June 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 June digest:
PROVIDER UPDATES
ON THE ROAD WITH OUR PROVIDERS
PHARMACY NEWS
ADMINISTRATION
PROVIDER TOOLS AND RESOURCES
MEMBER BENEFIT SPOTLIGHT
POPULATION HEALTH
QUALITY CORNER
PROVIDER UPDATES
New Value-Based Payment Programs Begin July 1
A new suite of value-based payment programs will kick off on July 1 for in-network providers. ACNC’s PerformPlus® Gaps in Care programs offer financial incentives to participating providers who close critical health care quality gaps for their patients. Coding tips and Gaps in Care resources are available on the HEDIS and Quality webpage. Our Account Executives are also available to help your practice review data and share best practices for closing gaps. In 2025, ACNC recognized more than 800 distinct providers through value-based programs.
The 2026 programs include:
ON THE ROAD WITH OUR PROVIDERS
Community Care Physician Network Annual Clinician Conference Recap
We enjoyed connecting with providers at the 2026 Community Care Physician Network (CCPN) Annual Clinician Conference held in Greensboro in May. In addition to exhibiting and sponsoring, we participated in the Support Center Session, where we had the opportunity to connect directly with our network providers for one-on-one conversations to address concerns and get important feedback.
PHARMACY NEWS
Pharmacy Prior Authorization Guidance
ACNC has developed Pharmacy Prior Authorization Request Documentation Guidance that provides helpful information on appropriate documentation for a pharmacy prior authorization (PA) request. By including complete and current documentation in the initial request, prescribers can ensure their patients get needed medications in a timely manner.
Missing core documentation elements like prescriber-specific information (name, NPI, and phone number) create unnecessary delays and denials. Additional documentation may also be necessary to demonstrate medical necessity.
Please download the guidance document as a ready resource for any prescribers in your office.
ADMINISTRATION
Prior Authorization Reminder: Three Points of Identification Needed for HIPAA Compliance
When submitting a prior authorization request, it is essential to include three points of member identification. This requirement supports compliance with HIPAA regulations. Ensuring all documentation is complete helps prevent delays in processing your submissions. Acceptable identifiers needed for every request are:
- First name, last name and suffix (mandatory) — as listed on the Medicaid ID Card
- Date of birth (mandatory)
- One of the following (mandatory):
- Member ID/plan ID
- Address
- JIVA ID
- Authorization number
As a reminder, the fastest way to submit medical prior authorization is electronically via Medical Authorizations in NaviNet. You may also submit a prior authorization request by faxing a completed Prior Authorization Request form to 1-833-893-2262 or by calling ACNC Utilization Management at 1-833-900-2262.
For questions or more information, please visit the Prior Authorization webpage or contact your Provider Network Account Executive.
PROVIDER TOOLS AND RESOURCES
Controlling Blood Pressure Toolkit: Reducing Disparities in the Management of Hypertension in African American Patients
According to the American Heart Association, about 58% of African American adults in the United States are affected by hypertension. To address this health disparity, ACNC is pleased to provide a controlling blood pressure toolkit, Reducing Disparities in the Management of Hypertension in African American Patients. This toolkit is designed to support providers by offering information on several key topics, including:
- Identifying and understanding barriers to care within the African American population
- Implementing best practices for collaborating with community-based organizations and supporting blood pressure management
- Accessing continuing education resources to enhance provider knowledge and skills
We encourage providers to utilize the controlling blood pressure toolkit to help reduce disparities and improve outcomes for African American patients living with hypertension.
Providers interested in learning more about practical application and implementation strategies in the toolkit to address health equity and hypertension are invited to request a lunch-and-learn with our team. Email acncprovidercommunications@amerihealthcaritasnc.com to get connected.
MEMBER BENEFIT SPOTLIGHT
School Supplies Award Available in July
While summer is just getting started, students will be headed back to school before we know it! Please remind your ACNC members about the school supplies benefit that will be loaded on their Care Card in early July.
ACNC provides $50 annually for each member ages 5 – 18 for school supplies. Funds are loaded each year in early July and must be used by September 30.
For more information on ACNC member extra benefits, visit the Extra Benefits webpage.
