Happy Tuesday! Enjoy your NCMS Morning Rounds.

August 3, 2021

New Prior Authorizations (PA) Required for Substance Use Disorder Prescriptions

To ensure a smooth transition of care during NC Medicaid Managed Care launch, plans were required to ingest existing PAs to reduce administrative burden and improve patient experience, with the exception of PAs subject to 42 CFR Part II. Clinicians will need to resubmit previously approved pharmacy PAs to the member’s new health plan. NCTracks will be doing outreach to impacted clinicians who will need to resubmit prior authorizations (PA) for services subject to 42 Code of Federal Regulations (CFR) Part II.

Q&A: What is 42 CFR Part II?

42 CFR Part II regulations prohibit the disclosure of patient records absent patient consent. Disclose means to communicate any information identifying a patient as being or having been diagnosed with a substance use disorder (SUD), having or having had a SUD, or being or having been referred for treatment of a SUD. Records include information regarding diagnosis, treatment, referral for treatment, billing information, emails, voice mails and texts. Withdrawal management means the use of pharmacotherapies to treat or attenuate signs and symptoms arising when heavy and/or prolonged substance use is reduced or discontinued.

Prepaid Health Plan Flexibility for Prior Authorizations During First 60 Days After Managed Care Launch

In response to clinician confusion about prior authorization requirements under managed care, NC DHHS announced the following solution to provide increased flexibility around Prepaid Health Plans’ prior authorizations for the first 60 days after managed care launch:

  1. Between July 1 and Aug. 30, 2021, medically necessary services that normally require prior authorization will still be reimbursed at 100% of the NC Medicaid fee-for-service rate for both in- and out-of-network clinicians.  To ensure that clinicians fully understand each PHP’s prior authorization requirements during the transition, the PHPs will still process and pay for these services if:
  2. a clinician fails to submit prior authorization prior to the service being provided and submits prior authorization after the date of service, or
  3. a clinician submits for retroactive prior authorizations.
  4. This exception does not apply to concurrent reviews for inpatient hospitalizations which should still occur during this time period.
  5. Beginning Aug. 31, 2021, the PHP may deny payment for services that require prior authorization.  For in-network clinicians this will apply to those services that normally require prior authorization. Out-of-network clinicians will need to seek authorizations for all services.
  6. The Department expects all clinicians to maintain scheduled medical care for beneficiaries through this transition.

The Department expects the PHPs and clinicians to continue to work to resolve any outstanding contracting barriers during this time to mitigate out-of-network challenges.

Latest COVID-19 updates from the NC Department of Health and Human Services

With COVID-19 cases again on the rise due to the more contagious Delta variant of the virus, here is the latest guidance from the state and the federal Centers for Disease Control and Prevention (CDC). You can keep up with all state COVID-19 updates at this website.

  • The NC Department of Health and Human Services (NCDHHS) announced last week that anyone who works or volunteers at a state-run health care facility in North Carolina will need to be fully vaccinated against COVID-19 by the end of September. NCDHHS also urged private facilities to follow suit. Several large health systems did announce vaccine mandates for employees.
  • The state will begin verifying COVID-19 vaccination status for all its employees and those state workers  who are not vaccinated are required to wear a mask and be tested at least once a week, as announced last week by Gov. Roy Cooper and NCDHHS Secretary Mandy Cohen, MD, MPH.
  • NCDHHS – and the NCMS – strongly urge all North Carolinians age 12 and older to get a COVID-19 vaccine. Data shows that the rapid increase in COVID-19 cases is largely due to those who are unvaccinated.

The Governor and Secretary Cohen also released updated guidance for the state’s K-12 students, which urges that everything possible be done to keep students in schools and emphasizes continued masking. This guidance became effective July 30. Review the guidance here.

In the News

What Delta Has Changed in the Covid Pandemic — and What It Hasn’t, Advisory Board, 7-30-21

Learning Opportunity

TODAY, Aug. 3, from 3:30 to 4:30 p.m. Dr. Anthony Fauci will share information on COVID-19 vaccines in preparation for school-aged children returning to class in the fall. The webinar is sponsored by the COVID-19 Vaccine Education and Equity Project, which is supported by Pfizer, Inc., Johnson & Johnson and Novartis.

Dr. Fauci, Director of the National Institutes of Health’s National Institute of Allergy and Infectious Diseases and Chief Medical Advisor on COVID-19 to the president, will answer common questions about the vaccine and provide information for your patients as they prepare their children to return to school.

Other participants in the webinar include Dr. Peter Marks, director of the Center for Biologics Evaluation and Research (CBER) at the Food and Drug Administration and Dr. Lee Savio Beers: President of the American Academy of Pediatrics, professor of Pediatrics and the medical director for Community Health and Advocacy at Children’s National Hospital.

Please register to join the webinar here.


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