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AmeriHealth Caritas North Carolina Provider Training AmeriHealth Caritas Corporate Provider Network Management

Updates and Contact Information

AmeriHealth Caritas North Carolina 2

Please note that this presentation is subject to change based upon new information received from NCDHHS. The most up-to-date version will be posted on the website at www.amerihealthcaritasnc.com Not all phone numbers are operational at this time. Member Enrollment : To contact AmeriHealth Caritas North Carolina regarding enrollment, please call Member Services at 1-855-375-8811 Provider Contracting: To request a contract, please contact Provider Network Management at 1-844-399-0474 or email us at [email protected].

http://www.amerihealthcaritasnc.com/

mailto:[email protected]

Overview


Who We Are Provider Network Management and Administrative Provider Support Contracting and Credentialing Eligibility and Covered Services Pharmacy Claims and Billing Integrated Care Advanced Medical Homes Utilization Management/Prior Authorization Value-based Care Culturally and Linguistically Appropriate Services (CLAS) Member Grievances and Appeals Provider Grievances and Appeals Compliance Advance Directives Marketing Guidelines Resources

Who We Are


Mission and Vision


AmeriHealth Caritas North Carolina is part of the AmeriHealth Caritas Family of Companies (AmeriHealth Caritas). AmeriHealth Caritas is part of the Independence Health Group in

partnership with Blue Cross Blue Shield of Michigan. AmeriHealth Caritas is one of the nation’s leaders in health care solutions for those most in need.

Our mission To help people get care, stay well, and build

healthy communities. We have special concern for those who are poor.

Our vision

Our goal is to develop strategic partnerships and build accessible, flexible health systems across the nation. Moving forward as health care evolves, we will continue to ensure the greatest level of

care at maximum value for members, providers, and governments.

Where We Are


NC Medicaid Managed Care Program


The NC Medicaid Managed Care program is administered through the North Carolina Department of Health and Human Services (DHHS), and includes:

• Medicaid benefits for families enrolled in Temporary Assistance for Needy Families (TANF), including children who qualify for Title IV-E foster care and adoption assistance and pregnant women; individuals who receive Supplemental Security Income (SSI) but are not eligible for Medicare; and adults ages 19 to 64 who are not eligible for Medicare with income levels up to 133 percent of the Federal Poverty Level (FPL).

• Long Term Services and Supports (LTSS) beneficiaries. • Aged, Blind, Disabled (ABD) eligible population.

• NC Health Choice program members.

Provider Network Management and

Administrative Provider Support

Provider Network Management: Dedicated Account Executives


Local and knowledgeable Provider Network Management Account Executives (AEs):

• Live and work in North Carolina

• Are assigned to your specific service area/tribal entity

• Possess knowledge and experience working with the substance use disorder and behavioral health provider community

• Are well-versed in our physical and behavioral health benefits

Your AE is your single point of contact and is available to assist you in resolving issues and answering any questions you may have regarding:

• Your AmeriHealth Caritas North Carolina contract

• Provider orientations and trainings occurring in your region

• Ongoing education and assistance.

Note: Each contracted tribal entity will have a local tribal liaison who will act as the dedicated provider Account Executive and will be your single point of contact. If you have questions, please call our local Tribal Liaison, Julie Keiper, at 1-828-508-4991.

The Provider Services department and the Medical Management team are also available to assist you.

Indian Health Care Providers (IHCPs)


Tribal members are eligible to receive services from an IHCP and to choose the IHCP as their PCP, if the IHCP has the capacity to provide primary care provider (PCP) services at all times.

Tribal members have direct access to an IHCP. Out-of-network IHCPs can make referrals to participating providers for any tribal members without a prior authorization or referral from a participating provider.

If you have questions, please call our local Tribal Liaison, Julie Keiper, at 1-828-508-4991.

E-Solutions to Foster Communication


AmeriHealth Caritas North Carolina recognizes how busy our participating providers are. We are dedicated to supporting you and ensuring that you have the information you need at your fingertips through convenient electronic solutions and support. We keep you informed through several communication methods:

• Provider manual • Network News • Fax blast and email • Provider newsletter • Provider-focused website section • Provider education and training • Webinars. • Let Us Know program.

And, we provide searchable online tools: • Online provider directory. • Drug formularies.

Excellent provider communication and service is an organization-wide priority!

Let Us Know Program


AmeriHealth Caritas North Carolina is eager to partner with the provider community in supporting our members who may require a helping hand. The Let Us Know program is a way for us to collaborate in the engagement and management of our members.

If you have a member who could use support from our care management team, here are a few ways to “let us know”:

Let Us Know options Examples of reasons for referral:

Call our Rapid Response and Outreach Team (RROT) at 1-833-808-2262, or Fax the Member Intervention Request Form to RROT at 1-833-816-2262. You can find the form at www.amerihealthcaritasnc.com under the Forms section. Click to submit an electronic referral www.amerihealthcaritasnc.com For guidance on completing this form, or to inquire about a submission, please call 1-833-808-2262.

Pharmacy consult on controlled substances Assistance locating a specialty provider Education plan benefits and resources Assistance with appointment scheduling Unmet resource — social determinant of health

(SDOH) screening SDOH resource follow-up (transportation, food

pantry, housing application, etc.)

Call in a referral to the Care Management department at 1-833-808-2262.

Education on health conditions Screening for mental health or substance use

services Crisis follow-up resources (recent suicide attempt

or bereaved after a death by suicide)



E-Solutions to Simplify Administration


• Efficient claims solutions

• Accurate and secure reimbursements

• Early detection of claims errors

• Faster claim payment and billing reconciliation through electronic funds transfer (EFT) and electronic remittance advice (ERA)

• Lower administrative, postage and handling costs

• NaviNet® claim inquiry

• EDI member eligibility verification through your electronic health record/practice management software (EHR/PMS) system

AmeriHealth Caritas North Carolina partners with Change Healthcare, the largest electronic data interchange (EDI) clearinghouse in the country, to offer state-of-the-art EDI services to our providers. EDI optimizes productivity by streamlining your workflows and ensuring:

E-Solutions to Support Patient Care Management


Our secure provider portal www.navinet.navimedix.com offers web-based solutions that allow providers and health plans to share critical administrative, financial and clinical data in one place.

This tool can help you manage patient care with quick access to:

• Member eligibility and benefits information

• Panel roster reports

• Care gap reports to identify needed services and preventive screenings

• Member clinical summaries

• Social determinants of health status

• Admission and discharge reports

• Medical and pharmacy claims data

• Electronic submission of prior authorization requests

If you have not yet done so, please visit www.navinet.navimedix.com to sign up for NaviNet.

https://navinet.navimedix.com/sign-in?ReturnUrl=/Main.aspx

https://navinet.navimedix.com/sign-in?ReturnUrl=/Main.aspx

Member Access and Availability Standards


AmeriHealth Caritas North Carolina providers must comply with access standard guidelines as outlined in the provider manual to help ensure that Plan members have timely access to care.

The standards outlined apply to health care services, medical health providers and behavioral health providers. AmeriHealth Caritas North Carolina monitors access standards on an annual basis. If at any time your practice becomes unable to meet these standards, you must immediately advise your Provider Network Account Executive or the Provider Services department at 1-888-738-0004.

For the full list of member access standards, please refer to the provider manual available at www.amerihealthcaritasnc.com.


Primary Care Provider (PCP) Changes


• Provide primary care services • Arrange for inpatient care, consultations

with specialists or laboratory or radiological services when reasonably necessary

• Arrange for consultation appointments • Coordinate and interpret any consultation

findings with an emphasis on continuity of medical care

• Arrange for services with qualified licensed or certified providers

• Coordinate the member's overall medical care such as periodic immunizations and diagnosis and treatment of any illness or injury

AmeriHealth Caritas North Carolina members: • May change their PCP twice a year (without cause) • Have thirty (30) days from the initial PCP assignment to change their PCP • Thereafter may change their PCP one additional time without cause during the calendar year Members may also change their PCP for “cause,” including failure on the part of the PCP to:

For more information, please refer to the provider manual available at www.amerihealthcaritasnc.com.


Contracting and Credentialing

How Do I Participate? Contracting


1. Enroll as a Medicaid provider with the North Carolina Department of Health and Human Services (DHHS).

2. Complete the DHHS credentialing process

3. Execute a Participating Provider agreement.

For contract information, please contact Provider Network Management at 1-844-399-0474 or email us at [email protected].

You will need to complete one of the following forms and send them along with your contract:

• Provider Data Intake Form

• Facility Data Form for North Carolina Providers

• Behavioral Health Data Intake Form

• Ancillary Data Intake Form


How Do I Participate? Credentialing


The Credential Verification Organization (CVO) is certified by the National Committee for Quality Assurance (NCQA) to perform the primary source verifications related to the credentialing/recredentialing process.

Providers will use a single electronic application to submit information to be primary source verified and screened to become a Medicaid-enrolled provider, with the application serving for enrollment as a Medicaid fee-for-service provider as well as a Medicaid managed care provider.

AmeriHealth Caritas North Carolina will not request any additional credentialing information from a provider without the Department’s written prior approval; however, AmeriHealth Caritas North Carolina is not prohibited from collecting other information from providers that is necessary for the contracting process.

All practitioners and organizational providers will be reverified and recredentialed by the Prepaid Health Plan (PHP) every three (3) years, except as otherwise specifically permitted by DHHS.

Providers who have questions about the Medicaid enrollment process should call NCTracks at 1-800-688-6696 or visit [email protected].

Providers who have questions about the credentialing process should call AmeriHealth Caritas North Carolina Credentialing at 1-833-559-2262.


Eligibility and Covered Services

Eligibility and Enrollment: How Do I Verify Eligibility?


Prior to rendering services, providers are responsible for verifying member eligibility. You can check member eligibility by:

• Logging in to our secure provider portal https://navinet.navimedix.com/main.aspx, a web-based application that allows providers and health plans to share critical administrative, financial and clinical data in one place. You can also access the provider portal on our website at Providers > Provider Resources > NaviNet > Log in to NaviNet.

• Verifying EDI eligibility verification through your EHR/PMS with Change Healthcare’s Eligibility and Enrollment Advocate system.

• Contacting AmeriHealth Caritas North Carolina’s Provider Services department at 1-888-738-0004 and using the automated real-time eligibility service by following the prompts for Member Eligibility.

• Accessing the North Carolina Medicaid Management Information Systems (NC MMIS) via the NCTracks Web Portal at https://www.nctracks.nc.gov

For more information or to sign up for NaviNet access, go to https://navinet.secure.force.com/ or call NaviNet Customer Support at 1-888-482-8057.

https://navinet.navimedix.com/main.aspx

https://www.nctracks.nc.gov/

https://navinet.secure.force.com/

Continuity of Care


All new members are screened and assessed to identify needed services. We will implement a continuity of care transition plan to provide continuity of care for new members transitioning from fee-for-service to managed care for up to ninety (90) days. This includes members receiving LTSS.

If you have questions, please refer to the provider manual or call Provider Services at 1-888-738-0004.

Member ID Cards


Cost Sharing (Copays)


AmeriHealth Caritas North Carolina does not require members to pay for any covered services other than the copayment amounts as specified by DHHS. For a complete list of services and applicable copays, please refer to www.amerihealthcaritasnc.com.

Exceptions to cost sharing — copayments do not apply to:

• Tribal members who receive services from an Indian Health Service, an Indian tribe, an Indian tribal organization, or an Urban Indian Organization; or through referral under contract health services

• Children under age 21 • Pregnant women • Individuals receiving hospice care • Federally recognized American Indians/Alaska Natives • Breast and Cervical Cancer Control Program (BCCCP) beneficiaries • Foster children • Disabled children under the Family Opportunity Act, individuals whose medical assistance for

services furnished in an institution is reduced by amounts reflecting available income other than required for personal needs

AmeriHealth Caritas North Carolina will not impose cost sharing on behavioral health services, as defined by DHHS.


Cost Sharing (Copays)


Covered Services


Covered Services Ambulance Services Federally qualified health center services Certified pediatric and family nurse practitioner services

Freestanding birth center services (when licensed or otherwise recognized by the state)

Chiropractic services Hearing aids Clinic services Home health services Diagnostic, screening, preventive and rehabilitative services

Home infusion therapy

Dietary evaluation and counseling and medical lactation services

Hospice

Durable medical equipment Into the Mouths of Babes dental services Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services

Inpatient hospital services

Family planning services Laboratory and X-ray services


Covered Services Non-emergency medical transportation Physician services Nursing facility services Podiatry Services Obstetrics and gynecology and maternal support services

Private duty nursing services

Ophthalmology and vision services Respiratory care services Optometry Services Rural health clinic services

Outpatient hospital services Speech, hearing and language disorder Personal Care Telemedicine Pharmacy Services Tobacco cessation counseling for pregnant

women Physical and occupational therapy Transplants and related services

This table is not meant to be exhaustive and is only a summary of the services

Covered Services (continued)

Covered Behavioral Health Services


Covered Behavioral Health Services Inpatient behavioral health services Outpatient behavioral health services Facility-based crisis services for children and adolescents

Mobile crisis management services

Nonhospital medical detoxification services and partial hospitalization

Professional treatment services in a facility-based crisis program

Medically supervised alcohol and drug abuse treatment center detoxification, crisis stabilization

Ambulatory detoxification services

EPSDT authorized services Diagnostic assessment services

Substance abuse intensive outpatient program

Research-based behavioral health treatment – SPA approved by CMS; awaiting completion of promulgated policy

Value Added Services


Weight Watchers® membership for qualifying members

Boys and Girls Club membership for qualified members under age 19

GED assistance for qualifying members Free meals for qualifying members discharged from a hospital

Gift cards valued at up to $75 per year and other rewards for completing certain qualifying healthy behaviors

Up to $500 in rewards for completing substance use disorder program

Free cellphone with monthly minutes and texts for qualifying members

Pain management program to include alternative treatment options, such as acupuncture, biofeedback and massage therapy for qualifying members

Home educational visits for children with asthma and supplies to control allergies

Home educational visits for high-risk pregnant women

Long Term Services and Supports (LTSS)


We understand and appreciate that receiving LTSS is often a very personal matter — based on a sense of trust and reliability.

To that end, we offer a holistic, person-centered approach that integrates and coordinates primary, acute and behavioral health care with LTSS. AmeriHealth Caritas North Carolina supports and enhances member-centered care, regardless of the setting in which our members receive services. AmeriHealth Caritas North Carolina develops a care plan to address the care and treatment needs of our members to help ensure their health and safety, and to proactively address the risks a member may face in desiring to live as independently as possible.

The DHSS Division of Medicaid & Medical Assistance (DMMA) determines initial and continued eligibility for LTSS.

Please refer to the LTSS training presentation on the AmeriHealth Caritas North Carolina website at www.amerihealthcaritasnc.com in the Training section.


Laboratory Services


Quest Diagnostics and LabCorp provide outpatient lab services for AmeriHealth Caritas North Carolina members.

Dental Services: Into the Mouths of Babes (IMB)


Dental services includes all services billed as dental using the American Dental Association’s Current Dental Terminology (CDT) codes.

With the exception of the two CDT codes (D0145 and D1206) associated with the IMB physician fluoride varnish program, all dental services are carved out of the NC Medicaid Managed Care program, and should therefore be billed to the NC Medicaid Fee for Service program.

IMB is a clinical program that trains medical providers to deliver preventive oral health services to young children insured by North Carolina Medicaid. Services include:

• Oral evaluation and risk assessment

• Counseling with primary caregivers

• Application of topical fluoride varnish

• Referral to a dental home

Into the Mouths of Babes (IMB)


AmeriHealth Caritas North Carolina’s participating providers can complete the IMB online training or the one-hour Continuing Medical Education (CME) session. A step-by-step guide can be found on the DHHS website at:

https://publichealth.nc.gov/oralhealth/partners/IMB-toolkit.htm. Providers will be responsible for knowing the following:

Member eligibility, documentation, fluoride varnish information and procedures, supplies, the practice’s dental referral policy and procedures, referral guidelines for risk assessment-based referral, and the resources for parent education and information.

For more information, please visit: https://publichealth.nc.gov/oralhealth/partners/IMB.htm.

https://publichealth.nc.gov/oralhealth/partners/IMB.htm

Non-Emergency Medical Transportation (NEMT)


AmeriHealth Caritas North Carolina contracts with LogistiCare for NEMT. Providers may contact AmeriHealth Caritas North Carolina at the following numbers to arrange NEMT services on the member’s behalf:

Member Services 1-855-375-8811 (TTY: 1-866-209-6421)

Rapid Response and Outreach Team: 1-833-808-2262

For more information, please refer to the provider manual at www.amerihealthcaritasnc.com.


Pharmacy

Pharmacy


Pharmacy services covered by AmeriHealth Caritas North Carolina are managed by the Plan’s delegated pharmacy benefit manager (PBM), PerformRxSM.

PerformRx provides case management, pharmacy network management and pharmacy benefits management.

For questions about pharmacy services, providers can contact PerformRx Pharmacy Provider Services at 1-866-885-1406.

Formulary

AmeriHealth Caritas North Carolina uses the North Carolina Medicaid Preferred Drug List (PDL). This drug benefit has been developed to cover medically necessary prescription products and provides outpatient prescription services that are appropriate, medically necessary, and not likely to result in adverse medical outcomes.

For the most current and complete information on pharmacy services and the formulary, please visit the Pharmacy section at www.amerihealthcaritasnc.com.

Pharmacy: Prior Authorizations


Pharmacy Services will issue prior authorization for drugs on the PDL that require it.

For prior authorization, providers can contact Pharmacy Provider Services at 1-866-885-1406 between 7:00 a.m. and 6 p.m. Eastern time, Monday through Friday and state holidays.

After business hours, please call Pharmacy Member Services at 1-855-375-8811.

Prior authorization procedures are as follows:

The prescriber contacts AmeriHealth Caritas North Carolina by: • Submitting a web request under Pharmacy Services at

www.amerihealthcaritasnc.com or • Faxing a completed prior authorization form to

1-877-234-4274

Pharmacy prior authorization forms are available at www.amerihealthcaritasnc.com>Forms>Pharmacy Prior Authorization.

Claims and Billing

Electronic Claim Submission


All claims submitted by providers must be billed on the CMS-1500 or UB-04, or the electronic equivalent (EDI) of these standard forms.

AmeriHealth Caritas North Carolina partners with Change Healthcare. As long as you have the ability to send EDI claims to Change Healthcare, whether through direct submission or through another clearinghouse/vendor, you may submit claims electronically. If you are not set up for electronic submissions: • Contact your practice management software vendor or EDI software vendor. • Inform your vendor of AmeriHealth Caritas North Carolina ’s EDI Payer ID number 81671, or • Contact Change Healthcare at 1-877-363-3666 or visit www.changehealthcare.com for

information on contracting for direct submission to Change Healthcare.

Note: AmeriHealth Caritas North Carolina does not require Change Healthcare payer enrollment to submit EDI claims.

http://www.changehealthcare.com/

Paper Claim Submission


AmeriHealth Caritas North Carolina accepts paper claims. However, Plan practitioners and providers are encouraged to bill electronically. Some of the benefits of billing electronically include accurate and secure reimbursements, early detection of claims errors and faster claim and billing reconciliation.

Paper claims may be submitted to:

AmeriHealth Caritas North Carolina Attn: Claims Processing Department

P.O. Box 7380 London, KY 40742-7380

Claims : Electronic Funds Transfer (EFT)


AmeriHealth Caritas North Carolina partners with Change Healthcare for EFT. EFT simplifies reimbursement by transferring funds from one bank account to another, eliminating the use of paper checks. Using EFT is convenient and can reduce administrative overhead while allowing access to your funds more quickly.

To enroll, please call 1-866-506-2830 or visit the Change Healthcare EFT Enrollment Center at https://www.changehealthcare.com/support/customer-resources/enrollment-services/medical-hospital-eft-enrollment-forms.

https://www.changehealthcare.com/support/customer-resources/enrollment-services/medical-hospital-eft-enrollment-forms













Claim Filing Deadlines


Type of claims Description and time frame Original claim Must be submitted within 180 calendar days from the date service(s)

were rendered or compensable items were provided.

Rejected claim A claim not registered in the claim processing system and can be resubmitted as a new claim. Corrected and resubmitted within 180 calendar days from the date of service.

Denied claim A claim that was processed in the claim system and that may have a payment attached or may have been denied. A corrected claim may be submitted within 365 days of the original date of service to have the claim reprocessed.

Claims with EOB (TPL)

Must be submitted to the plan within 60 days from the date on the primary EOB.

Please refer to the provider manual or the Claims Filling Instruction Guide for more information at www.amerihealthcaritasnc.com.

EOB: Explanation of benefits. TPL: Third-party liability.


NaviNet: Claim Inquiry Adjustment


You may open a claims investigation via NaviNet with the Claim Inquiry Adjustment function. Requests for adjustments may also be submitted by phone to Provider Claims Services at 1-888-738-0004.

Claim types that are eligible for submission through the Claim Inquiry Adjustment option are: • Updated Eligibility • Updated/On File Authorization • TPL/COB Changed • Duplicate Payment Received • Claim Underpaid • Claim Overpaid

All requests are processed within ten (10) business days.

For more information, please refer to the Claims Investigation user guide on your NaviNet Plan Central page.

Integrated Care

An Integrated Approach to Care


Our multifaceted approach addresses the needs of our members, connecting them with the health care and services they need to get well and stay well. Our approach includes:

• Engaging, educating and empowering members to actively participate in improving their health outcomes

• Providing members with the information they need when they need it through our use of personal outreach and member portals

• Person-centered care planning where the member identifies their care team members including natural and professional supports of their choosing

• Using and supporting growth of community-based services

• Incentivizing and rewarding healthy behaviors

The Clinical Education Team


The Clinical Education Team is inspired by SAMHSA’s Center for Integrated Health Solutions Levels of Integration Framework (2013). Clinical Educators, as subject matter experts in behavioral health disorders and physical health conditions, partner with providers to collaboratively assess training needs, and develop and deliver training related to behavioral health, physical health and other clinical and person-centered initiatives.

Modality:

• Instructor-led and virtual training available

Overview:

• Integration of physical health and behavioral health conditions: o Information on Plan resources

• Screening tools or special considerations: o Behavioral Health Toolkit (available for physical health providers) o Physical Health Toolkit (available for behavioral health providers)

• TeleECHO Clinics available on some topics: o Collaborative Case-Based Learning

Trauma-Informed Care


AmeriHealth Caritas North Carolina understands that trauma impacts individuals, families and communities on many levels. Trauma-informed care is an organizational structure and treatment framework created to recognize, understand and respond to the effects of all types of trauma.

Trauma-informed care seeks to:

• Realize the widespread impact of trauma and understand paths for recovery

• Recognize the signs and symptoms of trauma in patients, families and staff

• Integrate knowledge about trauma into policies, procedures and practices

• Actively avoid re-traumatization.

For more information on trauma-informed care, visit https://www.samhsa.gov/samhsanewsletter/Volume_22_Number_2/trauma_tip/guiding_principles.html.

The Plan encourages all providers to provide trauma-informed care. For assistance and referral pathways for specialized trauma treatment, please use our Let Us Know program.

https://www.samhsa.gov/samhsanewsletter/Volume_22_Number_2/trauma_tip/guiding_principles.html

https://www.samhsa.gov/samhsanewsletter/Volume_22_Number_2/trauma_tip/guiding_principles.html

Opportunities for Health


AmeriHealth Caritas North Carolina will identify, assess and address health care, including opportunities for health in the populations we serve, enabling them to live healthier lives and achieve maximum independence.

AmeriHealth Caritas North Carolina administers universal social determinants of health (SDOH) screenings with escalation pathways for actionable member support.

Sharing Data With Providers


Responses to SDOH screenings appear on the Member Clinical Summary available to providers through the provider portal.

Risk Score Integration


Risk scores are used to guide care management outreach and as triggers for the level of intervention.

International Classification of Diseases ICD.10 Z codes refer to factors influencing health status.

The following self-reported data elements and relevant ICD.10 Z codes enhance the AmeriHealth Caritas risk score modeling:

• Distance from PCP office

• Poverty index

• Housing

• Food

• Transportation

• Utilities

• Health literacy

• Legal circumstances

• Physical environment

• Employment status

• Safety (exposure to trauma, stress, violence)

• Social isolation

• Technology (access)

Please include the appropriate supplemental ICD-10 diagnosis codes on your claim to report SDOH.

Note: SDOH should not be used as the admitting or principal diagnosis.

For information about the applicable ICD-10 codes, please refer to the AmeriHealth Caritas North Carolina Claims and Billing Manual found on our website at www.amerihealthcaritasnc.com.


Connecting to Community Resources


Aunt Bertha Platform

www.auntbertha.com • Internet-based community-resource directory

• Listed agencies verified on a routine basis to ensure information is current

• Available to internal health plan staff and directly to members and providers through the Plan website and plan-branded mobile application

NCCare360

https://www.ncdhhs.gov/

• A robust statewide community-resource platform for payers, care managers, clinicians, community health workers, social service agencies and community members

• Telephonic, online and interfaced IT platform

• A robust statewide resource database of community-based organizations and social service agencies

• Used by associates to identify community-based resources and connect members to the appropriate resources. Associates will also use the platform for referring members to community-based organizations and social service agencies available and track closed-loop referrals once this functionality is available for use.

http://www.auntbertha.com/

https://www.ncdhhs.gov/

Identifying High-Risk, High-Need Members


With the support of our provider partners, we identify priority populations and high-risk, high-need members through assessment, stratification and referrals. These members will receive community-based, local care management.

Our risk scoring and stratification method will take into account:

• Results of the care needs assessment and health risk screenings • Claims history and encounter data • Pharmacy utilization data • Recent overdoses and suicide attempts • Admission, discharge and transfer data • Adverse childhood experiences (ACEs) and trauma exposure • Extended hospital stays • Members with significant unmet resource needs • Emergency department (ED) utilization • Inpatient behavioral health discharges • Neonatal intensive care unit discharges

Coordination Is Key


Without effective coordination, high-risk members in particular are likely to be overwhelmed by multiple well-intentioned but uncoordinated initiatives.

Care Coordination Through Collaboration


There are six core components to our Population Management program:

1. Bright Start® (maternity management). Assists expectant mothers by promoting healthy behaviors and controlling risk factors during pregnancy. The program is based on the Prenatal Care Guidelines from the American College of Obstetricians and Gynecologists (ACOG).

2. Rapid Response and Outreach Team (RROT). Addresses the needs of members and supports providers and their staff. The team is composed of Clinical Care Managers and nonclinical Care Connectors.

3. Transitional Care Management. Coordinates services for members to ensure that the members are receiving the most appropriate care in the right setting.

4. Complex Care Management Team (CCMT). Voluntary program that serves members identified as needing comprehensive and disease-specific assessments and reassessments, along with developing person-centered goals with a focus on prevention. Provides face-to-face engagement for high-risk members with complex care needs, including overutilization of acute services as their primary source of care. This team is composed of licensed nurses, licensed social workers and Community Health Navigators, with Medical Director oversight, helping members receive the right care in the right place at the right time.

5. Pediatric Preventive Health Care. Helps improve the health of members under age 21 by increasing adherence to EPSDT guidelines.

6. Care Coordination. Programs that address members’ health care needs while assessing for and addressing social needs and barriers and providing hands-on coordination. AmeriHealth Caritas North Carolina will work with Advanced Medical Homes (AMHs) Tier 1 and Local Health Departments (LHDs) as a component of our local care management model.

Early Periodic Screening, Diagnostic and Treatment (EPSDT)


AmeriHealth Carita North Carolina’s Pediatric Preventive Health Care program is designed to improve the health of members from birth to age 21 by increasing adherence to EPSDT guidelines.

PCPs are responsible for coordinating and managing the medical needs of members through identification of growth and development needs and coordination of appropriate health care services according to the American Academy of Pediatrics (AAP) Bright Futures Periodicity Schedule or upon request at other times in order to determine the existence of a physical or mental condition.

The most current periodicity schedules are available online at https://brightfutures.aap.org/Pages/default.aspx.

https://brightfutures.aap.org/Pages/default.aspx

Clinical Help Lines


AmeriHealth Caritas North Carolina members have an added benefit of a Nurse Line at 1-888-674-8710.

Our 24/7 Nurse Line is a toll-free private service. Nurses can answer members’ questions about their health.

The Behavioral Health Crisis Line is also available for members and can be reached at 1-833-712-2262.

Our 24/7 Behavioral Health Crisis Line is a toll-free private service. Licensed clinicians can assess and activate crisis services for members in need.

Advanced Medical Homes

Advanced Medical Homes (AMHs)


AmeriHealth Caritas North Carolina’s AMH care delivery model is designed to enhance access, coordinate care and increase patient engagement through a team approach that includes disease management, population analytics and electronic medical records. This model offers providers the opportunity to be rewarded for high-quality care by aligning payment to value.

Practices are compensated based on a tier system for maintaining a high degree of access for Medicaid patients. Practices will be eligible to participate in the AMH program if they are primary care practices as defined by the current requirements for participation in the Carolina ACCESS program.

For more information about AMHs, contact Provider Services at 1-888-738-0004 or your Account Executive.

AMH Eligibility


Practices will be eligible to participate in the AMH program if they are primary care practices as defined by the current requirements for participation in the Carolina ACCESS program. DHHS has developed a centralized process for designating practices into the appropriate tier.

Practice requirements for Tiers 1 and 2 are the same as requirements for Carolina ACCESS.

AMH Tier 3 is a more advanced tier for practices ready to take on care management responsibilities in addition to the requirements in Tiers 1 and 2.

For details, please call Provider Services at 1-888-738-0444 or contact your Account Executive.

Examples of care management activities include: • Conducting health risk assessments • Arranging wellness visits • Conducting comprehensive assessments • Ensuring collaboration between care team members • Providing transitional care management • Coordinating with and integrating social services to address unmet needs

Advanced Medical Homes


For more information about Advanced Medical Homes, contact Provider Services at 1-888-738-0004 or your Account Executive.

Utilization Management Prior Authorization

Utilization Management Prior Authorization


Utilization Management decision-making is based only on appropriateness of care and services and existence of coverage. AmeriHealth Caritas North Carolina’s providers are responsible for obtaining prior authorization for certain services.

For a full list of services that require prior authorization, please refer to the provider manual at www.amerihealthcaritasnc.com.

How to obtain prior authorization:

• By form. Providers may need to complete a form before administering some health services to members. The forms can be found at www.amerihealthcaritasnc.com in the Forms section and faxed to 1-833-893-2262.

• By phone. Call our Utilization Management department at 1-833-900-2262.

• By provider portal. Access our online prior authorization management system, Jiva, via our secure provider portal on NaviNet at www.navinet.navimedix.com.

Referrals

Referrals are not required by AmeriHealth Caritas North Carolina.



http://www.navinet.navimedix.com/

Services Requiring Prior Authorization


This a summary of some of the services that require prior authorization. For a full list of services, please refer to the provider manual at www.amerihealthcaritasnc.com. Please note: Prior Authorization is not required for Primary Care Physicians or Local Health Departments.

• All out-of-network services excluding emergency services • All services that may be considered experimental and/or investigational • All miscellaneous/unlisted or not otherwise specified codes • All services not listed on the AmeriHealth Caritas North Carolina fee schedule • Elective air ambulance • All inpatient hospital admissions, including medical, surgical and rehabilitation • Speech, occupational and physical therapy (after 24 visits for each modality) • Durable medical equipment (DME) • Pain management • Psychiatric inpatient hospitalization • Behavioral health partial hospitalization • Behavioral health intensive outpatient program • Behavioral health residential treatment facility including Institution for Mental Disease (IMD) • Transcranial magnetic stimulation (TMS) • Vagus nerve stimulation (VNS) • Substance use disorder (SUD) programs • Electroconvulsive therapy (ECT) • Psychological and neuropsychological testing • LTSS will be authorized/reauthorized during the face-to-face assessment and care planning process


Services Requiring Notification


Providers are asked to notify AmeriHealth Caritas North Carolina within one business day of when the following services are delivered:

• All newborn deliveries including those that occur in birthing centers.

• Maternity obstetrical services (after first visit) and outpatient care (includes observation).

• Continuation of covered services for a new member transitioning to the Plan the first 90 calendar days of enrollment.

• Inpatient admissions following emergency room medical care, emergency short procedure unit services, or an observation stay.

For certain behavioral health services, notification is required within 48 hours of admission or within 48 hours prior to discharge, for assistance with discharge planning. Please note that the claim will not pay without a notification reference number.

• SUD detox (residential and ambulatory)

• Crisis intervention

• Crisis stabilization

American Society of Addiction Medicine (ASAM)


ASAM levels of care: Notification is required at time of admission • Level 1-WM: Ambulatory Withdrawal Management Without Extended On-Site Monitoring

All other ASAM Levels of Care (prior authorization is required):

• Level 3.7-Medically Monitored Intensive Inpatient Services • Level 3.9 (NC) Medically Supervised/ADATC Detox Crisis Stabilization Service • Level 4-Medically Managed Intensive Inpatient Services

Utilization Management Prior Authorization: Tribal Members


AmeriHealth Caritas North Carolina will consider any referral from an Indian Health Care Provider (IHCP) acting as the member’s PCP to a network provider as satisfying any coordination of care or referral requirement.

Out-of-network IHCPs can make referrals to contracted providers for any tribal members without prior authorization or a referral from a participating provider.

Access to care

AmeriHealth Caritas North Carolina will provide tribal members eligible to receive covered services from an IHCP with direct access, defined as no requirement for referral or prior authorization. If AmeriHealth Caritas North Carolina cannot provide timely in-state or in-network access to necessary services for tribal members, the Plan will provide access to out-of-state and/or out-of-network IHCPs.

Imaging: National Imaging Associates


AmeriHealth Caritas North Carolina’s radiology benefits vendor, National Imaging Associates (NIA), provides utilization management review and authorization for non-emergent, advanced, outpatient imaging procedures.

Procedures requiring prior authorization: The following radiology services, when performed as an outpatient service, require prior authorization:

• CT scan • PET scan • MRI • MRA • Nuclear cardiac imaging

The ordering physician is responsible for obtaining prior authorization for the requested radiology service. Patient symptoms, past clinical history and prior treatment information will be requested by NIA and the ordering physician should have this information available at the time of the call.

NIA will provide prior authorization within 48 hours.

NIA: How to Submit Authorization


The ordering facility or provider must obtain the appropriate prior authorization via NIA’s website or by calling NIA.

Ordering providers:

To initiate a request for an authorization, please contact NIA online at www.RadMD.com or by phone toll-free at 1-800-424-4784.

To check the status of an authorization, please contact NIA online at www.RadMD.com or by Interactive Voice Response (IVR) System at 1-800-424-4784.

Rendering providers:

To check the status of an authorization, please contact NIA online at www.RadMD.com or by IVR at 1-800-424-4784.

http://www.radmd.com/



Value-based Care

Value-based Care


AmeriHealth Caritas North Carolina’s value-based programs are designed to compensate providers who provide high-quality, cost-effective, appropriate care to our members while addressing their unique needs.

AmeriHealth Caritas North Carolina’s value-based programs are not based on fee-for-service reimbursement; instead, they are driven by quality while offering providers customizable solutions. Our adaptable, customized solutions are easily transferrable and can be tailored to meet the needs of state-specific initiatives.

This model includes a suite of incentive value-based programs called PerformPlus®. PerformPlus programs are available to PCPs, physical and behavioral health specialists, hospitals and integrated delivery systems. Examples of the program are:

• Quality Enhancement Program (QEP) • Community Partners Program • Shared Savings Program Not every practice is ready to move to a value-based system; therefore, our practice transformation support team can assist practices in transitioning to a value-based model by helping them choose the program that best fits the size of their practice, goals, experience and level of readiness for participation in a value-based program.

Value-based Incentive Programs


Quality Enhancement Program (QEP) — PCPs • Quality

• HEDIS • PCMH status

• Efficiency • Cost efficiency • Non-emergent ER utilization • Improvement incentive • Preventable readmissions • Total cost of care

Community Partners Program — FQHCs • Quality

• HEDIS • Efficiency

• Potentially preventable readmissions

• Potentially preventable admission rate

• Potentially preventable ER visit rate

• Administrative bonus • PCMH status

Women’s Health Program • Quality

• HEDIS • NQF

• Efficiency/transparency • NICU rates • ONAF forms

• Participation standards and administrative • Program participation

standards • Performance on Access to

Care survey • Complaints and grievances

Cardiology Pay for Performance • Quality

• NQF • Cost/efficiency

• Potentially preventable readmissions

• Potentially preventable admission rate

• Potentially preventable ER visit rate

• Administrative • “Distinguished Provider” • Medical home bonus • Other: EMR, electronic claims

submission, etc.

Shared Savings Program Quality

• HEDIS • Hospital safety measures • Transitions in care

• Efficiency • Potentially preventable

readmissions • Potentially preventable

admission rate • Potentially preventable ER

visit rate • NICU LOS

Integrated Behavioral Health • Efficiency measures including

potentially preventable ER utilization

• Behavioral health quality measures such as: • Adherence to antipsychotic

medications for individuals with schizophrenia

• Antidepressant medication management (AMM)

• Follow-up after hospitalization for mental illness (FUH)

Partial Risk Model • Continuously enrolled

population identified by specific risk stratification

• Excludes non-users, maternity members and those with malignancies and catastrophic health conditions

• Outcomes capped at upside and downside corridors

MLR/Total Cost of Care Model — Upside Only Year One: • Quality-based guardrails

governing risk allocation/sharing.

• MLR/percentage of premium/total cost of care

• Outcomes capped at upside and downside corridors

Practice Transformation


Our Practice Transformation team will partner with your practice to create a customized strategy aimed at improving patient outcomes and managing the cost of care. This is done through continuous quality improvement.

Your Practice Transformation team will:

• Assess organizational and practice readiness for transformation and targeted practice improvement opportunities

• Assist with use of available data to improve performance, optimizing health information technology for performance monitoring and population management

• Identify and cross-pollinate best practices

• Create an infrastructure for continuous improvement and support in developing, implementing, monitoring and tracking of improvement activities

• Facilitate development of a goal-oriented plan for interim monitoring of process

Culturally and Linguistically Appropriate Services (CLAS)

What Is CLAS?


The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (The National CLAS Standards) were created to advance health equity, improve quality of care and eliminate health care disparities.

AmeriHealth Caritas North Carolina recognizes the need to effectively respond to a diverse and multicultural patient population, and to understand and address issues that lead to health disparities.

In an effort to deliver culturally competent, respectful, appropriate care to members who have limited English proficiency (LEP); who are low literacy proficient (LLP); who represent diverse, multicultural backgrounds; or may have special health needs, AmeriHealth Caritas North Carolina offers ongoing CLAS training and requires providers to complete annual training.

Please refer to the provider manual for more information, or go to www.amerihealthcaritasnc.com and visit the CLAS page.


Interpretation and Translation Services


Barriers in communication can impact quality of care. AmeriHealth Caritas North Carolina offers language services to facilitate better communication between members and their providers.

