Sharing from NC DHHS
December 6, 2021
Provider appeal rights defined in the Standard Plan Contract Section V.D.5 Provider Grievances and Appeals, and the appeal processes outlined in the Prompt Payment Fact Sheet (PDF), include deadlines to submit appeals which may vary by Standard Plans, from 30 days to 365 days after the decision giving rise to the right to appeal.
The Department shared concerns from providers about these deadlines with the Standard Plans. In response, Standard Plans will temporarily extend the following minimum appeal timeframes to support the transition to NC Medicaid Managed Care:
For more information, see Extension to NC Medicaid Managed Care Appeals Deadlines.
|Appeal Submission Date||Minimum Appeal Timeframe|
|Through Jan. 31, 2022||
90 calendar days from the decision giving rise to the right to appeal
|Feb. 1, 2022 through March 31, 2022||
60 calendar days from the decision giving rise to the right to appeal
|April 1, 2022 and later||
30 calendar days from the decision giving rise to the right to appeal
The North Carolina Department of Health and Human Services today announced that Behavioral Health and Intellectual/Developmental Disabilities (I/DD) Tailored Plans will launch Dec. 1, 2022, instead of July 1, 2022.
Wednesday, November 17, 2021
The NC Medicaid Ombudsman presents a monthly webinar about Medicaid Managed Care and related topics. The webinars are designed for Medicaid beneficiaries, health care providers and other Managed Care stakeholders. We’re interactive! Presenters will solicit feedback from attendees about their experiences with Managed Care and answer questions from attendees.
To find out more about the NC Medicaid Ombudsman and access our outreach materials, visit ncmedicaidombudsman.org.
Thursday, November 18, 2021
5:30 PM - 6:30 PM
Please join NC Medicaid Chief Medical Officer (CMO) Dr. Shannon Dowler and Chief of Quality Kelly Crosbie, along with all the NC Medicaid Managed Care Plan CMOs and Behavioral Health (BH) Directors, for the November Back Porch Chat on Thursday, November 18 from 5:30 p.m. - 6:30 p.m. In addition to timely hot topic updates, this webinar will focus on Behavioral Health Collaborative Care Codes and how we can support practices ability to help us achieve the goal of integrated physical and behavioral healthcare for Medicaid beneficiaries in NC. The Managed Care Plan BH Directors will be speaking to key aspects of successfully using BH collaborative care codes and we will be joined from colleagues in practice to share how they are being used in primary care including best practice, lessons learned, specific use cases/scenarios and more! Have a question you would like addressed during the webinar? Please access this link to enter your questions to be sure they are asked and answered on Thursday night! The link will become inactive on Monday, November 15th
Sharing on behalf of NC DHHS
October 14, 2021
Due to the COVID-19 Public Health Emergency and to expedite a hospital’s ability to discharge patients to lower levels of care when medically appropriate, the prior authorization (PA) waiver is extended to Oct. 31, 2021 for:
For more information, please see SPECIAL BULLETIN COVID-19 #190: Extension of Temporary Suspension of Prior Authorization for Post-Acute Placements.
Sharing from NC DHHS:
Please join NC Medicaid Chief Medical Officer (CMO) Dr. Shannon Dowler, along with all the NC Medicaid Managed Care plan CMO’s, for our October Back Porch Chat on October 21 from 5:30-6:30 p.m.
We will review new COVID-19 surge response offerings from NC Medicaid, including a COVID-19 vaccine incentive program for NC Medicaid beneficiaries. We will also review how to help a patient who needs Behavior Health and Individual Developmental Disabilities (I/DD) Tailored Plan behavioral health services move from a standard plan to NC Medicaid Direct.
In our efforts at improving transparency, we will provide an overview of a claims dashboard and clinical quality measures, and show results across plans in our first quarter of NC Medicaid Managed Care. Finally, we will summarize the “latest and greatest” in recent Medicaid bulletins and answer your questions, Please use this link to submit your questions in advance.
The Department is launching a Tailored Plan Care Management webinar series on October 1, 2021. This is designed to help develop a shared understanding of the model across the North Carolina provider community (including advanced medical homes and behavioral health, I/DD and TBI providers) and anyone interested.
