North Carolina Medicaid provider reimbursement rate reductions go into effect October 1, 2025.
The reduction percentages vary from 3%, 8% or 10% and apply to procedure codes.
NC Medicaid plans to publish detailed updated fee schedules to the NC Medicaid Covered Codes and Fee Schedules Portal. You are advised to check back frequently for these updated documents.
North Carolina Division of Health Benefits officially notified Vaya Health of upcoming changes to the NC Medicaid fee schedule rates effective October 1, 2025. The new detailed fee schedule changes have not yet been provided.
Vaya Health notified network providers in their recent bulletin that it will update their systems to implement the fee schedule changes no earlier than November 1, 2025. If there is no legislative agreement by October 31, Vaya will implement the rate cuts on November 1, retroactive to the effective date of October 1. On that date they plan to update their systems to pay at the newly published rates, and will take steps to recoup the difference in reimbursement for services provided back to October 1.
Vaya indicated they will issue more detailed communications soon, and provided links to email them with questions as well as a link to join the Vaya Provider Touchpoint webinar on October 3rd.
NC Medicaid, in collaboration with the five NC Medicaid Managed Care Standard Plans, hosts the...
Fifth Annual Virtual Statewide Quality Forum
Wednesday, October 8 from noon-1:30 p.m.
Topics will include:
The forum is designed for providers, practice managers, and quality managers to engage in
focused discussion about how to successfully apply Medicaid Managed Care quality initiatives to
generate positive outcomes.
Please register to participate in this valuable and informative forum that will offer practical
applications to enhance and improve your services to NC Medicaid members.
Register now to attend the (free) Second Annual Piedmont Area Falls-Free Expo!
Open to health care professionals and the adults they serve, this year's expo is filled with events--- from stability and balance exercise classes to chair yoga, to educational presentations including the importance of hearing in fall risk and other concepts related to fall prevention in older adults.
Did we forget to mention there is also free food and raffles to win prizes?
WHEN: Wednesday, September 24, 2025
WHERE: Intergenerational Center for Arts and Wellness
114 West 30th Street, Winston-Salem, NC 27105
TIME: 9:30 AM - 2:30 PM
Registration is available online or by phone at (336) 904-0328.
Use these links to learn more and view the schedule of events.
Need free Contact Hours on this topic? Could your staff benefit from a refresher on falls in older adults?
Northwest AHEC has two self-paced, interactive, online courses on the topic! Check them out!
Falls: Screening, Risk Assessment and Care Planning for Older Adults in the Community
Double Trouble: Diabetes and Falls
On September 12, 2025,Governor Josh Stein directed the State Health Director, as a measure for the prevention and control of communicable disease, to issue statewide standing orders to facilitate access to the COVID-19 vaccine in accordance with NC laws and FDA approvals for those who wish to receive it.
These orders allow an immunizing pharmacist licensed with the NC Board of Pharmacy and practicing in North Carolina in accordance with the conditions of their licensure to administer COVID-19 vaccines approved by the FDA per the conditions outlined in the orders.
These include Comirnaty (manufactured by Pfizer), Mnexspike (manufactured by Moderna), Nuvaxovid (manufactured by Novavax) and Spikevax (manufactured by Moderna).
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.
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:
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:
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:
Register by clicking the blue button below. We look forward to connecting with you!
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:
Learn more about this benefit from North Carolina AHEC here.
