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NC Department of Health and Human Services
NC Division of
Medical Assistance
 
 

Community Care of North Carolina/Carolina ACCESS

Darryl Frazier
Chief, CCNC-Managed Care
Phone Number, 919-855-4780
Fax. 919-715-5235

Community Care of North Carolina/Carolina ACCESS (CCNC/CA) is a managed primary care program which serves the majority of Medicaid beneficiaries in the state, as well as N.C. Health Choice (NCHC) beneficiaries between the ages of 6 through 18 years. The program aid category in which a person receives Medicaid determines if a beneficiary is mandatory, optional or exempted from CCNC/CA.

Under CCNC/CA, eligible beneficiaries join Medical Homes which coordinate a patient's healthcare services. Primary care services are managed through the medical home, and acess to specialty care is coordinated through the primary care physician. Each patient has access to a case manager to ensure individualized care (e.g., if prescribed medicine must be refrigerated the case manager can ensure the patient has a refrigerator). CCNC/CA also provides health education to its plan members and assists them in maximizing their own health care through self management.

In order to assist providers enrolled in Community Care of North Carolina/Carolina ACCESS (CCNC/CA) with managing and coordinating care for their Carolina ACCESS patients, DMA currently provides a Monthly Carolina ACCESS Enrollment Report.  The report is mailed to provider each month.  Primary care providers are strongly encouraged to review their report each month.

More information is available on the CCNC/CA website and DMA's History of Managed Care in North Carolina web page.


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Participation Requirements of Primary Care Providers (PCPs)

The PCP is key to the ability to achieve the goals of CCNC/CA. A medical provider who is interested in serving as a Carolina ACCESS PCP must complete an application for participation. The application will be reviewed by the Provider and Recipient Services Section at DMA who notifies the applicant if the application is approved or denied and the reason for the denial. If for any reason a candidate does not or cannot meet these criteria, an exceptions’ review will be done. An exception may be granted if it is determined that access to care for Medicaid beneficiaries would be impeded if all criteria are not met. Each request for an exception is evaluated on an individual basis. A candidate for participation must meet the criteria below:

  • Perform primary care that include certain preventative services;
  • The ability to create and maintain a patient/doctor relationship for the purpose of providing continuity of care;
  • Establish hours of operation for treating patients at least 30 hours per week;
  • Provide access to medical advice/services 24/7;
  • Maintain hospital admitting privileges or have a formal agreement with another doctor based on ages of the members accepted;
  • Refer or authorize services to other providers when the service cannot be provided by the PCP;
  • Use reports provided by the DMA managed care section as guides in maintaining the level of care that meets the goals of CCNC and patient needs. Reports are available via the web and paper copies that are mailed.

In order to serve as a PCP in a CCNC/CA network, the provider must first be enrolled with DMA as a Carolina ACCESS PCP. An interested provider may contact the regional managed care consultant for more information. The provider will be required to sign a contract with the local network.

Enrolling Medicaid and NCHC Patients in CCNC/CA

Remember: Patients have freedom of choice. They do not have to choose you as their medical home. If they prefer to choose another provider or do not want to enroll, refer them to their caseworker at the department of social services.

Check the Medicaid card. If the patient is enrolled with another provider, but wishes to join your practice, use an enrollment form to enroll them. Their enrollment will be changed to your practice. The effective date is determined by the date the change is made in the eligibility system.

Medicaid beneficiaries are enrolled in CCN/CA by the Department of Social Services (DSS) located in the county in which they reside. Enrollment can be done at anytime during the beneficiary’s eligibility period; however, it is required at application or review for continuation of eligibility. The program aid category of eligibility determines if a beneficiary is mandatory, optional, or ineligible for enrollment in CCNC.

MANDATORY OPTIONAL INELIGIBLE
AAF (Work First Family Assistance) HSF (Medicaid Non-Title  IVE Foster Care Children) MQB (Medicare Qualified Beneficiaries)
MAB (Aid to the Blind) IAS (Medicaid Title IVE Adoption Subsidy Foster Care Children) MRF (Medicaid for Refugees)
MAD (Aid to the Disabled) MPW (Medicaid for Pregnant Women) RRF (Refugee Assistance
MAF (Medicaid for Families and Children) MAA (Medicaid for the Aged – over 65 years of age) SAA (Special Assistance to the Aged)
MIC (Medicaid for Infants and Children)    
MSB (Special Assistance to the Blind)    
SAD (Special Assistance to the Disabled)    

Exceptions to the Mandatory Program Aid Categories:

  1. Any Medicaid beneficiary who receives Medicare in addition to Medicaid becomes optional for enrollment;
  2. Anyone under the age of 21 years and who is also identified as having special needs becomes optional for enrollment. Special needs is defined as:
    • A child receiving SSI;
    • A child in foster care or receiving adoption assistance;
    • Self-identified as having special needs
  3. Current or potential enrollees who are mandatory can request an exemption from participation for medical reasons. Beneficiaries can request exemption request forms from the county DSS. Each request is evaluated on an individual basis. Medical records may be requested to determine if an exemption will be approved.

