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 Mismatched or outdated information may result in rejected or denied claims.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.

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.

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.

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.

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)

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.

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.

UnitedHealthcare’s New Remote Monitoring Policy

UnitedHealthcare (UHC), one of the nation’s largest health insurers, has announced an updated policy change regarding coverage for remote patient monitoring services. As of the latest update, UHC will end coverage for most remote patient monitoring (RPM) when it is determined to be “unproven and not medically necessary,” specifically targeting standard cases of Type 2 diabetes and hypertension. This decision has broad implications for healthcare professionals, patients, and those tracking healthcare policy developments.

Details of the Policy Change

UHC’s new policy discontinues coverage for remote patient monitoring in cases where the service is considered unproven or not medically necessary, focusing chiefly on routine management of Type 2 diabetes and most hypertension cases. However, there are notable exceptions:

• Heart Failure: Remote monitoring will continue to be covered for patients diagnosed with heart failure, reflecting evidence supporting improved outcomes in this population.
• Hypertensive Disorders of Pregnancy: Coverage remains in place for pregnant individuals with hypertensive disorders, a group for whom remote management has shown benefit and can mitigate risks to both mother and child.

These exceptions underscore UHC’s commitment to supporting RPM where research demonstrates clear clinical value. The policy applies to new and existing patients as of the effective date, which is detailed in UHC’s provider communications.

Impact on Members: Who Is Affected?

The policy affects UHC members across several plan types, including those enrolled in Medicare Advantage, commercial employer-sponsored insurance, individual exchange (Marketplace) plans, and Medicaid. For most individuals with Type 2 diabetes or standard hypertension, remote monitoring devices and associated services will no longer be reimbursed unless a specific exception applies. Providers and patients should carefully review plan details to understand ongoing eligibility and coverage for RPM.

CMS Rule Changes: Upcoming Service Rate Adjustments

The Centers for Medicare & Medicaid Services (CMS) is expected to implement new rules that adjust payment rates for remote patient monitoring services in 2025. These changes may influence how payers and providers structure RPM programs and could impact future coverage decisions. Stakeholders are watching closely to understand how these federal updates will interact with insurer policies like UHC’s.

Implications for Patients and Providers

UnitedHealthcare’s revised remote patient monitoring policy marks a notable shift in coverage for chronic disease management. While the decision narrows access for many with Type 2 diabetes and hypertension, it maintains support for populations where RPM has proven benefits. As CMS finalizes new rules and advocacy groups push for policy reconsideration, patients and providers should stay informed about coverage updates and seek guidance to ensure continuity of care where remote monitoring remains essential.

What Healthcare Professionals Need to Know About the Latest Medicare Flexibility Extensions

The federal government has officially reopened following the recent shutdown, bringing relief and important updates for healthcare professionals and policy watchers. As part of the reopening, significant developments regarding telehealth billing and Medicare flexibilities have been enacted that are crucial for providers to understand.

Legislative Update: Passage and Signing of H.R. 5371

On November 2025, Congress passed and the President signed H.R. 5371, a Continuing Resolution that ended the government shutdown. This legislation not only funds the government but also extends several Medicare telehealth flexibilities that were set to expire, ensuring continuity of care and operational stability for providers across the country.

Medicare Telehealth Flexibilities Extended Through January 2026

H.R. 5371 extends select Medicare telehealth flexibilities through January 30, 2026. This extension allows providers to continue delivering vital services remotely, supporting patient access and practice sustainability.

Detailed Flexibilities Extended

• Home as an Originating Site: Patients can receive telehealth services from their home, maintaining convenience and access.
• No Geographic Restrictions: The requirement that patients be located in rural or certain geographic areas to receive telehealth services is suspended, broadening eligibility nationwide.
• FQHCs and RHCs as Distant-Site Providers: Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) may continue to serve as distant-site telehealth providers, expanding care delivery options.
• Audio-Only Visits: Providers can bill for eligible audio-only telehealth visits, supporting patients who may lack video access.
• Telehealth for Hospice Recertification: Telehealth remains available for conducting hospice recertification assessments, streamlining care for seriously ill patients.
• Expanded Provider Eligibility: A wider range of practitioners, including therapists and allied health professionals, can continue to furnish telehealth services under Medicare.
• Acute Hospital Care at Home Program: The program allowing hospitals to provide inpatient-level care at home is extended, sustaining hospital capacity and patient-centered care.

Behavioral Health In-Person Visit Requirement Aligned

The requirement for an in-person visit prior to and during ongoing behavioral health telehealth services is also delayed until January 30, 2026. This alignment offers continuity for behavioral telehealth care without disrupting established patient relationships.

Looking Ahead: Pending CMS Guidance

While these extensions provide immediate clarity, further guidance from the Centers for Medicare & Medicaid Services (CMS) is expected. Upcoming updates will cover operational details, billing instructions, and any additional compliance requirements. Providers should stay tuned for future announcements to ensure continued adherence with federal policies.

In Short:

The extension of Medicare telehealth flexibilities following the government shutdown offers critical support for healthcare delivery through January 2026. Providers are encouraged to review these changes on the CMS website, maintain compliance, and monitor for further CMS guidance. 

Provided by our friends at Wake AHEC...

Download PDF Flyer here

This year, providers across the United States will be experiencing a different kind of Cold & Flu season. At this time, many practices are electing to refer patients with Asthma symptoms in need of care to facilities that can both provide care and protect their healthcare workers from COVID-19. As we move into the annual Cold & Flu season that can also be a time of heightened asthma symptoms, having a good plan in place will help yo

u manage your patient volume as well as help you maintain the high level of care you provide. This resource sheet outlines what you can do to enhance your asthma care to patients during the COVID-19, Cold & Flu season.