Several health insurance companies in North Carolina have recently implemented programs to review claims and codes that results in the down coding of Level 4 and Level 5 Evaluation and Management (E/M) claims.

According to the North Carolina Medical Society, Aetna's process does not target all Level 4 and 5 codes, nor does it include all providers within the state. However, there remains confusion about why the insurer has implemented this program. Cigna's approach is broader and applies to all physicians and to six E/M codes: 99204-99205 (new patient), 99214-99215 (established patient), and 99244-99245 (consult for new & established patients). Cigna will implement this review nationally on October 1, 2025.  

Along with the North Carolina Medical Society, many professional societies across the country are also alerting their members to this issue. 

It is critical to follow the appropriate appeals process for any claims you believe to be inappropriately down coded! 

From CMS Quality Payment Program Newsletter:

As previously announced (QPP listserv sent 7/25/2025), there was a delay with receiving some of the final Medicare claims data needed to calculate cost measures, which is delaying the release of MIPS final scores for the 2024 performance year and the Targeted Review period.

• We’re currently targeting mid-September for releasing 2024 MIPS final scores and opening the Targeted Review period.

MIPS payment adjustments for the 2026 MIPS payment year will be released approximately one month after the release of final scores. The Targeted Review period will close 30 days after the release of MIPS payment adjustments. From now until mid-September, you’ll continue to be able to access measure and activity-level scores for the data you reported during the submission period. However, performance period benchmarks are part of final scoring and won’t be available until final scores are released. In the meantime, we encourage you to confirm your MIPS eligibility and review the following scoring resources so that you’re prepared to understand your scores when they’re released. To confirm your eligibility for a MIPS payment adjustment, enter your National Provider Identifier (NPI) on the QPP Participation Status Look Up tool (check “PY 2024”) or sign into the QPP website and navigate to the Eligibility & Reporting page on the left hand navigation. Review pages 12 – 16 of the 2024 MIPS Eligibility and Participation Guide (PDF) for more information about what you see.

Review these scoring resources:

• 2024 Traditional MIPS Scoring Guide (ZIP, 6MB)
• 2024 APP Scoring Guide, included in the 2024 APP Toolkit (ZIP, 2MB)
• 2024 MVPs Implementation Guide (PDF, 1MB)

August 31 is recognized each year as Overdose Awareness Day, to share knowledge necessary to end overdose deaths and to remember those who have passed from overdoses.

WEBINAR

Medicaid Managed Care

NC Medicaid Quality Measurement & Benchmarking

Tuesday, September16|noon-1p.m.

Please join us on September 16 at noon for a webinar on NC Medicaid Quality Measurement and Benchmarking which will include the following:

• Introduction to NC Medicaid's quality measurement strategy and the Advanced Medical Home (AMH) measure set.
  
• Summary of annual update process for the AMH measure set & review of changes to MY2026 AMH set.
  
• Update to NC Medicaid's benchmarking approach for quality measures. We will walk through the Gap-to-Goal and Beat the Trend methodologies and how they apply to the AMH measure set.

Register by clicking on the blue button below.

WEBINAR

Virtual Office Hours

STAY IN THE KNOW: Key NC Medicaid Updates for Provider Office Staff

Thursday, September 4 | noon - 1 p.m.

Please join us on Thursday, September 4 from noon-1 p.m. for an informative Virtual Office Hours webinar to get updates and hear the latest statuses on hot program topics that are impactful to the provider community! Get the insights and resources you need to navigate upcoming developments with NC Medicaid. 

Webinar topics will include:

• EPSDT: Pay and Chase
• Carolina ACCESS Enrollment Refresher
• Maintaining Eligibility Program
• Children and Family Specialty Program – Provider Contracting
• Credentialing Committee Updates
• Avoid Common Enrollment Application Issues Cont’d
• Key Resource: NC Medicaid Provider Ombudsman

Register by clicking the blue button below. We look forward to connecting with you!

In the face of rising pediatric mental health needs, Novant Health Twin City Pediatrics found itself at a crossroads. As adolescent mental health concerns such as depression and anxiety became more prevalent, clinicians found themselves increasingly fielding complex and time-consuming questions. These mild to moderate conditions required consistent follow-up and oversight, yet the surge in demand for mental health services made it difficult for patients to access timely care, particularly from providers who accepted their insurance. Many adolescents went without necessary treatment. 

Thanks to a powerful partnership with Northwest AHEC and the guidance of Lara Dickerson, MHA, Senior Quality Improvement Specialist, the practice chose a different path—one of innovation, collaboration, and compassion.

Adair Stewart, Dr. Elizabeth Allen, Dr. Gretchen Hoyle, Lara Dickerson, Jennifer Cleland Green, Lauren Stokes

The Challenge

Primary care pediatricians face a dilemma. Mental health visits are longer, emotionally taxing, and historically under-reimbursed. Yet the need is undeniable. Twin City Pediatrics chose to lean in—embracing the challenge rather than deflecting it.

The question became: Can mental health care in pediatrics be both impactful and financially viable? The answer, it turns out, is yes.

The Solution: Collaborative Care Model (CoCM)

With coaching from Lara Dickerson and guidance from AHEC Practice Support Services, Twin City Pediatrics implemented the Collaborative Care Model (CoCM).  A practice which emphasizes collaboration between primary care physicians, care managers, and psychiatric consultants to improve access, outcomes, and patient satisfaction within the pediatric medical home. 

Key components of the model include:

• A Behavioral Health Care Manager (BHCM) providing core services like parent coaching, brief therapeutic interventions, and referral coordination.
• A Psychiatric Consultant offering oversight and subspecialty advice..
• A Primary Care Provider trained in pediatric physical health.
• Validated clinical tools (PHQ-9, GAD-7, Vanderbilt, etc.) for measurement-based care.
• Customized EHR workflows and a patient registry to track progress and enable billing for behavioral health services within the primary care practice.

Practice Support Team Impact

The journey began with a conversation at the 2023 NC Pediatric Society Meeting, leading to a partnership with Northwest AHEC. Practice coach Lara Dickerson became a key ally, meeting monthly with the team for two years. Her support included:

• Coordinated with internal Novant departments (HR, billing, IT, compliance).
• Billing guidance and documentation templates.
• Consultation with NC Medicaid on psychiatric consultant roles.
• Staff training modules.
• Troubleshooting billing issues.
• Setting BHCM workload benchmarks.
• Secured a $50,000 Capacity Building Fund grant from Community Care of NC to support BHCM staffing.

Thanks to this comprehensive support, the program not only launched - it thrived.

The Results

By June 2025, the program became revenue-positive, six months ahead of schedule. With monthly BHCM costs of $5,400 and over $13,000 billed in June alone, the practice expects $6,500 in revenue—exceeding expenses by more than $1,100 per month. Today, the program includes a growing number of enrolled patients - many with complex needs - and is delivering tangible improvements in the lives of children and their families.

“The Psychiatric Collaborative Care Model has empowered our practice to provide meaningful, evidence-based mental health care for our pediatric patients. Our success is replicable, sustainable, and deeply impactful.”
— Gretchen S. Hoyle, MD - Twin City Pediatrics

“It was amazing to see how this model enables primary care practices to spend adequate time with each patient on physical and mental health concerns, developing treatment plans collaboratively with specialists and making a significant difference for kids in our community.”
— Christopher Jones, DrPH, MHA - Northwest AHEC

From Patients & Families

“I’m so glad he’s finally going to get the help he needs.”
“I’ve felt so alone for so long. Having someone to talk to means everything.”
“She is so much better. I can’t thank you enough.”

Read the full Report from Twin City Pediatrics & Gretchen S. Hoyle, MD

Did you know?

The North Carolina AHEC Practice Support Program is an approved provider of the North Carolina Maintenance of Certification (NC MOC) program.

Through this approval, physicians and physician assistants who work with a Practice Support coach to improve care for patients will meet the requirements of their specialty boards to maintain certification in their specialty (Family Medicine, Internal Medicine and Pediatrics).

To Qualify:

1.  Contact your coach
2. Enroll in a clinical improvement activity with NC AHEC Practice Support (The coach will work with you and your team to align your efforts to satisfy other requirements like MIPS, Medicaid PHP quality incentives).
3. Complete the requirements
4. Complete the attestation form (your coach will help) and submit it
5. Once the coach gives word that your credit was approved, confirm the status with your accrediting body

Learn more about this benefit from North Carolina AHEC here.

