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Most Important Thing- SEE PATIENTS DAY ONE!

­­NCDHHS and the Plans have put many guardrails in place to help make sure that patients can continue to get care without disruption, even if there are hiccups elsewhere.

  • Previous Prior Approvals still stand
  • Even if you are not signed up with a Plan, the Plan will pay you at in-network provider rates for the first 60 days for most* patients (until August 30) (*longer for newborns, see below)
  • Even if you are not signed up with a Plan, the Plan will pay at in-network provider rates for newborns (90 days from DOB)
  • Patients have 90 days to change Plans for any reason (until September 29)
  • Children who are currently (prior to 7/1/21) in foster care (DSS custody) should have no change to their Medicaid. They should be, and should remain, in Medicaid Direct.
  • Children who are enrolled in a Standard Plan but enter foster care after 7/1 will move into Medicaid Direct –fee for service Medicaid (like now) - with the same coverage foster children/youth get now and mental health authorized through the LME/MCOs

(Links to supporting documents for these items are at the bottom if you need them)

Resources

1. NCDHHS Day One Document: https://medicaid.ncdhhs.gov/media/9521/download?attachment

This document answers so many questions! For example:

  • Provider portals and Quick Reference Guides for all Plans
  • How to verify eligibility and Plan
  • How to contact the Provider Ombudsman if you run into problems
  • How to file a claim in first 60 days when not enrolled with the Plan: The claims section has numbers to call to file a claim.
    • Every place I called required at least an NPI and sometimes a claim number to get started
    • United’s hours are 10 to 4
    • There is a typo for Healthy Blue’s number – like elsewhere (correctly) on the fact sheet, the area code is 844 (correct number is 844-594-5072)
    • Wellcare recommends on-line and CCH is only on-line
    • A human answers at Amerihealth and said that they could help me with a paper check

2. AmeriHealth
  • Provider Manual
  • Billing and Claims (Expand Claims Submission and Payment)
  • AMHC will issue the first payment for medical and pharmacy claims on July 7, 2021. After the first payment runs on July 7, medical payment cycles will be every Monday and Wednesday, while Pharmacy cycles will run every four days.
  • Member Services Line- Phone Number: 1-855-375-8811 • Website: www.amerihealthcaritasnc.com

3. Carolina Complete

4. Healthy Blue
  • Provider Manual
  • Billing and Claims
  • Medical claims submitted on July 1, 2021, will be paid by July 30, 2021 or sooner. Pharmacy claims that are submitted on July 1, 2021 will be paid by July 14, 2021 or sooner. Payment disbursements for both medical and pharmacy claims are sent on Wednesdays.
  • Member Services Line-  Phone Number: 1-844-594-5070 • Website: www.healthybluenc.com

5. United Healthcare
  • Provider Manual
  • Billing and Claims
  • UNHC’s first check cycle will be on July 12, 2021. • Check cycles take two days to complete. One day for ERA (electronic remittance advice)/PRA (paper remittance advice) generation and one day for check payment either through paper or electronic EFT. Therefore, the first payment for North Carolina Medicaid will be completed on July 14, 2021. Payment cycle for both medical and pharmacy claims will be a daily check cycle
  • Member Service Line- Phone Number: 1-800-349-1855 • Website: www.uhccommunityplan.com/nc
  • Provider portal functionality will not be live until 7/1/21.   Eligibility will also not be available until 7/1/21.

6. WellCare
  • Provider Manual
  • Billing and Claims
  • WCHP will issue the first medical claims payment on July 6, 2021. Pharmacy payments are issued at the point of sale and the first pharmacy payment will be issued on July 1, 2021. Both medical and pharmacy claims will be paid daily, thereafter. Check runs take place daily except for Sundays, last day of the month and national holidays.
  • Member Services Line- Phone Number: 1-866-799-5318 • Website: www.wellcare.com/nc
  • Provider Portal Guide attached.
Troubleshooting
To help a patient change the PCP:  Contact the Plans' Members Services. Phone or App.

To help a patient change a Plan: Contact the Enrollment Broker at 1-833-870-5500. 

To get paid by a Plan You Don’t Take – reach out through the Claims information in NCDHHS’ Day One document

For other questions, reach out to the Plan through the links/numbers in the NCDHHS Day One document.

NCDHHS has a WEALTH of information on their website. Here is one of my favorite pages: https://medicaid.ncdhhs.gov/blog/2021/06/16/nc-medicaid-managed-care-provider-update-june-16-2021 (remember, “control f” is a handy way to find your specific topic).

If you can’t find it there, try googling your topic plus NC Medicaid transformation 2021 (like NC Medicaid transformation 2021 prior authorizations).


Problems that you can’t get resolved with the Plan?: From NCMS - As with any major change, there are sure to be things that do not go according to plan, and the NCMS and our partners have developed a process we hope will help our members deal with this momentous shift in how services will be delivered to patients covered by Medicaid. We have created a special form where you can log your issues with us. The purpose is to aggregate common complaints so we can communicate with the state and our contacts at each health plan what many members are experiencing. If issues occur, please reach out to the plan first to share your experience. If the issue persists, then you can complete our Medicaid Transformation Issues form.
Back Up Info for Bullets At The Top
Current prior authorizations still stand: From NCDHHS Medicaid Managed Care Provider Update - Sept. 29, 2021 – Last date by which the health plan must honor existing and active prior authorizations on file with the North Carolina Medicaid or NC Health Choice program (or until the end of the authorization period, whichever occurs first) https://medicaid.ncdhhs.gov/blog/2021/06/16/nc-medicaid-managed-care-provider-update-june-16-2021

First 60 days paid at in-network rates: From NCDHHS Transition of Care Policy -  For the first sixty (60) days after MCL, PHPs are required to pay claims and authorize services for Medicaid eligible nonparticipating/out-of-network providers equal to that of in-network providers until the end of Episode of Care or the 60 days, whichever is less. In these circumstances, the PHP shall follow the timeframes provided in N.C. Gen. Stat. § 58-67-88(d), (e), (f), and (g).  https://files.nc.gov/ncdma/documents/Transformation/caremanagement/NCDHHS-Transition-of-Care-Policy-20210225.pdf (page 18) 

90 days from birth for newborns: From NCHHS Provider Playbook Eligibility for Newborns - Health plans will treat all out-of-network providers the same as in-network providers for purposes of prior authorization and will pay out-of-network providers the Medicaid fee-for service rate for services rendered through the earlier of: 1. 90 days from the newborn’s birth date or 2. The date the health plan is engaged* and has transitioned the child to an in-network primary care provider (PCP) or other provider. https://medicaid.ncdhhs.gov/media/9529/download?attachment

First 90 days for patients to change plans: From NCDHHS Provider Fact Sheet - 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. https://files.nc.gov/ncdma/documents/Providers/playbook/NCMT-Provider-FactSheet-Beneficiary-Enrollment-and-Timelines-20210422-DRAFT.pdf  (Page 2. Page 3 answers the Q what if beneficiaries want to keep me as their PCP?)
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