This updates information in Retroactive Disenrollment from NC Medicaid Managed Care posted on August 15, 2022. The update is to information the provider should send to the NC Medicaid Managed Care Provider Ombudsman:

  • If the service provided is a nursing facility, include admission and discharge dates and dates for any hospital stays.
  • These tickets and the claims they represent will be given high priority, but missing information will delay research into the issue.

A delay in identifying individuals in NCTracks as dually eligible for Medicare and Medicaid has been discovered. If an individual is enrolled in a health plan and Medicare data is delayed, submission of Medicare evidence will trigger an automatic retroactive disenrollment of the member back to the first day of the month of the Medicare effective date. This retroactive disenrollment can span back several months and, in some cases, back to the NC Medicaid Managed Care Go-Live on July 1, 2021.

The enrollment change will trigger a recoup of payments made to the health plan by the Department, and the health plan will in turn recoup any claims paid for the period while the individual was in managed care. To ensure the provider is paid for recouped services rendered due to no fault of the provider, the provider agency should submit claims to NCTracks for the dates of service that now fall in NC Medicaid Direct.

For example, a member is enrolled in health plan1 beginning July 1, 2021, and is receiving personal care services (PCS). They became dually eligible Feb. 1, 2022, but the system does not show the Medicare information until June 15, 2022.

  • NCTracks will update the enrollment segment retroactively to reflect the health plan1 effective disenrollment date to align with an NC Medicaid Direct effective date of Feb. 1, 2022.
  • In this example, the provider should submit claims to NCTracks for services rendered for dates of service from Feb. 1, 2022, to June 15, 2022.

The provider should check NCTracks for appropriate prior authorizations (PAs) and submit claims to NCTracks. If the provider receives a denial of those claims or experiences other difficulties submitting the claims to NCTracks, the provider should contact the NC Medicaid Managed Care Provider Ombudsman at 866-304-7062 or [email protected] to generate a ticket for claim reprocessing.

The provider should include the following information:

  • Subject: Retro Disenrollment Claims Issue
  • Provider Name and NPI
  • Previous Health Plan Name
  • MID
  • Service Provided
  • Dates of Service
  • If the service provided is a nursing facility, include admission and discharge dates and dates for any hospital stays
  • EVV provider, if applicable
  • Copies of health plan PAs, if applicable
  • Evidence documenting recoup of health plan claims

Contact

NC Medicaid Contact Center, 888-245-0179