Translation

Commonly used materials are automatically translated into Spanish and any threshold language spoken by our members in North Carolina. Other materials are translated upon request. Translations can be done in nearly every language spoken by our members in North Carolina.

Interpretation

AmeriHealth Caritas North Carolina provides telephonic interpretation services, free of charge, to any AmeriHealth Caritas North Carolina member through Language Access Services associates.

Member Grievances and Appeals

Grievances A member grievance expresses the member’s dissatisfaction with services received from AmeriHealth Caritas North Carolina. The member may file a grievance in writing or by phone at the numbers below. It may be filed at any time either orally or in writing. It may also be filed by the treating provider or PCP (or another authorized representative) at the member’s request.

To file a grievance:

Call Member Services at 1-855-375-8811 (TTY 1-866-209-6421), 24 hours a day, seven days a week.

Write: AmeriHealth Caritas North Carolina Attn: Complaints and Grievances P.O. Box 7382 London, KY 40742-7382

AmeriHealth Caritas North Carolina will send the member an acknowledgement letter within five (5) business days of receiving the grievance. The Plan will send a decision letter within thirty (30) calendar days of receiving the request.

Standard Appeal


A standard appeal asks AmeriHealth Caritas North Carolina to review an adverse benefit determination. If the member does not agree with AmeriHealth Caritas North Carolina’s determination, the member may file an appeal. The member must file an appeal within sixty (60) calendar days from the Notice of Adverse Benefit Determination.

An Appeal Request Form will be sent to the member with the Adverse Benefit Determination or the member may access the form at www.amerihealthcaritasnc.com.

To file an appeal, the member or authorized representative may send a written appeal by completing and sending the Appeal Request Form to: AmeriHealth Caritas North Carolina Attn: Member Appeals Coordinator Member Appeal Department P.O. Box 7378 London, KY 40742-7378 Or they can submit by phone by calling Member Services at 1-855-375-8811 (TTY 1-866-209-6421).

Please refer to the provider manual for the Expedited Appeal process.


State Fair Hearing


The member or their authorized representative may seek a fair hearing after the appeals process has been exhausted, but the fair hearing must be requested within 120 calendar days from the date of AmeriHealth Caritas North Carolina’s Notice of Adverse Benefit Determination or appeal decision letter. A provider may also request a fair hearing on behalf of a member with the member’s written consent.

Members have the right to self-represent or to be represented by a family caregiver, legal counsel or other representative during a fair hearing. Parties to the fair hearing are the Plan and the member or their authorized representative.

A state fair hearing can be requested by calling or writing to North Carolina’s Office of Administrative Hearings, Hearings Division and Clerk’s office.

Office of Administrative Hearings 6714 Mail Service Center Raleigh, NC 27699-6714 Phone: 1-919-431-3000 Fax: 1-919-431-3100

Provider Grievances and Appeals

Grievances


A provider grievance is a verbal or written complaint or dispute by a provider over any aspect of the operations, activities or behavior of AmeriHealth Caritas North Carolina, except for any dispute over which the provider has appeal rights. It is an opportunity for the provider to bring issues to the Plan.

Providers have the opportunity to make inquiries, register complaints and to settle with AmeriHealth Caritas North Carolina. Providers may register grievances about contracting differences, the Plan’s policies, procedures or any aspects of the Plan’s administrative functions, other than claims.

Examples of provider grievances include:

• Service issues with AmeriHealth Caritas North Carolina including failure to return a provider’s calls, frequency of site visits by AmeriHealth Caritas North Carolina’s Provider Account Executives and lack of Provider Network orientation/education by AmeriHealth Caritas North Carolina.

• Issues with AmeriHealth Caritas North Carolina’s processes, including failure to notify providers of policy changes or dissatisfaction with AmeriHealth Caritas North Carolina’s prior authorization process, referral process and/or formal provider appeals process.

• Contracting issues, disputes and differences, including dissatisfaction with AmeriHealth Caritas North Carolina’s reimbursement rate, and incorrect information about the provider in AmeriHealth Caritas North Carolina’s provider database.

Filing a Grievance


Online: Providers can file a grievance online in the Provider Grievances and Appeals section of the AmeriHealth Caritas North Carolina website, www.amerihealthcaritasnc.com.

By phone: Providers can call the Provider Services department at 1-888-738-0004.

By mail: Providers can mail a written grievance to: Provider Grievance AmeriHealth Caritas North Carolina P.O. Box 7379 London, KY 40742-7379 On-site meeting: Providers may request an on-site meeting with a provider Account Executive, either at the provider’s office or at AmeriHealth Caritas North Carolina to discuss the grievance.

AmeriHealth Caritas North Carolina will investigate, conduct an on-site meeting with the provider (if one was requested) and issue the informal resolution of the grievance within thirty (30) calendar days of receipt of the grievance from the provider.


Appeals


Providers may appeal most grievances not resolved to the provider’s satisfaction through the provider appeals process.

Reasons for appeals include:

.

Network providers Out-of-network providers

• Program integrity related findings or activities • Finding of fraud, waste or abuse by the Plan • Finding of or recovery of an overpayment by the Plan • Withhold or suspension of a payment related to fraud, waste or

abuse concerns • Termination of, or determination not to renew, an existing contract

based solely on objective quality reasons outlined in the Plan’s Objective Quality Standards

• Termination of, or determination not to renew, an existing contract for local health department care/case management services

• Determination to lower an AMH provider’s tier status • Violation of terms of the provider contract between the provider

and AmeriHealth Caritas North Carolina

• A determination not to initially credential and contract with a provider based on objective quality reasons outlined in the Plan’s Objective Quality Standards

• An out-of-network payment arrangement • Finding of waste or abuse by the Plan • Finding of or recovery of an overpayment by the Plan

Filing an Appeal


The provider’s right to appeal will generally follow a decision by AmeriHealth Caritas North Carolina that is adverse to the provider. The Plan provides written notice of a provider’s right to appeal in the written notice from the Plan of its decision giving rise to the right to appeal.

Providers wishing to file an appeal must do so within thirty (30) calendar days from the date on which:

• The provider received written notice from AmeriHealth Caritas North Carolina of the decision giving rise to the right to the appeal, or

• AmeriHealth Caritas North Carolina should have taken a required action but failed to take such action.

Provider appeals must be submitted in writing to the address below. Provider appeals may also be submitted through the provider portal in the Provider Grievance and Appeals section of our website, www.amerihealthcaritasnc.com. Provider Appeals Department AmeriHealth Caritas North Carolina P.O. Box 7379 London, KY 40742-7379

AmeriHealth Caritas North Carolina will provide written notice of the decision of the appeal within thirty (30) calendar days of receiving a complete appeal request, or if an extension is granted to the provider to submit additional evidence, within thirty (30) calendar days of the date on which all the evidence is submitted to the Plan.


