June Provider Digest

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

You will find the following topics in this June digest:

NCDHHS UPDATES

QUALITY CORNER

CLAIMS AND BILLING

PHARMACY

PRIOR AUTHORIZATIONS

MEMBER SPOTLIGHT

TOBACCO CESSATION

      Primary Care Provider Change Request Form Is Live

      If your practice has a member who wishes to make your practice their PCP, visit the Provider Manuals, Policies and Forms webpage. At the bottom of the page, under the heading Provider change, find the English form (PDF) for submission. The form includes the propr fax number for notifying ACNC about the request to update a members’ primary care provider.

      NCDHHS UPDATES

      NCDHHS Releases Care Management Rate Bulletin

      Effective July 1, 2025, the North Carolina Department of Health and Human Services (NCDHHS) will release updated information about the assumptions underlying the care management component of capitation payments to NC Medicaid Managed Care Standard Plans. This information applies to care management performed by Standard Plans and Advanced Medical Home (AMH) Tier 3 providers. Providers can locate details in the Managed Care Rate Assumptions bulletin.

      Additional information on NC Medicaid’s AMH program can be found on the Advanced Medical Home webpage [medicaid.ncdhhs.gov].  

      Healthy Opportunities Pilot (HOP) Update

      At present, proposed House and Senate budgets put forward by the North Carolina General Assembly do not include funding for the HOP’s ongoing operations or statewide scaling. The potential absence of available funding means that there is no funding scheduled for distribution to health plans for HOP service delivery beginning July 1, 2025. While new services are expected to stop beginning July 1, NCDHHS hopes this will only be a pause, and HOP could resume once additional funds are appropriated by the General Assembly. See the June 2, 2025, bulletin for additional information.

      QUALITY CORNER

      Measles, Mumps and Rubella Vaccine Rates Low Amid Outbreaks

      Measles, mumps and rubella (MMR) vaccine coverage among kindergartners nationwide is decreasing and is now below the 95% coverage target.1 In North Carolina, 93.8% of kindergartners were vaccinated against MMR in the 2023 – 2024 school year.2

      “Measles is an airborne, extremely infectious, and potentially severe rash illness. Before the measles vaccine was introduced, an estimated 48,000 people were hospitalized and 400–500 people died in the United States each year.”3

      According to the CDC, even though measles is usually a mild or moderately severe illness, it can result in several complications. Some of these are:

      • Diarrhea
      • Dehydration
      • Pneumonia
      • Encephalitis

      Two to three cases of measles out of every 1,000 reported are fatal, and one out of five cases in the U.S. requires hospitalization.4

      As of May 29, 2025, 1,088 confirmed measles cases have been reported to the CDC. The cases are spread out across 33 jurisdictions: Alaska, Arkansas, California, Colorado, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Missouri, Montana, Nebraska, New Jersey, New Mexico, New York City, New York State, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Texas, Vermont, Virginia, and Washington.5

      Of the 1,088 confirmed cases, 322 (30%) are under 5 years old and 407 (37%) are 5 - 19 years old. 96% of the 1,088 cases are unvaccinated or have an unknown vaccine status. As of May, there have been three confirmed deaths from measles in 2025.5

      Measles is an acute viral respiratory illness that has the following symptoms:

      • Fever (as high as 105°F), malaise, cough, coryza, and conjunctivitis
      • A pathognomonic enanthema (Koplik spots)
      • A maculopapular rash, typically appearing about two weeks from date of exposure6

      Preventing measles transmission

      • The MMR vaccine provides the best protection, and it is vital to ensure community immunization.7
      • Determine which individuals have or may have measles and quarantine them.7
      • Follow standard and airborne precautions if you know or suspect that a person has measles.7
      • Report any suspected measles to your local health department.
      • Report any suspected measles to the North Carolina Division of Public Health (NCDPH).8

      The measles, mumps and rubella (MMR) vaccine is recommended to be administered at the following times:

      • 1st dose at 12 – 15 months old 
      • 2nd dose at 4 – 6 years old  

      1 Ranee Seither et al., “Coverage with Selected Vaccines and Exemption Rates Among Children in Kindergarten — United States, 2023 – 24 School Year,” Weekly, Vol. 73. No. 41, October 17, 2024, https://www.cdc.gov/mmwr/volumes/73/wr/mm7341a3.html, accessed June 4, 2025.

