December Provider Digest

AmeriHealth Caritas North Carolina (ACNC) is committed to providing the support you deserve. You will find the following topics in this December digest:

NC MEDICAID NEWS

ACNC POLICY UPDATES

CLAIMS AND BILLING GUIDANCE

MEMBER BENEFIT SPOTLIGHT

TRAININGS AND FORUMS

2024 PerformPlus® True Care Programs Launch

AmeriHealth Caritas North Carolina (ACNC) is pleased to announce enhanced incentive programs for selected providers, effective January 1, 2024. The PerformPlus True Care Programs are reimbursement systems developed for participating practitioners to deliver quality, cost-effective and timely care to our members. These programs suggest opportunities for providers to enhance revenue while providing quality and cost-effective care.

Manuals and measures for 2024 will be posted to our Value-Based Programs webpage soon. The 2024 programs include:

  1. PerformPlus True Care — Maternity Care Providers
  2. PerformPlus True Care — Behavioral Health Providers
  3. PerformPlus Total Cost of Care — Primary Care Providers
  4. PerformPlus True Care — Maternity Care Incentive Plan
  5. PerformPlus True Care Gaps in Care — Primary Care Gaps in Care

Please join Practice Transformation Director Pinkey Slade for a training opportunity in February to learn more about these enhancement programs.

NaviNet Plan Central Homepage Has a Fresh Look!

The NaviNet Provider Portal helps speed up the provider-health plan connection and can often replace paper transactions. Here are some of the key enhancements that make using NaviNet even more convenient:

  • Fresh new look with larger text sizes for easier reading
  • Cleaner layout for improved alphabetical navigation
  • Faster access to key quality improvement information
  • Extended list of resources to close gaps in care

If you haven’t yet signed up for NaviNet, the provider portal, register today for this important tool.

Start Reading Connections Annual Provider Newsletter Online Now!

In this issue (PDF), you will find interviews and articles promoting HEDIS measures and value-based programs; quality improvement initiatives; and helpful provider resources, such as Provider Reverification instructions, Early and Periodic Screening, Diagnostic and Treatment (EPSDT) and training registration for NaviNet, our provider portal. We also highlight our Wellness & Opportunity Centers and activities.

AmeriHealth Caritas North Carolina Now Managing Prior Authorization Requests Previously Managed by eviCore healthcare

As of December 1, 2023, AmeriHealth Caritas North Carolina (ACNC) is the single point of contact for prior authorization requests that are new or for continuation of services. There has been no change to the process for Radiology service authorizations, which are managed by NIA.

Any prior authorization requests submitted to eviCore healthcare before midnight on November 30, 2023, for selected service or items outlined on our website will be managed by eviCore. To ensure a smooth transition of the management of prior authorization requests, we ask that providers refrain from submitting duplicate requests to eviCore and ACNC.

The ACNC Prior Authorization webpage, Lookup Tool, and Reference Guide have been updated to address changes to instructions for providers with new guidelines. Specific rule changes include an increase in visits without prior authorization for specialized therapies (Physical, Occupational and Speech) to 72 visits for members ages 20 and younger and 27 visits for members ages 21 and older.

Providers should submit all prior authorization requests that are new or for continuation of services directly to ACNC via any one of the following ways: 

  • The fastest way to submit medical prior authorizations is electronically, via Medical Authorizations in NaviNet.
  • Request authorization by phone from ACNC Utilization Management at 1-833-900-2262 (8 a.m. to 5 p.m., Monday to Friday). After hours, weekends and holidays, please call Member Services at 1-855-375-8811.
  • Fax a completed Prior Authorization Request Form (PDF) to 1-833-893-2262.

To verify whether a service or item requires prior authorization, use the Prior Authorization Lookup tool on our website. Please remember, the results of this tool are not a guarantee of coverage or authorization. If you do not see the service you are seeking, please contact Utilization Management at 1-833-900-2262.

If you have questions about this transition, please contact your designated Provider Network Account Executive.

NC MEDICAID NEWS

NCDHHS Increased Behavioral Health Reimbursement Rates Effective in 2024

Following a significant investment in behavioral health care services in the 2023 – 2025 state budget, the North Carolina Department of Health and Human Services (NCDHHS) announced Medicaid reimbursement rate increases to be implemented on January 1, 2024, for most mental health, substance use, intellectual and developmental disabilities (I/DD) and traumatic brain injury (TBI) services in North Carolina. See the Medicaid bulletin for more details.

New Private Duty Nursing and Personal Care Service Medicaid Rates Increased

The North Carolina budget is now Session Law – 2023-134 (PDF). A new fee schedule has been published on the NCDHHS Medicaid website that outlines new Private Duty Nursing (PDN) and Personal Care Service (PCS) rates that are retroactively effective as of July 1, 2023.

ACNC will reprocess the PDN and PCS claims from July 1, 2023, to date. If you have questions, please reach out to your provider network account executive. The policy in full is found on our website.

ACNC POLICY UPDATES

Post Service Review (Retrospective) Policy and Procedure Update

Effective December 17, 2023, ACNC will follow the retrospective review policy criteria outlined as follows, and all requests will be denied unless they meet the requirements in the policy. 

Per the ACNC UM Post Service Review (Retrospective) Policy & Procedure, a retrospective/post-service UM review will only be performed in the following circumstances:

  • When the member obtains retroactive eligibility
  • When pertinent coverage information is not available, or incorrect, upon admission or at the time of the service (i.e. member presented as self-pay or with altered level of consciousness)
  • When an out-of-state facility treats the member emergently/urgently
  • When a provider is able to show that attempts were made to submit request prior to the service but the plan did not receive the request
  • Based on specific provider contract terms

Sexually Transmitted Infection Treatment Policy Change

Effective December 1, 2023, ACNC will no longer review laboratory services related to sexually transmitted infection treatment (STI) screenings for bundled reimbursement. For questions, please contact Provider Services at 1-888-738-0004.

