Providers participating in the North Carolina Medicaid program are reminded of their responsibility to complete regular credit balance audits and submit required Credit Balance Reports. These reports help ensure that any overpayments or improper payments owed back to Medicaid are identified and resolved promptly.
Recent Posts
Billing in today’s healthcare environment is rarely straightforward. For many practices participating in NC Medicaid, even well-designed workflows can be disrupted by claim issues, coding updates, and evolving requirements. These challenges not only affect revenue—they also create administrative burden and frustration for care teams already operating at capacity.
Hospital readmissions remain a persistent challenge for health systems and primary care practices alike. While the policy drivers behind readmission reduction are well known, translating those expectations into day-to-day clinical workflows is where the real work begins. For many practices, implementation is less about a single intervention and more about building a coordinated, sustainable approach across the care continuum.
We previously shared important updates regarding the Wellcare and Carolina Complete Health (CCH) merger, including an initial effective date of April 1, 2026. That timeline has now changed.
New Effective Date and Key Change
Effective June 4, 2026, Carolina Complete Health, Trillium Physical Health, and Partners Physical Health have transitioned from claims denials to upfront rejections for certain billing and credentialing issues.
This change means claims with errors will now be rejected before processing rather than denied after submission. Providers will need to correct and resubmit any rejected claims.
What Providers Should Do
To reduce the risk of claim rejections, providers should review their billing and credentialing practices carefully. It is essential to confirm that all information in NCTracks is accurate and up to date, including NPI, taxonomy, service location, and enrollment details. Mismatched or outdated information may result in rejected or denied claims.
Providers should also ensure that NPI and taxonomy codes are placed in the correct fields on all claims and align with the Carolina Complete Health Provider Billing Manual (pages 48 through 74). When services are rendered at a location different from the billing address listed in field 33, boxes 32, 32a, and 32b must be completed as outlined on page 58 of the manual.
Common Reasons for Rejections
Most upfront rejections are related to NPI status, taxonomy alignment, or missing provider information. Common issues include inactive or unrecognized NPIs, missing or invalid taxonomy codes, and discrepancies between credentialing records and submitted claims.
Errors may involve multiple provider roles, including attending, billing, rendering, referring, supervising, and service facility providers. Rejections can also occur when required provider information is missing, not active for the date of service, or not properly linked within NCTracks.
In some cases, claims may be rejected when a rendering provider is required but not submitted for certain billing taxonomies, or when supervising or service facility provider information is incomplete or not found on file.
Why This Matters
Because claims are now rejected before processing, providers may experience delays in reimbursement if errors are not addressed promptly. This shift increases the importance of accurate credentialing data and correct claim submission.
Taking time now to verify NCTracks information and billing practices can help minimize disruptions and reduce administrative burden.
Key Takeaways
- New effective date: June 4, 2026
- Claims are now rejected upfront instead of denied later
- Most issues involve NPI or taxonomy mismatches
- Providers should review and update NCTracks and billing practices
For background information, review our earlier post: Important Updates on the Wellcare and Carolina Complete Health Merger .
NC Medicaid’s May 2026 Back Porch Chat highlighted several updates that affect providers across the state, including new data tools, pharmacy benefit changes, and updates to care management programs. These sessions are designed to keep providers informed about program changes and resources that support care delivery.
Below is a summary of key updates and what they mean for your practice.
New TBI Dashboard Improves Access to Data
NC Medicaid introduced a new Traumatic Brain Injury (TBI) dashboard that provides a centralized, publicly accessible view of service use across the state.
| What this means for providers: The new TBI dashboard gives providers and partners clearer visibility into service use, helping support data-driven planning, advocacy, and care coordination. |
The dashboard was developed in response to the need for more transparent and actionable data. It allows users to better understand who is accessing TBI services, what types of services are most commonly used, and how frequently those services are delivered.
This tool is intended to support a wide range of stakeholders, including providers, policymakers, advocates, and individuals with TBI and their caregivers. By making this information more accessible, the dashboard can help inform program planning and guide decisions about resource allocation across North Carolina.
New Pharmacy Benefit Administrator Transition Now in Place
NC Medicaid also shared updates about the transition to a new Pharmacy Benefit Administrator (PBA). Prime Therapeutics began serving in this role on May 2, 2026, and now processes all Medicaid Direct pharmacy point-of-sale claims.
| Key takeaway: While the claims processing system has changed, clinical policies and reimbursement remain under state control, and managed care pharmacy processes are not affected. |
For providers, the transition is intended to simplify pharmacy-related processes while improving transparency and consistency in how pharmacy benefits are managed. Importantly, the state retains authority over clinical policies and reimbursement methodologies, which means core program rules remain unchanged.
Providers working with Medicaid Direct should be aware that pharmacy prior authorizations are now handled through Prime Therapeutics. However, there are no changes to pharmacy processes within Medicaid Managed Care plans, and providers should continue to follow their existing workflows for those patients.
Care Management Programs Extended Through 2026
NC Medicaid announced an extension for two longstanding care management programs: Care Management for At-Risk Children (CMARC) and Care Management for High-Risk Pregnancies (CMHRP). These programs support vulnerable populations including young children and pregnant individuals at higher risk for complications.
| Important update: Local Health Departments can continue providing CMARC and CMHRP services through December 31, 2026, ensuring continuity of care during ongoing program transitions. |
Local Health Departments will continue to provide these services through December 31, 2026, extending the current arrangement by six months beyond the previously planned transition date. Existing payment structures and technology support will remain in place during this period.
Additional guidance is expected regarding how care management for these populations will be structured beginning in 2027, so providers should watch for future updates.
New Quality Measures Dashboard Supports Performance Improvement
NC Medicaid is also advancing efforts to make quality data more accessible through a new public-facing Quality Measures Dashboard. This tool is designed to help providers and stakeholders better understand performance across the Medicaid program.
| Why this matters: Providers can use the dashboard to compare performance, identify gaps, and support quality improvement efforts across patient populations. |
The dashboard allows users to view and compare quality measures across managed care plans and explore results by demographic and geographic factors. By making this information easier to access and interpret, NC Medicaid aims to support continuous quality improvement and help identify opportunities to improve patient outcomes.
The measures included focus on key areas such as preventive care, chronic disease management, and follow-up after hospitalization, reflecting priorities that align closely with primary care and population health efforts.
Why These Updates Matter for Providers
Taken together, these updates reflect a continued focus on transparency, data-driven decision-making, and coordinated care. New dashboards provide greater visibility into both service use and quality outcomes, while program updates aim to reduce disruption and maintain continuity of care for vulnerable populations.
For providers, these changes offer new tools to support clinical decision-making and population health management, while also reinforcing the importance of staying current with evolving Medicaid processes and requirements.
Learn More
To explore these updates in more detail and access related training materials, visit the NC Medicaid Provider Playbook:
Provider Playbook Training Courses – Second Quarter 2026 Meeting (May 21, 2026)
The transition from training to independent clinical practice is a critical period for advanced practice providers (APPs), particularly those entering primary care settings. To help support this transition, the North Carolina AHEC Program is launching a new fellowship focused on early‑career APPs working in community‑based practices.
This fellowship is designed for recent graduates entering primary care roles in settings that are not system‑owned, including independent practices, federally qualified health centers (FQHCs), rural health centers, and local health departments. These settings often face workforce challenges and may have fewer structured supports for onboarding new clinicians. This program aims to help bridge that gap.
The fellowship uses a primarily virtual format, with structured learning sessions held every other week. These sessions include didactics and case‑based discussions intended to reinforce core primary care knowledge and support clinical decision‑making. Participants will also engage in two in‑person learning experiences during the year to reinforce skills and build professional connections.
Curriculum topics include complex care management, core primary care content, and updates to current clinical guidelines. Additional focus areas include professional identity development, peer networking, and hands‑on skill building during in‑person sessions. The program is led by experienced faculty clinicians from multiple disciplines.
