Questions and Answers for Providers
- Is non-emergency transportation covered?
- Does AmeriHealth Caritas North Carolina provide interpretation and translation services?
- How do I get paid?
- If Medicaid is the secondary payer, will Medicare cross the claim over to us?
- Do providers need to be enrolled in North Carolina Medicaid?
- How is continuity of care managed?
- How can I find out who my network account executive is?
- Will members be required to select a primary care provider (PCP)?
- How does a member change his or her PCP?
- If the member changes PCP, when will the new PCP be effective?
- Are there pharmacy copays?
- Do specialty drugs require prior authorization?
- Is there a formulary?
- How do I obtain prior authorization?
- Do certain diagnostic services require authorization?
- Do Medicaid patients need a referral?
- How can I obtain a copy of the fee schedule?
Is nonemergency medical transportation (NEMT) covered?
Yes. This benefit is covered. The provider or the member can call Member Services at 1-855-375-8811 or the Rapid Response and Outreach Team at 1-833-808-2262 — up to two business days before the appointment to arrange transportation.
Does AmeriHealth Caritas North Carolina provide interpretation and translation services?
Yes — interpretation and translation, and services for the hearing and visually impaired are free to AmeriHealth Caritas North Carolina members.
How do I get paid?
We want to go green. We encourage our providers to sign up for electronic funds transfer (EFT). If you would like to sign up for EFT, contact Change Healthcare at 1-877-363-3666. If you do not sign up for EFT, you will receive payment by a check in the mail.
If Medicaid is the secondary payer, will Medicare cross the claim over to us?
Yes. We will accept claims directly from Medicare when we are the secondary payer. If the primary payer does not cross over the claim to AmeriHealth Caritas North Carolina, providers should submit secondary claims to AmeriHealth Caritas North Carolina with the explanation of benefits (EOB) from the primary payer within 60 days of the date on the EOB. We will accept third party liability (TPL) claims with the primary insurer EOB electronically or via paper.
Do providers need to be enrolled in North Carolina Medicaid?
Yes. Providers must be enrolled in North Carolina Medicaid.
How is continuity of care managed?
If a member is new to AmeriHealth Caritas North Carolina and has an existing authorized service, the Plan will honor the existing authorization. For more information, please refer to the provider manual (PDF) or call Provider Services at 1-888-738-0004.
Will members be required to select a primary care provider (PCP)?
Yes. During the open enrollment period, the Enrollment Broker will engage in proactive outreach that explains the Enrollment Broker’s services, provides managed care education and supports the selection of a Prepaid Health Plan and an Advanced Medical Home (AMH)/PCP to beneficiaries eligible for Medicaid Managed Care.
If the member is automatically assigned to AmeriHealth Caritas North Carolina and the member does not select a PCP, AmeriHealth Caritas North Carolina will assign the member to an AMH/PCP within 24 hours of effective date of enrollment in AmeriHealth Caritas North Carolina. If no PCP is selected via the Enrollment Broker, AmeriHealth Caritas North Carolina will:
- Inform the member of their right to choose a PCP
- Assist the member in selecting a PCP
- Inform the member that each eligible family member has the right to choose his or her own PCP
- Automatically assign a PCP to members who do not proactively choose a PCP within 24 hours of enrollment with the Plan
Newly enrolled members receive a welcome packet from the health plan that includes a member handbook and an AmeriHealth Caritas North Carolina member identification card that lists the member’s PCP and phone number.
How does a member change his or her PCP?
A member can change his or her PCP by contacting member services. The provider office can also call Member Services with the member present to request the change, but the member must give their approval for the change.
A member can change his or her AMH/PCP without cause twice per year. A member will be given 30 days from receipt of notification of their AMH assignment to change their AMH/PCP without cause (first instance) and will be allowed to change their AMH/PCP without cause up to once per year thereafter (second instance).
If the member changes PCP, when will the new PCP be effective?
The PCP change will take effect the same day the member contacts Member Services.
Are there pharmacy copays?
Yes. Reference the Pharmacy section on this website or consult your provider manual.
Do specialty drugs require prior authorization?
Yes. Get an up-to-date list of the drugs that require prior authorization.
Is there a formulary?
Yes. The online formulary is currently under development. In the meantime, please refer to the most current preferred drug list on the NCDHHS website.
How do I obtain prior authorization?
Prior authorization can be obtained three ways. Providers may need to complete a form before administering some health services to members.
- By fax: Prior authorization forms can be found in the Forms section of this website. Fax the form to Utilization Management at 1-833-893-2262.
- By phone: For physical health, behavioral health and LTSS, call our Utilization Management department at 1-833-900-2262.
- Online: providers may complete prior authorization forms online through Jiva.
For Pharmacy Prior Authorization, call 1-866-885-1406 or fax your completed prior authorization request form to 1-877-234-4274.
Do certain diagnostic services require authorization?
Yes, AmeriHealth Caritas North Carolina's radiology benefits vendor, National Imaging Associates, Inc. (NIA), provides utilization management review and authorization for non-emergent, advanced and outpatient imaging procedures. Services managed and authorized by NIA include outpatient:
- MUGA scan
- Myocardial perfusion imaging (MPI)
- PET scan
Please contact NIA at www.radmd.com or 1-800-424-4784.
Do Medicaid patients need a referral?
No. AmeriHealth Caritas North Carolina does not require referrals.
How can I obtain a copy of the fee schedule?
Please contact your Provider Account Executive.