Provider Playbook - Managed Care Claims and Prior Authorizations

State of North Carolina • Department of Health and Human Services • Division of Health Benefits (NC Medicaid)

www.medicaid.ncdhhs.gov • NCDHHS is an equal opportunity employer and provider. MAY/2024

NC Medicaid Managed Care

Provider Playbook

Managed Care Claims and Prior Authorizations Submission:

Frequently Asked Questions – Part 2

Question

WellCare (WCHP) Response

AmeriHealth Caritas (AMHC)

Response

Healthy Blue Response

Carolina Complete Health (CCH)

Response

United Healthcare (UNHC) Response

How to file a claim with

the PHP – what are the

options (virtual, fax,

paper, etc.)?

WellCare (WCHP) accepts both

electronic and paper claims (no

faxes). Paper claims must be

received on original red/white

CMS claim forms, so faxes are not

considered compliant.

See the provider manual, provider

resource guide and Quick

reference guide at this link for

detailed information regarding

clean claims and step by step filing

instructions. wellcare.com/en/Nor

th-Carolina/Providers/Medicaid

Electronic Claim Submission

Via Wellcare provider portal at

provider.wellcare.com

Paper Claim Submission

All paper claims should be

submitted to:

WellCare Health Plans

The claims submission process

applies to providers who wish to

submit out-of-network claims. This

process can be found on page 4 of

the AmeriHealth Caritas North

Carolina (AMHC) Provider Claims and

Billing Manual, found at

amerihealthcaritasnc.com:

“In accordance with 42 C.F.R.

§438.602(b), health care providers

(including ordering, prescribing, or

referring only providers) interested in

participating in the AMHC network

must be screened and enrolled as a

Medicaid provider by the North

Carolina Department of Health and

Human Services (NCDHHS) and shall

be reenrolled every three years,

except as otherwise specifically

permitted by DHHS in the Revised

and Restated RFP 30-190029-DHB,

Section V. This applies to non-

Providers have the option of

submitting claims electronically or by

mail. Providers participating and

those not participating with Healthy

Blue may enroll with our trading

partner, Availity at availity.com.

Additional Claims information can be

received by calling 844-594-5072,

select the Claims prompt.

Paper Claim Submission

All paper claims should be submitted

to:

Blue Cross NC | Healthy Blue Claims

P.O. Box 61010

Virginia Beach, VA 23466

Electronic Claims Submission

CCH can receive ANSI X12N 837

professional, institution or encounter

transactions. In addition, it can

generate an ANSI X12N 835

electronic remittance advice known

as an Explanation of Payment (EOP).

Providers that bill electronically have

the same timely filing requirements

as providers filing paper claims.

Providers that bill electronically must

monitor their error reports and

evidence of payments to ensure all

submitted claims and encounters

appear on the reports. Providers are

responsible for correcting any errors

and resubmitting the affiliated claims

and encounters.

CCH’s Payor ID is 68069. Our

Clearinghouse vendors include Availity

and Change. Visit our website for our

Both in-network and out-of-network

providers may submit claims via EDI

submission, under Payer ID 87726.

Prior to doing so, they need to enroll

with our clearinghouse OptumInsight

to establish a secure connection, and

they (or their claims processing

service) may do so by calling 866-367-

9778 and selecting option 3.

UNHC uses this clearinghouse for

both in-network and out-of-network

providers.

An out-of-network provider can submit

a paper claim by mail to:

UnitedHealthcare Community

Plan

P.O. Box 5280

Kingston, NY 12402-5240

NC Medicaid

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Question

WellCare (WCHP) Response

AmeriHealth Caritas (AMHC)

Response

Healthy Blue Response

Carolina Complete Health (CCH)

Response

United Healthcare (UNHC) Response

Attn: Claims Department

P.O. Box 31224

Tampa, FL 33631-3224

participating in and/or out of the

State providers as well. Claims for all

services provided to Plan members

must be submitted by the provider

who performed the services.

Submitting Claims

Providers may submit claim via

electronic or paper methods:

Electronic/EDI

Use the payer ID for AmeriHealth

Caritas North Carolina: 81671.

Paper/Mail

AmeriHealth Caritas North Carolina

Attn: Claims Processing Department

P.O. Box 7380

London KY 40742-7380

Additional details regarding the

billing and the claims submission

process is available in the Provider

Claims and Billing Guide at

amerihealthcaritasnc.com

electronic Companion Guide which

offers more instructions.

