November 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 November digest:

NEW PROVIDER RESOURCE

MEMBER BENEFITS SPOTLIGHT

ON THE ROAD WITH OUR PROVIDERS

QUALITY CORNER

VALUE-BASED CARE

CLAIMS AND BILLING

ADMINISTRATION

QUALITY CORNER

Promoting Vaccine Adherence Among Black and African American Patients

We are pleased to announce the launch of the ACNC toolkit, Communicating With Black and African American Patients To Promote Vaccine Adherence. This downloadable toolkit (PDF) covers topics such as barriers to care within the Black and African American population and supportive best practices, tools, and strategies when working to promote vaccine acceptance and adherence for your patient population that identify as Black and African American.

Black and African Americans are more likely to report “poor experience” with health care providers, which may influence their trust in why your practice is recommending vaccines.1

We hope that you find the toolkit useful when providing care to your patients. We welcome your feedback on the toolkit — please complete our survey. If you would like a printed copy of the toolkit, please reach out to your Provider Network Management Account Executive.

1 Martha Hostetter and Sarah Klein, “Understanding and Ameliorating Medical Mistrust Among Black Americans,” The Commonwealth Fund, January 14, 2021,  http://www.commonwealthfund.org/publications/newsletter-article/2021/jan/medical-mistrust-among-black-americans, accessed September 17, 2025.

MEMBER BENEFITS SPOTLIGHT

Expecting and New Moms Are Focus of New Benefit Offerings

In response to member feedback, ACNC has made support for expecting and new moms a priority in our expanded extra benefit offerings. Some of the new benefits will come in the form of funds autoloaded to the members’ CARE Card. The CARE Card is a reloadable debit card that members can use to make purchases at selected retail outlets and online. ACNC has created a video about using the CARE Card that is posted to our YouTube channel. 

Extra benefits* now available to new and expecting moms:

  • Breast pumps and supplies — member calls Aeroflow directly to make a request.
  • Baby diapers and wipes — $50/month for the baby’s first 12 months, automatically loaded to mom’s CARE Card
  • Bright Start® program — ACNC’s prenatal support program
  • Baby showers — offered at our regional Wellness & Opportunity Centers and through community partners
  • Cribs and sheets — $50 to purchase a crib or sheets, automatically loaded to mom’s CARE Card.
  • Doula service — available in selected areas
  • Home-delivered meals — up to 14 days of meals for pregnant or new moms and up to five family members. Must be referred by their Primary Care Provider or Care Manager.
  • Infant formula — $100/month for the baby’s first 6 months, automatically loaded to mom’s CARE Card.
  • Free infant car seat, requested via the Member Intervention Request Form (PDF).

Visit our Extra Benefits webpage for more details.

*These benefits are offered in addition to regular Medicaid benefits. Certain terms and conditions may apply.

Pharmacy Benefits During Pregnancy

Please note there is a $0 copay on prescriptions for pregnant women. Please help us ensure that pregnant members receive this important benefit by encouraging moms to notify local Departments of Social Services. Contact ACNC Member Services for assistance at 1-855-375-8811 (TTY 1-866-209-6421).

Vision Benefits for Members

In addition to the standard Medicaid adult vision benefit, which offers one pair of glasses every two years, AmeriHealth Caritas offers an additional pair of glasses as an extra benefit for our members. To support providers in fulfilling this popular service for our members, ACNC has a dedicated Vision Services page on our website to detail the process.

It is important to note that Medicaid vision providers must be able to do the vision exam as well as the eyeglass fitting for any Medicaid-covered glasses, whether fabricated by Nash Optical or by ACNC’s vendor. Please contact your Provider Network Management Account Executive with any questions.

ON THE ROAD WITH OUR PROVIDERS

Provider Engagement Is Top Priority

Thanks to nearly 1,000 provider offices for opening your doors to our Provider Network Management team over the past few months. Through in-person visits, Joint Operating Committee Meetings, web-based and in-person training courses, our PNM team has received important feedback to help us improve collaboration with providers in our network.

ACNC’s Provider Network Management team was all smiles at a recent training event.
ACNC’s Provider Network Management team was all smiles at a recent training event.
“ACNC has really treated us as a business partner who understands our business. We see them as a strong partner in providing care for our patients.” – Atrium Health, Wake Forest Baptist

We will continue our in-person visits over the coming months, so you may hear from us soon. If you would like to schedule a visit with a member of our team, please contact your Provider Network Management Account Executive.

ACNC Disaster Response Featured at NC Public Health Association Conference

Mike Bridges, ACNC Director of Population Health and Care Management, spoke at the opening session of the NC Public Health Association Conference about lessons learned from Hurricane Helene, and how they are informing ongoing disaster preparedness and proactive member outreach. Our PNM team also got to meet many of our local health department partners, like Yolanda Davis, from the Cumberland County Health Department.

