This bulletin provides information about referrals for specialty care for NC Medicaid beneficiaries.
This bulletin provides information about referrals for specialty care for NC Medicaid beneficiaries. The information in this bulletin applies to both NC Medicaid Direct and NC Medicaid Managed Care.
Historically, in NC Medicaid, members were enrolled in Carolina Access (CA) and assigned a primary care provider (PCP). Additionally, in the past specialists were required to obtain a PCP referral and their CA provider number on the claim for the claim to process.
In November 2016, NC Medicaid removed the requirement to enter the CA provider number on the claim for claims adjudication. Additionally, providers were no longer required to enter referrals into NCTracks.
For patient care coordination purposes, specialist providers are encouraged to coordinate care and share records with the PCP when they are treating a member. However, since 2016, specialists do not need a referral from the PCP when deciding whether to treat a member with NC Medicaid coverage.
Although some specialty offices may require a PCP referral prior to treating a member, NC Medicaid and NC Medicaid Managed Care plans do not require a PCP referral prior to claims payment for specialist office visits.
- For NC Medicaid Direct members, there are no barriers for specialists to provide office visits (evaluation and management services) to members when the provider is enrolled with NC Medicaid.
- For members enrolled with NC Medicaid Managed Care plans, there are no barriers for specialists to provide office visits (evaluation and management services) to members when the specialist provider is enrolled with NC Medicaid and contracted with the members’ assigned health plan.
- If the member is enrolled with a NC Medicaid Managed Care plan and the provider is not in the members’ assigned health plan’s network (i.e., out of network with the plan), prior authorization may be required. For this reason, all out of network (OON) providers (primary care and specialists) should check with the members’ assigned health plan prior to seeing the patient.
- Providers should consult with the NC Medicaid Managed Care health plan to assure that any needed prior authorizations for certain tests or imaging services are obtained prior to rendering these services.
Plan Resources for Referrals and OON Requirements:
- AmeriHealth Caritas Provider Manual
- See Section V. Utilization Management > Referrals
- For OON:
- See Section V. Utilization Management > Prior Authorization Policy and Procedure
- See Section XI. Claims Submission Protocols and Standards > Claims Submission
- See Section XI. Claims Submission Protocols and Standards > General Procedures for Claim Submission
- Carolina Complete Provider Manual
- See Guidelines for Providers > Referrals (this contains information on OON providers)
- See Guidelines for Providers > Specialist Responsibilities
- Healthy Blue Provider Manual
- See Section 2.9 Role and Responsibilities of Specialty Care Providers
- See Section 5.6 Prior authorization/Notification Coverage Guidelines > Out-of-area/ out-of-network care
- United Healthcare
- PA for OON Requirements
- See General information
- Provider Manual
- See Chapter 2: Care Provider Standards and Policies > Specialist responsibilities
- See Chapter 4: Medical Management > Referral guidelines
- PA for OON Requirements
- WellCare Provider Manual
- See Section 4: Utilization Management (UM), Care Management (CM) and Disease managed (DM) > Utilization Management > Utilization Management Process > Referrals
- See Section 4: Utilization Management (UM), Care Management (CM) and Disease managed (DM) > Utilization Management > Authorization Request Forms
Summary
For NC Medicaid Direct and NC Medicaid Managed Care health plans there is no requirement for a specialist to require a referral from the PCP for NC Medicaid members.
- NC Medicaid Direct and NC Medicaid Managed Care do not require PCP referrals to see specialists, some specialists may require a referral from the PCP to see the patient.
- NC Medicaid and the NC Medicaid Managed Care health plans encourage coordination of care between specialists and the member’s PCP.
Provider Reverification Reminder
As a reminder, re-credentialing/reverification is an evaluation of a provider’s ongoing eligibility for continued participation in NC Medicaid, normally conducted every five years as mandated 42 CFR 455.414. Reverification is required for continued participation with NC Medicaid programs.
Now that the federal PHE has ended, NC Medicaid must ensure that all enrolled providers, including those whose reverification was delayed, are compliant with the federal regulation. Providers for whom reverification was delayed have been organized into groups to ensure the timely completion of the reverification process. For more information on provider reverification, see the Provider Reverification Reminder bulletin from June 20, 2023.