The fellowship is open to APPs early in their primary care careers who are working in, or planning to work in, community‑based settings. A letter of support from the participant’s practice is required, reflecting the program’s emphasis on integrating learning into real‑world practice environments.
This initiative reflects a broader effort across the NC AHEC system to strengthen the primary care workforce by supporting clinicians at key transition points. By equipping new APPs with additional resources, mentorship, and structured learning, the program seeks to enhance both clinician confidence and quality of care in community settings.
Practices that employ or are recruiting new APPs may find this fellowship to be a valuable support for onboarding and retention. Sharing this opportunity with eligible clinicians can help strengthen care teams and improve continuity of care for patients.
Learn more and apply:
APP Fellowship application
For questions, contact: APP_Fellowship@NCAHEC.net
As measles cases continue to rise across North Carolina and the surrounding region, it’s important for practice staff and managers to be equipped with clear, up‑to‑date information. This guidance combines essential material from the Measles Patient FAQ (Jan. 15, 2026) and reporting from North Carolina Health News, tailored specifically for frontline teams and leaders working to maintain high‑quality, safe clinical environments.
We encourage all practices to review the details below and share them with their teams.
What Is Measles?
Measles is a highly contagious viral illness that spreads quickly in unvaccinated populations. Early symptoms include:
- High fever (often >104°F)
- Cough
- Runny nose
- Red or watery eyes
- A rash starting on the face, spreading downward
- Small white mouth spots (Koplik’s spots) [Debrief Re...Ethics_v2 | PowerPoint]
Measles can cause severe complications—especially among children, older adults, and immunocompromised patients—making early identification essential in clinical settings.
How It Spreads — and Why Practices Should Stay Alert
The measles virus can remain airborne for up to two hours after an infected person leaves the area. Approximately 90% of unvaccinated individuals exposed will become infected. [Debrief Re...Ethics_v2 | PowerPoint]
Given this high infectivity, even a brief clinic exposure may require rapid response and coordinated communication with public health partners.
Why North Carolina Is Seeing More Cases
Recent reporting from North Carolina Health News highlights a continued rise in statewide measles cases, many linked to the ongoing outbreak in Spartanburg County, SC. Key takeaways include:
- Cases in NC have increased since December, primarily among unvaccinated children.
- Early symptoms may not be recognized immediately, allowing unintentional spread.
- The two‑dose MMR vaccine remains the most reliable prevention tool. [northcarol...thnews.org]
For practice leaders, this underscores the importance of reinforcing vaccination outreach, screening protocols, and rapid response workflows.
MMR Vaccination Guidance for Patients
Vaccination remains the strongest protection.
Standard schedule
- First dose: 12–15 months
- Second dose: 4–6 years [Debrief Re...Ethics_v2 | PowerPoint]
Adult considerations
Most adults with two documented doses do not need a booster; those uncertain should speak with their provider. Immunity testing is not recommended for those with two recorded doses. [Debrief Re...Ethics_v2 | PowerPoint]
In outbreak areas
Providers may consider early second doses or early infant vaccination (6–12 months), depending on risk. [Measles Patient FAQ | PDF]
Exposure Guidance to Share with Patients
Your local health department determines what meets the criteria for exposure.
If vaccinated (2 doses) or born before 1957:
- No post‑exposure treatment
- No work restrictions
- Monitor for symptoms days 5–21
- Call the clinic or health department if symptoms appear [Debrief Re...Ethics_v2 | PowerPoint]
If unvaccinated, unsure, or immunocompromised:
- May require prophylaxis
- Stay home days 5–21 after exposure
- Contact healthcare provider promptly with any symptoms [Debrief Re...Ethics_v2 | PowerPoint]
Guidance for Managing Pediatric Populations
When coaching your teams, emphasize:
- Infants 0–6 months: Avoid exposure entirely
- Infants 6–12 months: Discuss early MMR dose when appropriate
- Children with one dose: Consider early second dose during outbreaks
- Unvaccinated children: Begin the MMR series immediately [Measles Patient FAQ | PDF]
If measles is suspected, have families call before arrival so your clinic can prepare isolation precautions. [Measles Patient FAQ | PDF]
Testing, Treatment & Clinical Considerations
There is no antiviral treatment for measles. Vitamin A may be used in treatment after infection but does not prevent illness. Only the MMR vaccine prevents disease. [wunc.org]
Practices should reinforce workflows for:
- Prompt masking and isolation
- Airborne precautions where possible
- Immediate notification of Infection Prevention or public health partners
- Reviewing room‑closure procedures for airborne pathogens
Recommended Webinar for Staff Education
To support your quality improvement efforts, we encourage you and your teams to watch this short webinar on measles preparedness:
👉 Webinar: Measles Overview & Preparedness Strategies
Include this resource in your next staff meeting or circulate it through internal communication channels.
