The Northwest AHEC Practice Support team have several important updates to share following the recent merger of WellCare of North Carolina Medicaid and Carolina Complete Health (CCH), effective April 1, 2026. These updates address provider portal access issues, claim reprocessing timelines, and revised billing guidance for antepartum care.

Temporary Access Issue: WellCare Secure Provider Portal

Carolina Complete Health has identified an issue affecting provider access to the WellCare Secure Provider Portal following the merger. Practices that previously held only a WellCare of North Carolina Medicaid contract—and no other WellCare contracts—may currently be unable to log in.

This issue has been escalated due to its impact on historical claims activity. A fix has been identified and was deployed April 3, 2026. Once deployed, providers should again be able to access the WellCare Secure Provider Portal to submit and review claims with dates of service prior to April 1, 2026.

It is important to note that while claims access is expected to be restored, some wraparound functions (including consent forms and the claim reimbursement calculator) will not yet be available as work continues to fully restore portal functionality.

Additional details are available here.

Interim Guidance: Claims with Dates of Service Before April 1, 2026

While portal access is being restored, providers can continue submitting Medicaid claims with dates of service prior to April 1, 2026 through existing electronic pathways. Claims may be submitted via Availity Essentials by selecting WellCare of North Carolina as the payer, or by EDI using WellCare Payer ID 14163.

Once portal access is fully restored, the WellCare Secure Provider Portal will again be available for historical claims submission and review.

No Change for Claims with Dates of Service On or After April 1, 2026

Claim submission for services provided on or after April 1, 2026 is not impacted by the portal issue. Providers should continue submitting these claims to Carolina Complete Health using their established workflows, including the Carolina Complete Health Secure Portal, Availity Essentials (selecting Carolina Complete Health as the payer), or EDI using Payer ID 68069.

Update on WellCare Claim Reprocessing (Rate Rebase Reversal)

An update is also available regarding WellCare claim reprocessing related to the rate rebase reversal. WellCare did not meet NC DHHS-established timelines for completion, but the claims team is providing regular progress updates.

To date, over 508,146 claims have been adjusted and moved to payment, with the remaining claims continuing to be processed daily. The team is currently on track to complete reprocessing by April 30, inclusive of all North Carolina tickets received year to date, with remaining activity tracking through April. Any changes to this timeline will be shared as soon as they are known.

Revised Guidance: Antepartum Billing Across the Merger Date

Carolina Complete Health has also revised its guidance on antepartum billing and coding following a clarification request. Under North Carolina Medicaid Clinical Coverage Policy, CPT code 59426 must be billed using the date of delivery as the date of service.

As a result, if the delivery date occurred prior to April 1, 2026, the claim should be billed to WellCare, even when antepartum visits span the merger date. Practices may be advised that antepartum care beginning before April 1 should continue to be billed to WellCare, even if some visits took place after April 1.

Healthy Blue has released two updated resources to support Medicaid providers as they prepare for HEDIS® Measurement Year 2026. These tools are designed to help practices stay current with evolving measure specifications while strengthening documentation, coding accuracy, and overall quality performance for Healthy Blue Medicaid patients.

Both resources are especially useful for practices participating in Advanced Medical Home (AMH) programs, quality improvement initiatives, and value‑based arrangements where accurate HEDIS reporting and reliable data capture are essential.

HEDIS 2026 Desktop Reference Guide

The Healthy Blue HEDIS 2026 Desktop Reference Guide provides a high‑level, measure‑by‑measure overview of HEDIS quality requirements for Medicaid providers. It includes concise descriptions of each measure, eligible populations, exclusions, measurement timing, and documentation expectations. The guide is intended to serve as a quick reference for clinical and quality teams who need to understand what counts for HEDIS without navigating full technical specifications.

This resource is particularly helpful during visit workflows, chart reviews, and quality planning discussions. By summarizing key requirements across preventive care, chronic disease management, behavioral health, maternal health, and pediatric measures, the Desktop Reference Guide helps teams focus on capturing the right information at the point of care. It also reinforces how routine clinical actions—such as timely follow‑up, screenings, and assessments—contribute directly to quality scores and reporting outcomes.

Download the Healthy Blue HEDIS 2026 Desktop Reference Guide (PDF)

HEDIS 2026 Coding Booklet

The Healthy Blue HEDIS 2026 Coding Booklet is a detailed companion resource that focuses on the “how” behind HEDIS reporting. It includes diagnosis, procedure, and service codes associated with each measure, along with practical documentation tips to support accurate claims submission and data capture. The Coding Booklet helps reduce gaps between care delivered and care reported—an essential step for reliable HEDIS performance.

This resource is especially valuable for billing staff, quality specialists, and clinical team members responsible for documentation accuracy. Clear coding guidance can help decrease the need for medical record reviews, reduce audit risk, and support appropriate reimbursement. For practices using electronic medical records, the Coding Booklet can also inform workflows, order sets, and reminders that improve consistency across providers and staff.

