August 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 to providers in NaviNet.

You will find the following topics in this August digest:

CLINICAL INITIATIVES

QUALITY CORNER

ADMINISTRATION, BILLING AND CLAIMS

MEMBER BENEFITS

NCDHHS Measles Resources Hub

The North Carolina Department of Health and Human Services (NCDHHS) Division of Public Health (DPH) has developed guidance that brings together the latest recommendations in one centralized location to support schools; child care centers; institutions of higher education; and, soon, farmworker and correctional facility settings. General measles prevention and response guidance is also available, which is applicable across most settings. This effort aims to streamline communication; reduce individual requests; and ensure consistent, accessible information across the state. For the most up-to-date information on measles in North Carolina, visit NCDHHS DPH’s measles webpage.

Credentialing Reminder

Updating practice information and obtaining Medicaid credentialing information is all done through North Carolina via NCTracks.

Providers who participate in the Medicaid line of business do not need to complete a separate credentialing application. ACNC mirrors provider and practice information listed in NCTracks. If you need assistance updating or verifying your provider information, you may contact NCTracks Provider Services directly at NCTracksProvider@nctracks.com or phone 1-800-688-6696.

Provider Satisfaction Survey

Be part of 2026 results by sharing your feedback this fall. A sample of the practices in our network will receive a satisfaction survey to help us gain insight into how we are doing. The survey takes about 15 minutes to complete. Results from the survey will be used to guide administrative and operational changes to our health plan and point out areas that might need improvement.

If you receive the welcome letter and survey in the mail, there are two ways to complete the survey:

  1. Online, using the credentials given in the letter by going to https://www.qualtrics.com/.
  2. By completing the paper survey and returning it using the prepaid envelope.

If you have any questions related to this survey, please reach out to the Qualtrics Help Desk Team at ah-provider-study@qualtrics.com.

CLINICAL INITIATIVES

Join Us for Lunch and to Learn About Value-Based Care Incentive Programs

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.

Join AmeriHealth Caritas North Carolina (ACNC) leadership in person on October 8, 2025, at noon for lunch and an overview of both our health plan and the following available incentive programs. Register to attend this event and meet us at the Embassy Suites by Hilton Raleigh Durham Airport Brier Creek at 8001 Arco Corp. Drive, Raleigh, NC.

The 2025 programs include:

  1. July 1, 2025, Updated Primary Care Gaps in Care Closure Incentive Program (see Primary Care Incentive Increase below)
  2. Maternity Care Gaps in Care Incentive Program
  3. PerformPlus True Care — Behavioral Health Providers
  4. PerformPlus Total Cost of Care Primary Care Providers

Primary Care Incentive Increase

As of July 1, 2025, to reward primary care providers for their efforts in closing the care gap, we have increased incentive amounts from $75 to $100 for controlling high blood pressure and glycemic status for patients with diabetes. This change impacts dates of service in the second half of 2025. See the updated flyer and other manuals and measures on the Value-Based Programs page on our website.

ECHO Behavioral Health Bootcamp Returns, Offering FREE CME

Dr. Nerissa Price, BH Medical Director, will once again host the highly successful Behavioral Health Bootcamp this fall.

“The spring bootcamp was a tremendous success! It is a great example of how we are committed to listening to what our providers need, especially in rural parts of the state, to deliver excellent behavioral health care to our members,” said Dr. Nerissa Price.

Participants are eligible to earn continuing education credits at no cost. The bootcamp will begin on September 24, 2025, and continue through December 10, 2025. Topic information and registration are on our Provider Training web page. If you have further questions or would like to register, please email projectecho@amerihealthcaritas.com.

QUALITY CORNER

Colorectal Cancer Screening HEDIS® Measure

Colorectal Cancer Screening (COL-E) assesses the percentage of adults ages 45 – 75 who had an appropriate screening for colorectal cancer.1 Colorectal cancer typically “develops from precancerous polyps (abnormal growths) in the colon or rectum…regular screenings can lead to the detection and removal of polyps before they develop into cancer.”2

With just a few months left in 2025, it’s an ideal time to begin connecting with patients who are due or overdue for this important screening. Using the reports available to you in NaviNet, such as the Gap Closure Reports, will be beneficial in identifying these patients.

