Beginning April 1, 2026, several Medicaid managed care plans in North Carolina will change how certain claims are handled. Carolina Complete Health, Trillium Physical Health, and Partners Physical Health will move from post‑payment denials to upfront claim rejections when provider information on a claim is incorrect or incomplete.
This change applies broadly and will impact all provider types that submit claims—not just hospitals.
Under this new process, claims with provider data that does not match NCTracks will be rejected immediately, rather than processed and denied later.
Upfront rejections may occur when information such as:
is missing, inactive, or does not align with what is on file in NCTracks.
If a claim is rejected upfront, it will not enter adjudication. Providers must correct the information and resubmit the claim.
These changes apply to ALL enrolled providers who submit claims, including:
If you submit claims, these rules apply to you.
Claims may be rejected upfront if any of the following issues are identified:
To reduce the risk of upfront rejections starting April 1, practices should take the following steps as soon as possible:
Confirm that all of the following are current, active, and accurate in NCTracks:
Ensure the taxonomy on your claim matches your NCTracks enrollment for the services being billed.
Double‑check that claim fields are completed correctly, including:
Refer to the Carolina Complete Health Provider Billing Manual, particularly sections detailing:
If a claim is rejected upfront:
No appeal is required for upfront rejections.
In addition to upfront rejection changes, beginning April 15, 2026, hospital inpatient claims billed at $250,000 or more will move to pre‑payment review rather than post‑payment review. These reviews will continue to be conducted by 6 Degrees Health and apply to claims processed for Carolina Complete Health, Trillium Health Resources, and Partners Health Management.
Hospitals should be prepared to submit itemized bills proactively for high‑dollar inpatient claims to avoid processing delays.
Starting April 1, 2026, accurate provider data matters more than ever.
These upfront rejection changes apply to all providers submitting claims. Ensuring that your NPI, taxonomy, rendering provider, and service location information exactly match what is on file in NCTracks is essential to avoid immediate claim rejections and payment delays.
Your Northwest AHEC Practice Support Team is available to help practices:
If you have questions or would like assistance, please reach out to your local practice support coach.