      2 “Vaccination Coverage and Exemptions Among Kindergarteners,” October 2, 2024, https://www.cdc.gov/schoolvaxview/data/index.html, accessed June 4, 2025.

      3 “Measles Cases and Outbreaks,” CDC, May 30, 2025, https://www.cdc.gov/measles/data-research/index.html, accessed June 4, 2025.

      4 “Chapter 7: Measles,” CDC, June 3, 2025, https://www.cdc.gov/surv-manual/php/table-of-contents/chapter-7-measles.html, accessed June 4, 2025.

      5 “Measles Cases and Outbreaks,” CDC, May 30, 2025, https://www.cdc.gov/measles/data-research/index.html, accessed June 4, 2025.

      6 “Clinical Overview of Measles,” CDC, May 23, 2025, https://www.cdc.gov/measles/hcp/clinical-overview/index.html, accessed June 4, 2025. 

      7 “Interim Infection Prevention and Control Recommendations for Measles in Healthcare Settings,” CDC, May 21, 2025 https://www.cdc.gov/infection-control/hcp/measles/index.html, accessed June 4, 2025. 

      8 “Communicable Disease,” North Carolina Division of Health and Human Services (NCDHHS), September 22, 2020, https://epi.dph.ncdhhs.gov/cd/report.html, accessed June 4, 2025.

      9 “Measles Vaccination,” CDC, January 17, 2025, https://www.cdc.gov/measles/vaccines/index.html, accessed June 4, 2025.

      CLAIMS AND BILLING

      Skilled Nursing Facility Eligibility    

      The North Carolina Department of Health and Human Services (NCDHHS) requires NC Medicaid beneficiaries to meet eligibility criteria for nursing facility or long-term care facility services. Approval is based on the level of care needed by the individual and the individual’s financial eligibility, which are determined by coordination between the member’s prepaid health plan (PHP) and local Departments of Social Services (DSS). Providers seeking nursing facility placement for ACNC Medicaid members should closely review the process found in the NC Medicaid Managed Care County Playbook (PDF). 

      Home Health Electronic Visit Verification Required October 1 

      Per guidance from the NCDHHS, Electronic Verification Visit (EVV) for Home Health Care Services (HHCS) providers is required as of October 1, 2025, for HHCS providers who offer the following services: Home health aide services, physical therapy, occupational therapy, speech therapy, and skilled nursing visits. As a reminder, claims submitted without the required EVV criteria will be denied. Providers can locate Service Codes Crosswalk with HCPCS (PDF) and Revenue Codes on the new Home Health Electronic Visit Verification (EVV) website.

      PHARMACY

      Preferred Drug List (PDL) Updates

       The NC Medicaid Preferred Drug List (PDL) update will occur on July 1, 2025.

      Reminder on NC Medicaid Pharmacy Copayment Requirements 

      "NC Medicaid recently received questions regarding Medicaid beneficiaries who cannot pay pharmacy copays for medication. A provider cannot refuse to provide services if a beneficiary cannot pay a copay at the time of service. The issue is addressed in Pharmacy Policy 9 under section 5.5 Copayments. The specific guidance with reference is below.

