Care. 

• Providers may use the NCTracks MCR process, available in the Secure NCTracks Provider Portal, to modify any provider record or service location information as well as individual to organization affiliations.
• If the Provider Affiliation information is incorrect, the affiliated individual provider or the office administrator for the affiliated individual provider must update the group affiliation.
• Providers unable to find their practice associated with the correct health plans should reach out directly to the health plan to discuss contracting options. If contracting with health plans through a Clinically Integrated Network (CIN), providers should reach out to their CIN to resolve.

Participating providers are contractually obligated to maintain their NCTracks provider record, which serves as the source of truth for managed care entities.  It is vital for enrolled providers to use these resources to thoroughly and regularly review their individual and organization provider enrollment information and submit changes as needed using the Manage Change Request process.

More information about this tool is available in a Medicaid Bulletin posted on Sept. 25, 2020.

PHP Quick Reference Guides Created

NC Medicaid’s Managed Care Prepaid Health Plans (PHPs) created quick reference guides to include the most current and comprehensive information for providers.

The PHP quick reference guides are available on the Provider Playbook Fact Sheet webpage under the Health Plan Resources section. Links to the health plan training webpages have also been added on the Provider Playbook Training Courses webpage.

Help Center Available for Providers to Find Information

The NC Medicaid Help Center is an online source of information about Managed Care, COVID-19 and Medicaid and behavioral health services, and is also used to view answers to questions from the NC Medicaid Help Center mailbox, webinars and other sources. To use this new tool:

1. Go to NC Medicaid Help Center
2. Type a topic or key words into the search bar
3. Select a topic from the available list of  categories

Detailed information about the NC Medicaid Help Center is available in a Medicaid Bulletin updated on June 17, 2021.

Contact:

NCTracks Contact Center: 800-688-6696