February Provider Digest

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

PHARMACY

TRAINING

RESOURCES

Public Health Emergency Update

During the Public Health Emergency (PHE), the federal government established rules to allow Medicaid beneficiaries to continue receiving health care coverage. This was referred to as “continuous enrollment.” This provision meant that individuals who were already on Medicaid before the PHE, as well as those who were added to Medicaid rolls during the PHE, were able to stay on Medicaid without going through a renewal, or redetermination, process.

As part of an end-of-the-year spending bill signed into law on December 29, 2022, Congress set an end to the continuous enrollment provision as of March 31, 2023.

Based on the federal action, the NC Department of Health and Human Services (NCDHHS) has announced that they expect local Divisions of Social Services (DSS) to resume the annual renewal, or redetermination, process beginning April 1. Based on the expected 90-day review process, individuals who are no longer eligible for Medicaid coverage could begin to lose this coverage on July 1.

Meanwhile, the federal government announced on January 11 that the Public Health Emergency had been extended for at least 90 more days. The federal Department of Health and Human Services has indicated it will give at least a 60-day notice of the ending of the PHE.

For the latest information provided by the NCDHHS, please visit their website.

Provider Total Cost of Care (TCOC) and Quality Enhancement Programs (QEP) Launch

AmeriHealth Caritas North Carolina (ACNC) is pleased to announce enhanced incentive programs for selected providers effective January 1, 2023. The Quality Enhancement 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 are found on the new Provider Incentive Programs page.

Join Practice Transformation Director Pinkey Slade on Tuesday, March 7, 2023, at 11:30 a.m. or Thursday, March 9, 2023, at 9:00 a.m. to learn about the new Primary Care Physician Total Cost of Care program.

The 2023 program manuals below are available on the new Provider Incentive Programs webpage:

  1. Behavioral Health Quality Enhancement Program (BH QEP)
  2. Perinatal Quality Enhancement Program (PQEP)
  3. Primary Care Provider Total Cost of Care (PCP TCOC)

2023 Clinical Leadership Forums

ACNC is pleased to provide an opportunity for providers to engage with our clinical and behavioral health leaders to discuss quality improvement activities, associated challenges, and best practices related to quality and population health outcomes. Register here for one or more dates.

We invite you to join ACNC clinical leaders on March 8, 2023, for the topic Behavioral Health (BH) Chronic Conditions to include:

  • Introduction
  • Behavioral Health Chronic Conditions
  • Overview of Collaborative Care Model
  • Screening for Depression Follow-up Plan Measure Overview
  • Behavioral Health Quality Enhancement Program (BH QEP) and Resources
  • Best Practice Spotlight
  • Feedback and Questions
Topics Quarterly on Wednesdays Time
Behavioral Health Chronic Conditions March 8, 2023 Noon – 1:00 p.m.
Women’s Health and Wellness June 14, 2023 Noon – 1:00 p.m.
Health Equity and Social Determinants of Health September 13, 2023 Noon – 1:00 p.m.
Physical Health Chronic Conditions December 13, 2023 Noon – 1:00 p.m.

NC Health Choice (North Carolina’s CHIP program) is moving to Medicaid.

On April 1, 2023, approximately 55,000 children (aged 6 – 18) who are currently enrolled in NC Health Choice will move to Medicaid. Beneficiaries moving from NC Health Choice to Medicaid will be eligible to receive additional benefits, including:

  • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) to discover and treat childhood health conditions before they become serious.
  • Assistance getting to and from Medicaid-covered services through Non-Emergency Medical Transportation (NEMT) services.
  • Prenatal care, childbirth, and postpartum care.
  • No enrollment fees or copays.

Effective April 1, 2023, all copays and other cost-sharing mechanisms currently in place for NC Health Choice beneficiaries and providers will sunset due to the transition of those beneficiaries to the Medicaid benefit plan. Beneficiaries currently under NC Health Choice will then be subject to the cost-sharing structure for general Medicaid. In practical terms, this change means that these beneficiaries should no longer be assessed copays for Medicaid-eligible services since children are not subject to copays. (See NCDHHS post: Cost-Sharing Implications of NC Health Choice Move to Medicaid MONDAY, JANUARY 30, 2023.)

Beneficiaries do not need to take any action to move to Medicaid. Their Medicaid ID (Recipient ID) number will not change.

  • Beneficiaries will receive a notice from NCDHHS in March 2023 regarding the change in benefits.
  • They will receive a Medicaid ID card from their health plan or from NC Medicaid Direct that will replace their NC Health Choice ID card.

All ACNC member ID cards will be the same. There will no longer be an NC Health Choice identifier at the top of the card. The member’s Medicaid ID and AmeriHealth Caritas North Carolina ID numbers will not change.

NC Health Choice to Medicaid: Claims and Billing

  • ACNC will follow published NC Health Choice billing guidance for NC Health Choice services rendered before April 1, 2023. New day claims for services rendered on or after April 1, 2023, for former NC Health Choice beneficiaries will be billed per the General Medicaid portion of the Medicaid Billing Guide.
  • ACNC will follow existing claim-filing deadlines and payment timelines as outlined in our Claims and Billing manual, found on our website.
  • Existing authorizations will remain with the member record and will not need to be resubmitted even after the benefit category is changed.