Download the Healthy Blue HEDIS 2026 Coding Booklet (PDF)

What Practices Should Know About the Administrative Simplification Final Rule (CMS‑0053‑F)

The Centers for Medicare & Medicaid Services (CMS) has finalized a major Administrative Simplification rule that will modernize how health care claims attachments are exchanged across the health care system. Known as CMS‑0053‑F, this final rule establishes, for the first time, national HIPAA standards for the electronic submission of health care claims attachments—such as medical records, imaging, clinical notes, and laboratory results—replacing long‑standing manual processes like faxing, mailing, and portal uploads.
CMS fact sheet on the final rule

Why this rule matters

Despite widespread adoption of electronic health records and HIPAA transaction standards, the exchange of claims attachments has remained largely manual for many practices. When payers request additional documentation to adjudicate a claim, practices have often relied on fax machines, scanned PDFs, or mailed records—contributing to delays, administrative burden, and rework.

The CMS‑0053‑F final rule addresses this gap by establishing standardized, interoperable electronic transactions for claims attachments. CMS estimates the rule will save the health care industry approximately $781 million annually, largely by reducing administrative overhead and shortening claims processing timelines.
Overview of expected savings and impact

What the rule does—and does not—cover

This rule is focused specifically on health care claims attachments. It does not apply to prior authorization attachments. CMS intentionally narrowed the scope of the final rule after extensive stakeholder feedback, noting that additional work is needed to align prior authorization standards with existing regulations and workflows.
Details from the Federal Register notice

Key standards adopted

The final rule adopts updated national standards that support secure, structured electronic exchange of both administrative and clinical information tied to claims. These include:

• Updated X12 standards for claims attachment transactions
• HL7 implementation guides to support standardized clinical documentation
• Electronic signature requirements to ensure transactions are authenticated, secure, and compliant with federal regulations

Together, these standards are designed to support faster, more reliable claims adjudication while strengthening data security and interoperability across payers, providers, clearinghouses, and vendors.
CMS summary of adopted standards

Effective date and compliance timeline

The rule is effective May 26, 2026, with a 24‑month compliance period, meaning covered entities must be compliant by May 26, 2028. CMS is encouraging health plans, providers, and technology partners to begin preparing now to ensure a smoother transition and avoid last‑minute implementation challenges.
Effective and compliance dates

What practices should do now

Although compliance is still two years away, early preparation can help practices minimize disruption and take advantage of the efficiencies this rule is intended to deliver. Practices may want to:

• Talk with EHR vendors and clearinghouses about readiness for electronic claims attachments
• Review current workflows for responding to claims documentation requests
• Identify areas where fax‑ or paper‑based processes remain in use
• Plan for future updates to internal policies related to documentation exchange and electronic signatures

Looking ahead

CMS‑0053‑F represents a significant step toward reducing administrative burden and modernizing claims processing nationwide. By replacing fragmented, manual attachment workflows with standardized electronic transactions, the rule aims to help practices spend less time on paperwork and more time focused on patient care—while improving efficiency, security, and consistency across the health care system.

For many practices, the next two years will be an opportunity to streamline workflows, strengthen partnerships with technology vendors, and prepare for a more interoperable future.

Early identification and high‑quality care can make a meaningful difference for autistic children and their families. In partnership with Wellcare, we are inviting North Carolina primary care providers to deepen their expertise in autism screening, evaluation, and ongoing care through a collaborative, case‑based learning experience.

Project ECHO Autism – Medical, led by UNC TEACCH, connects primary care clinicians with an interdisciplinary team of autism specialists through a virtual learning model designed to fit into busy clinical schedules. Participants gain practical, evidence‑based knowledge while learning alongside peers who share similar clinical challenges.

What to expect

The Project ECHO Autism series meets virtually on the 1st and 3rd Mondays of each month from 12:30–2:00 PM, beginning May 4, 2026. Sessions combine short didactic presentations with real‑world case consultation, allowing participants to apply new knowledge directly to patient care. Topics focus on improving screening practices, strengthening diagnostic understanding, and enhancing confidence in caring for autistic children across the continuum.

In addition to clinical learning, participants receive free continuing medical education (CME) credits, contact hours, and continuing education units (CEUs) for attending sessions—removing cost as a barrier to participation.

Who should participate

This series is designed for primary care providers in North Carolina who care for children and want to strengthen their skills in autism‑related screening, evaluation, and management. No prior specialty training in autism is required—just a commitment to learning and improving care for patients and families.

Learn more and register

Full details, including session dates, topics, and registration information, are available on the Project ECHO Autism – Medical website

This post explains how Lantern works, who is eligible, what types of procedures are covered, and what practices should understand when patients ask about surgical options under the State Health Plan.

