NCMS Morning Rounds 9-9-21

Happy Thursday! Enjoy your NCMS Morning Rounds.

September 9, 2021

NC Medicaid Announces Additional Prior Authorization Provision Extended from August 30 to November 30

Between Aug. 31, 2021, and Sept. 30, 2021, medically necessary services that normally require prior authorization (PA) will still be reimbursed at either 100 percent of fee-for-service rates (for out-of-network providers) or the contracted rate (for in-network providers) when PA is obtained following the service provision. To ensure that providers fully understand each PHP’s prior authorization requirements during the transition, the PHPs will still process and pay for these services if:

  • a provider fails to submit prior authorization prior to the service being provided and submits prior authorization after the date of service, or
  • a provider submits for retroactive prior authorizations. This exception does not apply to concurrent reviews for inpatient hospitalizations which should still occur during this time period.

For more details, read the August 27 bulletin In-Network Provisions Extended Through September

Reminder: Taxonomy Codes Must Be Included on Claims Submitted to Prepaid Health Plans
Clearinghouses may be updating taxonomy information submitted by providers, so it is important that providers work with their clearinghouse to ensure valid taxonomy data is submitted to the PHPs on their claims. If a clearinghouse does not submit a taxonomy or if the taxonomy is incorrect, these errors may increase the provider’s claim denials with the PHPs they submit claims to.

For more details read the August 27 bulletin Claims Denied – Taxonomy Codes Missing, Incorrect, or Inactive.

Troubleshooting United Healthcare T1015 Claims

United Healthcare has recognized that Federally Qualified Health Centers (FQHCs) claims have been adjudicating inappropriately since July 1, 2021. Recently you may have experienced T1015 claims, with the below reason code:

  • A12, 1427 –  FQHC services need to be billed under the FQHC provider information with the T1015 code or the appropriate billing CPT, not the individual practitioner.

Submitted claims with these reason codes are being reprocessed and will be paid appropriately. UHC is monitoring the claims daily, and they expect the volume of claims to subside with this remark code beginning soon. Providers do not need to resubmit the claims at this time.

Medicaid Extends End Date for Out-of-Network Provisions from August 30 to November 30

DHHS and the PHPs have agreed to extend the policy for out of network flexibilities to providers who have not contacted with a PHP through Nov. 30, 2021. These flexibilities were originally expected to sunset on Aug. 30, 2021.  Under this policy, the PHPs have agreed to:

  • permit uncontracted, out of network providers enrolled in NC Medicaid to follow in network provider prior authorization rules and may continue to get a prior authorization retroactively;
  • reimburse out of network providers at the in-network rate of 100% of the Medicaid fee schedule;
  • delay implementation of the 90% rate reduction following good faith contracting provision;
  • allow beneficiaries to change their Primary Care Provider for any reason; and
  • extend flexibility for Non-Emergency Medical and Non-Emergency Ambulance Transportation providers through November 2021.

During this period, the Department will allow for beneficiaries to change PHPs as needed. Additionally, PHPs will work to expedite hospital discharge to skilled nursing facilities and rehabilitation facilities to allow for increased bed capacity in the hospitals.

In the News

Scientists Hunt For New Antibiotics With Old-fashioned Exploration, STAT, 9-8-21

Learning Opportunity

THIS IS U.S.: DISSENT, DENIAL, AND THE HEALTH OF POPULATIONS—27th National Health Equity Research Webcast, September 17, 3:00 pm – 4:30 pm

The National Health Equity Research Webcast emphasizes issues and solutions related to collecting and analyzing data for racial and ethnic populations, studying the relationship between race and socioeconomic status, identifying and reducing barriers to conducting research in minority communities, and devising surveys to study minority populations and subpopulations.

Learn more and 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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