      “5.5.1 Medicaid Co-payment Requirements

      An eligible Medicaid beneficiary, who receives prescribed drugs, is required to make a copayment of $4.00 for each prescription received unless they are exempt for one of the reasons listed … in Subsection 5.5.2. A provider may not deny services to any Medicaid beneficiary because of the individual’s inability to pay a deductible, coinsurance or co-payment amount. A provider may not willfully discount copays for a Medicaid beneficiary, and an individual’s inability to pay does not eliminate his or her liability for the cost sharing charge. The provider shall open an account for the beneficiary, collect the amount owed at a later date, and document all attempts to collect the copay. If the account has not been paid, the pharmacy may, in the course of normal accounting principles, write off the charges and stop monitoring the claim.”10

      For assistance with pharmacy prior authorizations or pharmacy claim questions, contact PerformRxSM Provider Services at 1-866-885-1406.

      10“North Carolina Medicaid Pharmacy Newsletter: Number 376,” NCDHHS, March 2025, https://medicaid.ncdhhs.gov/march-2025-pharmacy-newsletter/open, accessed June 4, 2025.

      PRIOR AUTHORIZATIONS

      Tip for Submitting Delivery Notifications Correctly

      Please view the NaviNet Medical Authorizations Participant Guide (PDF) for full instructions on submitting a delivery notification. Accurately submitting a delivery notification via the NaviNet provider portal will provide a real-time response to the provider with no need for further follow-up or faxes.

      Clinical Leadership Forums Continue in July

      ACNC is pleased to provide opportunities for providers to engage with our team to discuss quality improvement activities and associated challenges related to quality and population health outcomes. Register from the link below or visit our new HEDIS and Quality webpage for more details.

      Saving Time With Prior Authorizations Submissions:

      We recognize that valuable treatment time can be lost for our members when providers are saddled with overly restrictive processes. ACNC recently announced the removal of more than 240 physical health codes and a dozen behavioral health services codes. If you missed the full announcement, find it on the Newsletters and Updates webpage. In this forum, ACNC clinical leaders will share tips and tricks to streamline your prior authorization for submissions.

      July 8, 2025, at noon (presenters arrive at 11:50 a.m.)

      Via Microsoft Teams Webinar 

      MEMBER SPOTLIGHT

      Regional Baby Showers Celebrate Moms and Help Achieve Quality Goals

      ACNC hosts baby showers in each of the six Medicaid regions throughout the year to provide support and improve health outcomes for moms and babies. Our next event is on 3120 Wilkinson Boulevard, Suite D-1, Charlotte, NC. Community partners and providers are invited to participate in these events to bring important health information to our members and visitors. ACNC members can get no-cost transportation to any of our sponsored events through our transportation provider.

      Baby shower goals:

      1 Improving birth outcomes
      2 Encouraging member engagement in the Bright Start Care Management program
      3 Encouraging members to receive prenatal and postpartum care
      4 Offering opportunities to learn about child vaccinations/well-child visits
      5 Increasing member and family use of Wellness & Opportunity Centers for ongoing education and support

      Please encourage your patients to register for a baby shower this year via the event calendar links on the Wellness & Opportunity Centers webpage or the Provider Training Calendar. Providers also are welcome to participate in our baby showers as presenters or to host an information table. If your practice would like to participate in the Charlotte event or learn more about our baby showers, please contact Denise Rivera-Coladonato at 980-748-2373.

      New Moms and dads celebrated during the Fayetteville baby shower held on April 26, 2025. Members and families attending baby showers in all our regions can pose for photos as we celebrate and educate them on prenatal and postpartum care.  

      TOBACCO CESSATION NEWS

      Member Quit for Life Info Session

      Quit for Life® can help individuals stop vaping, smoking, or chewing tobacco. While quitting can be tough and it may take more than one attempt to stop, the no-cost Quit for Life® Program could help. If you have a patient struggling with tobacco use, join us to learn about why quitting is so hard; the nicotine replacement therapies that are available to help; and what you can do to support a patient, friend or loved one.

      DatesTime
      Thursday, August 7, 2025Noon ET

      The content presented within is for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions and claims submissions for their patients and should not use the information presented and accompanying materials to substitute independent clinical judgment.