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AmeriHealth Caritas North CarolinaProvider TrainingAmeriHealth Caritas North Carolina Provider Network Management
North Carolina Medicaid Transformation The North Carolina Department of Health and Human Services (NCDHHS) hasapproved a new start date for Medicaid Managed Care, which will be no later thanJuly 1, 2021. Until the start of Medicaid Managed Care, eligible North Carolina Medicaid and NCHealth Choice beneficiaries will continue to receive health services as they do today. Until the start of Medicaid Managed Care, all health providers enrolled in Medicaidwill continue to submit claims through NCTracks as they do today. Health providers are encouraged to contract with PHPs, as broad providerparticipation in health plan networks will help beneficiaries understand whichproviders will be available to them by health plan before open enrollment restarts onMarch 15, 2021.Source: NCDHHSAmeriHealth Caritas North Carolina2
How Providers Can Stay InformedWell-informed providers are essential to the success of managed care. As one way tosupport providers, NCDHHS has created an online Provider Playbook that includes: Beneficiary Materials Readiness Resources Calendar of Upcoming Training Courses Information on Meet and Greet Sessions Virtual Office Hours Frequently Asked QuestionsOr visit AmeriHealth Caritas North Carolina directly at www.amerihealthcaritasnc.comAmeriHealth Caritas North Carolina3
Updates and Contact InformationPlease note that this presentation is subject to change based upon newinformation received from NCDHHS. The most up-to-date version will be postedon the website at www.amerihealthcaritasnc.comMember Enrollment: To contact AmeriHealth Caritas North Carolina regardingenrollment, please call Member Services at 1-855-375-8811.Providers Services: 1-888-738-0004.Provider Contracting: To request a contract, please contact Provider NetworkManagement at 1-888-738-0004 or email us com.AmeriHealth Caritas North Carolina4
OverviewWho We AreProvider Network Management and Administrative Provider SupportContracting and CredentialingEligibility and Covered ServicesPharmacyClaims and BillingIntegrated CareAdvanced Medical HomesUtilization Management/Prior AuthorizationValue-based CareCulturally and Linguistically Appropriate Services (CLAS)Member Grievances and AppealsProvider Grievances and AppealsComplianceQuality ManagementAdvance DirectivesMarketing GuidelinesResourcesAmeriHealth Caritas North Carolina5
AmeriHealth Caritas North CarolinaWho We Are6
Mission and VisionAmeriHealth Caritas North Carolina is part of the AmeriHealth Caritas Family ofCompanies (AmeriHealth Caritas). AmeriHealth Caritas is part of the IndependenceHealth Group in partnership with Blue Cross Blue Shield of Michigan.AmeriHealth Caritas is one of the nation’s leaders in health care solutionsfor those most in need.Our missionTo help people get care, stay well, and buildhealthy communities. We have special concern for those who are poor.Our visionTo be a national leader in empowering those in need, especially the poor and the disabled,across their full life journey, from wellness to resilience, in order to achieve their AmericanDream.AmeriHealth Caritas North Carolina7
Where We AreAmeriHealth Caritas North Carolina8
North Carolina Medicaid Managed Care ProgramThe NC Medicaid Managed Care program is administered through the North Carolina Departmentof Health and Human Services (NCDHHS), and includes: Medicaid benefits for families enrolled in Temporary Assistance for Needy Families (TANF),including children who qualify for Title IV-E foster care and adoption assistance and pregnantwomen; individuals who receive Supplemental Security Income (SSI) but are not eligible forMedicare; and adults ages 19 to 64 who are not eligible for Medicare with income levels up to133 percent of the Federal Poverty Level (FPL). Long Term Services and Supports (LTSS) beneficiaries. Aged, Blind, Disabled (ABD) eligible population.NC Health Choice program members.AmeriHealth Caritas North Carolina9
Provider Network ManagementandAdministrative Provider Support
Provider Network Management:Dedicated Account ExecutivesLocal and knowledgeable Provider Network Management Account Executives (AEs): Live and work in North Carolina. Are assigned to your specific service area/tribal entity. Possess knowledge and experience working with the substance use disorder and behavioral health providercommunity. Are well-versed in our physical and behavioral health benefits.Your AE is your single point of contact and is available to assist you in resolving issues and answering anyquestions you may have regarding: Your AmeriHealth Caritas North Carolina contract. Provider orientations and trainings occurring in your region. Ongoing education and assistance.Note: Each contracted tribal entity will have a local tribal liaison who will act as the dedicated provider AccountExecutive and will be your single point of contact. If you have questions, please call our local Tribal Liaison, JulieKeiper, at 1-828-508-4991.The Provider Services department and the Medical Management team are also available to assist you.AmeriHealth Caritas North Carolina11
