September 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.

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You will find the following topics in this September digest:

TOP NEWS

• Medicaid Changes for Non-Citizens Beginning October 1
• New CPT Codes for Maternity Care

ADMINISTRATION

• Provider Annual Satisfaction Survey
• Take Advantage of Provider Drop-In Hours at Our Wellness & Opportunity Centers

MEMBER BENEFITS SPOTLIGHT

• ACNC Offers Telehealth Options
• Offering Members Access to No-Cost Language Interpretation Services

VALUE-BASED CARE

• Don’t Miss Out: ACNC Gaps in Care Programs’ Reporting Period Ends December 31, 2026

ON THE ROAD WITH ACNC

• North Carolina Pediatric Society 2026 Annual Meeting Recap
• ACNC Is Hitting the Road This Fall!

POPULATION HEALTH

• Let Us Know Your Thoughts! Complete the Tobacco Cessation Provider Survey 

QUALITY CORNER

• Well-Care Visits for Children and Adolescents
• Tips to Maintain Compliance With Critical Incident Reporting for Behavioral Health Providers and NC IRIS Users

EDUCATION AND TRAINING

• Register to Attend the Sixth Annual Statewide Standard Plan Annual Quality Forum

PHARMACY

• PDL Update Coming in October

Medicaid Changes for Non-Citizens Beginning October 1

The North Carolina Department of Health and Human Services (NCDHHS) has begun notifying affected Medicaid beneficiaries about eligibility changes under H.R. 1, the new federal Medicaid law. Beginning October 1, 2026, many non-citizens will no longer qualify for Medicaid coverage.

The NCDHHS Medicaid Is Changing webpage explains who will remain eligible, who will lose coverage and what steps affected individuals can take next.

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.

Maternity Billing CPT Coding Changes Effective January 1, 2027

To align with updated Centers for Medicare & Medicare Services (CMS) guidance, CPT coding used to support reporting of the Prenatal and Postpartum Care (PPC) measure is being updated. Beginning January 1, 2027, bundled prenatal and postpartum CPT codes will be retired and replaced with revised and new phase-specific codes.

To support a smooth transition, beginning September 1, 2026, NC Medicaid Direct and NC Medicaid Managed Care providers are encouraged to use Evaluation and Management codes (E/M 99202-99215) with the TH modifier to indicate prenatal or postpartum care. These codes should be used for:

• All claims and documentation for beneficiaries presenting for their first prenatal visit after confirmation

• Antepartum visits where the delivery and/or the postpartum visit is anticipated to occur after January 1, 2027

For more information, refer to the Maternity Billing provider notice (PDF). For questions, please contact your Provider Account Executive.

Provider Annual Satisfaction Survey

Your practice may receive an invitation to complete our annual satisfaction survey. The online survey will take about 15 minutes to complete. Your answers will help guide administrative and operational improvements to our health plan. If you receive an invitation by mail, please scan the QR code in the letter to complete the web-based survey.

Take Advantage of Provider Drop-In Hours at Our Wellness & Opportunity Centers

Get one-on-one support for your billing, claims, value-based program and other provider-related questions at 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, check the ACNC In-Person and Virtual Training Calendar contact your Provider Account Executive. We hope you drop in at an upcoming session!

ACNC Offers Telehealth Options

ACNC is excited to offer telehealth options to our members to avoid unnecessary emergency room visits. Teladoc and Blueberry are covered options that may help with many non-emergency health needs. Members can talk with a doctor or nurse practitioner by phone or video 24/7 and get the care they need without having to leave their home.

Teladoc can help adults 18 and older with treatment and advice for colds, flu, sinus problems, stomach issues, and minor aches and pains. You can also ask health questions or get help with medicine refills. 

Blueberry is an option for children up to 18 that helps parents and caregivers chat with a pediatrician through a secure app and get treatment and advice for non-emergency health needs.

For further questions, contact your Account Executive.

Offering Members Access to No-Cost Language Interpretation Services 

Members should be advised that interpretation services from ACNC are available at no cost. When a member uses ACNC interpretation services, the provider must sign, date and document the services provided in the medical record in a timely manner.

How to use our interpretation services:

• Inform the member of their right to no-cost interpretation services.
• Make sure a phone is in the room or use a cell phone.
• Call Member Services at 1-855-375-8811, 24 hours a day, 7 days a week, with the member ID number, and Member Services will connect you to the necessary interpreter.
• Conduct an exam with the interpreter over the phone.

Tips for working with a member using an interpreter

• Speak directly to the patient, not to the interpreter.
• Do not rush. Pause every sentence or two for interpretation.
• Use plain language. Avoid slang and sayings. Jokes do not always translate well.
• Check for understanding occasionally by asking the patient to repeat back what you said. This is better than asking, “Do you understand?”

Translation services must be provided to ensure adherence to providing services in a culturally competent way. Please review additional details about culturally competent care, including a language access flow chart to help providers identify and access interpretation and translation services on our website.

Don’t Miss Out: ACNC Gaps in Care Programs’ Reporting Period Ends December 31, 2026

There’s still time to take advantage of ACNC’s annual Gaps in Care programs before the reporting period ends on December 31, 2026. This year, ACNC has significantly increased gap closure incentives, with some paying up to $350 per gap. Visit the Value-Based Programs webpage to learn more about the three available Gaps in Care programs. For details about available resources and how ACNC can support your practice, contact your Provider Account Executive.

