October Provider Digest

AmeriHealth Caritas North Carolina (ACNC) is committed to providing the support you deserve. A Known System Issues Tracker is updated weekly and also available in NaviNet to providers.

You will find the following topics in this October digest:

• NC Medicaid Temporary Flexibilities Due to Hurricane Helene
• Prior Authorization Lookup Tool Now References the NC Medicaid Fee Schedule
• Updated Provider Manual Now Available
• NC Medicaid Reimbursement Rates Increased for Substance Use Treatment

QUALITY CORNER

• Controlling High Blood Pressure (CBP)

CLAIMS AND BILLING

• Electronic 275 Document Submission — New Availity Functionality
• Access to Claims Recovery Report
• Provider Claims Inquiries

MEDICATION AND PHARMACY

• Key COVID-19 Changes
• NC Medicaid Preferred Drug List (PDL): October 1, 2024

MEMBER BENEFIT SPOTLIGHT

• New Member Intervention Request Form

TRAININGS AND FORUMS

• Breathe Easy NC: Professional Development Series
• Ongoing Provider Training

NC Medicaid Temporary Flexibilities Due to Hurricane Helene

AmeriHealth Caritas North Carolina has established a dedicated web page with information about provider flexibilities, member eligibility and ways providers can report ongoing impact from Hurricane Helene. Please visit the Hurricane Helene Disaster Recovery page on our website.

Prior Authorization Lookup Tool Now References NC Medicaid Fee Schedule

In order to provide clear and transparent prior authorization requirements, providers may see a new message displayed when using the ACNC Prior Authorization Lookup Tool.

• If a code is not on the NC Medicaid fee schedule, the message below should appear:
  
  This code is not on the NC State Medicaid fee schedule and prior authorization is required. Please submit your request with supporting clinical documentation through NaviNet or fax to 1-833-893-2262.
  
  
• If a code is on the NC Medicaid Fee Schedule, the appropriate message regarding service prior authorization will populate.
• Providers using fax should include a completed Prior Authorization Request form found on the Prior Authorization webpage.

Updated Provider Manual Now Available

The updated Provider Manual (PDF) is available. For your convenience, a revision log is found at the back of the appendix to help identify updates. Several high-level revisions include:

• What to expect from Special Investigations Unit (SIU) activities
• Covered Behavioral Health services
• Local Health Department (LHD) High-Risk Pregnancy and At-Risk Children notification process
• Explanation of Benefits (EOBs) program and Service Exceptions for Third Party Liability (TPL)
• DHHS Tobacco Free Policy information — effective July 1, 2025

NC Medicaid Reimbursement Rates Increased for Substance Use Treatment

As of August 1, 2024, NC Medicaid increased the Substance Abuse Intensive Outpatient Program (SAIOP) and Substance Abuse Comprehensive Outpatient Treatment (SACOT) reimbursement rates to reflect a 29.2% increase over the current rates. This increase reflects combined annual inflation since the rates were last increased in 2012. For more information, read the NCDHHS blog from August 27, 2024.

Controlling High Blood Pressure (CBP)

This month, we want to spotlight the Controlling High Blood Pressure HEDIS measure. This measure is equal to the percentage of members 18 – 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90 mm Hg) during the measurement year.¹

Best practices² to meet the Controlling Blood Pressure (CBP) measure include:

• Document BP readings at every visit.
• Schedule follow-up visits for blood pressure control after diagnosis or medication adjustment.
• Consider referral to a cardiologist for those whose blood pressure goal cannot be attained, or for medically complex patients.
• Ensure proper cuff size is used on the patient's bare arm.
• Ensure the patient’s feet are flat on the floor and their legs are uncrossed during the reading. Crossing legs can raise the systolic pressure by 2 – 8 mmHg.³
• Make sure the elbow is at the same level as the heart. If the patient’s arm is hanging below heart level and unsupported, this position can elevate the measured blood pressure by 10 mmHg.³
• Take it twice: if the patient has a blood pressure reading 140/90 mmHg or greater at the beginning of the visit, retake and record it at the end of the visit. Consider switching arms for subsequent readings.
• Educate patients about the risks of uncontrolled blood pressure and reinforce the importance of medication adherence.
• Utilize CPT Category II coding in claims submission; guidance outlined below:
• Diastolic < 80 mm Hg: 3078F
• Diastolic between 80 – 89 mm Hg: 3079F
• Diastolic ≥ 90 mm Hg: 3080F
• Systolic < 130 mm Hg: 3074F
• Systolic between 130 – 139 mm Hg: 3075F
• Systolic ≥ 140 mm Hg: 3077F

Please contact your Provider Network Management Account Executive with any questions.

If your practice is interested in partnering with ACNC on Controlling Blood Pressure educational events for your patients, please contact our Quality team at ACNCQualityManagement@amerihealthcaritas.com

New Member Intervention Request Form

Providers are encouraged to refer members to the Population Health (PH) program for support with missed appointments, transportation services, or further education on their treatment plan or chronic condition, or who need assistance with value-added benefits, including ordering a car seat for pregnant members. Providers can complete a Member Intervention Request form and fax to our Rapid Response Outreach Team at 1-833-816-2262.

Key COVID-19 Changes

Effective October 1, 2024, North Carolina Medicaid changed the coverage, cost sharing and reimbursement for COVID-19 related products and treatment. Find more information in the September 25, 2024 NCDHHS blog post.

Included in the reminder:

• Pharmacy point-of-sale coverage of FDA-authorized over the counter (OTC) COVID-19 tests ended on September 30, 2024. The NC Department of Health and Human Services (NCDHHS) has partnered with more than 270 local organizations statewide, called Community Access Points, to distribute free COVID-19 at-home tests in their communities. Individuals can use this website to find COVID-19 home tests for pickup near them. Individuals must be 14 years or older to pick up free at-home tests. An ID is not required.
  
  

The COVID vaccine administration rate with revenue code 0771, will no longer reimburse at the $65 vaccine administration rate. Reimbursement rates for COVID-19 vaccine administration will revert to the vaccine administration rates as posted in the appropriate North Carolina Medicaid Fee Schedule

NC Medicaid Preferred Drug List (PDL): October 1, 2024

Visit the NC Medicaid website for the October 1, 2024, PDL updates.

Breathe Easy NC: Professional Development Series

Every day in communities across North Carolina, Breathe Easy NC is working to connect people who struggle with mental health and substance use to the best practice tobacco treatment they deserve. The Breathe Easy NC Professional Development Series prepares professionals from diverse disciplines and settings to help those with behavioral health conditions to become tobacco-free.

The South Piedmont Area Health Education Center (AHEC) offers FREE MODULES with 1.5-hour modules, including Continuing Education Units (CEU). Visit the training modules library focused on tobacco-free living to participate and register.

Reprinted with permission from NCDHHS Tobacco Prevention and Control Branch.

Ongoing Provider Training

Our Provider Account Executives and Clinical Educators support providers with virtual or face‐to‐face meetings (as feasible), formal training, and ad hoc programs to support care management, prior authorizations, correct billing procedures and other secure online services and programs to identify and improve health outcomes based on HEDIS measures and Opportunities for Health. If you would like a one-on-one, virtual or in-person visit from your dedicated Provider Network Account Executive, inquire via email.

Visit our Provider Training webpage for the latest offerings including quarterly Clinical Leadership Forums, a new Behavioral Health webinar series, monthly Provider Orientations and NaviNet Provider Portal trainings and a weekly, Electronic Visit Verification (EVV) informal Q&A session specifically for Home Health Providers that bill taxonomy code 251E00000X.