This guide provides need-to-know information regarding the provider portal, securing prior authorizations, important phone numbers, and more!
This document provides timely information related to known issues impacting providers. This will be updated weekly on Thursdays.
We are pleased to announce that, effective January 1, 2024, Express Scripts® will begin processing pharmacy claims for our plan members.
Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.
Members have been notified in advance and will receive a new ID card with updated pharmacy information, so that they are prepared to begin having their prescriptions filled at participating network pharmacies when this change occurs.
Providers can direct members to call the Member Services phone number listed on their ID card should they have questions about this change.
Please contact your Provider Relations Representative with any additional questions.
Thank you for the care you provide to our members.
Opioid Treatment Program providers, please review newly posted Opioid Treatment Program Service 8A-9 policy. In addition to this policy update, effective 10/01/2023, Carolina Complete Health has also removed prior authorization for Opioid Treatment Program Service (specific to code H0020) for in-network providers.
Coming Soon in 4th Quarter!
Enhancements to the 835
Previously, Carolina Complete Health (CCH) has required authorization for behavioral health (BH) outpatient therapy after members utilized 24 sessions. Beginning on 09/12/2023, Carolina Complete Health removed the prior authorization requirement for BH outpatient therapy. These therapy codes include 90832, 90834, 90837, 90846, 90847, 90849, and 90853. In order to ensure appropriate utilization without prior authorization requirements, CCH will monitor utilization trends across providers. Please read on for additional information regarding coding guidelines.
Carolina Complete Health follows NC Medicaid policy 8B for Inpatient Behavioral Health Services. The most recent update to this policy notes that there is no authorization required for the first 72 hours of a member’s Inpatient admission. Authorization is required if a member’s stay is beyond 72 hours.
In order for CCH to assist with discharge planning as needed, the request is for providers to submit a notice of admission within 48 hours of a member’s admission via the usual Prior Authorization form submission. You can use the PA form, found here, to submit notification.
Urgent Reminder: North Carolina Medicaid Providers should review the NC DHHS reverification due date list, and frequently check their Provider Message Inbox for notifications or the reverification section of the Status and Management page in the NCTracks Secure Portal. Failure to renew Medicaid eligibility or re-credential will result in claims denials. Expand for more information
Re-credentialing/reverification is an evaluation of a provider’s ongoing eligibility for continued participation in NC Medicaid, normally conducted every five years as mandated by the Affordable Care Act. However, the federal Public Health Emergency (PHE) paused reverification from March 2020 through May 11, 2023, delaying the due date for nearly 30,000 providers over that three-year period. Now that the federal PHE has ended, NC Medicaid must ensure that all enrolled providers, including those whose reverification was delayed, are compliant with the reverification requirement.
Reverification notifications are sent to the provider 70 days prior to the reverification due date, with reminders at 50 days, 20 days, and 5 days. Non-responsive providers then receive a notice of suspension which gives an additional 50 days to submit their reverification application before being terminated from the program. Including the notice of termination, and depending on the provider’s responsiveness, each will receive up to 6 targeted notifications over a 120-day period. If terminated, the provider may re-enroll at any time.
For convenience, NC Medicaid offers a list of “Active Provider Re-Verification Due – July 2023 – Dec 2023” dates (updated biannually). The reverification due date displayed is also the health plan suspension date of the provider record if no action is taken to submit the reverification application under the applicable NPI. If the health plan is suspended, claims payment will stop.
Providers are encouraged to review the reverification due date list, and frequently check their Provider Message Inbox for notifications or the reverification section of the Status and Management page in the NCTracks Secure Portal for the option to reverify. In addition to the resources below, providers may contact the NCTracks Call Center at 800-688-6696 for assistance.
Failure to renew Medicaid eligibility or re-credential will result in claims denials.
Resources: