NCMS Morning Rounds 11-11-21

Happy Thursday! Enjoy your NCMS Morning Rounds!

November 11, 2021


Review of Practitioner Affiliation in NCTracks

This Medicaid bulletin article, Organizational Provider Records Without the Required Individual Provider Affiliation Risk Suspension/Termination, signifies a critical change in the NCTracks data system, which could impact both Medicaid practice billing and beneficiary attribution in Medicaid managed care.

Beginning Nov. 21, 2021, organizational providers with certain taxonomies are required to have at least one active affiliated individual provider with at least one active taxonomy related to their credentialed status as a taxonomy level 1 provider.

  • This modification will verify providers meet the enrollment criteria for each taxonomy and supports efforts to keep provider enrollment files current.
  • Once implemented, this will become an ongoing requirement, obligating providers to maintain and update affiliations in order to avoid potential claims suspension and/or provider enrollment termination.

Why is this happening? Medicaid Health Plans require the rendering provider to be listed on a claim and the practitioner to be affiliated in NCTracks with the service location on the claim. In Medicaid before MMC, the claim would still pay even if the practitioner wasn’t accurately affiliated because the claim was paid based on the site’s enrollment with Medicaid. With this change to billing in Medicaid managed care, when a practitioner is not appropriately listed with a site NPI, this can (a) negatively impact beneficiary assignment and (b) potentially impact claims processing. Thus, it is critical that all practices review their practitioner information in NCTracks to make sure (a) current practitioners are appropriately affiliated with the site NPIs where they work and (b) practitioners no longer affiliated with your practices/sites are removed.

Prepaid Health Plan Interest and Penalties for Provider Claims

In accordance with Section V. H.1.d of the NC PHP Contract, prepaid health plans (PHPs) are required to pay interest and penalties to health care professionals if the PHP fails to accurately pay or inappropriately denies a clean claim within 30 calendar days of receipt of medical claims or within 14 calendar days of receipt for pharmacy claims. Read the full Sept. 16, 2021 Medicaid bulletin for more details.

PHP Claims Issues Troubleshooting Steps:

NCMS Medicaid Transformation Page

As a reminder, the NCMS is offering resources and a process to help you make the transition to Medicaid managed care. Visit our Medicaid Transformation page, where you will find a handy list of state and individual health plan resources as well as a special NCMS form to log any specific issues you are encountering.

*Please make sure that your first step is to reach out to the plan itself to log your problem before you share your issue with the NCMS. The NCMS and our partners will give an aggregated list of concerns to health plan representatives to make them aware of widespread issues.*

In the News

What Dr. Fauci Sees Coming For The Pandemic This Winter, NPR, 11-8-21

Learning Opportunity 

Transgender-Affirming Primary Care, Wednesday, November 17, Noon-1:00 p.m. ET

Learning Objectives:

  1. Describe how to inquire about transgender-specific medical needs for patients.
  2. Discuss how to conduct a sexual history with transgender and gender non-binary patients.
  3. Identify preventative screenings for transgender patients.

Register here


If you have policies you’d like your NCMS Board of Directors to consider, please complete the Board input form here. Thanks for reading!


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