CLAIMS AND BILLING GUIDANCE

Billing Guidance for High-Density Lipoprotein (HDL) or Lipid Testing

Lipid testing is used for patients with an established diagnosis that supports medical necessity. ACNC follows the National Coverage Determination guidelines for medical necessity. Some examples of the conditions in which lipid testing may be indicated include, but are not limited to:

  • Assessment of patients with atherosclerotic cardiovascular disease
  • Evaluation of primary dyslipidemia
  • Any form of atherosclerotic disease, or any disease leading to the formation of atherosclerotic disease
  • Diagnostic evaluation of diseases associated with altered lipid metabolism, such as nephrotic syndrome, pancreatitis, hepatic disease, hypothyroidism and hyperthyroidism
  • Secondary dyslipidemia, including diabetes mellitus; disorders of gastrointestinal absorption and chronic renal failure
  • Signs or symptoms of dyslipidemias, such as skin lesions
  • As follow-up to the initial screen for coronary heart disease (total cholesterol + HDL cholesterol) when total cholesterol is determined to be high (>240 mg/dl), borderline-high (200 – 240 mg/dl) plus two or more coronary heart disease risk factors, or an HDL cholesterol (<35 mg/dl)

Stop Claims Denials and Receive Faster Payment

If you are struggling with claims, please see this list of the most common reasons for claims denials. Contact your dedicated Network Account Executive with questions. ACNC has a 180-day timely filing deadline for original claims with date of service prior to July 1, 2023. Effective July 1, 2023, ACNC has a 365-day timely filing deadline for original claims with dates of service July 1, 2023, and forward. Corrected claims can be submitted within 365 days of original service.

  • Explanation of Benefits from Primary Carrier Required
    Required when the member has an insurance plan (other than Medicaid) that is the primary payer for services or products provided.
  • Submitted After Plan Filing Limit
    ACNC has a 180-day timely filing deadline for original claims, while corrected claims can be submitted within 365 days of the original service.
  • Definite Duplicate
    Occurs when a claim for the same member/date/service/provider has been previously received and adjudicated by the health plan.
  • No Precertification/Authorization Obtained
    There is no evidence that required authorization was obtained for the service or product.
  • Ordering, Rendering, Prescribing (ORP) Provider Taxonomy Missing/Inaccurate
    Required taxonomy codes are missing or do not match what is on file for the provider with NCDHHS/NCTracks.
  • No Medicaid ID (NO MAID)
    Monitoring warning messages to ensure the NO MAID denials are appropriate.

Rendering Provider Information Required for Claims

Providers billing with Taxonomy IDs 193200000X or 193400000X must include the rendering provider information with their claim submission. Claims that do not include this information will be rejected by our clearinghouse. See page 29 of the ACNC Provider Claims Billing Guide (PDF) for instruction on completing Boxes 24I and 24J on the CMS-1500 claim form.

Providers Required to Resubmit Claims with Missing Revenue Codes

In adherence with federally required rebate guidelines, NC Medicaid requires the submission of a Healthcare Common Procedure Coding System (HCPCS) code AND the National Drug Code (NDC) on all drug claim lines with revenue codes 0250-0259 and 0631-0637 that are submitted on outpatient hospital institutional claims, which are billed on a UB-04/837-I. For dates of services prior to May 1, 2022, North Carolina Medicaid is requiring that prepaid health plans recover all impacted claims that were previously paid incorrectly. The detail of this notification is included on the ACNC Known Issues Tracker (PDF), dated 10/11/23.

Providers are required to resubmit claims with missing HCPCS and NDC on Outpatient Hospital claims. Any claims resubmitted to correct this error will not be subject to timely filing denials.

Providers are encouraged to review the March 30, 2022, Pharmacy Billing Reminder for Revenue Codes 025x and 063x.

MEMBER BENEFITS SPOTLIGHT

Electric Non-medical Breast Pumps Are Available for Expectant or New Moms

ACNC provides electric non-medical breast pumps for expectant or new moms who are between 26 weeks gestation and 12 months postpartum. The value-added benefit also includes 270 milk storage bags every 3 months for up to 1 year. This benefit is limited to one pump per member per lifetime.

Prior authorization is not required. Eligible members can contact our vendor, Aeroflow, directly at 1-844-867-9890 or visit their website at aeroflowbreastpumps.com. Aeroflow’s dedicated specialists will verify plan enrollment and contact the member’s provider to confirm details. Visit our website for more information on value-added benefits for pregnancy and women’s health

TRAINING AND FORUMS

2024 PerformPlus True Care Programs Launch

Please join Practice Transformation Director Pinkey Slade, for one of the following training opportunities to learn more about the enhancement programs:

  • Wednesday, January 17, 2024, at 12:00 p.m.
  • Monday, January 22, 2024, at 12:00 p.m.

NEW Electronic Funds Transfer Enrollment Link

ACNC contracts with Change Healthcare and ECHO Health, Inc., to administer electronic funds transfer (EFT) payments and electronic remittance advice (ERA). If your practice has not yet registered for EFT, enroll using this direct ACH enrollment link where there are no fees for single payer agreements. If you have any questions or are experiencing any problems with payments or registration, please contact our Provider Network Account Executive.

Trainings and Forums Continue into 2024

Check back often on our Training webpage for the latest educational, forum and self-paced training opportunities. We continue to offer ways for our providers to engage with quality measures, resources, best practices and forums.

Providers