The webinar series will run from October through mid-December, on Fridays from 12 to 1 PM ET, and cover various topics:
Register for the webinar series
Sharing from NC DHHS:
In an effort to ensure optimal access to care for Medicaid beneficiaries, to support providers during the recent COVID-19 surge, and to alleviate potential provider payment concerns, DHHS and the prepaid health plans (PHPs) have agreed to extend the policy for out of network flexibilities to providers who have not yet contacted with a PHP through Nov. 30, 2021. These flexibilities were originally expected to sunset on Aug. 30, 2021.
Under this policy, the PHPs have agreed to:
For more information, please see Medicaid bulletin Extension of Out of Network Provisions.
Sharing from NC DHHS:
Join us on Tuesday, Aug. 31, 2021, from 9:30-11:00 a.m. ET for a webinar on North Carolina’s Healthy Opportunities Pilots.
This webinar will provide an overview of the Pilot program, with a focus on the essential roles and responsibilities of human services organizations that will provide Pilot services to eligible Medicaid members. The webinar will also highlight important upcoming implementation milestones and next steps. The session will be geared towards human services organizations that are interested in providing Pilot services, but is open to the public. There will be time reserved at the end for Q&A.
The Pilots offer the unprecedented opportunity to evaluate the impact of providing evidence-based, non-medical interventions to a subset of high-risk eligible Medicaid members in select regions of the state. The federal government has authorized up to $650 million in state and federal Medicaid funding to cover the cost of providing select Pilot services related to housing, food, transportation and interpersonal safety that directly impact the health outcomes and health care costs of Medicaid members.
Sharing from NC DHHS:
Tailored Care Management Update: AMH+/CMA Certification Round One Desk Reviews Completed
The Department has conducted desk reviews of round one Advanced Medical Home Plus (AMH+) practices/Care Management Agencies (CMAs) provider applications and advanced 54 providers to the site review stage.
Providers will be able to receive technical assistance from NC AHEC to prepare for site reviews. The Department will share more information on preparation and timing for site reviews with providers moving to this stage. See Medicaid bulletin article Tailored Care Management Update: AMH+/CMA Certification Round One Desk Reviews Completed for more information.
Potential Clinically Integrated Network or Other Partners Statement of Interest
Advanced Medical Home Plus (AMH+) practices and Care Management Agencies (CMAs) may choose to contract with a Clinically Integrated Network (CIN) or other partners to share responsibility for specific functions and capabilities required to operate as an AMH+ practice or CMA and meet the requirements of the Tailored Care Management.
To give providers additional information about the North Carolina CIN or other partners market, in May and June 2021, the Department solicited responses to a voluntary, non-binding Statement of Interest on the type of services that CINs and other partners offer to providers applying to become certified as AMH+ practices and CMAs.
The Department has compiled all responses received from CINs and other partners and is making this information available to prospective AMH+ practices and CMAs and other stakeholders on the Tailored Care Management webpage.
On Monday July 26th, The North Carolina Department of Health and Human Services announced the selection of seven organizations to serve as Behavioral Health and Intellectual/Developmental Disability Tailored Plans (Behavioral Health I/DD Tailored Plans). Tailored Plans are scheduled to launch July 1, 2022.
Read the full press release
The following fact sheets were updated by the Department of Health Benefits
The Provider Playbook contains Fact Sheets, Trending Topics, FAQs, and more!
Health plans have identified a common billing error of providers submitting professional and institutional EDI claims (ASC X12 837-P and ASC X12 837-I) with missing or invalid billing provider, rendering provider and attending provider taxonomy codes.
When billing NC Medicaid Direct claims, providers may have directed clearinghouses to append billing provider, rendering provider, or attending provider taxonomy codes to the claims. This process may not have been established for NC Medicaid Managed Care claims being submitted to the prepaid health plans (PHPs), causing these claims to deny for missing or invalid taxonomies.
Providers should work with their clearinghouses to ensure that the same processes are followed when submitting claims to NC Medicaid Direct and the PHPs.
To facilitate timely adjudication, providers should include the billing provider taxonomy and, when applicable, the rendering provider taxonomy and attending provider taxonomy on claims before sending them to a clearinghouse.
For claims that have been submitted to PHPs and denied for invalid billing, rendering, or attending provider taxonomy codes, please immediately resubmit the denied claims using the process outlined above. For assistance, please follow up with the PHP your agency contracts with.
