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)

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!

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.

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.

At this time, there’s been no indication that the Clear Pricing Project (CPP) will be extended or replaced for primary care. The only new program announced so far is the Behavioral Health Access Program (BHAP), which does not apply to primary care providers.

That said, here are a few proactive steps you can take:

• Review your current contracts with Aetna to understand how your reimbursement rates may change once CPP ends.
• Consider renegotiating your contract. Many practices are already doing this to secure more sustainable terms.
• Ensure you’re part of Aetna’s Choice POS II network, which the NC State Health Plan will use exclusively starting January 1, 2025.
  
  👉 Join the Aetna Network
  👉Behavioral Health Access Program(BHAP)

MEDICAID MANAGED CARE

Disaster Preparedness for Members with Chronic Conditions

August 19 | NOON - 1 p.m.

Please join us for the last webinar in this series focused on disaster preparedness for members with chronic conditions.  This webinar will cover the following:

• Long term recovery considerations
• Behavioral Health impacts
• Finding resources
• Crisis Services
• Hope 4 NC
• Understanding Resilience
• Building Resilience

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

A new toolkit from NCDHHS offers a variety of resources to support healthcare providers with giving vaccines. The information and tools address the challenges involved in providing vaccines, including conversation guides, communication tools, and population-specific guidance.