North Carolina Pediatric Society 2026 Annual Meeting Recap

We were grateful for the opportunity to connect with pediatric providers and practice managers at the North Carolina Pediatric Society 2026 Annual Meeting in Durham at the end of August. ACNC was proud to host an exhibit at the event and sponsor the Social Networking Room.

ACNC Is Hitting the Road This Fall!

Fall conference season is here, and ACNC is excited to be part of several upcoming events! Be sure to stop by our booth at the conferences listed below to meet our team, say hello and register for a chance to win a gift basket!

Let Us Know Your Thoughts! Complete the Tobacco Cessation Provider Survey

Help us better support members who are working to quit tobacco products by completing a brief Tobacco Cessation Provider Survey. Your feedback will help us understand current tobacco cessation practices, common barriers to counseling conversations, and provider training and support needs.

Remember, counseling patients who smoke cigarettes, tobacco or vape products to quit is a billable service under NC Medicaid.

Thank you for taking the time to share your input. Learn more about ACNC smoking cessation services on our website.

Well-Care Visits for Children and Adolescents

Wellness visits are an essential part of children’s health. Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit covers regular wellness visits for children and adolescents 0 – 21 years of age.

To increase visit rates, one of the best practices is to use a modifier to add well-visit components to a sick visit³:

• Add Modifier 25 for separate identifiable E/M service on the same day (e.g. sick visit and well visit).
• Documentation should include details of the well-care visits, including the dates, services provided, and relevant screenings or assessment, ensuring a comprehensive record of the child’s health care.

Well-child/EPSDT visit criteria is based on American Academy of Pediatrics Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents.

¹ Well-Child Visits in the First 30 Months of Life (W30)
² Child and Adolescent Well-Care Visits (AWC, WCV)
³ Setting the record straight on proper use of modifier 25

AmeriHealth Caritas NC Gaps in Care for Primary Care Physicians Program

Beginning July 1, 2026, primary care physicians are eligible for a per-gap closure incentive once a year for each member assigned to their practice who meets the population and compliance criteria for the quality measure.

For further questions regarding claims issues or value-based programs, contact your Account Executive.

If your practice is interested in collaborating with ACNC for well-visit gap-closure events, please contact the quality management department at ACNCQualityManagement@amerihealthcaritas.com.

Tips to Maintain Compliance with Critical Incident Reporting for Behavioral Health Providers and NC IRIS Users

Use these tips to support timely, compliant critical incident reporting in NC IRIS.

Timely critical incident reporting:

Level II and III critical incidents must be submitted in NC IRIS within 72 hours of learning of the incident.

Exceptions:

• Level III reports also require a verbal report to ACNC immediately
• Death within 7 days of seclusion or restraint require an NC IRIS report immediately

Critical incidents initiated in NC IRIS within the 72-hour required time frame, but not submitted, are not considered timely unless submitted within the required time frame.

• Ensure the Supervisor Actions section is completed before you submit the report. Submission is confirmed when you see the thumbs up. If you do not see the thumbs up graphic along with the incident number after completing the report, the critical incident report has not been submitted.
• Print or make a note of the incident number so that you can easily access the report when you have the necessary information to update and complete the report.

Abuse and/or neglect reports:

• Must be reported to the Department of Social Services (DSS) as soon as you become aware of the allegation and noted in the Authorities Contacted section of the report.
• ACNC is unable to complete the incident review until the DSS Reporter Letter is received by the provider and uploaded to the IRIS report (typically received within 30 days of the initial DSS report).
  • This letter contains the determination of whether the report was accepted by DSS for further investigation, not the outcome of an investigation.

Level III incident reporting:

Complete an internal team review and upload/attach the findings to the critical incident report

Death reporting:
ACNC is unable to close the critical incident in NC IRIS without official documentation of the cause of death; therefore: behavioral health providers must:

• Request the Medical Examiner’s Report/Autopsy Report/Toxicology Report from the North Carolina Office of the Chief Medical Examiner (OCME).
• If an autopsy was not performed, contact the Register of Deeds Office in the county where the consumer passed away to request the death certificate. (An uncertified copy is sufficient.)
• Once the supplemental information is received, amend the critical incident report in NC IRIS to reflect the new information, including updating the Supervisor Actions section (Cause of Incident/Incident Prevention).

For more information visit the NC IRIS webpage or send questions concerning critical incident reporting to ACNC Quality Management team

Register to Attend the Sixth Annual Virtual Statewide Standard Plan Annual Quality Forum

Join the North Carolina Department of Health and Human Services (NCDHHS) on Wednesday, October 14, from 11:00 a.m. to 1:00 p.m. for the Sixth Annual Virtual Statewide Standard Plan Annual Quality Forum. This year’s forum will focus on women’s health and Early and Periodic Screening, Diagnostic and Treatment (EPSDT). The interactive webinar will feature a provider panel sharing best practices in women’s health. Even if you cannot attend live, register to receive the slides and recording when they become available.

PDL Update Coming in October

The NC Medicaid Preferred Drug List (PDL) update will occur on October 1, 2026.

As a reminder, the Pharmacy webpage provides current information about covered member prescriptions and other pharmacy services, including copays, prior authorization and medication limits.