Please refer to the July 9, 2021, Common Billing Error: Taxonomy Codes Missing, Incorrect or Inactive bulletin for additional guidance on submitting valid taxonomy codes.
THURSDAY, JULY 15 | 5:30-7 PM
Hosted by Shannon Dowler, MD, Chief Medical Office of the NC Division of Health Benefits, this 90-minute session welcomes each of the Chief Medical Officers of North Carolina's five Medicaid Managed Care plans to bring you late breaking information and guidance on NC Medicaid’s transition to Managed Care
THURSDAY, JULY 22 | 4-5 pm
Virtual Office Hour: Medicaid Managed Care Hot Topics
Medicaid Transformation Provider Services and North Carolina AHEC are conducting a series of Virtual Office Hours to offer an interactive format for providers to have their questions answered
NC Medicaid seeks your feedback on the Medicaid Managed Care webinar series (i.e., Medicaid Managed Care Hot Topics webinars, Back Porch chats, Fireside chats, Clinical & Quality webinars) hosted by Shannon Dowler, MD, Chief Medical Officer of the NC Division of Health Benefits, which began in March of 2020.
Your feedback will inform the topics and content provided for future webinars. Please access the link to the survey below to contribute your feedback. This survey has 5 questions and will take 3-5 minutes to complete.
The NCMS has developed a Medicaid Transformation landing page where you can access a wealth of information to help guide you and your practice. Additionally, the NCMS has created a Medicaid Transformation Issues form to log any specific issues you are encountering during this transformation. Information we compile from these online forms will be used to better serve you and your patients as we undergo this transition.
Due to the passage of SL 2021-62, effective July 1, 2021 , the following services are carved out of NC Medicaid Managed Care and should continue to be billed through NCTracks:
CDSAs and independent practitioner providers providing IFSP services for the CDSA should hold their claims from July 1, 2021, through July 12, 2021, for dates of service starting on July 1, 2021.
For more information, please see the Medicaid bulletin article Children’s Developmental Services Agency Providers Carved Out of Managed Care.
On June 14, the Department released updated Fact Sheets:
Please note that on the Introduction to Medicaid Transformation: Part 2 – Enrollment and Timelines it is indicated that mandatory beneficiaries (required to enroll in a health plan) have a 90-day choice period in which they can change health plans for any reason. The 90-days start as of the effective date of enrollment. Beneficiaries have 30 days after PCP assignment to change their PCP. Carolina Complete Health members can change their PCP by calling member services at 1-833-552-3876
Sharing on behalf of DHHS:
The NC Department of Health and Human Services will hold a webinar on June 4, 2021, from noon to 1 p.m. to update the public and interested stakeholders on the development of the Specialized Foster Care Plan.
The Department will review planning efforts underway for the Specialized Foster Care Plan and allow time for questions and answers. The webinar is open to the public and all interested stakeholders.
To register for the webinar simply click the link below. Feel free to share the webinar invitation and registration link with others who may be interested in attending.
Update on North Carolina’s Specialized Foster Care Plan
Noon – 1 p.m., June 4, 2021: Register in advance
For more information visit the Specialized Foster Care Plan page or contact Medicaid.NCEngagement@dhhs.nc.gov
The North Carolina Department of Health and Human Services has selected organizations to serve three regions of the state, marking a major milestone towards launching the nation’s first comprehensive program to test evidence-based, non-medical interventions designed to reduce costs and improve the health of Medicaid beneficiaries.
The North Carolina Department of Health and Human Services announced all Medicaid beneficiaries currently eligible to transition to managed care have selected or been assigned a health plan with 97% enrolled in a plan that includes their current primary care provider (PCP) in network.
View the entire press release from The Department, published on May 26, 2021
In response to stakeholder requests and feedback, the Department of Health and Human Services (the Department) is releasing data on the number of Medicaid and NC Health Choice beneficiaries, as of April 2021, who currently meet the eligibility criteria to enroll in Behavioral Health and Intellectual/Developmental Disability (I/DD) Tailored Plans and receive Tailored Care Management scheduled to launch in July 2022.