Best practices for COL-E measure: 3,4,5

  • Educate patients on the importance of and the process of completing colorectal cancer screenings.
  • In addition to colonoscopy, offer other screening options such as Fecal Occult Blood Test (FOBT), Fecal Immunochemical Test (FIT), and multiple-target stool DNA Test (mt-sDNA).
    • Cologuard is a three-year test, whereas FIT is a one-year test.
  • Assist with scheduling appointments for screening at the time of referral.
  • Deploy automated interventions, such as reminder calls or text messages.
  • Submit claims and documentation in a timely manner.
  • Consider Electronic Medical Records (EMR) reminders for preventive health maintenance.
  • Consider EMR remote access for the ACNC quality department to assist in closing care gaps.      

Common chart deficiencies:6

  • Member-reported data not captured within history in chart with sufficient information to show the screening was completed in the measurement year time frame.
  • FOBTs performed in an office setting or performed on a sample collected via Digital Rectal Exam (DRE).
  • Fewer than three samples documented for guaiac fecal occult blood test (gFOBT).
  • Documentation is not clear if FIT-DNA or FIT FOBT.
  • In situations of incomplete colonoscopy or flexible sigmoidoscopy, the documentation is not clear as to the location to which the scope advanced.
  • Most recent screening dates are not documented in the record or updated in the patient history.

Resources:

1“HEDIS MY 2025 Measures and Descriptions,” National Committee for Quality Assurance, https://wpcdn.ncqa.org/www-prod/wp-content/uploads/HEDIS-MY-2025-Measure-Description.pdf

2Samantha Cho, “HEDIS Measures for Health Plans: Colorectal Cancer Screening,” LetsGet Checked, September 20, 2024, https://www.letsgetchecked.com/articles/hedis-measures-for-health-plans-colorectal-cancer-screening/#:~:text=About%20the%20COL%2DE%20HEDIS,%2C%20FIT/iFOBT%20(immunochemical)

3“American Cancer Society Guideline for Colorectal Cancer Screening,” American Cancer Society, January 29, 2024, https://www.cancer.org/cancer/types/colon-rectal-cancer/detection-diagnosis-staging/acs-recommendations.html

4Shailavi Jain et al., “Optimal Strategies for Colorectal Cancer Screening,” Curr Treat Options Oncol., Vol. 23, No. 4, March 22, 2022, https://pmc.ncbi.nlm.nih.gov/articles/PMC8989803/

5“North Carolina’s Medicaid Quality Measurement Technical Specifications Manual,” NC Department of Health and Human Services, June 2025, https://medicaid.ncdhhs.gov/medicaid-managed-care-quality-measurement-technical-specifications-manual/download?attachment  

6Reprinted from the ACNC HEDIS® Quick Reference Guide.

Please contact your Provider Network Management Account Executive with any questions. If you are interested in partnering with ACNC on improving quality outcomes, please contact ACNC quality management by email at ACNCQualityManagement@amerihealthcaritas.com. 

Attention Behavioral Health Providers and NC IRIS Users

We have included helpful tips for maintaining compliance with critical incident reporting in the North Carolina Incident Response Improvement System (NC IRIS).

Timely critical incident reporting:

  • Level II and III critical incidents must be submitted in NC IRIS within 72 hours of learning of the incident
    • Exceptions: 
      • Level III reports also require a verbal report to ACNC immediately.
      • Death within seven days of seclusion or restraint require an NC IRIS report immediately.
  • Critical incidents initiated in NC IRIS within the 72-hour required time frame but not submitted are not considered timely. To be considered timely, they must be submitted within the required time frame.
    • Ensure the Supervisor Actions section is completed and submission is confirmed. When submission is confirmed, you will see a thumbs up icon. If you do not see the thumbs up icon along with the incident number after completing the report, the critical incident report has not been submitted.
    • Print or make a note of the incident number so that you can easily access the report when you have the necessary information to update and complete the report

Abuse and/or neglect reports:

  • Must be reported to the Department of Social Services (DSS) as soon as you become aware of the allegation and noted in the Authorities Contacted section of the report.
  • ACNC is unable to complete the incident review until the DSS Reporter Letter is received by the provider and uploaded to the IRIS report. (The letter is typically received within 30 days of the initial DSS report.) 
    • This letter contains the determination of whether the report was accepted by DSS for further investigation, not the outcome of an investigation.

