November Provider Digest

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

• AmeriHealth Caritas North Carolina To Manage Prior Authorization Requests Now Managed Through eviCore Healthcare Beginning December 1, 2023
• New Private Duty Nursing and Personal Care Service Medicaid rates increased
• Post Service Review (Retrospective) Policy & Procedure Update
• Providers Required to Resubmit Claims with Missing Revenue Codes

REMINDERS

• Rendering Provider Information Required for Claims
• Sexually Transmitted Infection Treatment Policy Change
• 2023 NC Community Health Worker Summit
• NC Medicaid Expansion Policy Flexibilities Announced
• Care Gap Response Form and Documentation Deadlines
• Provider Reverification

AmeriHealth Caritas North Carolina To Manage Prior Authorization Requests Now Managed Through eviCore Healthcare Beginning December 1, 2023

Effective December 1, 2023, AmeriHealth Caritas North Carolina (ACNC) will be the single point of contact for prior authorization requests that are new or for continuation of services. There will be no change to the process for Radiology service authorizations, which will continue to be 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 assure 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 will be updated to address changes to instructions for providers and guidelines that will be effective December 1, 2023.  The changes will include an increase in the number of visits for specialized therapies (Physical, Occupational and Speech) covered without prior authorization. Specifically, ACNC will cover up to 72 visits for members ages 20 and younger and 27 visits for members ages 21 and older without prior authorization provided that members meet eligibility and other plan criteria.

Beginning December 1, 2023, 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

New Private Duty Nursing and Personal Care Service Medicaid Rates Increased

The NC budget is now Session Law – 2023-134 (PDF). A new Medicaid fee schedule has been published by NC DHHS 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 the present. If you have questions, please reach out to your designated provider network account executive.  

Post Service Review (Retrospective) Policy & Procedure Update

Effective on December 17, 2023, ACNC will follow the retrospective review policy criteria outlined below 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

Providers Required to Resubmit Claims with Missing Revenue Codes

In adherence to 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 the claims and include the NDC data and HCPCS code that were missing on the original 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.

REMINDERS

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.

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.

NC Medicaid Expansion Policy Flexibilities Announced

Please see the October 28, 2023, Provider Digest for the full article with a flexibilities grid.

Care Gap Response Form and Documentation Deadlines

Providers are encouraged to have all Care Gap Closure Forms uploaded via the NaviNet provider portal by Thursday, December 14, 2023.

• Prospective Year-Round Medical Record collection efforts for hybrid measures end on December 16, 2023.
• Prospective Year-Round Medical Record collection efforts for administrative measures end on January 20, 2024.

Provider Reverification

Recredentialing/reverification is an evaluation of a provider’s ongoing eligibility for continued participation in NC Medicaid. Providers who do not complete the recredentialing process on time will be suspended from Medicaid program participation.

Providers are encouraged to review the list and check your Provider Message Inbox in the NCTracks Secure Portal for notifications. For more information, visit NC Tracks (the reverification section of the Status and Management page) for the option to reverify. Find more information on the NCDHHS website, or contact the NCTracks Call Center at 1-800-688-6696 for assistance.