The table included shows this information in aggregate, and broken down by county and condition. For more information, please see Data on Medicaid and NC Health Choice Beneficiary Eligibility for Behavioral Health I/DD Tailored Plans and Tailored Care Management (PDF)
Sharing on behalf of DHHS:
May 18, 2021
The North Carolina Department of Health and Human Services is extending open enrollment for NC Medicaid Managed Care through Friday, May 21. This extension will not impact the NC Medicaid Managed Care launch date of July 1, 2021.
"Open enrollment allows NC Medicaid beneficiaries to choose a health plan that best suits the needs of their family," said Deputy Secretary for NC Medicaid Dave Richard. "We want to be sure beneficiaries have every opportunity to choose a plan, so even after open enrollment ends, they have until Sept. 30 to pick a different plan for any reason."
Beneficiaries can enroll in a health plan by calling the NC Medicaid Enrollment Broker Call Center at 833-870-5500 (TTY: 833-870-5588), going to the Enrollment Broker website or using the free NC Medicaid Managed Care mobile app available on Google Play or the App Store. The NC Medicaid Enrollment Broker also provides choice counseling to help beneficiaries determine which health plan is best for them. Most beneficiaries in NC Medicaid must be enrolled in a managed care health plan. More information can be found on the “Do I Need to Choose a Health Plan?” fact sheet.
To ensure health care continues without interruption, beneficiaries who do not choose a health plan by May 21 will be automatically enrolled in a health plan by NC Medicaid. The auto-enrollment process prioritizes existing relationships between beneficiaries and their primary care provider and, where possible, a plan that has contracted with that provider will be selected for the beneficiary.
Federally recognized tribal members living in the Tribal service area who do not choose a health plan by May 21 will be enrolled into the EBCI Tribal Option. The EBCI Tribal Option is primarily offered in five counties: Cherokee, Graham, Haywood, Jackson and Swain to federally recognized tribal members and others eligible for services through Indian Health Service (IHS).
Whether beneficiaries enroll through the NC Medicaid Enrollment Broker or are auto-enrolled by NC Medicaid, everyone will have through September 30, 2021, to change their health plan or primary care provider for any reason.
Beneficiaries are encouraged to reference the letter received from NC Medicaid Managed Care, visit the NC Medicaid Enrollment Broker website or call the Enrollment Broker Call Center at 833-870-5500 (TTY: 833-870-5588).
Duke will be a participating health system in Medicaid Managed Care. Visit the Plan for Duke webpage for more information on which PHPs Duke will be accepting in Medicaid Managed Care
NC DHHS has published new fact sheets on Enrollment and Timelines, as well as Managed Carolina Populations that do and do not need to enroll into pre-paid health plans
To assist with identifying North Carolina Medicaid and NC Health Choice beneficiaries currently assigned under the Community Care of North Carolina/Carolina ACCESS (CCNC/CA) program, NCDHHS generated a new Advanced Medical Home (AMH) NC Medicaid Direct/NC Medicaid Managed Care Primary Care Provider (PCP) Enrollee Report for distribution to CCNC/CA participating providers.
The report, initially made available on March 15, 2021, is delivered each month to the NCTracks Secure Provider Portal Message Inbox the Monday before the second checkwrite to coincide with the receipt of CCNC/CA management fees.
The AMH Medicaid Direct/Managed Care PCP Enrollee Report contains a list of all NC Medicaid beneficiaries who have been assigned to the identified NPI in the past 12 months and contains:
To effectively use the report, add filters or sort the report based on an Active status of “Y.” In this way, the provider can narrow the results to display only those currently enrolled in NC Medicaid and assigned to the identified NPI.
In addition to the Active status, the End Date of assignment will display the current eligibility span for the beneficiary which includes the provider assignment.
Back Porch Chat Webinar on Medicaid Managed Care Hot Topics, Thursday, May 6, from 5:30 p.m. - 6:30 p.m.
Shannon Dowler, MD, Chief Medical Officer, NC Medicaid, Division of Health Benefits, NC Department of Health and Human Services will host the event, which will focus on Behavioral Health Services in Standard Plans and related topics, including:
To ensure timely distribution of Glidepath payments, attestation deadlines for the May and June timeframes have been updated. Please note:
Glidepath Payment Reconsideration Process
As a reminder, once an AMH Tier 3 practice has attested to meeting Glidepath payment eligibility in NCTracks, DHHS will validate that the practice is enrolled with NC Medicaid and attested as an AMH Tier 3 practice. DHHS then confirms the attestation with the respective pre-paid health plans in order to validate that each Tier 3 practice has met contracting and testing criteria.