For questions or more information on

electronic filing please contact:

CAROLINA COMPLETE HEALTH

C/O CENTENE EDI DEPARTMENT

800-225-2573, ext. 25525

Or by e-mail at EDIBA@centene.com

Paper Claim Submission

All paper claims and encounters

should be submitted to:

Carolina Complete Health Attn:

Claims

PO Box 8040

Farmington MO 63640-8040

How does the health plan

determine if the provider

made a

“good faith” effort in

contracting to determine

reimbursement?

Per our Good Faith contracting

policy NC35-ND-001) if within 30

calendar days the potential

network provider rejects the

request or fails to respond either

verbally or in writing, WellCare

may consider the request for

inclusion in the NC Medicaid

Managed Care Provider Network

rejected by the provider. If

discussions are ongoing or the

contract is under legal review,

WellCare shall not consider the

request rejected. The 30-day

period begins when the provider

The Good Faith Contracting Policy

must be developed in and submitted

for approval to fulfill a PHP/DHB

contract requirement. If NC

Medicaid determines appropriate,

AMHC is willing to share the policy in

redacted form to remove

information that is considered

proprietary and/or confidential.

AmeriHealth Caritas North Carolina

will share a redacted version with NC

Medicaid upon request.

• AMHC offers to contract with a

provider using a NCDHHS

Healthy Blue maintains a Good Faith

Contracting policy and requires three

unsuccessful attempts at completing

a contract before the determination

is made.

The Good Faith Effort starts from

when the provider receives a version

of the contract which is consistent

with the version approved by the

Department and include the standard

provisions for provider contracts

found in Attachment G. Required

Standard Provisions of PHP and

Provider Contracts, including the

prescribed provisions located therein.

The initial contract offering will serve

as the first effort. If the provider does

not execute the first effort, CCH will

make a second effort at least 10

UNHC developed a “Good Faith

Provider Contracting Policy” which

was submitted for Department

review and approval 90 days post

contract award. Per those

requirements, UNHC included a

definition of “good faith” contracting

effort and defined it as “United

engaged in a good faith effort to

contract with a provider of

healthcare services but the provider

refused or failed to meet United’s

objective quality standards.” The

policy expands on the process for

documenting contracting outreach

NC Medicaid

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Question

WellCare (WCHP) Response

AmeriHealth Caritas (AMHC)

Response

Healthy Blue Response

Carolina Complete Health (CCH)

Response

United Healthcare (UNHC) Response

has received a copy of the contract

that is consistent with the version

of the contract approved by the

department.

approved provider agreement in

writing via letter, email, or fax; an

AMHC Account Executive will

follow up the initial outreach

within 10 business days and

negotiations will continue until

both parties agree on contract

terms or decide not to move

forward

• If within 30 calendar days of

receiving an agreement, the

potential network provider rejects

the agreement or fails to respond

verbally or in writing, AMHC may

consider the request for inclusion

in the AMHC network rejected; if

discussions are ongoing or the

contract is under legal review,

AMHC shall not consider the

request rejected.

• AMHC will consider all facts and

circumstances surrounding a

provider’s willingness to contract,

including reviews of non-standard

requests, prior to determining that

AMHC made a good faith effort

which was not accepted.

calendar days after the first effort

taking into consideration any

feedback from the provider. If the

provider does not execute the

agreement from the second effort,

CCH will make a third and final effort

at least 10 calendar days after the

second effort taking into

consideration any feedback from the

provider from the previous efforts.

CCH will have exhausted all good

faith contracting efforts after the

third and final effort. The good faith

contracting effort period must be at

least 30 calendar days, but CCH may

allow additional time if discussions

are ongoing, contract revisions are

being made or negotiated, the

contract is under legal review by the

provider or if in the opinion of CCH

such additional time could lead to an

executed contract. If after at least 30

days and the three good faith

attempts, the provider fails to

respond to the efforts verbally or in

writing, the request to join the

network will be considered rejected.

attempts and objective further

elaborates on what it means to meet

objective quality standards.

In summary, Good Faith negotiation

and contracting efforts are tracked in

our database. We will not reimburse

the out-of-network provider more

than 90% of the Medicaid fee-for-

service rate if the provider refuses to

contract or fails to meet objective

quality standards.

What information is

needed from the provider

to file a claim?

Paper claims must be received on

original and complete red/white

CMS claim forms. Please see the

provider manual, provider

resource guide, and quick

reference guide. All these

resources including detailed

information regarding clean claims

and step-by-step are available on

the public Provider Portal, which

does not require a username and

password, by going to: th-

AMHC is required by applicable

contract requirements with the

Department and by applicable North

Carolina and federal regulations to

capture specific data regarding

services rendered to its members.

A detailed list of data elements, as

listed here, are needed for a claim to

be paid. This information is found in

the AMHC Provider Claims and Billing

Manual at amerihealthcaritasnc.com.

Electronic claim submissions will

adhere to specifications for

submitting medical claims data in

standardized Accredited Standards

Committee (ASC) X12N 837 formats.

Electronic claims are validated for

Compliance SNIP levels 1 to 4:

• Professional claims that meet

standardized X12 EDI Transaction

Standard: 837P -

• Professional Claims

• Institutional claims that meet

CCH follows Centers for Medicare &

Medicaid Services (CMS) rules and

regulations, specifically the Federal

requirements set forth in 42 USC §

1396a(a)(37)(A), 42 CFR §447.45 and

42 CFR § 447.46; and in accordance

with State laws and regulations, as

applicable.

Providers must bill with their NPI

number in box 24Jb. We encourage

our providers to also bill their

In terms of data elements needed for

a provider to file a claim - this

information is available in our

provider administrative guide and

located on UNHC’s provider website:

uhcprovider.com/en/ad min-

guides/administrative-guides-

manuals-2021/ch10-our-claims-

process-2021/claims-enc-data-sub-

ch10-guide.html

• Billing provider name, address,

telephone number (F1)

NC Medicaid

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Question

WellCare (WCHP) Response

AmeriHealth Caritas (AMHC)

Response

Healthy Blue Response

Carolina Complete Health (CCH)

Response

United Healthcare (UNHC) Response

Carolina/Providers/Medicaid/Form

All claims must have complete and

compliant data including:

• Current CPT and ICD-10 (or its

successor) codes

• TIN

• NPI number(s)

Provider and/or practice name(s)

matching the W-9 initially

submitted to WellCare

The following mandatory information

is required on all claims, both

institutional and professional:

• Member’s (patient’s) name

• Member’s Plan ID number

• Member’s date of birth and

address

• Other insurance information:

company name, address, policy

and/or group number

• Amounts paid by other insurance

(with copies of matching EOBs)

• Information advising if member’s

condition is related to

employment, auto accident or

liability suit

• Date(s) of service, admission,

discharge

• Primary, secondary, tertiary and

fourth ICD-10-CM/PCS diagnosis

codes, coded to the full

specificity available, which may

be 3, 4, 5, 6, or 7 digits.

• Name of referring physician, if

appropriate

• HCPCS procedures, services or

supplies codes

• CPT procedure codes with

appropriate modifiers

• CMS place of service code

• Charges (per line and total)

• Days and units

• Physician/supplier Federal Tax

Identification Number or Social

Security Number

• National Practitioner Identifier

(NPI) and Taxonomy

• Physician/supplier billing name,

address, zip code, and telephone

standardized X12 EDI Transaction

Standard: 837I -

• Institutional Claims

Claim submissions, whether

electronic or paper, must include the

following information:

• Member’s ID number including

alpha prefix

• Member’s name

• Member’s date of birth

• ICD-10-CM diagnosis code

• Date of service

• Place of service

• Procedures, services or supplies

rendered with CPT-4

codes/HCPCS codes/

• disease-related groups

• Itemized charges

• Days or units

• Provider tax ID number

• Provider name according to

contract

• Billing provider information, and

rendering provider information

when different than billing or

when billing a group taxonomy

• NPI of billing and rendering

provider when applicable, or API

when NPI isn’t appropriate

• Taxonomy of billing provider,

attending and rendering provider

when submitted

• Coordination of benefits/other

insurance information

• Precertification number or copy

of precertification

• NDC, unit of measure and

quantity for medical injectables

taxonomy code in box 24Ja and the

Member’s Medicaid number in box 1a

to avoid possible delays in processing.

Claims missing the required data will

be returned, and a notice sent to the

provider, creating payment delays;

Such claims are not considered “clean”

and therefore cannot be accepted into

our system.

Claims eligible for payment must

meet the following requirements:

• The enrollee must be effective

on the date of service (see

information below on

• identifying the enroll(lee),

• The service provided must be a

covered benefit under the

enrollee’s contract on the date of

service, and Referral and prior

authorization processes must be

followed, if applicable.

• Payment for service is contingent

upon compliance with referral

and prior authorization policies

and procedures, as well as the

billing guidelines outlined in this

manual.

When submitting your claim, you

need to identify the enrollee. There

are two ways to identify the enrollee:

• The CCH enrollee number found

on the enrollee ID card or the

provider portal.

