Key Milestone Dates for NC Medicaid Managed Care

Provider Playbook Updates

The Provider Playbook is a collection of essential information and tools designed specifically to assist providers in transitioning to NC Medicaid Managed Care. Recent updates include:

• Managed Care Claims and Prior Authorizations Submission – Part 2 (Updated) – An updated overview addressing frequently asked questions regarding providers and PHPs during the claims and prior authorization submission process.
• What Providers Need to Know After Managed Care Launch (Updated) – A summary of key dates, reminders, and links to resources to assist providers and their patients after the July 1, 2021, Managed Care launch.

Provider Prior Authorizations

If a prior authorization (PA) was previously granted by your practice for Medicaid members before the managed care implementation on July 1, 2021, that PA has already been sent from the State to your health plan. Therefore, no further action is required from your end.

Health plans are currently processing PA requests that were submitted and approved prior to the transition. Please refrain from resubmitting a PA that has already been approved by the State. To verify if a health plan has received a PA, it is advisable to contact the provider relations team of the health plan directly:

• 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

Further information about PAs can be found within the Managed Care Claims and Prior Authorization Submission fact sheets under Programs and Services.

Frequently Asked Questions from Providers

What ID is printed on my patient’s ID Card? Health plans must generate an ID card for every member enrolled that includes the member’s North Carolina Medicaid or NC Health Choice Identification number. Some health plans also include their unique member ID on the card.

What member ID can I utilize to search for patients in health plan portals? Providers are allowed to use a member’s North Carolina Medicaid or NC Health Choice Identification number to search in health plan provider portals. Some plans also allow searching by their health plan member ID.

Which member ID should be used when submitting claims? This varies by health plan:

Provider Contracting Reminders

With the transition of NC Medicaid beneficiaries to managed care, providers are reminded that contracting remains an ongoing process. Uncontracted providers are encouraged to begin the process at their convenience, with an understanding that health plans require adequate processing time to integrate a new provider into their network.

Beneficiaries have the option to contact the Enrollment Broker to change their health plan at any point until September 30, 2021. After this date, changes may only occur during Medicaid recertification periods. Health plan changes outside of the designated 90-day choice period are permissible “with cause” upon requesting via the Enrollment Broker and submitting a Health Plan Change Request form.

Beneficiaries can change their assigned primary care provider (PCP) or Advanced Medical Home (AMH) within 30 days after receiving their initial assignment notification, which was issued by June 12, 2021. Following the initial assignment, any subsequent changes may be requested only once annually or “with cause.” To alter their assigned PCP, beneficiaries must reach out directly to their health plan.

Your reference for Member Enrollment fact sheets can provide more specific information.

Provider Ombudsman Services

NC Medicaid provides a Provider Ombudsman to assist healthcare providers by addressing inquiries, concerns, and complaints related to health plans. This service is designed to advocate for the provider community, furnishing supportive resources, and aiding in issue resolution.

The Ombudsman additionally investigates and resolves complaints alleging maladministration or rights violations by health plans, ensuring that issues are addressed promptly with a summary of the actions taken provided to NC Medicaid.

Inquiries can be directed to Medicaid.ProviderOmbudsman@dhhs.nc.gov or the NC Medicaid Managed Care Provider Ombudsman at 866-304-7062. Responses can be offered via email or by phone. All contact details for the Provider Ombudsman are available in each health plan’s Provider Manual found on the Health Plan Contacts and Resources Page.

It is important to note, the Ombudsman service operates separately from health plans’ Provider Grievances and Appeals processes, which are detailed in each health plan’s Provider Manual.

Upcoming NC Medicaid Managed Care Webinars

Back Porch Chat: Medicaid Managed Care Hot Topics Thursday, Sept. 16 | 5:30 to 6:30 p.m. Register Join us for important updates related to Medicaid in the upcoming Back Porch Chat scheduled for Thursday, September 16. Carie Brown, Chief Medical Officer for Behavioral Health & Intellectual and Developmental Disabilities at the NC Department of Health and Human Services, will host the event, which includes a Q&A session and presentations covering:

• Quick Updates on Current Issues
  • Hope4Healers
  • Standard Plan Claims & Taxonomy
  • COVID-19 Developments
  • Advanced Medical Home (AMH) vs. AMH+
• An Introduction to Medicaid Managed Care & Behavioral Health and Intellectual/Developmental Disability (I/DD) Tailored Plan Overview
• Details on Tailored Care Management (TCM)
• Process to Request a Transfer to TP or NC Medicaid Direct

For the latest schedules, registration, and access to previous webinars—recordings, slides, and transcripts—check the AHEC Medicaid Managed Care website.

Virtual Office Hours

NC Medicaid, in collaboration with the NC AHEC, continues to host virtual office hours for providers on the fourth Thursday of each month. These sessions provide an interactive platform to address provider inquiries.

Upcoming Virtual Office Hours: Thursday, Sept. 23, 2021 | Provider Hot Topics Register Online

Providers are encouraged to submit their questions in advance. To stay informed on the latest schedule, please visit the AHEC Medicaid Managed Care webpage.

Verify Your Information in NC’s Provider Directory

Reports are accessible on the Managed Care Provider Playbook Resources page to assist providers in confirming their records. The Provider Directory Listing Report and the Provider Affiliation Report are available to all actively enrolled Medicaid and NC Health Choice providers. These reports help ensure correctness in the information visible to NC Medicaid beneficiaries via the Provider and Health Plan Look-up Tool.

It is critical for participating providers to maintain their NCTracks provider record since this serves as the primary source of truth for managed care entities. Providers must utilize these resources, including the NCTracks Manage Change Request process, to thoroughly and regularly verify and update their provider enrollment information.

Commonly overlooked sections include:

• Health Benefit Plan Selection: Confirm the health plans you intend to participate in are listed.
• Service Location Address and Taxonomy Classification: Include all service locations you want displayed. Each address must be entered precisely as per the USPS standards.
• Accreditation: Keep licenses, certifications, and accreditations updated.
• Hours of Operation: Confirm that the stated hours for providing care are accurate.
• Services: Ensure all indicators related to special needs and languages supported are correctly configured.
• Affiliated Providers: Verify that all individual providers are accurately linked to the organizations billing for their services.

For guidance on completing an NCTracks Manage Change Request, refer to the available NCTracks Provider User Guides and Training materials at NCTracks User Guides.

Provider Health Plan Office Hours

The most current information regarding health plan office hours for providers can be accessed via the Provider Playbook Training Courses webpage.

PHP Quick Reference Guides

Prepaid Health Plans (PHPs) under NC Medicaid have assembled quick reference guides, encapsulating the most updated and thorough information essential for providers.

These guides can be found on the Provider Playbook Fact Sheets webpage, under the Health Plan Resources section. Links to health plan training web pages have also been included on the Provider Playbook Training Courses webpage.

Help Center for Provider Information

The NC Medicaid Help Center serves as an online hub for information related to Managed Care, COVID-19, and Medicaid and behavioral health services. It is also a resource for responding to questions received through the NC Medicaid Help Center mailbox or webinars. To utilize this new tool:

1. Go to NC Medicaid Help Center.
2. Type a topic or keywords into the search bar.
3. Select a specific topic from the provided categories.

More information regarding the NC Medicaid Help Center can be found in a Medicaid Bulletin that was updated on June 17, 2021.

Contact Information

For immediate assistance, providers can reach the NCTracks Call Center at 800-688-6696.