NORTH CAROLINA
"THE SKY IS ONLY ONE SHADE OF BLUE"
"THE SKY IS ONLY ONE SHADE OF BLUE"
NC Caid BH AUTH or ICM BH ABA If ABA request (per SSG)
For Virginia CAID, how to we handle Personal Care Service (PCS) auth requests?
Connect provider to Home and Community Based Services (HCBS) phone # 844-842-6910 (Per SSG)
Do we allow Lock-ins?
Pharmacy-yes, PCP-no
How should we handle a request from a provider to refer a member to TN Choices or ECF Choices?
First, make sure their Tenncare Medicaid plan is active with UHC. If they are active with UHC submit a member assignment in ICUE and use the member referral template to submit the referral.
Does UHC hand transportation?
Medical Assistance Transportation Program (pa.gov) Must contact at least 3 business days in advance.
What code is For Personal Care Services (PCS) for NC Medicaid?
99509 (Per SSG)
True or False: On vaccine claims, Virginia Medicaid pays on the serum code rather than the vaccine administration code, and the administration code is not required to be on the claim.
True (Per the Vaccine’s for Children Reimbursement policy)
What pharmacy do we use and contact #?
OptumRx 855-427-4682 and Specialty Medications: BriovaRX 855-438-4510
What SOP gives me information about the TN Prepayment Process for R70-R99 Claim denials?
Fraud Waste Abuse – Medicaid State Specifics. In the SOP under member drop down select TN. This will open a drop down review the TN Prepayment Review in detail and how to assist provider with these denials.
Case manager contact process?
Answer: Member will need to speak with the PA Special Needs Unit to request Case Manager. 877-844-8844
What is the max Benefit Limit for Home Health Care visits per fiscal year?
100 (per B360 & SSG)
Where would you locate a list of Non-covered codes for Virginia Medicaid?
The Non-Covered & Covered Codes Reimbursement Policy
Can there be changes for the members PCP?
May change PCP at any time. If member has not seen another PCP in the current month, the PCP change can be back dated to the first of the month. If member has seen another PCP in the current month, the PCP change would be effective the first of the following month.
For TN Medicaid plans how should advocates handle Out of Network Authorization requests?
A Prior Authorization request from a Primary Care Provider or Participating Physician for Out-of-Network request is not required for Members. All Out-of-Network requests must be reviewed. Do not redirect. Create Case regardless of requesting physician network status.
Who handles BH?
MH & BH are handled by the behavioral health carrier in the member's county. Please refer to the State's website for the county contact numbers:
What POS does NC not recognize?
02 &10 (found in the Procedure to Place of Service Reimbursement Policy)
What are the Chiropractic Benefits and restrictions for Virginia Medicaid?
6 Visits per calendar year to INN provider & Member must be 21 or older. (Per B360)
What is the National NPI callout for Florida?
National Provider Identification (NPI) number for both billing and rendering provider. This is the NPI enrolled (limited/fully) with Florida Medicaid. Taxonomy Code for both billing provider and rendering provider. This is the taxonomy code appropriate to the services provided and to your enrolled provider type and specialty. Address with ZIP+4 code This is the provider's street address and ZIP+4 code that’s enrolled with Florida Medicaid.
What are the steps in CSP Facets to locate a members TN Health Link Provider?
• In Facets CSP, select Transfer.
• Select Subscriber/Family.
• Select Open Customer.
• The Subscriber/Family tab will open.
• Select Member from the tabs at the top of the page.
• Select Health Status tab.
• Review the following fields:
• Code: TNHL
• Last: Effective date
• Next: Term date
• Comments: Current TIN and provider name
Are referrals required?
Referrals are not required for any Community Plan for this state.
Can OON providers start auths for NC Caid members?
Yes (Per SSG)
Where do we check to see if the Provider is registered with Virginia Medicaid?
We use the ClaimsEditReport and/or the Pending provider Spreadsheets on the C&S Projects- Home Sharepoint (per NPI/taxonomy Section of the Claim research Job Aid)
What is IHS? And meaning?
Indian Health Services/ Native American members can access care to tribal clinics and Indian hospitals and can be in or out of network.
If a Provider disagrees with the dates of attribution for a TN Health Link Provider what do we advise?
We should advise the provider to email bh_payment_reform@uhc.com
What counties does UHC manage?
UHC is in the Southeast counties of PA for Medicaid i. Bucks ii. Chester iii. Delaware iv. Montgomery v. Philadelphia.