October 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 October digest:
TOP NEWS
- Pharmacy Benefit Management Transition to Optum Rx Beginning January 1, 2027
- Federal Changes to Medicaid Begin on January 1, 2027
VALUE-BASED PROGRAMS
- ACNC Recognizes Thomasville Archdale Pediatrics With Quality Award
- Help Members, and Earn Annual Incentives for Closing Diabetes Care Gaps
PROVIDER EDUCATION AND TRAINING
PROVIDER UPDATES
- Fall Conference Recap
- Take Advantage of Local Office Hours With Our Provider Team
- Get to Know Our Team — Sean Light
ADMINISTRATION
MEMBER BENEFIT SPOTLIGHT
QUALITY CORNER
PHARMACY
CLINICAL INITIATIVES
TOP NEWS
Pharmacy Benefit Management Transition to Optum Rx Beginning January 1, 2027
AmeriHealth Caritas North Carolina (ACNC) will conclude pharmacy benefit management operations with PerformRxSM effective December 31, 2026. Effective January 1, 2027, ACNC will transition its pharmacy benefit management services to Optum Rx. Optum Rx will manage claims processing, mail order and network contracting. AmeriHealth Caritas’ Pharmacy Department will manage Formulary, Clinical Programs, Prior Authorizations and Member Services. The change to Optum Rx will not affect the formulary or the preferred drug list (PDL). ACNC will continue to align with NC Medicaid Outpatient Pharmacy Medication Coverage.
Please see the Provider Update (PDF) for additional information.
Federal Changes to Medicaid Begin on January 1, 2027
New federal rules begin on January 1, 2027. The changes include Medicaid expansion work, renewal and eligibility requirements. ACNC has developed a Medicaid Requirements webpage to help members understand these changes and learn what steps they can take if they are affected. Additionally, the North Carolina Department of Health and Human Services recently launched a webpage with information and resources for providers titled Federal Medicaid Changes: What Providers Need to Know.
ACNC has trained facilitators available to provide an overview of H.R. 1 policy changes. If your practice or community organization would like to schedule a presentation, please contact your Provider Account Executive.
VALUE-BASED PROGRAMS
ACNC Recognizes Thomasville Archdale Pediatrics With Quality Award
ACNC leadership recently recognized Thomasville Archdale Pediatrics as one of the top three quality providers in the network. The AmeriHealth Caritas North Carolina IMPACT Award celebrates provider partners who exemplify excellence through improved member outcomes, collaboration, accountability, innovation and transformation in health care delivery. The practice received the award for dedication to quality care and the positive impact they make within their community. In honor of their achievements, ACNC also donated funds to the practice’s Blessings and Hope resource pantry.
Help Members, and Earn Annual Incentives for Closing Diabetes Care Gaps
ACNC offers annual incentives for providers based on the members assigned to your practice via the PerformPlus® Gaps in Care for Primary Care Physicians Program.
- Include the date of the HbA1c test or glucose management indicator (GMI) and the actual result; don’t use ranges and thresholds.
- Include available continuous glucose monitor (CGM) data in the office-visit note.
You can learn more about this program by visiting the Value-Based Programs webpage. Please contact your Provider Network Management Account Executive with any questions regarding claims or incentive settlements.
PROVIDER EDUCATION AND TRAINING
Project ECHO Behavioral Health Bootcamp Returns, Offering FREE CME
ACNC is partnering with Southern Regional AHEC to offer Project ECHO Behavioral Health Bootcamp! All types of providers are invited to participate in our no-cost 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 participate. Sessions are held on Wednesdays from 12:00 p.m. to 1:00 p.m.
The next bootcamp session will be held Wednesday, November 4th, at noon. Topics for the series include suicide risk across the life span, serious mental illness and psychosis, trauma and adverse childhood experiences, and working with difficult patients.
Learn more on the ACNC Behavioral Health webpage, and register for the series:
A MyAHEC account is required. One registration enrolls you in the full series.
PROVIDER UPDATES
Fall Conference Recap
This fall, our ACNC team connected with providers, practice managers, public health and behavioral health professionals, and other partners statewide. In addition to the North Carolina Psychiatric Association Annual Meeting, the Carolinas Medical Group Management Association Fall Conference and Benchmarks Destination 2026, we participated in the North Carolina Public Health Association Fall Education Conference. Thanks to all of you who stopped by to spin our wheel and meet our teams in person!
Take Advantage of Local Office Hours With Our Provider Team
Get one-on-one support for your billing, claims, value-based program and other provider-related questions at monthly Provider Network Management office hours. Stop by our local regional Wellness & Opportunity Center between 10:00 a.m. and 2:00 p.m. to meet with an account executive. No appointment is needed.