Final Notes for Practice Leaders
As your AHEC Practice Support team, we encourage practices to:
- Review vaccination outreach strategies for gaps
- Reassess triage and front‑desk screening workflows
- Reinforce airborne isolation procedures
- Ensure your team understands exposure timelines and reporting expectations
- Share this blog post with all team members, including supervisors and clinical staff
Measles remains highly preventable, and strong practice‑level systems make a meaningful difference in patient and community safety.
If you’d like help conducting a workflow assessment, staff training, or readiness review, your NC AHEC Practice Support coach is here to help.
Effective July 1, 2026, Trillium Health Resources, a leading specialty care manager (LME/MCO) for individuals with serious behavioral health, intellectual/developmental disabilities, and traumatic brain injury in North Carolina, will implement a major enhancement to streamline operations for providers across its Tailored Plan. The organization is transitioning to a unified claims system, designed to simplify processes and improve efficiency for all stakeholders.
Under this new approach, all providers—including those delivering behavioral health, physical health, and long-term services and supports (LTSS)—will submit claims through a single, centralized portal. This change eliminates the need for multiple systems, reducing administrative burden and creating a more seamless experience for providers.
Why This Change Matters
Moving to a unified claims system ensures:
- Consistency in claims processing across all service types.
- Reduced administrative complexity for providers.
- Improved transparency and faster resolution of claims issues.
Provider Support Resources
Trillium offers comprehensive tools and contact points to assist providers during this transition:
- Provider Portals
Access claims submission, eligibility verification, and authorization tools through the secure provider portal. - Contact Directory
Find dedicated phone numbers and email addresses for provider relations, claims assistance, and technical support in the contact directory. - Training & Guidance
Explore manuals, FAQs, and step-by-step instructions for portal navigation and claims processes via training and guidance section. - Specialized Support
Separate contact options for behavioral health, physical health, and LTSS services ensure tailored assistance. Details are available on the contact and information portal.
Actionable Tips for Providers
- Review Current Processes – Identify workflows impacted by the new portal.
- Train Your Staff – Use Trillium’s guides and recorded webinars.
- Set Up Portal Access Early – Complete registration as soon as instructions are released.
- Update Compliance Documentation – Align policies with new requirements.
- Stay Connected – Subscribe to provider bulletins and attend office hours.
Next Steps for Providers
- Mark Your Calendar: The unified claims system goes live on July 1, 2026.
- Attend Training: Watch for announcements about upcoming webinars and office hours.
- Stay Informed: Review provider bulletins and subscribe to Trillium updates.
ACCESS Model: What You Need to Know
Last week, CMS launched important information about the Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model, and we want to make sure your practice is ready to take advantage of this opportunity.
Key Highlights
- Launch Date: July 1, 2026
- Duration: 10-year voluntary program within Original Medicare
- Goal: Improve care for conditions that affect millions of beneficiaries through innovative, scalable solutions.
Four Clinical Tracks
The ACCESS Model focuses on:
- Early Cardio-Kidney-Metabolic (CKM) Conditions
Hypertension, high cholesterol, obesity, and prediabetes. - Established CKM Disease
Diabetes, chronic kidney disease, and heart disease. - Musculoskeletal Chronic Pain
- Behavioral Health
Depression and anxiety.
