May 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 May digest:

• Successful Behavioral Health Bootcamp Series Returning in the Fall
• Multiple ACNC Behavioral Health Resources Are Available
• Share Your Clinical Feedback

QUALITY CORNER

• Controlling High Blood Pressure (CBP) and Blood Pressure Control for Patients With Hypertension (BPC-E)
• 2025 Clinical Leadership Forums Begin in June

CLAIMS AND BILLING

• Your Claims. Paid Right. The First Time.
• Institutional Ambulance Emergency Services Reminder
• Personal Care Services (PCS) Billing and Reimbursement Policy Update

SAVING TIME

• Prior Authorizations Time-Saving Tips

MEMBER SPOTLIGHT

• CARE Card Rewards Promote Preventive Care
• Member Newsletters

OPPORTUNITIES

• Need to Connect With Us?
• Primary Care Providers Are Invited for a No-Cost CME and CEU Opportunity

Successful Behavioral Health Bootcamp Series Returning in the Fall

Earlier this year, our Behavioral Health (BH), Quality Management and Population Health Training teams partnered with one another to offer a Project ECHO Behavioral Health Bootcamp series that included no-cost continuing medical education (CME) credits. The topics were designed to support practices with an increase in patients seeking support for mental health conditions. This no-cost lunchtime series was offered to all pediatricians, primary care family practices, OB/GYNs, local health departments, and behavioral health care providers, along with all clinical staff providing care for our members.

Dr. Nerissa Price, BH Medical Director, shared, “The Bootcamp was a tremendous success! The level of participation highlights the need and interest that primary care providers have in expanding their knowledge base to care for members with common behavioral health conditions. BH Bootcamp is a great example of how we are committed to listening to what our providers need and partnering with them to deliver excellent care to our members.”

Multiple physicians, registered nurses, therapists, counselors, case managers, and Licensed Clinical Social Workers from leading health care systems and community organizations across North Carolina, including Duke University Hospital, Atrium Health, Novant, Wake Forest Baptist Health, and NC Community Health Association, attended consistently throughout the series.

Stay tuned to our Provider Training calendar webpage for a new BH Bootcamp series launching later this year in September. If you would like to be alerted or to receive a special invitation, please email ACNC Project ECHO.

Multiple ACNC Behavioral Health Resources Are Available

• Behavioral Health Care webpage
• Provider Guide: Behavioral Health Crisis Services (PDF)
• Behavioral Health Provider Toolkit (PDF)
• Behavioral Health Services webpage (for members)
• Behavioral Health Utilization Management Guide (PDF)
• Collaborative Care Management (CoCM) Grant Opportunity
• Quarterly Behavioral Health Provider Network Management webinar series — next session is July 10, 2025, at noon.
• Reductions in prior authorization requirements for behavioral health care providers (PDF)
• Value-based care program manual for behavioral health providers (PDF)

Share Your Clinical Feedback

As an ACNC network provider, you are encouraged to offer your expertise to evaluate the effectiveness of our Quality Assessment Performance Improvement (QAPI) program and share insights regarding clinical initiatives by participating in virtual committee meetings hosted by ACNC medical leadership.

Providers are compensated for their time and participation. Please see the following for more details, and use this link to email our Quality team if you would like to know more.

Please see the updated Providers webpage with additional information.

Controlling High Blood Pressure (CBP) and Blood Pressure Control for Patients With Hypertension (BPC-E)

These measures look at 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 and/or whose most recent BP result was <140/90 mm Hg during 2025.¹

Here are some recommended best practices to ensure members have the appropriate tools to manage their hypertension and the work done at your practice is recognized.

• Systolic Less Than 130: 3074F
• Systolic 130 – 139: 3075F
• Systolic Greater Than or Equal To 140: 3077F
• Diastolic Less Than 80: 3078F
• Diastolic 80 – 89: 3079F
• Diastolic Greater Than or Equal To 90: 3080F
• Please note:

• • Services provided during a telephone visit, e-visit, or virtual check-in are acceptable.
  • Member-reported data documented in medical record is acceptable if BP is captured with a digital device and documented in the medical record with date BP taken.

Blood pressure monitors for members with hypertension

• Blood pressure monitors can be a tool members utilize to keep track of their blood pressure and share results at their appointments.
• Blood pressure monitors are covered for members with essential hypertension under durable medical equipment (DME). To facilitate access to blood pressure monitors, ensure the ICD10 Code I10 is on the prescription and sent to a Medicaid-contracted pharmacy.

Addressing barriers to hypertension control

Food insecurity can be a contributor to cardiovascular risk⁴. Members can be connected to programs such as the North Carolina Healthy Opportunities Pilot (HOP) to address this barrier in HOP participating regions. Reach out to our Case Management Department by calling Provider Services at 1-888-738-0004 to ensure members are connected to the appropriate resources.

AmeriHealth Caritas member incentives: adult preventive/ambulatory visit

• Members aged 22 and older who complete an adult preventive/ambulatory visit are eligible to receive a $50 incentive once per year that may be used for items such as over-the-counter medications, diabetic supplies and healthy foods.

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

For providers that would be interested in partnering with ACNC on improving quality outcomes, please contact ACNC quality management by email at ACNCQualityManagement@amerihealthcaritas.com.

2025 Clinical Leadership Forums Begin in June

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 links below or visit our new HEDIS and Quality webpage for more.