Patient Referrals and Exemptions

Refering a Beneficiary for Specialized Services

In order to manage a patient’s health care and assure access to all necessary health care services, the PCP is contractually obligated to refer patients or authorize treatment for patients when unable to provide the necessary service. It is the domain of the PCP to refer/authorize treatment and define the scope. The PCP can authorize refer/authorize services by telephone or in writing. In referring or authorizing a service:

  • The PCP's authorization number must be communicated to the service provider;
  • The PCP defines the scope of a referral which includes the number of visits being authorized and the extent of the diagnostic evaluation;
  • The PCP should be informed if a secondary referral, sending patient to a second provider for the same diagnosis, should be made. The authorization number should accompany the secondary referral;
  • A provider who has received a referral should consult the  PCP before referring to a secondary provider for situations not related to the diagnosis of the first referral;
  • The PCP may authorize care retroactively; however, it is at the discretion of the PCP.

If a non-PCP provider has provided a service and is denied authorization by the PCP, the service provider may request an override. (Carolina ACCESS Override Request Form) To request an override the provider must contact the Medicaid fiscal agent. Contact information is provided on the form.

Services Exempt from Authorization by the PCP

Enrollees can receive the following services from any qualified provider who accepts Medicaid (subject to Medicaid coverage policies and limitations) without first obtaining authorization from their primary care physician:

  • Ambulance
  • Anesthesiology
  • At Risk Case Management
  • CAP Services
  • Certified Nurse Anesthetist
  • Child Care Coordination
  • Dental
  • Developmental Evaluation Centers
  • **Emergency Services provided in a hospital emergency department or a hospital owned urgent care center.
  • Eye Care Services (limited to CPT codes: 92002, 92004, 92012, 92014, and Diagnosis codes related to conjunctivitis: 370.3; 370.4; 372.0; 372.1; 372.2; 372.3)
  • Family Planning (Including Norplant)
  • Health Department Services
  • Hearing Aids (Under age 21)
  • Hospice
  • Independent & Hospital Lab Services
  • Maternity Care Coordination
  • Optical Supplies/Visual Aids
  • Pathology Services
  • Pharmacy
  • Psychiatric/Mental Health (Psychiatrists, Psychiatric Hospitals, Area Mental Health Programs, Psychiatric Facilities, and Inpatient & Outpatient services billed with a hospital provider number with a primary or secondary diagnosis of 290-319.)
  • Radiology (only includes services billed under a radiologist provider number)
  • Services Provided by Schools and Head Start Programs

**(Any provider who receives a referral from the ED for follow up treatment must receive authorization from the PCP)

See also the FAQ about patient referrals at the bottom of this page.

Women, Infant and Children (WIC) Supplemental Nutrition Program

Federal law mandates coordination between Medicaid managed care programs and the Women, Infants, Children (WIC) supplemental nutrition program.  CCNC/CA PCPs are required to refer potentially eligible enrollees to the WIC program. Copies of the WIC Exchange of Information Form for Women, the WIC Exchange of Information Form for Infants and Children and the Medical Record Release for WIC Referral Form can be found in the "CCNC/CA Forms" section below.

More information can be found on the Division of Public Health main WIC page and the WIC Provider Resource Page.  

County WIC programs are administered statewide through county health departments, community and rural health centers, and community action agencies. For more information, contact the N.C. Department of Health and Human Services (DHHS) Customer Service Center at 1-800-662-7030 (TTY: 1-877-452-2514). DHHS Customer Service Center staff will never ask callers for bank account or credit card information.

Beneficiary Education

When a person applies for Medicaid or when a Medicaid beneficiary is being reviewed for continuing eligibility, a county Department of Social Services (DSS) representative is responsible for providing information to the client about the Carolina ACCESS health plan and how they access care as members. Education includes:

  • Definition of the medical home concept and the benefits this offers for quality health care;
  • Medicaid covered services are not changed; however, CA provides accessibility to physician services, coordination of health care services,  enhanced services through case management/disease management;
  • Availability of medical advice/services 24/7 from the PCP;
  • Ability to choose a medical home and the frequency with which a medical home can be changed;
  • Necessity for contacting the medical home for an appointment to become an established patient;
  • No longer a need to use the Emergency Department for primary care;
  • Right to file a complaint against a PCP for situations of poor quality of care which may be caused by contractual violations, physical/sexual/ substance abuse, professional conduct, or program fraud/abuse if this is suspected.
  • Referrals for specialty services.
  • Importance of getting preventative services, i.e., well check ups, pap smears, mammography, diabetic screenings, etc.
  • Process for requesting an exemption from enrollment for medical reasons.
  • Information on services not requiring authorization by the PCP.

Always give your patient a Carolina ACCESS member handbook (PDF, 899 KB). This book can be your guide when explaining the benefits and requirements of being a member of Carolina ACCESS. You can order handbooks by contacting the Division of Medical Assistance, Managed Care Section, at 919-855-4780 or faxing a request to the Managed Care Section at 919-715-0844 or 919-715-5235.

Carolina ACCESS and NPI

Information on this topic can be found on the N.C. Division of Medical Assistance (DMA) NPI web page and on the bottom of this page under Frequently Asked Quesitons - Referral FAQs.

Seminars/Webinars

CCNC/CA Forms and Fact Sheets

Medicaid Bulletins

For changes and updates to coverage criteria, billing information, and other program requirements refer to the N.C. Medicaid general and special bulletins.

Key Program Contacts/Resources

  1. N.C. Division of Medical Assistance, Managed Care Section, phone number (919-855-4780). A toll free phone number is available for current or potential Medicaid beneficiaries. Calls are answered by a team of Customer Service Representatives. The number is 1-888-245-0179. When corresponding by mail to the managed care section, send correspondence to:

    Division of Medical Assistance
    Managed Care Section
    2501 Mail Service Center
    Raleigh, NC 27699-2501

    If you know the name of the person to whom you are trying to correspond, please put your letter to the attention of that person.

  2. Regional Managed Care Consultants (PDF, 46KB)
  3. Carolina ACCESS Monthly Dual Eligible Status Reports
  4. Carolina ACCESS Monthly Enrollment Reports
  5. Carolina ACCESS Monthly Exemption Report by County and Type
  6. Automated Voice Response (AVR) system (1-800-723-4337)
  7. Beneficiary Handbooks available in English and Spanish

 

Frequently Asked Questions (FAQs)

Primary Care Provider (PCP) Enrollment Frequently Asked Questions (FAQs)

Can I decide how many Carolina ACCESS (CA) patients we would like to enroll?

Yes. You can set an enrollment limit. The maximum allowed is 2000 enrollees per physician or physician extender.

How do I change my enrollment limit?

You may make changes to your enrollment limit or restrictions by completing a Manage Change Request through NCTracks. To access Manage Change Requets, go to the secure Provider Portal (which requires an NCID and password) and click on "Status and Mangement."

Carolina ACCESS (CA) Enrollee FAQs

How can I tell if a patient is enrolled with Carolina ACCESS?

Carolina ACCESS enrollment can be verified by:

  • Viewing the patient's current month's Medicaid Identification Card (MID)
  • Call the Automated Voice Inquiry System at 1-800-723-4337
  • Review your practice's current Carolina ACCESS Monthly Enrollment Report

What should I do if a patient does not bring their Medicaid Identification Card for appointment?

Providers have a few options to verify eligibility and CA enrollment when patients present without their Medicaid Card:

  • Call Automated Voice Inquiry System (1-800-723-4337)
  • Review your practice's current Carolina ACCESS Monthly Enrollment Report
  • Require the patient to sign a "Self Pay" agreement.

Can enrollees change primary care providers?

Yes. Carolina ACCESS enrollees may request a change by contacting their caseworker or the Medicaid supervisor at their county Department of Social Services (DSS). Under normal circumstances the change will take approximately 30 days. Changes are effective the first day of the month. Until the change is made by the DSS, your practice must either provide services or refer the enrollee to another PCP for service.

What should be done if a patient is enrolled with the wrong PCP?

Advise the patient to contact his caseworker or the Medicaid supervisor at the DSS to enroll with the correct PCP immediately. If the patient does not request the change in a timely manner, contact your regional Managed Care Consultant for assistance.

Referral FAQs

What if my Carolina ACCESS panel members need specialized health care services that my office cannot provide?

Primary Care Providers (PCPs) are responsible for referring Carolina ACCESS enrollees to specialists and other health services as needed. Medicaid will only pay for Medicaid covered services if the PCP authorizes treatment, except for the exempt services.

When authorizing treatment, the PCP must give the treating specialist or provider his NPI number. CA enrollees may be referred to any specialist who accepts Medicaid. Be sure to identify your patient as a CA enrollee when making the referral. In most situations, authorization should be given prior to services being rendered. However, authorization may be granted in other situations at the PCP's discretion.