Download our flyer here.

From NC Medicaid:

Children & Families Specialty Plan

The Primary Care Provider (PCP) contracting deadline for Beneficiary Choice Period is September 1, 2025.

The Children and Families Specialty Plan (CFSP) is a single, statewide NC Medicaid Managed Care health plan designed to support children, youth and young adults currently and formerly served by the child welfare system. Sept. 1, 2025, is the last day for PCPs to have fully executed contracts with the CFSP for inclusion at the start of the Beneficiary Choice Period.  Go Live Date is 12/1/25. 

Providers who wish to participate in CFSP should contact Health Blue Care Together to discuss the contracting process and requirements.

For inquiries, please use the following contacts:

Email:

• Contracting Inquiries: NC_Contracting@healthybluenc.com
• General Questions and Comments: NC_Provider@healthybluenc.com

Phone:

1-844-594-5072

For more details on the CFSP, including eligibility, covered services and updates, please visit our Children and Families Specialty Plan website. You can also find more information by reviewing the What Providers Need to Know fact sheet.

From 2000-2023, more than 41,500 North Carolinians lost their lives to a drug overdose. Each day in 2023, 12 North Carolinians died from a drug overdose. Recent year death data is not yet final, but an estimated 3,025 North Carolinians (8 per day) are suspected to have died from an overdose in 2024.

Overdose does not discriminate.

One important way you can help is to have Naloxone on hand, ensure it is available to your patients and their families, and educate yourself, your staff, and people you care about, how Naloxone saves lives.

A person with a substance use disorder cannot begin recovery if they are not alive!

Who should have Naloxone on hand?

In 2018, United States Surgeon General, Dr. Jerome Adams, issued a public health advisory emphasizing the importance of naloxone in savings lives. In this advisory, he recommended the following groups of people carry naloxone and know how to use it:

• Individuals taking high doses of opioids as prescribed for the management of chronic pain
• Individuals taking prescription opioids concurrently with alcohol or sedating medications (i.e. benzodiazepines)
• Individuals misusing prescription opioids or using illicit opioids such as heroin
• Individuals with a history of opioid use disorder
• Individuals completing opioid detoxification
• Individuals recently discharged from emergency medical care following an opioid overdose
• Individuals recently released from incarceration with a history of opioid use disorder
• Family and friends of people who have opioid use disorder
• Community members who come into contact with people at risk for opioid overdose

Learn more here:

Responding to an Opioid Overdose

Source: https://naloxonesaves-nc.org/safer-use-and-overdose-prevention/what-is-naloxone/

https://naloxonesaves-nc.org/

Date: August 26, 2025

Time: 12:00 - 1 p.m.

The Statewide Health Information Exchange Act was passed in 2015 by the North Carolina General Assembly.  This legislation paved the way for a statewide health information exchange (HIE), now known as NC HealthConnex.

NC HealthConnex is a valuable tool to support care improvement efforts.  In the context of value-based care, providers need access to timely, accurate clinical data to track outcomes and coordinate care effectively.  By its very definition, value-based care requires visibility into a patient's full journey across the care continuum.

Real-time, reliable clinical data is a critical tool for delivering appropriate care and closing information gaps. NC HealthConnex supports this by offering services that allow providers to:

• Query patients,

• Receive Admission, Discharge and Transfer notifications, and

• Send encrypted messages to other providers involved in a patient’s care.

NC Medicaid’s transition to NC Medicaid Managed Care, the launch of Tailored Care Management, and Medicaid Expansion make NC HealthConnex services an increasingly valuable follow-up tool for providers. The North Carolina Health Information Exchange Authority (NC HIEA), the state  agency that oversees NC HealthConnex, and NC Medicaid have built a strong partnership, collaborating through NC Medicaid Managed Care launch and the COVID-19 pandemic. Today, they are working together on a series of use cases that leverage NC HealthConnex to support NC Medicaid’s quality and population health goals.

In this session, speakers will explain how NC HealthConnex works, review available services, and provide a live demonstration of the NC HealthConnex Clinical Portal. They will also highlight current innovations stemming from the collaboration between NC Medicaid and the NC HIEA. Attendees will leave with an understanding of how NC HealthConnex and its services can serve as valuable tools to support high-quality, coordinated patient care.