Flexibility for Your Practice
Here’s the good news: You can participate in just one component. For example, if your team is ready to start with reporting depression and anxiety measures, that’s an option. This flexibility makes it easier for practices to engage without overhauling all workflows at once.
Why This Matters
- Better Outcomes: Supports proactive, coordinated care for chronic conditions.
- Practice Growth: Positions your team as a leader in value-based care.
- Patient Engagement: Helps address behavioral health needs alongside physical health.
Next Steps
- Learn More: Review CMS details here
- Assess Readiness: Identify which track aligns best with your patient population.
- Plan Ahead: Start conversations with your team about workflows for reporting measures.
Guidance for Practice Managers on Navigating the 2026 Network Transition
Practice managers should be fully prepared for the substantial changes coming to the North Carolina State Health Plan (NCSHP) network in 2026. The Plan is facing a $507 million deficit, prompting a thorough evaluation of existing programs and reimbursement models. Sincere gratitude is extended to all organizations that have supported both the Plan and its members during these times. This post outlines what’s changing, why, and what practical steps your practice may need to take.
Clear Pricing Project (CPP) Ending December 2025
The Clear Pricing Project (CPP), launched in 2020, promoted transparent healthcare pricing and aimed to incentivize quality primary and behavioral health care by offering zero copays to members who visited participating providers. While this model brought increased reimbursement rates for many providers, it has not been financially sustainable. As a result, CPP will conclude on December 31, 2025. After that point, providers will no longer receive current elevated reimbursement rates, and members will not have a $0 copay structure for behavioral health services.
Preferred Providers: New Structure in 2026
Effective in 2026, the State Health Plan will roll out the Preferred Provider initiative. The only way for practices to become Preferred Providers will be through affiliation with CCPN (Community Care Physician Network), Aledade, or The Alliance. Practices outside these partnerships will still be considered in-network, but cost shares for members will be different—typically higher than those for Preferred Providers.
Key Action: Review your current affiliations and consider whether joining CCPN, Aledade, or The Alliance is right for your practice. Preferred Providers will grant patients access to lower copays starting in 2026.
Behavioral Health Access Program (BHAP)
To continue supporting behavioral health, the Plan is launching the Behavioral Health Access Program (BHAP) in 2026. This program creates a custom fee schedule for behavioral health providers, specialties, and a specific set of CPT codes:
- 140% of current NC Medicare rates (updated annually, effective May 1) for key codes: psychotherapy, evaluation & management, psychological testing
- ABA services reimbursed at NC Medicaid rates
- TMS codes reimbursed at Aetna Market Fee Schedule (AMFS) rates (same as current CPP)
Action for Behavioral Health Practices: If interested in joining BHAP, visit the Aetna website for enrollment details and next steps.
Working with Aetna: Network Participation & Resources
Aetna will serve as the third-party administrator for the Plan starting January 2026. Practices must be part of Aetna’s Choice POS II network to remain in-network for State Health Plan patients. If not already participating, please visit the Aetna website to begin the enrollment process.
Additional Resources for Practice Managers:
- 2025 NCSHP Network Participation Agreement (Aetna)
- 2025 NCSHP Network Rate Schedule (Aetna)
- 2025 NCSHP Network Professional Fee Schedule (Aetna)
- Aetna Provider Website
- Signup for Aetna emails
- OfficeLinks Updates Newsletters
- Aetna Provider State Health Plan site
- Aetna Resources
For contract, reimbursement, or benefits questions, contact Aetna Provider Line at 888-632-3862. For clinical or precertification information, refer to Aetna’s clinical information and prior review resources. Email NorthCarolinaNetwork@aetna.com for network queries, or SHPProviderNetwork@nctreasurer.com for State Health Plan questions.
What Practice Managers Should Do Now
- Evaluate providers’ current affiliations and consider joining CCPN, Aledade, or The Alliance for Preferred Provider status.
- For behavioral health, review the BHAP program and assess if it matches the needs of your practice.
- Ensure participation in Aetna’s Choice POS II network before January 2026 to maintain in-network status.
- Stay updated on policy changes, copay and reimbursement structures, and communicate these changes to your team and patients.