DHHS has developed a reconsideration process for providers who either missed the March Glidepath attestation deadline due to specific circumstances related to the COVID-19 pandemic and public health emergency or who disagree with the outcome of the validation determinations for the March Glidepath payment.
If you are a Tier 3 AMH, reach out to your Provider Engagement Coordinator for help!
Since most Medicaid beneficiaries will receive Medicaid services through health plans under managed care it is important they choose a health plan by May 14, 2021. Beneficiaries that do not choose a plan by May 14 will have a plan chosen for them.
Please join NC DHHS for a webinar to hear the latest updates in the state’s transition to Medicaid Managed Care including an overview of auto-enrollment and how it works. There will also be an opportunity for questions and answers.
Next steps in NC Medicaid’s Transition to Managed Care 2-3 p.m., April 21, 2021
Monday, April 5, 2021
On April 5, 2021, the Department of Health and Human Services posted the updated draft of NC Medicaid’s Managed Care Quality Strategy for public comments until May 6, 2021.
The strategy details the Department’s goals to improve the health of North Carolinians through an innovative, whole-person centered and well-coordinated system of care and measurement of quality, which addresses both medical and non-medical drivers of health. The Department’s Quality Strategy details Medicaid Managed Care aims, goals and objectives for quality management and improvement and details specific quality improvement (QI) initiatives that are priorities for the Department.
The updated Quality Strategy now incorporates the quality activities of all managed care plans, including the Behavioral Health I/DD Tailored Plans, the Eastern Band of Cherokee Indians (EBCI) Tribal Option and Community Care of North Carolina.
The North Carolina Medicaid Managed Care Quality Strategy update draft is available on the Quality Management and Improvement webpage. To comment on the strategy, please email Medicaid.NCEngagement@dhhs.nc.gov.
NC DHHS has added a number of helpful fact sheets to support providers during the transition to NC Medicaid Managed Care.
For a full collection of NC DHHS Fact Sheets and other resources, visit the NC Provider Playbook
Back Porch Chats (formerly Fireside Chats) will continue taking place every first Thursday of the month from 5:30-6:30PM. Hosted by Shannon Dowler, MD, Chief Medical Officer, NC Division of Health Benefits and moderated by moderated by Hugh Tilson, Director, NC AHEC Program.
Back Porch Chats cover a range of Medicaid Managed Care Topics and are great sources of information for all provider types!
For more information and to register, visit the NC AHEC Medicaid Managed Care webpage
The NC Medicaid Provider Services team is partnering with NC AHEC to host virtual Health Plan Meet and Greet sessions. NC Medicaid consultants and health plan representatives will be available to address your concerns and questions about the transition from Medicaid fee-for-service to Medicaid Managed Care.
Virtual Meet and Greet sessions are structured as conversations between providers and Managed Care Health Plan staff with a Q&A for participants. Sessions will be delivered live with a recording and transcript made available on this page after each event. Feel free to drop in at any time during the sessions below.
AMH Tier 3s may be eligible to receive $8.51 PMPM from NC DHHS beginning in April.
To receive the glidepath payment, a practice must attest to meeting the following requirements in NCTracks:
Your Provider Engagement team is here to help! Reach out to your Provider Engagement Coordinator (PDF) to get set up for AMH testing that will help you meet requirement #3 above.
To receive AMH Tier 3 glidepath payment for each month, practices must complete attestation before the deadlines lists below:
Beginning Monday, March 15, Medicaid beneficiaries are able to enroll into Medicaid managed care health plans. Last week, NC DHHS began mailing enrollment packets statewide and launched the NC Medicaid Enrollment Call Center and a mobile app called NC Medicaid Managed Care.
Beneficiaries can reach the NC Medicaid Enrollment Call Center at 833-870-5500 (TTY: 833-870-5588) or download the app on Google Play or the App Store.
The NC Medicaid enrollment website is also a resource for members to select a health plan.
The next important milestone for providers it to ensure they execute a contract before April 12th, so you are included in the period of auto-enrollment, beginning May 15.