Authorization for referrals may be given by telephone or in writing. It is recommended that PCP's store documentation on all CA referrals for internal tracking purposes and quality of care issues. This can be done in the patient's record or on a comprehensive referral log.

CA PCPs should specify the number of visits and length of time that an authorization is valid in order to eliminate unnecessary phone calls or misunderstandings. It is important for the PCP to be specific when authorizing care.

If PCPs identify discrepancies with the use of their NPIs by other health care proviers, they can contact their Regional Managed Care Consultant.

Does the doctor to whom we refer a patient have to be participating with Carolina ACCESS (CA)?

No. Carolina ACCESS does not have a network of specialists so you may refer your patients to any provider who accepts Medicaid.

What if we receive a request for a referral for a patient we have never seen before?

PCPs are contractually required to provide services or authorize another provider to treat the enrollee. PCPs should develop referral or authorization protocols and ensure that all office staff is knowledgeable of the process.  All referrals or authorizations must be documented in the enrollee’s medical record.  In the absence of a medical record, documentation should be made on the CA enrollment report.  A referral log can also be created by the PCP.

PCPs may, but are not required to, authorize specialty care for patients they have not seen. If your practice chooses not to authorize in this situation, refer the patient to his caseworker or the Medicaid supervisor or refer the specialist to the regional Managed Care Consultant for assistance. Your monthly enrollment report identifies new enrollees to your practice; you are strongly encouraged to make contact

Is PCP authorization required each time a Specialist sees a CA enrollee?

Unless the service you are providing is an exempt service, you must obtain authorization from the PCP. The length and scope of the authorization is at the discretion of the PCP.See section of this page titled "Patient Referrals and Exemptions" for more information.

Can referrals be made by telephone?

Yes. PCPs may make referrals by telephone or in writing. Carolina ACCESS does not dictate how the referral process takes place. However, it is important to obtain authorization to treat a CA enrollee prior to services being rendered.

What if a CA Enrollee 'self refers' to our office?

CA enrollees must get PCP authorization before seeing another doctor, unless the service is exempt from authorization. See section of this page titled "Patient Referrals and Exemptions" for more information.

If you have not received authorization from the PCP you may contact the PCP listed on the Medicaid Identification Card to see if authorization can be given. If they do not authorize the service you may refer the patient back to the PCP or treat the patient as a "Self Pay" patient.

Billing FAQs

Are CA enrollees responsible for co-payments?

All Medicaid co-payment rules apply to Carolina ACCESS enrollees.

What if the patient has a Third Party Insurance?

Medicaid will always be the payor of last resort. If the patient has private insurance this must be billed before billing Medicaid. If the patient states he/she has other insurance, you should contact the local Department of Social Services (DSS) or complete a DMA 2057 form. For additional information about third party insurance, refer to DMA's Third-Party Insurance page.

How should claims be filed when a PCP refers a CA Enrollee to our office?

When a PCP refers a CA enrollee to your office, you should be given the PCP's NPI authorization number. When filing your claim, you must put the referring PCP's NPI authorization number in block 17b of the CMS-1500 claim form. Clarify with the PCP what time or treatment limitations are placed on the authorization; e.g., good for the full course of treatment, good for one visit, etc. Since CA enrollees can change PCPs monthly, you must check the card each month to verify the PCP.

If my office has questions concerning claims who should we contact?

You should make contact with the Provider Service Section of Computer Services Corporation (CSC) at 1-800-688-6696. To check on the status of a claim, contact the Automated Voice Response System at 1-800-723-4337.

Emergency Department FAQs

Do CA Enrollees admitted through the Emergency Department require PCP authorization?

No. However, physician services provided following admission from the Emergency Department billed on the CMS-1500 will require authorization from the CA enrollee's PCP listed on the current month's Medicaid card.

Is the Emergency Department required to obtain referral authorization from the PCP listed on the Medicaid Identification Card?

No. Services provided in the Emergency Department do not require authorization by the member's CA PCP.

Other FAQs

Do all Medicaid covered services require authorization?

No. There are some services that do not require the primary care provider's authorization.

What is NCHC Insurance?

NCHC is a state and federally funded health insurance for children under the age of 19 whose family cannot afford private insurance and who do not qualify for Medicaid. NCHC is administered by the North Carolina State Health Plan.

Who do I contact for additional questions or information?

Contact your Regional Managed Care Consultant (PDF, 47 KB).

If you are unable to reach the consultant, you may contact the state Managed Care office at 919-855-4780.

 

 

 

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