Appeals Peer-to-Peer


Providers may reach the peer-to-peer line by following the prompts at 1-800-900-2262 to discuss a medical determination with a physician in the AmeriHealth Caritas North Carolina Medical Management department.

Providers must call within two (2) business days of notification of the determination or within two (2) business days of the member’s discharge from an inpatient facility.

Note: The purpose of the peer-to-peer process is to address medical determinations regarding health care services. This process is not intended to address denied claims or other issues.

For more information, please visit www.amerihealthcaritasnc.com.


Compliance

Comprehensive Compliance Program


The AmeriHealth Caritas North Carolina Compliance department has implemented a Comprehensive Compliance Program to ensure compliance with all applicable federal and state laws.

If you have a compliance or privacy concern, we encourage you to contact our Compliance department. You can report issues to the Compliance department by:

• Calling the toll-free Compliance Hotline at 1-866-833-9718, which is available 24/7 and allows for the anonymous reporting of issues.

• Using our online reporting tool at www.amerihealth.ethicspoint.com, which is available 24/7 and allows for anonymous reporting of issues.

• Emailing us: AmeriHealth Caritas North Carolina Compliance: [email protected]. AmeriHealth Caritas Corporate Compliance: [email protected]. AmeriHealth Caritas Corporate Privacy: [email protected].

Compliance is a shared responsibility and

calls upon us to do the right thing in the right way.

http://www.amerihealth.ethicspoint.com/




Provider Compliance Responsibilities


As a network provider, you have the following compliance responsibilities:

• Implement a compliance program that meets the requirements of 42 CFR § 438.608.

• Implement policies and procedures that meet the requirements of the Deficit Reduction Act of 2005.

• Recognize through a formal policy that Medicaid is “the payer of last resort.”

• Notify us when a change in circumstances may affect your eligibility to participate in the Medicaid Managed Care program.

• Report and promptly return to us any overpayment that you identify within sixty (60) days of identification.

Fraud Prevention Program


AmeriHealth Caritas has an established enterprise-wide Program Integrity department with a proven record in preventing, detecting, investigating and mitigating fraud, waste and abuse (FWA).

Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law. 42 CFR § 455.2.

Abuse means provider practices that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicaid program. 42 CFR § 455.2



The Special Investigations Unit (SIU) proactively identifies potential incidents of suspected fraud and abuse as part of its program for ongoing monitoring and auditing.

The SIU investigates allegations such as:

• Missing documentation of services purportedly rendered

• Billing for services not rendered

• Alteration or forgery of documentation

• Misrepresentation of services provided, and/or

• Receipt of benefits due to potentially fraudulent actions.



As a network provider, you are responsible for reporting suspected fraud, waste and abuse issues.

Reporting issues to AmeriHealth Caritas North Carolina

If you are aware of a potential or actual fraud, waste or abuse issue, we encourage you to report the issue to our Special Investigations Unit by:

• Calling the toll-free Fraud, Waste and Abuse Tip Line at 1-866-833-9718, which is available 24/7 and allows for the anonymous reporting of issues.

• Emailing [email protected]; or

• Mailing a written statement to: Special Investigations Unit AmeriHealth Caritas North Carolina 200 Stevens Drive Philadelphia, PA 19113




As a network provider, you are responsible for reporting suspected fraud, waste and abuse issues.

Reporting issues to North Carolina

NC Attorney General’s Medicaid Investigations Division (MID)

Attorney General’s Medicaid Investigations Division (MID) Phone: 1-919-881-2320 Fax: 1-919-571-4837 Website: https://www.ncdoj.gov/getdoc/2afb32e0-9831-41b7-8d53-99c9216c76a7/Reporting-Medicaid-Fraud-and-Abuse.aspx NC Department of Justice’s Medicaid Investigations Unit 5505 Creedmoor Road, Suite 300 Raleigh, NC 27612

North Carolina Medicaid Division of Health Benefits

DHHS Customer Service Center Phone: 1-800-662-7030 (English or Spanish) Medicaid Fraud, Waste and Program Abuse Tip-Line Phone: 1-877-DMA-TIP1 (1-877-362-8471) Website: https://medicaid.ncdhhs.gov/meetings-and-notices/ocpifraud-waste-and-abuse Health Care Financing Administration, Office of Inspector General Fraud Line Phone: 800-HHS-TIPS State Auditor Waste Line Phone: 1-800-730-TIPS Contact: NC Medicaid Operations Section Phone: 1-919-814-0181 Fax: 1-919-814-0036

https://www.ncdoj.gov/getdoc/2afb32e0-9831-41b7-8d53-99c9216c76a7/Reporting-Medicaid-Fraud-and-Abuse.aspx

https://www.ncdoj.gov/getdoc/2afb32e0-9831-41b7-8d53-99c9216c76a7/Reporting-Medicaid-Fraud-and-Abuse.aspx

https://medicaid.ncdhhs.gov/meetings-and-notices/ocpifraud-waste-and-abuse

Advance Directives


Advance Directives


AmeriHealth Caritas North Carolina requires its contracted providers to maintain written policies and procedures concerning advance directives with respect to all adults receiving care.

Providers are required to document in the member’s medical record and plan of care whether or not the member has executed an advance directive.

For more information, please refer to the provider manual at www.amerihealthcaritasnc.com.

Members can be referred to the member handbook, also on the website, for additional information.


Marketing Guidelines


Provider Marketing


Provider marketing activities guidelines

As a contracted provider, you are permitted to share the following with Plan members:

• General and factual information about AmeriHealth Caritas North Carolina and your participation in the Plan’s network.

• Plan-provided member education materials that have been approved by the Plan and DHHS.

• Contact information for the DHHS contracted Enrollment Broker.

To the extent that any of these activities are considered “marketing activities,” providers must be aware that marketing activities are subject to restrictions that arise under federal Medicaid managed care law. Areas where marketing activities are permitted include hospital or nursing home cafeterias, community or recreational rooms and conference rooms.

Provider marketing restrictions

Providers are prohibited from conducting marketing activities in health care settings where patients primarily intend to receive health care services, such as emergency rooms, patient hospital rooms, exam rooms and pharmacy counter areas.

For more information regarding acceptable marketing practices, please consult our website at www.amerihealthcaritasnc.com.


Resources

For a current list of AmeriHealth Caritas North Carolina phone and fax numbers, please refer to the Provider Quick Reference Guide at

www.amerihealthcaritasnc.com.



Questions?


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Please take a few moments to complete the survey by clicking the link below. Provider Orientation

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