Access the NC DHHS Provider Playbooks to read more about each milestone in the transition to Medicaid manged care.
NC DHHS, after careful consideration and review of recommendations from stakeholders, is postponing the launch of the Foster Care Plan until July 1, 2023. This delay will allow time for additional design of and input on the key features of the FC Plan for children and youth currently and formerly involved in the child welfare system.
Individuals in Foster Care will continue to receive services through Medicaid Direct and the LME-MCO behavioral health system.
If you would like to participate in the Department's Foster Care Plan Workgroup to support the interim and long-term plan for children in foster care, you should email Medicaid.NCEngagement@dhhs.nc.gov
This notification was distributed in the March 5 NCTracks Update.
For more information and latest updates, visit the NC DHHS Specialized Foster Care Plan webpage
Consistent with federal requirements and NC Medicaid’s vision to ensure continuity of care for members transitioning between prepaid health plans (PHPs) or service delivery systems, NC Medicaid has released the NCDHHS Transition of Care Policy. The draft policy was released for public comment in February 2020 and finalized on February 25, 2021.
NC Medicaid will host a webinar overview of the Transition of Care Policy on Thursday, March 11, 2021, from 12 noon to 1 p.m. Please pre-register for the webinar.
For questions about the Transition of Care Policy, please email Medicaid.NCEngagement@dhhs.nc.gov.
The state will transition to Medicaid managed care as of July 1, 2021 and to help practices prepare for this change, Medicaid Transformation Provider Services and North Carolina AHEC are conducting a series of Virtual Office Hours for those who serve Medicaid beneficiaries beginning in March 2021. These sessions offer an interactive format to have your questions answered on a range of topics related to Medicaid Managed Care. Providers are encouraged to submit questions in advance to Medicaid.firstname.lastname@example.org for discussion. Virtual Office Hours will cover a range of Medicaid Managed Care topics
The first session was held on Tuesday, March 2 at 4 p.m. with a focus on the Medicaid Provider Directory. The presenter was Christina Bunch, Associate Director of Provider Operations, NC Medicaid Transformation, NC Department of Health and Human Services. View the recording
A Message from NCTracks on Behalf of NC Medicaid:The Department recently released the Advanced Medical Home (AMH) Provider Manual 2.0 (PDF). This version reflects program expectations as well as recent program modifications and changes that impact provider contracts. It replaces the prior version issued on December 12, 2019. Additional guidance and program information are available on the Advanced Medical Home webpage.
The following materials have been added to the NC Medicaid Managed Care County Playbook and are available for review.
On July 1, 2022, the Department of Health and Human Services will launch the statewide Specialized Foster Care Plan. This specialized plan is intended to meet the unique needs of North Carolina children and youth currently and formerly involved in the child welfare system and to address receiving seamless, integrated, and coordinated health care.
The Foster Care Plan will integrate comprehensive physical and behavioral health services while maintaining treatment plans when placements change. This plan will also include care management services to improve coordination among service providers, families, involved entities (such as the Department of Social Services, Division of Juvenile Justice, schools) and other stakeholders involved in serving Foster Care Plan members.
To access the white paper on North Carolina's Specialized Foster Care Plan or to view a recent webinar providing an overview of this plan, visit the DHHS website for the Specialized Foster Care Plan
*All Medicaid Prepaid Health Plan (PHP) contracts signed prior to the delay will remain in effect unless otherwise specified or termed by the individual PHP or Provider. There is no need to request a new contract at this time if you obtained a fully executed contract prior to the delay
Do you need to make changes to your roster?
Your regional CCHN Provider Engagement Coordinators are also here for you!
Your provider engagement coordinator will be reaching out to schedule your provider orientation. Our goal is to customize this process to what works best for YOU and we would love your input! We invite you to complete this survey so we can gather a few of your preferences. Orientations will be conducted 90 days before go-live.
As North Carolina moves closer to implementing Medicaid managed care, the state has published additional information in its NC Medicaid Provider Playbook to help you make the transition. The move to managed care is set to ‘go live’ July 1.
One fast approaching date to keep in mind is February 1, which is the deadline for you to contract with the pre-paid health plans (PHPs) if you want to be included in the open enrollment phase of the transition.
More information on contracting and the timeline are included in these updated parts of the playbook: