September Provider Digest

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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 September digest:

CLINICAL INITIATIVES

QUALITY CORNER BENEFITS

ADMINISTRATION, BILLING AND CLAIMS

You Are Invited to Lunch With ACNC Leadership 

Join AmeriHealth Caritas North Carolina (ACNC) leadership in person on October 8, 2025, at noon for lunch and an overview of our health plan and 2025 value-based 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. Registration deadline is Monday, October 6, 2025.

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.

NEW Vision Services Webpage

Ophthalmologists, optometrists and opticians offering general and special vision services for children and adults are encouraged to review the new Vision Services webpage with specific instructions for providers who supply eye exams and eyeglasses in their offices for members.

Before providing any services, verify member eligibility using ACNC’s provider portal, NaviNet, or by calling ACNC Provider Services at 1-888-738-0004.

Preferred Drug List Updates

The NC Medicaid Preferred Drug List (PDL) update will take effect on October 1, 2025. This update includes discontinuation of NC Medicaid coverage for GLP-1s for the treatment of obesity. See the North Carolina Department of Health and Human Services (NCDHHS) announcement here.

CLINICAL INITIATIVES

Primary Care Incentive Increase

As of July 1, 2025, ACNC has increased incentive amounts to primary care providers for the following controlling high blood pressure and glycemic status assessment measures for dates of service in the second half of 2025. 

Controlling High Blood PressureGlycemic Status Assessment for Patients With Diabetes
CPT II codes: 3074F, 3075F, 3077F, 3078F, 3079F, 3080FCPT II codes: 3044F, 3046F, 3051F, 3052F
Incentive amount:
$75 (January 1 – June 30)
$100 (July 1 – December 31) 		Incentive amount:
$75 (January 1 – June 30)
$100 (July 1 – December 31)

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

All types of providers are invited to participate in our NO COST ECHO Behavioral Health Boot Camp training series focused on engaging patients and members needing extra support. Providers in rural communities, including family practice clinicians, OB/GYNs, local health departments and federally qualified health centers (FQHCs), are encouraged to register.

The bootcamp will begin September 24 and continue through December 10, 2025. Major topics include Differential Diagnosis and Treatment of Narcissistic Personality Disorder, Borderline Personality Disorder and Bipolar Disorder; Collaborative Care: Most Common Billing Code Errors; Substance Use in the Adolescent Population; Evidence-Based Treatment Models for Trauma in Children, and more!

To print a flyer and share with your practice visit our Behavioral Health webpage or register via email: projectecho@amerihealthcaritas.com.

Evidence-Based Clinical Guidelines and Utilization Management Criteria

ACNC provides comprehensive, outcome-driven health solutions for our members. Part of this approach means making it a priority to reduce unnecessary variations in care. We've used the latest scientific evidence and research to create clinical guidelines, which represent the most current professional standards.

While these guidelines are intended to inform, they aren't intended to replace a physician's clinical judgment. The physician remains responsible for determining the applicable treatment for everyone. Clinical guidelines and utilization management criteria are made available to members, practitioners and providers on the ACNC website. Members and practitioners may request copies of guidelines used for a medical necessity determination at any time using the following methods.

Utilization Management (UM) Criteria is available upon request and is most easily located on our website:

A. Manuals, Policies and Forms webpage
B. ACNC Clinical Resources webpage

If you are a practitioner without fax, email or internet access:

A. Call 1-833-900-2262 to reach our Utilization Management department.
B. In person: AmeriHealth Caritas North Carolina

5th Floor
8041 Arco Corporate Drive
Raleigh NC 27617

Build a Culture of Prevention Through Early and Periodic Screening, Diagnostic and Treatment Services

Preventive care is a key driver in improving patient outcomes. By identifying health risks early, providers can intervene before conditions progress, helping patients live longer, healthier lives. To make these efforts more effective, diagnostic treatment program guides can serve as a valuable resource. These guides outline evidence-based pathways for screening, follow-up, and treatment, ensuring that patients receive consistent, high-quality care across the network.

When providers have these tools, it not only supports clinical decision-making but also strengthens the provider-patient relationship by focusing on wellness, not just illness. In March of 2025, NCDHHS provided an update to the Health Check Program Guide that defines parameters for the early and periodic screening, diagnostic and treatment (EPSDT) services offered in North Carolina.

The EPSDT benefit states that eligible children have access to early and regular medical surveillance and preventive services, including but not limited to physical assessments, vision, hearing, recommended vaccines, developmental/mental health screenings, referral and follow-up care to promote good health and to help ensure earliest possible diagnosis and treatment of health problems. This new guide is located on the NCDHHS website: https://medicaid.ncdhhs.gov/documents/medicaid/epsdt/health-check-program-guide.

QUALITY CORNER

Data Exchange Opportunities

ACNC strives to meet providers where they are and offers various methods to exchange quality data that supports care gap closure and top performance:

  • Data aggregator integration
  • Flat file submission
  • Direct EHR access
  • Clinical documentation upload via NaviNet

If you are interested in learning more about how you can share clinical quality data with us, please reach out to your assigned Account Executive.

Preparing for 2025 — 2026 Influenza Season

As a health care provider, you play a significant role in helping protect your patients against influenza. Your strong influenza vaccine recommendation is one of the most important factors in patients accepting the vaccine.

Best practices to consider for scheduling influenza vaccines in your practice:

  • Advertise the influenza vaccine as soon as it is available. 
  • Have separate nurse only visits or block scheduling for influenza vaccines.
  • Consider offering after-hour appointments or Saturday influenza vaccine clinic days.
  • Offer vaccines to siblings, parents/guardians, and caregivers in all practice type settings.
  • For children who need two influenza doses, schedule a second dose vaccine appointment at the time of the first dose. 
  • Recommend influenza and other needed vaccines at every clinical encounter. 

Resources for providers for influenza season

ADMINISTRATION, BILLING AND CLAIMS

Member Rights, Responsibilities and Privacy

As a reminder, ACNC, our network providers, and other service providers may not discriminate against members based on race, color, national origin, age, disability, creed, religious affiliation, ancestry, sex, gender identity or expression, or sexual orientation or any other basis prohibited by law. Please review the Member Rights, Responsibilities and Privacy section on our website or found on page 50 of the AmeriHealth Caritas North Carolina Member Handbook.

Streamlined Provider Website

We recently made some updates to our website to better support efficiency of administration within your practice. Please take some time to check them out and give us feedback!

Hard Launch for Electronic Visit Verification and Home Health Service Providers

This update is specifically for the home health providers that bill taxonomy code 251E00000X. NCDHHS reinstated an EVV hard launch date for HHCS providers as of October 1, 2025.

Providers should submit visit information using one of the two options below. 

1. Submit all visit information through HHAeXchange (HHAX) portal for claims creation.
  • Make sure your portal has been created. Being registered does not guarantee creation.
  • Member visit and EVV information must be submitted through your HHAX portal.
  • An updated Service Codes Crosswalk with HCPCS and Revenue Codes is found in the HHAX portal or on the ACNC Provider Manuals, Policies and Forms webpage.
2. Direct claims billing with ACNC after visit submission via HHAX.
  • Make sure your portal has been created in HHAX. Being registered does not guarantee creation.
  • The billed charge, number of units, and the invoice numbers are submitted directly to ACNC.
  • Providers can include supplies on the claim information submitted to ACNC.
  • If selecting this option, providers are still required to submit EVV information (date of service, billing codes, diagnosis, etc.) through HHAeXchange.
  • An updated Service Codes Crosswalk with HCPCS and Revenue Codes is found on the ACNC Provider Manuals, Policies and Forms webpage.

An informal webinar Q&A session is offered every Wednesday at 5 p.m. and discusses the necessary steps to establish a connection with HHAX and covers the options for billing claims. Register here for an upcoming session.

For a more complete description of services, see NCDHHS Medicaid Clinical Coverage Policy 3A for Home Health Services (PDF). Reach out to your Provider Network Management Account Executive for support training and billing.

Preventing Fraud, Waste and Abuse

According to the Centers for Medicare & Medicaid Services, “the Medicaid improper payment rate (comprised of reviews in 2021, 2022, and 2023) was 8.58 percent, or $50.3 billion, a significant decrease from the 2022 reported rate of 15.62%. Of the 2023 Medicaid improper payments, 82% were the result of insufficient documentation. These payments typically involve situations where a state or provider missed an administrative step and do not necessarily indicate fraud or abuse.”1

Providers are encouraged to review both the ACNC Claims and Billing Manual (PDF) and Provider Manual (PDF) for proper administrative steps.

Health care fraud affects everybody by raising taxes, decreasing the quality of health care, and taking funds away from members, hospitals and practitioners who are attempting to provide legitimate and necessary services.

It is everyone’s responsibility to be aware and report fraud, waste and abuse. Providers can monitor the activities of their employees through compliance audits; record reviews; and ongoing fraud, waste and abuse training. Additionally, providers should be aware of and able to recognize member fraud and abuse, such as member ID card sharing. Member ID card sharing can be stopped by checking the identification of the member who comes to the appointment versus the Medicaid ID card the member is provided with by the plan. If a member’s Medicaid ID does not match the name, birth date, and other information on a type of identification card, please report this to the necessary source. It is important to remember, members may also be the victim of identity theft.

Providers can report fraud, waste or abuse in the following ways:
  • Email us at FraudTip@amerihealthcaritas.com.
  • Call the AmeriHealth Caritas toll-free Fraud, Waste and Abuse Hotline at 1-866-833-9718.
  • Call the Medicaid Fraud, Waste and Program Abuse Tip Line at 1-877-DMA-TIP1 (1-877-362-8471).
  • Call the State Auditor's Waste Line at 1-800-730-TIPS (1-800-730-8477).
  • Call the U.S. Office of Inspector General's Fraud Line at 1-800-HHS-TIPS (1-800-447-8477).

1 “Fiscal Year 2023 Improper Payments Fact Sheet,” Centers for Medicare & Medicaid Services, November 2023, https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2023-improper-payments-fact-sheet.