Indian Health Care Providers (IHCPs)Tribal members are eligible to receive services from an IHCP and to choose the IHCP astheir PCP, if the IHCP has the capacity to provide primary care provider (PCP) services atall times.Tribal members have direct access to an IHCP. Out-of-network IHCPs can make referralsto participating providers for any tribal members without a prior authorization orreferral from a participating provider.If you have questions, please call our local Tribal Liaison, Julie Keiper, at 1-828-5084991.AmeriHealth Caritas North Carolina12
E-Solutions to Foster CommunicationAmeriHealth Caritas North Carolina recognizes how busy our participating providers are.We are dedicated to supporting you and ensuring that you have the information youneed at your fingertips through convenient electronic solutions and support. We keepyou informed through several communication methods: Provider manualFax blast and emailProvider newsletterProvider-focused website sectionProvider education and trainingWebinarsLet Us Know programAnd, we provide searchable online tools: Online provider directory Drug formulariesExcellent provider communication and service is an organization-wide priority!AmeriHealth Caritas North Carolina13
Let Us Know ProgramAmeriHealth Caritas North Carolina is eager to partner with the provider community insupporting our members who may require a helping hand. The Let Us Know program isa way for us to collaborate in the engagement and management of our members.If you have a member who could use support from our care management team, here area few ways to “let us know”:Let Us Know optionsExamples of reasons for referral:Call our Rapid Response and Outreach Team (RROT) at 1833-808-2262, or Fax the Member Intervention Request Form to RROTat 1-833-816-2262. You can find the form atwww.amerihealthcaritasnc.com under the Forms section.For guidance on completing this form, or to inquire about asubmission, please call 1-833-808-2262.Call in a referral to the Care Management departmentat 1-833-808-2262.AmeriHealth Caritas North Carolina Pharmacy consult on controlled substancesAssistance locating a specialty providerEducation plan benefits and resourcesAssistance with appointment schedulingUnmet resource — social determinant of health (SDOH)screeningSDOH resource follow-up (transportation, food pantry,housing application, etc.)Education on health conditionsScreening for mental health or substance use servicesCrisis follow-up resources (recent suicide attempt orbereaved after a death by suicide)14
E-Solutions to Simplify AdministrationAmeriHealth Caritas NorthCarolina partners withChange Healthcare, thelargest electronic datainterchange (EDI)clearinghouse in the country,to offer state-of-the-art EDIservices to our providers. EDIoptimizes productivity bystreamlining your workflowsand ensuring:AmeriHealth Caritas North Carolina Efficient claims solutions Accurate and secure reimbursements Early detection of claims errors Faster claim payment and billingreconciliation through electronic fundstransfer (EFT) and electronicremittance advice (ERA) Lower administrative, postage andhandling costs NaviNet claim inquiry EDI member eligibility verificationthrough your electronic healthrecord/practice management software(EHR/PMS) system15
E-Solutions to Support Patient Care ManagementOur secure provider portal www.navinet.navimedix.com offers web-based solutions thatallow providers and health plans to share critical administrative, financial and clinicaldata in one place.This tool can help you manage patient care with quick access to: Member eligibility and benefits information. Panel roster reports. Care gap reports to identify needed services and preventive screenings. Member clinical summaries. Social determinants of health status. Admission and discharge reports. Medical and pharmacy claims data. Electronic submission of prior authorization requests.If you have not yet done so, please visit www.navinet.navimedix.com to sign up forNaviNet.AmeriHealth Caritas North Carolina16
Member Access and Availability StandardsAmeriHealth Caritas North Carolina providers must comply with access standardguidelines as outlined in the provider manual to help ensure that Plan members havetimely access to care.The standards outlined apply to health care services, medical health providers andbehavioral health providers. AmeriHealth Caritas North Carolina monitors accessstandards on an annual basis. If at any time your practice becomes unable to meet thesestandards, you must immediately advise your Provider Network Account Executive orthe Provider Services department at 1-888-738-0004.For the full list of member access standards, please refer to the provider manualavailable at www.amerihealthcaritasnc.com.AmeriHealth Caritas North Carolina17
