Medicaid Referral Process Streamlined

The NC Division of Medical Assistance (DMA) recently updated its CCNC/CA referral authorization procedures. Read the special bulletin with the updates here.

Most importantly, DMA has dropped its proposal to require all referrals of Medicaid patients by primary care providers (PCPs) in the CCNC/CA networks to be arranged manually and exclusively via the NCTracks portal beginning Nov. 1, 2016. In addition, DMA is eliminating the current requirements that:

  1. PCPs must first receive a CCNC/CA authorization (via portal, phone, or otherwise) from NCTracks before referring to any specialist;
  2. the rendering-specialist must include the NPI of the patient’s PCP on his/her claim for the claim to process and pay; and
  3. rendering-specialists must request overrides/exceptions by phone if the authorization was not done in advance or there was some related problem.

The umbrella issue of “managed care referrals and overrides” is the highest-volume and longest-running complaint the North Carolina Medical Society (NCMS) has received involving Medicaid since NCTracks came online in 2013, so this is a welcome change.

DMA is hosting a series of training webinars to review these changes, as well as some new claims-processing rules known as the “ordering, prescribing, and referring (OPR) edits.” View the list of webinars beginning on page three of the special bulletin.

 
 

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1 Comment

  • As PCPs, we are all for specialists not calling us for Access Authorization when we have given them a bonafide referral, as this was redundant and highly disruptive. I am concerned, however, that by eliminating all gatekeeper functions of the PCP in regard to patients seeing specialists and visiting urgent care centers, that patients will adopt the mind set that “anything goes,” which may increase costs dramatically for the Medicaid program. Time will tell…….