January 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 January digest:
NC MEDICAID UPDATES
TRAINING AND LEARNING OPPORTUNITIES
- New On-Demand Content Available to Provider Practices
- New Vendor — Edifecs Clinical Insights (CI) Solution Informational Sessions
ON THE ROAD WITH OUR PROVIDERS
QUALITY CORNER
- Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey
- Medical Record Data Request for Select Providers
ADMINISTRATION
NC MEDICAID UPDATES
Medicaid Rates Reversal Updates
- On December 10, 2025, the N.C. Department of Health and Human Services (NC DHHS) announced the reversal of Medicaid reimbursement rate reductions that took effect October 1, 2025. NC DHHS is taking immediate action to update NC Medicaid Direct fee schedules to align with rates in effect September 30, 2025. The updated NC Medicaid Direct fee schedules are targeted to be posted on the department’s Fee Schedules and Covered Codes Portal by January 5, 2026. ACNC will continue to work with state leaders to ensure providers’ administrative burden is minimized as much as possible. For more information, please refer to the Medicaid Bulletin: Medicaid Rate Reduction Reversal Update.
- As of December 12, 2025, the department has reinstated its clinical criteria regarding its optional coverage of GLP-1s Wegovy, Zepbound, and Saxenda for weight loss that was in effect as of September 30, 2025, across all delivery systems of the NC Medicaid program. Please see Medicaid Bulletin: NC Medicaid to Reinstitute Coverage of GLP-1s for Weight Management.
Medicaid Readmission Review Updates
Effective January 1, 2026, NC DHHS updated the Clinical Coverage Policy for Acute Inpatient Hospital Services to include a definition for inpatient readmission review and to change the readmission review time frame from 72 hours to 30 days. Please refer to NC Medicaid Clinical Coverage Policy No: 2A-1 (PDF) for specific guidance.
TRAINING AND LEARNING OPPORTUNITIES
New On-Demand Content Available to Provider Practices
ACNC has developed two new training resources to support practice administrators and staff in working with our plan. We hope you will take advantage of these on-demand opportunities:
Let’s Work Together: Provider Orientation Training is a 25-minute overview of practices that are new to our network. The training provides valuable information as a refresher on operations and support available to your practice.
Registering for and Using Navinet is a 33-minute training course on how to use our provider portal, with helpful tips on checking claims status, accessing clinical reports, claims attachments, and the grievance process.
Please visit our Provider Training page for links to these trainings and other resources.
New Vendor — Edifecs Clinical Insights (CI) Solution Informational Sessions
Effective January 15, 2026, ACNC has contracted with Edifecs to enable a pre-adjudication technical solution, Clinical Insights, designed to improve the completeness and accuracy of diagnosis coding.
In an effort to ensure that all providers are well-informed about this new initiative, ACNC and Edifecs have collaborated to offer informational sessions via webinar.
These training sessions will:
- Define the Edifecs Clinical Insights (CI) technical solution.
- Define why we are using this solution.
- Identify benefits and potential outcomes.
The webinar will take place on:
| Date | Time (ET) | Registration link |
|---|---|---|
| 1/8/2026 | 1 p.m. – 2 p.m. | https://amerihealthcaritas.zoom.us/meeting/register/ZlEZzVNASPWUtl2UB1vo5g |
| 1/13/2026 | 11 a. m. – noon | https://amerihealthcaritas.zoom.us/meeting/register/GNbgC7DCSMCxq8e224JUQA#/ |
Registration is required.
After registering, you will receive a confirmation email with instructions on joining the webinar.
Questions:
If you have questions about this communication, please contact your Provider Account Executive or the Provider Services department at 1-888-738-0004.
ON THE ROAD WITH OUR PROVIDERS
Stop by and Say Hello at the i2i Conference
i2i Center for Integrative Health Winter Conference — January 13 – 15, Winston-Salem
This year, ACNC is sponsoring the Pre-Conference Medicaid Symposium and Lunch. Dr. Nerissa Price, our Behavioral Health Medical Director, will speak on identifying your guiding purpose and the importance of partnerships so make sure to attend! Additionally, stop by our booth in the main foyer to meet our team. If you tell us you read about it in the Provider Digest, you will be entered in a drawing for a special gift for your practice!
NC Academy of Family Physicians Winter Meeting
Winter weather did not dampen spirits at the North Carolina Academy of Family Physicians Annual Winter Meeting in Asheville. We are proud to be a consistent sponsor of this event, where our team always enjoys meeting and talking with providers that work so hard to support our members in getting and staying healthy. Congratulations to our door prize winners from Ashe Women & Children's Health, MAHEC Family Health Centers, and Novant Health New Hanover Regional Medical Center!
QUALITY CORNER
CAHPS Survey and Tips to Improve Patient Experience
AmeriHealth Caritas North Carolina (ACNC) collaborates with our providers to help ensure that our members receive comprehensive, quality, and culturally responsive care. One of the tools used to evaluate the member care experience is the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.
In February of each year, a CAHPS survey is mailed to a randomly selected group of ACNC members to ask about their experiences with their providers, health plan, and the care they receive.