Stop By and Say Hello!

NC Academy of Family Physicians Winter Meeting — December 4 – 7, Asheville

ACNC will again sponsor the Networking Lounge, so stop by our booth in the lobby or the lounge to meet our team. If you tell us you read about it in the Provider Digest, you’ll be entered in a drawing for a special gift for your practice!

QUALITY CORNER

It’s HEDIS Season: Medical Records Contact Information Needed

Data gathered in the annual Healthcare Effectiveness Data and Information Set (HEDIS) projects helps us identify opportunities for care improvement, monitor quality improvement initiatives, maintain health plan accreditation, and evaluate performance against other health plans. Please help us update information for your practice and streamline our data sharing by completing a short five-question survey.

Exact Sciences Cologuard Kits Being Sent to Selected Members

ACNC is working with Exact Sciences to offer Cologuard test kits for colorectal cancer screening to eligible members 45 or older at average risk for colon cancer who have gaps in care. This program aims to improve access to preventive screenings and help members manage their health proactively. Members will be identified based on their eligibility and need for screening and then sent a kit. Providers will receive test results directly from Exact Sciences. If members are unable to use their kit, they can recycle the kit’s components.

Glycemic Status Assessment for Patients With Diabetes (GSD) HEDIS Measure

The GSD measure is the percentage of members 18 – 75 years of age with diabetes (types 1 and 2) whose most recent glycemic status (hemoglobin A1c [HbA1c] or glucose management indicator [GMI]) was at the following levels during the measurement year1:

  • Glycemic status less than 8.0%
  • Glycemic status greater than 9.0%

How providers can enhance quality of care delivery and outcomes for patients with diabetes

  • The American Diabetes Association (ADA) recommends use of blood glucose management devices such as continuous glucose monitors (CGMs) and standard blood glucose monitors (BGM) to encourage self-efficacy and self-management in patients living with diabetes.2
    • These devices are covered when deemed medically necessary through durable medical equipment (DME) and pharmacy services.3
       
  • AmeriHealth Caritas North Carolina’s Gaps in Care for Primary Care Physicians Program per care gap closure incentive has increased from $75 to $100.
    • $75 (January 1 – June 30)
    • $100 (July 1 – December 31)
       
  • Best practice to capture hemoglobin A1c values and eligibility for care gap closure incentives:
    • Note the following CPT Category II coding in claims submission:
      • Less than 7.0%: 3044F
      • Greater than/equal to 7.0% and less than 8.0%: 3051F
      • Greater than or equal to 8.0% and less than/equal to 9.0%: 3052F
      • Greater than 9.0%: 3046F
  • Include date of HbA1c test or GMI and the actual result; do not use ranges and thresholds.
  • Include available CGM data in office visit note.

AmeriHealth Caritas North Carolina (ACNC) has several initiatives in place to address this measure:

  • Text messages and call reminders to members encouraging hemoglobin A1c checks
  • Programming at our Wellness & Opportunity Centers across the state
  • Collaboration launched with vendor Wider Circle in Charlotte, supporting members with food shopping education and making connections with other members living with diabetes.

If you are interested in connecting with ACNC regarding opportunities to improve quality of care for members, please contact ACNC Quality Management by email at acncqualitymanagement@amerihealthcaritas.com.

1 HEDIS Measurement Year (MY) 2025, Volume 2: Technical Specifications for Health Plans, National Committee for Quality Assurance (NCQA), 2025, https://www.ncqa.org/hedis/measures/, accessed September 30, 2025.

2 American Diabetes Association Professional Practice Committee, “6. Glycemic Goals and Hypoglycemia: Standards of Care in Diabetes—2025,” Diabetes Care, Vol. 48, Supplement 1, January 2025, https://doi.org/10.2337/dc25-S006, accessed November 17, 2025.

3 “Nursing Equipment and Supplies, Clinical Coverage Policy No. 5A-3,” North Carolina Medicaid, May 1, 2025, https://medicaid.ncdhhs.gov/5a-3-nursing-equipment-and-supplies/download, accessed November 17, 2025.

VALUE-BASED CARE

Incentive Available for UST HealthProof Provider Engagement Coordination Program

ACNC is committed to supporting providers in delivering high-quality, coordinated care. The UST HealthProof Provider Engagement Coordination (PEC) program will help improve care coordination by flagging past or suspected conditions and care gaps for providers to review during patient visits. These clinical documentation improvement (CDI) alerts identify potential diagnosis and quality measurement gaps based on member history and can be delivered on-site, remotely, or electronically to fit the provider's workflow. For more details on the program, see our July 24 notice (PDF). 

PEC program incentive opportunity

To support providers in properly documenting chronic medical conditions and quality care gaps, ACNC is offering providers an incentive for providing responses to CDI alerts. 

  • $50 per unique member if the practice closes 60% of the gaps identified on returned CDI alerts.
  • $100 per unique member if the practice closes 90% of the gaps identified on returned CDI alerts.

CLAIMS AND BILLING

Avoid Claims Denials: Include Prenatal and Postpartum Care (PPC) F Codes on Claims Submission

NC Medicaid’s Obstetrical Services Clinical Coverage Policy No: 1E-5 (PDF) requires the use of two CPT billing codes for prenatal and postpartum care. These codes will assist in capturing information about the timeliness of prenatal and postpartum care provided to NC Medicaid members. The two F codes are 0500F for initial prenatal visits and 0503F for postpartum care visits. Both codes are defined in the NCQA HEDIS value sets and are meant to support more accurate and complete data collection around prenatal and postpartum care delivery in North Carolina.

Review the PPC F Codes Fact Sheet (PDF) and PPC F Codes Frequently Asked Questions (PDF) documents published by NCDHHS in July 2024 for more detailed information or contact your Provider Network Management Account Executive.

ADMINISTRATION

Pharmacy Prior Authorization

Prior authorization (PA) is required for certain drugs prescribed to NC Medicaid recipients. Providers may submit electronic requests to AmeriHealth Caritas North Carolina for PA approval in any of the following ways:

You may also fax a prior authorization request to us by downloading and completing the appropriate form from the Pharmacy Prior Authorizations page on our website and faxing it to 1-877-234-4274. For additional guidance, please refer to the NC DHHS pharmacy clinical coverage policies. 

Discontinuation of Coverage: Xifaxan (Rifaximin)

Effective October 1, 2025, the manufacturer of Xifaxan (Rifaximin) will no longer participate in the Medicaid Drug Rebate Program which means it will not be covered by NC Medicaid. Bausch Health Companies, Inc. offers a patient assistance program aimed at supplying free medication, including Xifaxan, to eligible patients who do not have coverage under their Medicaid pharmacy benefit. Please refer to the NC Medicaid Pharmacy Newsletter for October 2025 for more information.

Cell and Gene Therapy Guidance

Prior authorization criteria for cell and gene therapy and other state-selected model drugs can be found here.  For further information, please refer to the NC DHHS cell and gene therapy policy No: 1S-13 (PDF).

Expectations for Home Health Electronic Visit Verification (EVV) Are in Effect

As of October 1, 2025, home health care services (HHCS) providers offering the following services: home health aide services, physical therapy, occupational therapy, speech therapy, and skilled nursing visits are required to use EVV. As a reminder, claims submitted without the required EVV criteria are being denied. Providers can locate Service Codes Crosswalk with HCPCS (PDF) and revenue codes on our Home Health Electronic Visit Verification (EVV) website. 

The latest NCDHHS bulletin provides reminders and specific expectations. Visit our Provider Training webpage to register for office hours on Wednesday evenings for support.

Let Us Know if You Need Help With Specialty Referrals

ACNC’s Let Us Know program offers our providers an additional resource for member support with missed appointments, transportation services, education on a treatment plan or chronic condition, and assistance with value-added benefits. It also can be used to request assistance in locating a specialty provider.

Specialty providers include but are not limited to providers who offer care in behavioral health, cardiology, dermatology, hospice and palliative medicine, neurology and orthopedics. You can find member guidance on the How to Get Specialty Care on our website. Providers can complete a Member Intervention Request Form (PDF) and fax to our Rapid Response Outreach Team at 1-833-816-2262.

Post-Appointment Survey Provider Scorecard in NaviNet

ACNC’s Post-Appointment Member Satisfaction Survey offers helpful feedback on the member care experience, by evaluating the comprehensive, quality, and culturally responsive care members receive. Your commitment to high quality patient care directly contributes to improving health outcomes and experiences for our members.

Scorecards will only be generated for provider groups who have received 10 or more member responses during a given reporting period. Providers can view their member satisfaction ratings through the Post-Appointment Survey Provider Scorecard, available in the NaviNet provider portal. To access this feature, log in and navigate to: Workflows for this Plan→ Report Inquiry→ Clinical Reports→ Post-Appointment Survey Provider Scorecard.

Scorecard refresh schedule

Scorecards are refreshed twice annually — in August and February — based on calendar year reporting periods:

  • February: Covers member responses from July to December of the previous year
  • August: Covers member responses from January to June of the current year

If you have any questions, please contact your Provider Network Account Executive.

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.