For more information or questions, contact your Provider Account Executive. We hope you drop in at an upcoming session!
| Date | Location |
|---|---|
| Wednesday, November 11 | Asheville Wellness & Opportunity Center 216 Asheland Avenue, Asheville |
| Wednesday, November 18 | Fayetteville Wellness & Opportunity Center 4101 Raeford Road, Fayetteville |
| Wednesday, December 2 | AmeriHealth Caritas North Carolina 8041 Arco Corporate Dr, First Floor, Raleigh |
| Wednesday, December 9 | Greensboro Wellness & Opportunity Center 3018 West Gate City Boulevard, Greensboro |
Sean Light, Account Executive
Sean Light, MBA, BS, Rt(R), is the main point of contact for assigned medical groups, health systems and clinics in western North Carolina. Prior to joining ACNC, Sean served as the Provider Relations Consultant at another health plan in Tennessee. He has 31 years of experience in provider relations, cross-functional collaboration and contract management. Sean earned an associate’s degree in applied science (radiologic technology) at East Tennessee State University, a Bachelor of Science degree in health care administration at East Tennessee State University and a master’s in business degree at King’s College University. Sean enjoys golfing, working out, hiking and watching college football while spending as much time as possible with his wife, Jodie, and his two children, Jackson and Colby.
ADMINISTRATION
Updated Prior Authorization Request Form
The Prior Authorization Request Form (PDF) was recently updated. In addition to being an editable form, the new version includes transplant information. The form can be found on the Prior Authorizations webpage and can be used when faxing a prior authorization form.
MEMBER BENEFIT SPOTLIGHT
Wellness & Opportunity Centers Spotlight
Did you know that ACNC has five Wellness & Opportunity Centers across the state and a Mobile Wellness & Opportunity Center? At these centers, we offer many opportunities at no cost to our members, including cooking, fitness and life skills classes. Our Wellness & Opportunity Centers are in Asheville, Charlotte, Greensboro, Greenville and Fayetteville and the mobile unit travels statewide. To learn more about each center and see their upcoming events, visit the Wellness & Opportunity Centers webpage.
QUALITY CORNER
Glycemic Status Assessment for Patients With Diabetes (GSD) HEDIS® Measure
The GSD HEDIS measure is the percentage of individuals 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 year:
- Glycemic status less than 8.0%
- Glycemic status greater than 9.0%
Evidence-based practices
The American Diabetes Association 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.1
- These devices are covered when deemed medically necessary (diabetes requiring insulin or gestational diabetes) through durable medical equipment and pharmacy services.2
- Eligibility criteria for CGMs has expanded. For more information, please refer to the North Carolina Medicaid Division of Health Benefits, clinical criteria website.
Blood Pressure Control for Patients with Diabetes (BPD) is a key aspect of preventing further diabetes-related complications.
- Consider providing members with a prescription or order for a blood pressure monitor, and encourage use of blood pressure logs.
- Implement recommendations in our Reducing Disparities in the Management of Hypertension in African American Patients toolkit (PDF).
- 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.
For providers who would be interested in connecting with ACNC regarding opportunities to improve quality of care for members, please contact ACNC Quality Management.
1 https://doi.org/10.2337/dc25-S006
2 https://medicaid.ncdhhs.gov/5a-3-nursing-equipment-and-supplies/download
PHARMACY
Medication Prior Authorizations for Point-of-Sale Pharmacies and Non-Point-of-Sale Pharmacies
Point-of-sale (POS) pharmacy
For some medications covered at point-of-sale pharmacies, providers are required to submit a prior authorization before prescribing them to our members. To find out what medications covered at the pharmacy require prior authorization, please refer to our Medication Look Up Tool or contact our Pharmacy Provider Services at 1-866-885-1406.
To submit a prior authorization for a medication covered at a point-of-sale pharmacy, refer to our Pharmacy Prior Authorization webpage.
Non-point-of-sale (POS) pharmacies
Providers are required to submit prior authorization for a medication acquired, administered and billed by a medical office or outpatient hospital unless indicated in service-specific guidance. Please refer to our Prior Authorization Lookup Tool to find out if a medication requires prior authorization. You can do this by typing in the Current Procedural Terminology (CPT) code or a Healthcare Common Procedure Coding System (HCPCS) for the medication. If you are unable to locate the service you are seeking, please call ACNC Utilization Management at 1-833-900-2262 for assistance.
CLINICAL INITIATIVES
ACNC Partners With Labcorp to Provide Prenatal Screening
ACNC is partnering with North Carolina-based Labcorp to offer prenatal screening that supports better care, closes care gaps, informs treatment and improves pregnancy outcomes. Labcorp’s testing includes prenatal screening and preeclampsia testing throughout pregnancy.