Some best practices for improving the patient’s experience include:
- Develop cross-functional integrated care teams to coordinate customized care for patients to improve overall health.2
- Offer advanced access and same day scheduling to patients with their primary care provider (PCP).1
- Direct patients to 24-hour nurse hotlines in between appointments.1 ACNC members can reach the Nurse Line by calling 1-888-674-8710 (TTY 1-866-209-6421) 24 hours a day, seven days a week.
- Offer telemedicine for treatment of minor conditions to reduce delays and increase access to patient care.1
- Implement patient portal systems for patients to access practitioner's notes and test results before and after visits.1
- Provide patients with recommended resources and web links from trusted sources during visits.1
If your practice is interested in partnering with ACNC on improving quality outcomes, please contact the ACNC Quality Management team at acncqualitymanagement@amerihealthcaritas.com.
1 “Section 6: Strategies for Improving Patient Experience With Ambulatory Care,” January 2016, Ahrq.gov, https://www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/index.html#table-6-1, accessed December 31, 2025.
2 Anna C. Greiner and Elisa Knebel, “Chapter 3: The Core Competencies Needed for Health Care Professionals, Health Professions Education: A Bridge to Quality,” 2003, National Institutes of Health, National Library of Medicine, National Center for Biotechnology Information, https://www.ncbi.nlm.nih.gov/books/NBK221519, accessed December 31, 2025.
Medical Record Data Request for Select Providers
The annual Healthcare Effectiveness Data and Information Set (HEDIS) reporting period begins in February. ACNC appreciates your cooperation with our efforts to collect medical record data for our enrollees treated by your practice. Records requested should be provided at no charge to the health plan. A frequently asked questions (FAQ) document about this process can be found on the HEDIS and Quality webpage.
ACNC is required to comply with Health Insurance Portability and Accountability Act (HIPAA) Privacy requirements throughout the retrieval process and is trained in medical record retrieval for HEDIS, Centers for Medicare & Medicaid Services (CMS), and state quality reporting programs. This data collection is permitted under HIPAA legislation.
If you have any questions, please reach out to the ACNC Quality Management team at acncqualitymanagement@amerihealthcaritas.com.
ADMINISTRATION
Vendor Outreach to Providers to Support Risk Adjustment Solutions
ACNC collaborates with health care providers to gather comprehensive and accurate member health histories to determine risk adjustment scores that help facilitate correct billing and clinical insights. To help us complete this process efficiently, ACNC has contracted with several vendors for assistance to conduct risk adjustment services. Please be aware that these vendors may reach out to you directly on our behalf.
The vendors we are partnering with include:
UST HealthProof: Helps retrieve records and ensure that medical records for our plan members with chronic health conditions that are coded and documented in compliance with Health & Human Services (HHS), CMS, or state specific documentation guidelines. UST HealthProof will support providers by providing onsite and remote Provider Engagement Coordination (PEC) services. UST HealthProof will support members by conducting targeted appointment scheduling to encourage member engagement in appropriate care such as annual wellness visits.
Edifecs: Concurrent Risk Adjustment (CRA) Review: Provides guidelines to support complete and accurate diagnosis coding on claims before submission to the health plan. The Clinical Insights (CI) solution is designed to alert providers when diagnosis codes are potentially missing from a claim.
Centauri Health Solutions: Connects eligible individuals with physical or mental health conditions in applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) through the Social Security Administration.
Clearview: Conducts member outreach to target risk adjustment members encouraging them to schedule a visit with their primary care provider to address open Hierarchical Condition Categories (HCC) gaps/suspected conditions.
To find out more, please contact your Provider Account Executive or call the Provider Services department at 1-888-738-0004.
Behavioral Health Prior Authorization Updates
Following NC DHHS guidance, AmeriHealth Caritas North Carolina now requires prior authorization for peer support services (H0038) and unlisted psychiatric services (90899) as of December 1, 2025.
For more information, please visit the Prior Authorization webpage or use the prior authorization lookup tool.
Help Us Support Our Members by Sharing Data
In support of our commitment to equitable health care access and improved provider and patient relations, we invite our providers to voluntarily share their demographic information. This includes your race and the languages you and your practices speak.
This data helps us better reflect the diversity of our networks, support member choice, and help improve access to culturally responsive care.
By collecting race, ethnicity, and language (REL) data we can:
- Highlight the diversity of our provider network.
- Improve how we present provider information.
- Support compliance with national standards including but not limited to culturally and linguistically appropriate services (CLAS) and National Committee for Quality Assurance (NCQA) accreditation.
AmeriHealth Caritas North Carolina collects provider REL data through our standard processes, including provider roster updates, using the federal categories established by the Office of Management and Budget (OMB).
- Gender data, provider and staff languages, and additional language services are available through ACNC provider directory.
- Race and ethnicity information are not displayed in the provider directory. The information is only made available to members upon request.
During touchpoints with your Account Executive, let them know if our provider directory includes your practice information about cultural competency training, as well as languages spoken and available to your patients. If your information is not complete, we can help you get up to date.
CMS Interoperability and Prior Authorization Final Rule Update
The Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F), which goes into effect in 2026, adds several new provisions to increase data sharing and reduce overall payer, health care provider, and patient burden through improvements to prior authorization practices and data exchange practices. Find out more about this rule on the CMS website and watch for implementation updates from ACNC in future Provider Digests.