Primary Care Provider (PCP) ChangesAmeriHealth Caritas North Carolina members: May change their PCP twice a year (without cause) Have thirty (30) days from the initial PCP assignment to change their PCP Thereafter may change their PCP one additional time without cause during thecalendar yearMembers may also change their PCP for “cause,” at any time including the PCP’s failureto: Provide primary care services Arrange for inpatient care, consultationswith specialists or laboratory or radiologicalservices when reasonably necessaryArrange for services with qualifiedlicensed or certified providers Coordinate the member's overallmedical care such as periodicimmunizations and diagnosis andtreatment of any illness or injury Arrange for consultation appointments Coordinate and interpret any consultationfindings with an emphasis on continuityof medical careFor more information, please refer to the provider manual available atwww.amerihealthcaritasnc.com.AmeriHealth Caritas North Carolina18
Contractingand Credentialing
How Do I Participate?Contracting1. Enroll as a Medicaid provider with the North CarolinaDepartment of Health and Human Services (NCDHHS).2. Enroll with NCTracks.3. Execute a Participating Provider agreement.For contract information, please contact Provider NetworkManagement at 1-888-738-0004 or email us com.You will need to complete one of the following forms andsend them along with your contract: Provider Data Intake Form Facility Data Form for North Carolina Providers Behavioral Health Data Intake Form Ancillary Data Intake FormAmeriHealth Caritas North Carolina20
How Do I Participate?Provider Enrollment Enroll as a Medicaid provider with NCDHHS. The enrollment process in NCTracks includes credentialing, endorsement, andlicensure verification. All practitioners and organizational providers will be reverified and recredentialed bythe Prepaid Health Plan (PHP) every five (5) years, except as otherwise specificallypermitted by NCDHHS. Providers who have questions about the Medicaid enrollment process should callNCTracks at 1-800-688-6696 or visit NCTracksProvider@nctracks.com.Additional information on provider enrollment is available at: rs/provider-enrollment.html meriHealth Caritas North Carolina21
Eligibility and Covered Services
Eligibility and Enrollment:How Do I Verify Eligibility?Prior to rendering services, providers are responsible for verifying member eligibility.You can check member eligibility by: Logging in to our secure provider portal https://navinet.navimedix.com/main.aspx,a web-based application that allows providers and health plans to share critical administrative,financial and clinical data in one place. You can also access the provider portal on our websiteat Providers Provider Resources NaviNet Log in to NaviNet. Verifying EDI eligibility verification through your EHR/PMS with Change Healthcare’sEligibility and Enrollment Advocate system. Contacting AmeriHealth Caritas North Carolina’s Provider Services department at1-888-738-0004 and using the automated real-time eligibility service by followingthe prompts for Member Eligibility. Accessing the North Carolina Medicaid Management Information Systems (NC MMIS) via theNCTracks Web Portal at https://www.nctracks.nc.govFor more information or to sign up for NaviNet access, go tohttps://navinet.secure.force.com/ or call NaviNet Customer Support at 1-888-482-8057.AmeriHealth Caritas North Carolina23
Member ID CardsAmeriHealth Caritas North Carolina will issue two different MemberID cards. One for Medicaid and one for Health Choice enrolleesMedicaid Beneficiaries will receive this card.AmeriHealth Caritas North Carolina24
Member ID The Member ID card will show NC Health Choice in upper right cornerof the front of the card if the member is a Health Choice beneficiary. NaviNet: Within the eligibility and benefits screen under InsuranceDetails/Type, the product will indicate Medicaid or Health Choice. NC Tracks: A provider will see the MCO in which the beneficiary isenrolled, and will see Medicaid or Health Choice and the list ofbenefits the beneficiary is eligible to receive.AmeriHealth Caritas North Carolina25
Continuity of CareAll new members are screened andassessed to identify needed services.We will implement a continuity of caretransition plan to provide continuity ofcare for new members transitioningfrom fee-for-service to managed carefor up to ninety (90) days. This includesmembers receiving LTSS.If you have questions, please refer tothe provider manual or call ProviderServices at 1-888-738-0004.AmeriHealth Caritas North Carolina26