• The Medicaid Number provided

by the State and found on the

enrollee ID card or the provider

portal

• Type of bill (F4)

• Statement Covers Period (F6)

• Patient Name (F8b)

• Patient Birth Date (F10)

• Patient Sex (F11)

• Admission date (F12)

• Admission Hour (F13)

• Admission Type/Visit (F14)

• Source of Referral for admission

(F15)

• Discharge Status (F17)

• Condition Codes (F18-28) if

applicable

• Occurrence Codes and Dates

(F31-34) if applicable

• Value Codes and Amounts (F39-

41) if applicable

• Revenue Code (F42)

• Revenue Code Description (F43)

• HCPCs, CPT Codes (F44)

• Service Date (F45)

• Service Units (F46)

• Total Charges (F47)

• Payer Name (F50A-C)

• NPI (F56)

• Insured Name (F58A-C)

• Patients Relationship to Insured

(F59A-C)

• Insured's Unique Identifier

(F60A-C)

• Principal Diagnosis Code (F67)

• Other Diagnosis Code (F67A-Q)

• Admitting Diagnosis Code (F69)

• Principal procedure code and

date (F74)

• Other procedure codes and dates

(F74a-e)

• Attending provider and

Identifiers (F76)

NC Medicaid

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WellCare (WCHP) Response

AmeriHealth Caritas (AMHC)

Response

Healthy Blue Response

Carolina Complete Health (CCH)

Response

United Healthcare (UNHC) Response

number

• Name and address of the facility

where services were rendered

• NDC’s required for physician

administered injectables that are

eligible for rebate

• Invoice date

• Provider Signature

• Other providers (F77-79) if

applicable

Like an in-network claim, an out-of-

network claim will require certain data

fields to be completed accurately and

the claim that is submitted to UNHC

must pass basic NC Provider Validation

rules. However, there is no rule

validation surrounding the address or

provider names so the rules will not

deny based on abbreviations for

address or name

alone.

In what instances would a

provider/health plan

need to agree to a single

case agreement?

Single case agreements are usually

reserved for services provided by

an out of network provider when

no in-network provider is

available. This would only likely

occur for a delivery out of state or

mother/baby requires highly

specialized care at out-of-network

facility. These are handled on a

case-by-case basis and are not a

normal occurrence.

If a non-participating provider offers

needed services that a participating

provider cannot offer in the

member’s service area, a single case

agreement would be needed.

For provider/PHP to develop a Single

case agreement, several criteria

must be present:

• A member is enrolled with NC

Medicaid and Healthy Blue

• The provider is not in-network

• The member cannot be

redirected to an in-network

provider

The out-of-network request has been

approved as medically necessary

Most Single case agreements (SCAs)

will be initiated internally by Medical

Management, Appeals & Grievances

(A&G) or Behavioral Health. On

occasion, we may get a direct

request from a provider, particularly

if they are waiting for a contract to be

effective.

There are two common origins for

SCAs:

1. Internal requests mainly from

Medical Management, Appeals &

Grievances (A&G) or Behavioral

Health and

2. The much rarer request directly

from a provider with an existing

relationship with a member

and/or the negotiator

This accounts for the two common

reasons where an SCA might be

requested; 1) to cover services

rendered out-of-network and 2) to

Single Case Agreements (SCAs) are

negotiated on a case-by-case basis,

and there is no default process to a

SCA if a provider decides not to enter

a contractual agreement with UNHC

through a good faith contracting

effort. With that said, at times (SCAs)

are created to ensure the

member’s needs are met. In such

instances, UNHC would typically

expect a referral from in-network to

an out-of-network provider to meet

medical needs, review the network

to ensure there is no in-network

provider that can render that same

service in the proximity.

NC Medicaid

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WellCare (WCHP) Response

AmeriHealth Caritas (AMHC)

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Healthy Blue Response

Carolina Complete Health (CCH)

Response

United Healthcare (UNHC) Response

cover services when the existing

network

providers are at capacity

What is the payment cycle

for medical and pharmacy

claims?

Pharmacy payments are issued at

the point of sale. Both medical

and pharmacy claims will be paid

daily. Check runs take place daily

except for Sundays, last day of the

month and national holidays.

Medical payment cycles will be

every Monday and Wednesday,

while pharmacy cycles will run

every four days.

Payment disbursements for both

medical and pharmacy claims are

sent on Wednesdays.

CCH runs checks each Tuesday and

Friday.