POPULATION HEALTH
Collaborating to Enhance Population Health
Providing care for our shared members requires teamwork, communication and a unified dedication to improving outcomes. Population health management aims to address care gaps, support those at highest risk and promote comprehensive well-being across our communities. We strive to supply your practice with valuable tools and resources that complement the exceptional care you already offer.
Defined roles and shared accountability
Successful population health management relies on clear role definitions and aligned responsibilities. Together, we are accountable for achieving measurable health results.
Your practice:
- Guides clinical decisions and oversees patient care
- Determines care needs and coordinates treatment plans
- Involves patients in recommended preventive and follow-up care as part of our health plan
- Communicates service delivery issues, member status changes and care coordination needs
Our health plan:
- Supplies actionable data and quality performance reports
- Identifies members who could benefit from extra support
- Engages members and reinforces care plans
- Offers care management services for members who are high-risk or have complex needs
- Connects members to community and social support services
When we work together around shared goals and maintain clear communication, we can address care gaps, enhance quality performance, minimize unnecessary utilization and improve the member experience.
Advancing population health through value-based collaboration
In addition to defining roles in coordinated care activities, we support providers through alternative payment model (APM) arrangements designed to align incentives with shared population health goals. These value-based strategies promote accountability for quality outcomes and care coordination. The strategies also facilitate overall member well-being by aligning performance expectations, data insights and financial incentives. APM opportunities further strengthen collaboration and support measurable improvements in health outcomes throughout our communities.
For more information about available resources, care coordination support or value-based partnership opportunities, please contact Provider Services at 1-888-738-0004.
QUALITY CORNER
Immunization for Adolescent (IMA) Combo 2 HEDIS® Measure
The Immunization for Adolescent (IMA) Combo 2 HEDIS® measure is the percentage of adolescents who have received the required vaccines by their 13th birthday. The required vaccines in the Combo 2 series are one meningococcal (MenACWY); one tetanus, diphtheria toxoids and acellular pertussis (Tdap); and two or three human papilloma virus (HPV) series.
Meningococcal vaccine (MenACWY)
- At least one MenACWY (serogroups A, C, W, Y or A, C, W, Y, B) with a date of service on or between the 10th and 13th birthdays
- Documented anaphylaxis due to the meningococcal vaccine on or before the 13th birthday
Tetanus, diphtheria toxoids and acellular pertussis vaccines (Tdap)
- At least one Tdap vaccine with a date of service on or between the 10th and 13th birthdays
- Documented anaphylaxis or encephalitis due to the Tdap vaccine on or before the 13th birthday
Human papillomavirus (HPV) vaccine
- At least two HPV vaccines on or between the 9th and 13th birthdays and with dates of service at least 146 days apart
- At least three HPV vaccines with different dates of service on or between the 9th and 13th birthdays
- Documented anaphylaxis due to the HPV vaccine on or before the 13th birthday
More about the HPV vaccine
- The vaccine is for adolescents of all genders.
- Giving the HPV vaccine to children between 9 and 12 years old can prevent more than 90% of HPV-related cancers.
- HPV vaccine is used as prevention prior to exposure to HPV. Early protection with the vaccine is recommended before the start of sexual activity, though it can also be helpful after the person has become sexually active.
Best practices to meet the Immunization for Adolescent (IMA) Combo 2 measure:
- Strongly recommend vaccines to parents; parents trust providers’ opinions more than anyone else regarding vaccines.
- Ensure consistency across all staff in messaging to educate parents of vaccine importance.
- Use a reminder system for vaccines (texts, calls, electronic record reminders).
- Schedule all appointments prior to the 13th birthday.
- Offer walk-in or immunization-only appointments.
- Document all vaccines in the North Carolina Immunization Registry (NCIR).
- Document anaphylaxis due to the meningococcal, Tdap or HPV vaccine with the date administered in the medical record.
- Ask your ACNC Account Executive for a care gap member list to assist with care gap closures.
Please contact your Provider Network Management Account Executive with any questions.
If you are interested in partnering with ACNC on well visit and/or vaccine events, please contact ACNC Quality Management by email at ACNCQualityManagement@amerihealthcaritas.com.