PHARMACY

Pharmacy Prior Authorization Forms Updated

As of February 6, 2023, the following pharmacy forms have been updated and contain edits like adjustments to age limitations for specific disease coverage or added disease coverages. Check out our comprehensive pharmacy webpage, and locate the updated forms on the pharmacy prior authorizations webpage.

  • Dupixent for Asthma
  • Nucala
  • PCSK9

PerformRxSM Changes to Pharmacy Professional Dispensing Fee

The NC Department of Health and Human Services (NCDHHS), Division of Health Benefits (DHB), received approval from the Centers for Medicare & Medicaid Services (CMS) on January 25, 2023, for the Medicaid State Plan Amendment for Professional Dispensing Fee (PDF) changes. The PDF change is retro-effective back to December 1, 2022.

The amendment revises the pharmacy reimbursement methodology for PDFs as follows:

  • It establishes the PDF at a flat fee of $10.24 per prescription, as determined by the Cost of Dispensing Study conducted on behalf of NCDHHS and DHB.
  • It removes the rule allowing only one PDF per drug, per member, per pharmacy, per month.
  • It permits PDF payment on emergency dispensations (including the one emergency fill allowed through the lock-in program per year).

ACNC implemented the PDF change on February 1, 2023, and will identify and reprocess the impacted claims adjudicated December 1, 2022, to January 31, 2023. No action is needed by the pharmacy at this time. Adjustments for the claims will be included in an upcoming remittance. Please contact PerformRx NC Provider Services at 1-866-885-1406 if you have questions.

NC Medicaid Preferred Drug List Update: Lantus Vial and Lantus SoloStar

The insulin glargine vial and insulin glargine SoloStar (authorized biologic for Lantus) was added as Preferred on the NC Medicaid Preferred Drug List (PDL), effective January 27, 2023.

The Lantus vial and Lantus SoloStar remained Preferred until shifting to non-Preferred status, effective February 17, 2023.

Per the current PDL guidelines, this off-cycle change has been deemed necessary due to significant financial implications to the state.

Insulin glargine vial/SoloStar is manufactured by Winthrop, a subsidiary of Sanofi (the manufacturer of Lantus) and is classified as an “unbranded biologic” by the Food and Drug Administration (FDA). It is considered by the FDA to be equivalent to Lantus because it is the same product as Lantus under the same Biologics Licensing Application (BLA). As such, the pharmacy would be allowed to substitute the generic without prescriber approval or obtaining a new prescription. More information from the Food and Drug Administration (FDA) for this equivalency is found on this webpage.

TRAINING

Are you still submitting paper claims? There is a better way.

Join our vendor, Change Healthcare, and learn how to use the electronic claims submission portal called Connect Center. Using this portal to submit claims electronically will decrease confusion and increase payment speeds. Find training dates and registration links on the Provider Training page of our website. Opportunities to learn are available twice a month.

NCDHHS Electronic Visit Verification Home Health Stakeholder Meeting

Please register for the NC Medicaid Home Health Care Services EVV Stakeholder Meeting on February 28, 2023, from 1:00 to 2:00 p.m. After registering, you will receive a confirmation email containing information about joining the webinar.

Let’s Work Together: New Provider Orientation

For 2023, ACNC presents Let’s Work Together, our reinvented provider orientation, with the goals of introducing our Account Executive team members and of sharing the tools necessary to be a successful provider in our network. We will meet February through December on the 2nd Tuesday of each month from Noon – 1:00 PM EST. Sign up for a training in 2023, and join us to learn about the following:

  • Our care delivery model
  • How quality management and value-based care tools can improve outcomes for our members
  • Eligibility, membership benefits and value-added services
  • Using the NaviNet portal
  • Provider compliance
  • Initiatives: Healthy Opportunities Pilots, Smoking Cessation and the Tailored Plan

2023 Substance Use Disorders (SUD) TeleECHO Clinic

The 2nd and 4th Thursdays of each month from January through April 2023, from Noon – 1:00 p.m.

Register for the series.

Download the Substance Use Disorder TeleECHO Training Series Flyer for 2023. (PDF)

Solution for Online Prior Authorizations Training: NaviNet Medical Authorizations

Register for one of the available Wednesdays from Noon – 1:00 PM on March 15 and April 19, 2023.

RESOURCES

Connecting with Your New Account Executive (AE)

ACNC has welcomed several new account executives to our team to expand our ability to serve our statewide provider network. To expedite your requests for assistance, we have established dedicated email boxes for specific regions.

Through this new process, you will be connected with a team member within two business days. Please visit our webpage for details on how to submit your request to ensure we have the information we need to respond. You’ll also see details on how to manage any protected health information (PHI) related to your concern. We look forward to hearing from you.

Veteran account executives pictured are: (Left to right) Demetrius Vaughn; Maria Abate; Doris Brown; Clarence Lawing; and in the front row, Bernadette Owens

Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents

Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition is an essential resource that provides health care professionals with updated background and recommendations for pediatric health promotion, health supervision and anticipatory guidance for 31 age-based visits.

The 4th Edition builds upon previous editions with thoroughly revised and updated content that reflects the latest research. It presents a new focus on the social determinants of health and on lifelong physical and mental health. The Bright Futures/AAP Periodicity Schedule presents (in chart form) the screenings, assessments, physical examinations, procedures, and timing of anticipatory guidance recommended for each age-based visit. Order a copy of the Bright Futures Guidelines, 4th Edition.

Article reprinted from American Academy of Pediatrics Bright Futures website.

Providers