Check cycles take two days to

complete. One day for ERA

(electronic remittance advice)/PRA

(paper remittance advice) generation

and one day for check payment

either through paper or electronic

EFT.

Payment cycle for both medical and

pharmacy claims will be a daily check

cycle.

What message will

providers see in the

Provider Portal regarding

individual claim status

prior to first payments

being released?

WCHP’s provider portal will display

a banner with the date they intend

on executing their first check run

(July 6, 2021, for medical claims

and July 1, 2021, for pharmacy

claims).

There will be no provider messaging

prior to first payments being

released.

The claims status in our secure

Provider Portal (Availity) will return

the status at the time of the inquiry.

Claim status will show as

Pending/Paid or Denied.

CCH portal returns an EMS message

queue, which includes the claim

number, rejection code/message etc.

The providers will see a message

displaying the claim has been

accepted.

The claim will show as Acknowledged

until the claim is processed.

It will show Pending if:

• We are waiting on additional

information from the provider or

• The claim is still being worked on

It will show Payable if it is processed

but waiting for the payment to be

posted.

How can I determine

which services require

prior authorization for a

health plan?

WCHP provides a Prior

Authorization Look-up Tool to

determine if a PA is required prior

to rendering services. WCHP’s

Provider Look-up Tool can be found

at: wellcare.com/North-

Carolina/Providers/Authorization-

Lookup

AMHC provides a Prior Authorization

Look-up Tool to determine if a PA is

required prior to rendering services.

AMHC’s Provider Look-up Tool can be

found at: amerihealthcaritasnc.com

Healthy Blue provides a Prior

Authorization Look-up Tool to

determine if a PA is required prior to

rendering services. Healthy Blue’s

Provider Look-up Tool can be found

at: provider.healthybluenc.com/

north-carolina-provider/prior-

authorization-lookup

CCH provides a Prior Authorization

Look-up Tool to determine if a PA is

required prior to rendering services.

Pre-Auth Tool can be found at:

network.carolinacompletehealth.com

/resources/prior-authorization.html

UNHC provides a Prior Authorization

Look-up Tool to determine if a PA is

required prior to rendering services.

UNHC’s Provider Look-up Tool can be

found at: UHCprovider.com/priorauth

How can I submit a prior

authorization to a health

plan?

WCHP submission methods:

Standard:

Online via Provider Portal:

provider.wellcare.com/

AMHC submission methods:

Standard:

Online via Provider Portal:

navinet.navimedix.com

Healthy Blue submission methods:

Standard:

Online via Provider Portal:

provider.healthybluenc.com/ north-

carolina-provider/prior- authorization

CCH submission methods:

Standard:

Online via Secure Provider Portal:

carolinacompletehealth.com/

UNHC submission methods:

Standard:

Online via Prior Authorization and

Notification Tool on Link:

NC Medicaid

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WellCare (WCHP) Response

AmeriHealth Caritas (AMHC)

Response

Healthy Blue Response

Carolina Complete Health (CCH)

Response

United Healthcare (UNHC) Response

Via fax to the numbers listed on

the associated forms:

wellcare.com/North-

Carolina/Providers/Medicaid/Form

Urgent:

Call 866-799-5318 and follow the

prompts.

Pharmacy:

Via fax to 800-678-3189

Online via Surescripts portal:

providerportal.surescripts.

net/providerportal/

Via fax to 833-893-2262

Call: 833-900-2262

After hours and holidays:

Call 855-375-8811

Pharmacy:

Via fax to 877-234-4274

Call 866-885-1406

Prior authorization is not required

for emergency services when a

member seeks emergency care.

Via fax to:

800-964-3627 (inpatient)

844-445-6649 (Outpatient)

Urgent:

Call 844-594-5072

Pharmacy:

Via fax to 844-376-2318

Call 844-594-5072

Use the Prior-Auth Check Tool on the

website to quickly determine if a

service or procedure requires prior

authorization. This tool will go live

later this summer, before the launch

of NC Medicaid Managed care.

Call 833-552-3876

Via fax to 833-238-7694

Urgent:

Call 919-719-4161.

Pharmacy:

Call 833-585-4309

UHCprovider.com/priorauth

If you’re unable to use the link, call

Provider Services at 877-842-3210.

Urgent:

Call Provider Services at 877-842-

3210 and follow the prompts.

Pharmacy:

Online via CoverMyMeds portal:

covermymeds.com/main/prior-

authorization-forms/optumrx/

Online via SureScripts portal:

providerportal.surescripts.net

/ProviderPortal/optum/login