Claims, Billing, and Payment
The North Carolina Department of Health and Human Services (DHHS) provided directives to Prepaid Health Plans (PHPs) to pend skilled nursing facility (SNF) claims submitted prior to patient monthly liability (PML) determination. PML is determined by the Department of Social Services (DSS) for North Carolina Medicaid.
Directives for processing claims
Claims received by Carolina Complete Health prior to PML determination will pend as an unclean claim for 90 calendar days. If the claim is clean as cited in section 3.41 of Managed Care Billing Guidance to Health Plans, version 24 and the PML is received within the 90 calendar days, we will pay the claim. If the PML is not received within 90 calendar days of receipt of the claim, we will deny the claim as consistent with North Carolina General Statute § 58-3-225(d). If the missing additional information (i.e., the PML) is received within 1 year after the date of the denial notice closing the claim, Carolina Complete Health is required to reopen and process the claim in accordance with North Carolina General Statute § 58-3-225(d).
Please view our Provider FAQ on the pended unclean claims for additional information (PDF).
Further, as required by North Carolina General Statute § 58-3-225(d), Carolina Complete Health will inform providers in the denial notice that the claim will be reopened if the PML is received within 1 year of the date of the denial notice closing the claim.
Reprocessing denied claims
DHHS requires PHPs to reprocess claims with dates of service from July 1, 2021, to present day that were previously denied for timely filing where the PML was delayed by DSS.
What this means for you
There’s nothing you need to do for us to reopen and process claims from this timeline. We’ll notify you of any affected claims.
Questions?
Contact Provider Services by calling 1-833-552-3876 or reach out to Network Support team directly via email: NetworkRelations@cch-network.com
Claim Dispute Form
- Carolina Complete Health Standard Plan: Claim Reconsideration and Grievance Form (PDF)
- Trillium Tailored Plan Physical Health: Claim Reconsideration and Grievance Form (PDF)
Billing Manual and Provider Guides
- UPDATED: Billing Manual (PDF)
- NEW: Tailored Plan Billing with Partners and Trillium for Physical Health Providers (PDF)
- NEW: Provider Taxonomy Guide (PDF)
- NEW: Provider Guide: Claim Corrections, Reconsiderations, and Grievances (PDF)
- UPDATED Claims Guide- Timely Filing (PDF)
- UPDATED: EPSDT Claims and Authorizations (PDF)
- Provider FAQ- Pended Claims Requiring Additional Information (PDF)
- Claims Guide- Duplicate Submissions (PDF)
- Pediatric Provider Billing Guidance (PDF)
- Claims Submission Reminder Guide (PDF)
- Provider Guide for 340B Drug Claims (PDF)
- Guidance for Submitting CLIA Claims (PDF)
- Coordination of Benefits Walkthrough (PDF)
- 835 EDI Companion Guide (PDF)
- 837 EDI Companion Guide (PDF)
- 2022 AMA Coding Guidelines for Social Determinants of Health (PDF)
Electronic Funds Transfer (EFT)
- Payspan is an innovative web-based solution for Electronic Funds Transfers (EFTs) and Electronic Remittance Advices (ERAs). By using Payspan, you can speed up the processing and payment of your claims.
- Note: In November of 2022, Zelis, a company modernizing the business of healthcare, completed the acquisition of Payspan. Read on for more details. Providers should continue using the Payspan payment portal. Login or register here: https://www.payspanhealth.com/nps
- Payspan: A Faster, Easier Way to Get Paid (PDF)
- To contact Payspan: Call 1-877-331-7154, Option 1 – Monday thru Friday 8:00 am to 8:00 pm est.
Troubleshooting Frequent Claims Questions/Issues
- Confirm that the Taxonomy on the claim matches what is in NCTracks.
- Review the Claims Submission Reminder Guide (PDF) and please also advise your Clearinghouse to make sure the changes made to taxonomy placement are permanent on your account going forward.
Taxonomy Placement:
CMS 1500 Paper Submission
- Rendering – Box 24i should contain the qualifier “ZZ”. Box 24j (shaded area) should contain the taxonomy code.
- Billing – Box 33b should contain the qualifier “ZZ” along with the taxonomy code.
- Referring – If a referring provider is indicated in Box 17 on the claim, Box 17a should contain the qualifier of “ZZ” along with the taxonomy code in the next column.
837 Professional Submission
- Billing –Loop 2000A PRV01=“BI” PRV02 = “PXC” qualifier PRV03 = 10 character taxonomy.
- Rendering – Loop 2310B PRV01=“PE” PRV02 = “PXC” qualifier PRV03 = 10 character taxonomy code002E.
- Please note that “PXC” is the correct qualifier and that there is no taxonomy number needed for referring physician.
UB-04 Paper Submission
- Billing – Box 81CCa should contain the qualifier of “B3” in the left column and the taxonomy code in the middle column.
837I Electronic Submission
- Billing - Loop 2000A PRV01 = “BI” PRV02 = “PXC” qualifier; PRV03 = 10 character taxonomy code.
Review the Billing Manual (PDF) for guidance.
- NCTracks is the “system of record” for provider enrollment data, which is then shared with health plans to inform contracting and provider directories. If provider information is not current, then the data that flows forward to the health plans and the enrollment broker will not be accurate.Refer to the Provider Data and Enrollment Guide (PDF) and the Claims Submission Reminder Guide (PDF).
- Refer to page 22 (see below) of the Billing Manual (PDF). Best practice is to submit corrected claims rather than new claims to avoid this denial.
- Duplicate Edits: Code auditing will evaluate prospective claims to determine if there is a previously paid claim for the same enrollee and provider in history that is a duplicate to the prospective claim. The software will also look across different providers to determine if another provider was paid for the same procedure, for the same enrollee on the same date of service. Finally, the software will analyze multiple services within the same range of services performed on the same day. For example a nurse practitioner and physician bill for office visits for the same enrollee on the same day.
- This comprehensive guide (PDF) walks you through how to submit COB information on a professional claim submitted via the Provider Portal. When following these instructions, it is not a requirement to include a copy of the explanation of Benefits received from the primary payer when submitting a claim via the Secure Provider Portal. We offer this as an optional feature. For claims submitted outside the portal, the EOB is required.
Definitions
- Paid in Full - The claim has been adjudicated, processed and reimbursed in accordance and with the executed provider contract on file including the coordination of benefits, as applicable per claim.
Provider Claims Payment Schedule
| Claim Type | Claims Payment Schedule |
|---|---|
| Medical | Weekly, Tuesday and Friday |
Envolve Vision | Weekly, Wednesday |
NIA | Weekly, Tuesday and Friday |
Pharmacy | Weekly, Wednesday |