Cost Sharing (Copays)AmeriHealth Caritas North Carolina does not require members to pay for any coveredservices other than the copayment amounts as specified by NCDHHS. For a complete listof services and applicable copays, please refer to www.amerihealthcaritasnc.com.Exceptions to cost sharing — copayments do not apply to: Tribal members who receive services from an Indian Health Service, an Indian tribe, an Indiantribal organization, or an Urban Indian Organization; or through referral under contract healthservices. Children under age 21. Pregnant women. Individuals receiving hospice care. Federally recognized American Indians/Alaska Natives. Breast and Cervical Cancer Control Program (BCCCP) beneficiaries. Foster children. Disabled children under the Family Opportunity Act, individuals whose medical assistance forservices furnished in an institution is reduced by amounts reflecting available income otherthan required for personal needs.AmeriHealth Caritas North Carolina will not impose cost sharing on behavioral healthservices, as defined by NCDHHS.AmeriHealth Caritas North Carolina27
Cost Sharing (Copays)AmeriHealth Caritas North Carolina28
Covered ServicesCovered ServicesAmbulance ServicesFederally qualified health center servicesCertified pediatric and family nursepractitioner servicesFreestanding birth center services (whenlicensed or otherwise recognized by thestate)Chiropractic servicesHearing aidsClinic servicesHome health servicesDiagnostic, screening, preventive andrehabilitative servicesHome infusion therapyDietary evaluation and counseling andmedical lactation servicesHospiceDurable medical equipmentInto the Mouths of Babes dental servicesEarly and Periodic Screening, Diagnosticand Treatment (EPSDT) servicesInpatient hospital servicesFamily planning servicesLaboratory and X-ray servicesAmeriHealth Caritas North Carolina29
Covered Services (continued)Covered ServicesNon-emergency medical transportationPhysician servicesNursing facility servicesObstetrics and gynecology and maternalsupport servicesOphthalmology and vision servicesPodiatry ServicesOptometry ServicesRural health clinic servicesOutpatient hospital servicesSpeech, hearing and language disorderPersonal CareTelemedicinePharmacy ServicesTobacco cessation counseling for pregnantwomenPhysical and occupational therapyTransplants and related servicesPrivate duty nursing servicesRespiratory care servicesThis table is not meant to be exhaustive and is only a summary of the servicesAmeriHealth Caritas North Carolina30
Covered Behavioral Health ServicesCovered Behavioral Health ServicesInpatient behavioral health servicesMobile crisis management servicesFacility-based crisis services for children andadolescentsProfessional treatment services in a facilitybased crisis programNonhospital medical detoxification servicesand partial hospitalizationAmbulatory detoxification servicesMedically supervised alcohol and drug abusetreatment center detoxification, crisisstabilizationDiagnostic assessment servicesEPSDT authorized servicesResearch-based behavioral health treatment –SPA approved by CMS; awaiting completion ofpromulgated policyOutpatient behavioral health servicesAmeriHealth Caritas North Carolina31
Value Added Services – May Require PriorAuthorizationValue Added Services*Asthma NavigationEligible children age 18 or younger may receivein-home visit services. Asthma navigators workwith members to teach them how to controlasthma, avoid triggers and provide supplies tocontrol allergies.*High Risk Pregnancy CareMembers with high risk pregnancies canreceive support and education fromcommunity health workers to help them learnabout prenatal and well-child visits, choose aPCP for their child(ren), and connect them withcommunity resources.*Post-discharge MealsMembers who have recently been dischargedfrom the hospital can receive up to two mealsper day, for up to seven days, once per year, atno cost.AmeriHealthCaritas North Carolina*Flexible Recovery BenefitA one-time flexible benefit offered whenmembers complete a non-hospital substanceuse disorder (SUD) treatment stay. This benefitcan be used for services such as transportationto support group meetings like AlcoholicsAnonymous and Narcotics Anonymous.*Mission GED ProgramA special program that can help members reachtheir goal of achieving your high schoolequivalency (HSE) diploma. AmeriHealth CaritasNorth Carolina will provide members withtesting vouchers for practice and regular testsfor an HSE diploma at no cost to them.32
Value Added Services (continued)Value Added ServicesAdult Vision ProgramAdults ages 21 through 64 can get an additionalpair of glasses and one extra eye exam every twoyears in addition to the standard Medicaidbenefit.Boys and Girls Club MembershipAny eligible children age 18 or younger mayreceive a membership at no cost to participatingBoys and Girls Clubs throughout North Carolina.CARE CardA reloadable reward card that qualifiedmembers can use for purchases at select
Enroll as a Medicaid provider with NCDHHS. The enrollment process in NCTracks includes credentialing, endorsement, and licensure verification. All practitioners and organizational providers will be reverified and recredentialed by the Prepaid Health Plan (PHP) every five (5) yea