Level III incident reporting:

  • Complete an Internal Team Review and upload/attach the findings to the critical incident report
  • Death reporting:
    • ACNC is unable to close the critical incident in NC IRIS without official documentation of the cause of death; therefore, behavioral health providers must:
      • Request the Medical Examiner’s Report/Autopsy Report/Toxicology Report from the North Carolina Office of the Chief Medical Examiner (OCME). The document request can be made at https://www.ocme.dhhs.nc.gov/docrequest.asp.
      • If an autopsy was not performed, contact the Register of Deeds Office in the county where the consumer passed away to request the death certificate. (An uncertified copy is sufficient.)
      • Once the supplemental information is received, amend the critical incident report in NC IRIS to reflect the new information, including updating the Supervisor Actions section (Cause of Incident/Incident Prevention).

Resources

Questions for ACNC Quality Management team concerning critical incident reporting:acnccriticalincident@amerihealthcaritasnc.com

IRIS Technical Manual: https://www.ncdhhs.gov/documents/files/iris6-4-10dhhsmanual/open

Incident Response and Reporting Manual: https://files.nc.gov/ncdhhs/documents/files/incidentmanual2-25-11.pdf

Incident Rules 10A NCAC 27C.0600-.0609 and Death Reporting Rules 10A NCAC 27C.0303:d. 10ANCAC

ADMINISTRATION, BILLING AND CLAIMS

Nursing Facility Cost of Care Payments Update

Effective September 1, 2025, ACNC will pay nursing facility claims for modified adjusted gross income (MAGI) members without the patient’s monthly liability (PML) being added to the 834-file. Non-MAGI members must have the PML added to the 834-file prior to paying nursing facility claims. ACNC cannot pay nursing facility claims for non-MAGI members until the 834-file is received confirming the PML. Once received, ACNC will pay the nursing facility for the member’s stay minus the PML.

Updates to NC Medicaid Payments to Prohibited Entities

NC Medicaid is communicating updated information about new federal prohibitions on certain providers, including Planned Parenthood Federation of America, Inc, which includes the NC Planned Parenthood entities (Planned Parenthood South Atlantic). Please review the July 29, 2025, bulletin from NCDHHS for detailed information.

NaviNet Improves Efficiency for Provider Operations

Claims Overpayment Recovery Systems (CORS)

Providers can now approve or dispute claims overpayments and submit supporting documentation electronically in real-time through NaviNet. This new functionality is being introduced to provide a more efficient way to respond to overpayment letters. It will help reduce the need to mail written correspondence and minimize response times. Providers will continue to receive notification of overpayments by mail. However, you will now be able to review and respond to these letters via NaviNet. Other enhancements include being able to:

  • Easily access the Overpayment – Approve/Dispute Submission Form.
  • Review the overpayments summary page and approve and/or dispute claims with overpayments down to the claim line level in real-time.
  • Attach and submit supporting documentation (Explanation of Benefits [EOB], eligibility/third-party liability [TPL] verification documentation and so on) directly in NaviNet.
  • Check for resolution on disputed overpayments.
  • Pull reports of claim overpayments.

UST HealthProof to Support ACNC Providers

Claims Overpayment Recovery Systems (CORS)

ACNC has contracted with UST HealthProof (UST) to support providers in collecting complete and accurate member health histories to help facilitate correct billing and clinical insights. Specifically, UST helps ensure that medical records for ACNC members with chronic health conditions are coded and documented in compliance with the Department of Health and Human Services (HHS), the Centers for Medicaid & Medicare Services (CMS), and state-specific documentation guidelines. For more information, read the July 24 Provider Notice found on the Newsletters and updates webpage.

MEMBER BENEFITS SPOTLIGHT

Transportation Vendor Update

AmeriHealth Caritas North Carolina has extended our Non-Emergency Medical Transportation (NEMT) service with Modivcare for our Medicaid members. We will not be making a transition to MTM Health for NEMT at this time.

The reservation number remains the same: 1-833-498-2262 (TTY 1-866-288-3133). That number is available Monday through Saturday, 7 a.m. to 6 p.m. 

If you have questions about this change, or need more information, please contact your Provider Network Account Executive or call Provider Services at 1-888-738-0004.