NC Managed Care Provider Updates and PHP Interest and Penalties for Provider Claims

Prepaid Health Plan Interest and Penalties for Provider Claims

In accordance with Section V. H.1.d of the NC PHP Contract, prepaid health plans (PHPs) are required to pay interest and penalties to providers if the PHP fails to accurately pay or inappropriately denies a clean claim within 30 calendar days of receipt of medical claims or within 14 calendar days of receipt for pharmacy claims.

• This includes incorrect denials, and under- or partial-payments that are identified and paid on reprocessed claims.

• It is the PHP’s responsibility to issue interest and penalty payments to providers when applicable.

A clean claim is a claim for services submitted to a PHP by an NC Medicaid Managed Care medical or pharmacy service provider which can be processed without obtaining additional information from the submitter in order to adjudicate the claim.

If the PHP fails to implement fee schedule changes and reprocess impacted claims with the correct rates within 45 calendar days of notification of a fee schedule change from NC Medicaid, the PHP must pay interest and penalties on the adjusted amount.

For more information, please see Medicaid bulletin Prepaid Health Plan Interest and Penalties for Provider Claims.

NC Medicaid Managed Care Provider Update

NC Medicaid Managed Care has released a new bulletin with several provider updates. Topics include:

• Key dates
• Playbook updates
• Prior authorization
• Frequently asked questions
• Contracting
• Provider ombudsman
• Webinars
• NC’s Provider Directory – Medicaid and NC Health Choice Provider and Health Plan Look-Up Tool
• Health plan office hours for providers
• PHP quick reference guides
• NC Medicaid help center

The bulletin article is available at https://medicaid.ncdhhs.gov/blog/2021/09/15/nc-medicaid-managed-care-provider-update-sept-15-2021.