What Is Lantern?

Lantern is a surgical care program included with the State Health Plan that helps match members with carefully vetted surgeons for planned, non‑emergency procedures. Members enrolled in the Plan are automatically enrolled in Lantern and do not need to take additional steps to sign up. There is no premium for the benefit; the cost is covered by the Plan.

Lantern is not available to members whose primary coverage is Medicare or to certain high‑deductible health plan participants. Members are not required to use a Lantern surgeon, but choosing a surgeon within Lantern’s Network of Excellence allows them to take advantage of the enhanced benefits associated with the program.

The Lantern Difference

A key feature of Lantern is its Network of Excellence™. Surgeons and facilities in this network are individually vetted based on licensure, board certification, fellowship training, malpractice history, reputational review, and outcomes data. Lantern reports complication rates of less than one percent, which is significantly lower than typical industry benchmarks.

Members are also supported by a dedicated Lantern Care Advocate. Care Advocates help explain the benefit, identify appropriate surgeons, coordinate appointments, and support members throughout the entire surgical journey so they can focus on recovery rather than logistics.

Covered Procedures and Costs

Lantern covers more than 1,500 planned, non‑emergency surgical procedures across a wide range of specialties, including orthopedics, spine, cardiac care, bariatric surgery, gynecology, general surgery, gastroenterology, ENT, and interventional pain management. Effective January 1, 2026, bariatric procedures are required to go through Lantern’s Network of Excellence.

When members use a Lantern surgeon, the core components of surgery—including the surgeon, hospital or surgery center, anesthesia, and inpatient stay—are covered at no cost to the member under Lantern, depending on the member’s plan. Some services before and after surgery, such as physical therapy, home health, advanced imaging, and durable medical equipment, are not covered by Lantern and remain subject to standard plan benefits.

Meaningful Savings and Travel Support

Lantern participants may experience meaningful savings. On average, members save between $2,000 and $4,000 per surgery, although actual savings vary based on the procedure and plan design.

If a member needs to travel to receive care, Lantern may cover certain travel‑related expenses, including mileage, lodging for trips over 100 miles, airfare for trips over 200 miles, and a daily per diem for meals and incidentals for the member and one companion. Travel arrangements are coordinated in advance by the Care Advocate.

How Members Use Lantern

For members, accessing Lantern starts with a single phone call. Members are encouraged to contact Lantern if they believe surgery may be necessary, have been advised to have surgery, or already have a procedure planned. A Care Advocate then helps guide them through surgeon selection, scheduling, and next steps.

Additional information for members is available on the State Health Plan website at www.shpnc.gov .

Information for Providers Interested in Becoming a Lantern Surgical Provider

Lantern partners with surgeons, hospitals, and ambulatory surgery centers performance and patient outcomes. Lantern partners with surgeons, hospitals, and ambulatory surgery centers across the country through its Network of Excellence™ .

Surgeons and facilities that participate in Lantern’s Network of Excellence may receive referrals for planned, non‑emergency procedures and work closely with Lantern’s clinical and operational teams. Lantern also notes that it emphasizes clear, transparent reimbursement and aims to reduce administrative burden for participating providers.

Providers in this network are individually vetted based on procedure‑specific experience, credentials, and quality outcomes. Lantern describes its approach as “specialist‑first,” focusing on partnering with providers who consistently demonstrate strong clinical performance, evidence‑based practice, and a commitment to delivering exceptional patient care. 

Providers or facilities interested in learning more about joining Lantern’s Network of Excellence can find additional information and submit an inquiry through Lantern’s specialist page at lanterncare.com/specialists . 

Bottom Line

Lantern is a key part of the State Health Plan’s approach to improving surgical quality while lowering costs for members. By guiding members to highly vetted surgeons and supporting them throughout the surgical process, Lantern helps reduce complications, improve outcomes, and minimize financial burden.

Practices that understand how Lantern works are better positioned to answer patient questions and help members navigate their surgical benefits with confidence.

How Practice Support Can Help

The Practice Support Coaching Team can help practices understand how Lantern fits within the State Health Plan, support staff education, and answer workflow questions when patients raise questions about surgical care.

Recent federal action brings welcome stability to telehealth services for Medicare providers and patients. Congress has formally extended key Medicare telehealth waivers through December 31, 2027, ensuring continuity after a brief lapse earlier this year.

For practices that rely on telehealth—particularly in primary care, behavioral health, rural health, and safety‑net settings—this extension reduces near‑term uncertainty and allows for more confident planning.

Stay Informed on Telehealth Policy

Ongoing telehealth policy changes can be complex and fast‑moving. The Center for Connected Health Policy (CCHP) is a trusted national resource that tracks federal and state telehealth developments. Practices can receive timely updates by signing up for CCHP newsletters at
Center for Connected Health Policy 

Medicare Telehealth Waivers Extended Through 2027

As an update to last week’s developments, the Medicare telehealth waivers that expired on January 30, 2026 have now been formally extended. Congress passed H.R. 7148, the Consolidated Appropriations Act, 2026, and the bill was signed into law last week. Importantly, the legislation retroactively covers the brief lapse period, restoring continuity to Medicare telehealth coverage.

This law extends key Medicare telehealth flexibilities through December 31, 2027, preventing a return to permanent, pre‑pandemic Medicare telehealth policy. These waivers have been in place since 2020, when the COVID‑19 public health emergency began, and have been extended multiple times—often for short periods. This nearly two‑year extension provides greater stability for both providers and patients who rely on telehealth services.

Telehealth Waivers That Are Now Extended

Under the new legislation, the following Medicare telehealth waivers remain in effect through the end of 2027:

• Waiver of location requirements, including both geographic restrictions and originating site rules
• Expanded list of eligible telehealth providers
• Continued eligibility of Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) as Medicare telehealth providers
• Delay of the prior in‑person visit requirement for mental health services when certain permanent telehealth policy requirements are not met
• Delay of the in‑person visit requirement for mental health services delivered via telecommunications technology for FQHCs and RHCs
• Continued allowance of audio‑only telehealth services
• Continued use of telehealth to conduct face‑to‑face encounters for hospice recertification

In addition, the Acute Hospital Care at Home Initiative has been extended through September 30, 2030, allowing participating hospitals to continue providing hospital‑level care in patients’ homes.

Additional Telehealth Provisions in the Law

The legislation also includes several forward‑looking telehealth provisions that practices should be aware of:

• CMS is required to establish billing modifiers by 2027 to identify telehealth services delivered through third‑party virtual platforms and services billed “incident to” another professional service.
• Through calendar year 2027, hospitals may furnish and bill Medicare for cardiopulmonary rehabilitation services delivered to hospital outpatients in their homes via live video.
• The Department of Health and Human Services must issue guidance within one year on best practices for delivering telehealth services to patients with limited English proficiency.
• CMS is required to educate Medicare clinicians by January 1, 2028 on screening for medication‑induced movement disorders in at‑risk patients, including best practices for telehealth screening and how these services should be reflected in billing.

CMS Telehealth Guidance Updates

Following enactment of this legislation, CMS has updated its Telehealth FAQ for Calendar Year 2026 to reflect the restored flexibilities and new expiration dates.

The CMS Telehealth and Remote Patient Monitoring (RPM) Medicare Learning Network (MLN) Guidance, most recently revised in December 2025, remains a primary reference source. However, it has not yet been fully updated to reflect the most recent legislative changes. Some elements—such as references to an in‑person mental health visit within six months—will require revision, as that requirement is now waived through the end of 2027.

At the same time, several telehealth policy changes finalized under the CY 2026 Physician Fee Schedule (PFS) and reflected in the December 2025 MLN guidance remain in effect, as they were not addressed in H.R. 7148.

Telehealth Policies That Continue to Apply

Key provisions from the existing MLN guidance that remain unchanged include:

• Permanent addition of new services to the Medicare Telehealth Services List, eliminating the former “provisional” versus “permanent” distinction
• Removal of frequency limitations for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations
• Allowance for teaching and supervising physicians to meet supervision requirements through virtual presence in appropriate clinical situations
• Clarification of enrollment and billing rules for clinicians furnishing telehealth services from their homes, including options to suppress home address information in PECOS for privacy
• Addition of new CPT and HCPCS codes to the Medicare Telehealth Services List, including codes for multiple‑family group psychotherapy, group behavioral counseling for obesity, certain infectious‑disease add‑on services, and auditory integrated sound processors

The MLN guidance also continues to reflect payment for telehealth services furnished by FQHCs and RHCs through December 31, 2026. Because the broader waivers have now been extended through 2027, FQHCs and RHCs remain eligible under the general waiver authority rather than relying on a more limited carve‑out.

DEA Extends Telehealth Prescribing Waiver Through 2026

Separately, the Drug Enforcement Administration (DEA) has extended the telehealth prescribing waiver for controlled substances through December 31, 2026. This extension allows prescribing without a prior in‑person visit or meeting a statutory exception and represents a clean, one‑year continuation with no new requirements.

This policy continues to suspend the initial in‑person visit requirement under the Ryan Haight Online Pharmacy Consumer Protection Act of 2008. The DEA’s rules apply nationwide and are separate from state requirements and Medicare reimbursement rules. Longer‑term federal prescribing policy remains unresolved, and additional changes may emerge.

How Northwest AHEC Can Help

Your Northwest AHEC Practice Support Team is here to help practices interpret telehealth policy changes and understand how they affect workflows, billing, and patient access. We encourage practices to stay informed through trusted resources like CCHP and to reach out with questions.