Your Claims. Paid Right. The First Time.

Visit the new Claims and Billing webpage for how ACNC works with ECHO Health Inc., a leading innovator in electronic payment solutions, to offer more electronic payment options to our health care providers. Providers can select the payment method that best suits their accounts receivable workflow. A Claims and Billing Quick Reference Guide has been added to this webpage for download and referral.

To avoid pending claims, delay of payment, rejections and denials, submit claims as soon as reasonably possible, and remember to attach documentation. Accuracy will help ensure your claims are clean and ready for submission.

Tips for submitting clean claims

• Include the Explanation of Benefits (EOBs) from the primary insurance carrier.
• If required, obtain prior authorization for the service or product and include the authorization number in your claim submission.
• Provider taxonomy codes must match the North Carolina Department of Health and Human Services (NCDHHS)/NCTracks file for the date of service on the claim.
• Utilize current CPT, HCPCS and ICD codes.
• Submit claims within 365 days from the original date of service.
• DO NOT SUBMIT duplicate claims! Instead, file a Claims Investigation by visiting the NaviNet provider portal.

You can now upload supporting documents with your electronic claim investigation request within the NaviNet provider portal!

This enhancement is designed to streamline your workflow by eliminating the need to:

• Complete forms.
• Fax or mail supporting documentation.

Each supporting document will need to be 32 MB or smaller and in one of the following formats:

• Docx, PDF, png, or gif

Institutional Ambulance Emergency Services Reminder

Providers who have recently received claim denials using discharge transfer status code 01 — Home or self-care for members who are brought to emergency departments for institutional ambulance emergency services — should submit corrected claims for payment consideration. Remember to ensure that the discharge transfer status code submitted on the claim aligns with the trip destination. Follow the guidance in the Center for Medicaid Services (CMS) and National Uniform Claim Committee (NUCC) billing guidance regarding the coding of discharge/transfer status codes for institutional-based emergency ambulance services.

Personal Care Services (PCS) Billing and Reimbursement Policy Update

As of April 1, 2025, North Carolina Department of Health and Human Services (NCDHHS) released reimbursement methodology changes for providers rendering personal cares services (PCS) in congregate care settings. Procedure code 99509 has been impacted, and new elements of the methodology are indicated in the December 20, 2024, NCDHHS bulletin.

Prior Authorizations Time-Saving Tips

Register via Microsoft Teams for the second Clinical Leadership Forum of the year, titled Saving Time With Prior Authorizations Submissions, scheduled for July 8, 2025, at noon. Check out this month’s tip to help decrease administrative burden and save you time.

Register for webinar

Tip for understanding provider types

• For outpatient requests:
• The requesting provider is the referring provider — the provider who is requesting the member have the service.
• The servicing provider is the treating provider — the provider who is completing the service.
• These could be the same provider or different in an outpatient request.
• For inpatient requests:
• The requesting provider is the referring provider — the provider who is requesting the member have the service.
• The servicing provider is the provider completing the service — also known as the attending provider.
• The servicing facility is the facility where the services are performed.

CARE Card Rewards Promote Preventive Care

ACNC has simplified our CARE Card incentives for members to better align with plan priorities for members to get regular preventive care. The CARE Card is a prepaid debit card that members can use to purchase food, medical supplies and over-the-counter medicines at selected retailers. Based on NCDHHS guidelines, member incentive payments cannot exceed $75 per member per year.

As of April 1, child and adult members are eligible to receive a $50 reward on their CARE Card when they complete a routine well visit. Members also can earn a reward for a prenatal visit and for a postpartum visit. Find complete details about ACNC CARE Card rewards on our website. If you would like printed copies of our CARE Card flyer to share with members, please speak with your Provider Network Management Account Executive.

Member Newsletters

ACNC knows how important it is for our members to stay informed. This is why we communicate with them regularly.

Take a look at our most recent Get Care, Stay Well member newsletter (PDF) for spring 2025, where we announce our new Youth Empowerment and Health (YEAH) Logo! YEAH was created to help young members on their health journey with resources, games and tips designed just for them.

Need to Connect With Us?

Let’s work together! Each provider group, facility or agency is assigned an Account Executive (or Tribal Liaison) who will meet with you routinely in person, by web meeting or by telephone to serve as an initial contact and resource to assist with provider inquiries, trainings, claim issues and plan programs and processes.

To connect with us, review your provider type and region. Please choose from the email addresses below. In the body of the email, include the practice name, your NPI or TIN, and the physical address of your practice. We look forward to hearing from you.

All other provider types should select the appropriate regional mailbox:

• Region 1
• Region 2
• Region 3
• Region 4
• Region 5
• Region 6

Primary Care Providers Are Invited for a No-Cost CME and CEU Opportunity

Primary care providers are invited to attend this tele-education series that will utilize the ECHO model to provide a learning community for family physicians, family nurse practitioners and physician assistants to enhance physical health care provided to people with intellectual/developmental disabilities (I/DD). The program will consist of eight sessions with a variety of topics.

Register or learn more about this no-cost CEU and CME opportunity with 90-minute sessions on Tuesdays between May 6 and July 15, 2025. This opportunity is a collaboration between NC Department of Health and Human Services, Area L AHEC, Autism Society of North Carolina, and The Arc North Carolina.

Register for webinar series