What North Carolina Primary Care Practices Need to Know
North Carolina Medicaid has released updated guidance on when providers can expect corrected payments and claim reprocessing following the reversal of the Medicaid reimbursement rate reductions that took effect October 1, 2025.
We know this issue has created uncertainty for practice managers, billing teams, and financial planning. Below is a plain‑language summary of the timelines so you can plan appropriately and communicate clearly with your staff.
Background: What Changed?
On December 10, 2025, North Carolina announced the reversal of the Medicaid rate reductions implemented on October 1, 2025. These reversals apply to both NC Medicaid Direct (Fee‑for‑Service) and NC Medicaid Managed Care (PHPs).
The state has now outlined how and when corrected rates will be implemented and when affected claims will be reprocessed, as detailed in the NC Medicaid Rate Reduction Reversal Update.
Updated Fee Schedules
NC Medicaid has announced that updated fee schedules, reflecting the reversal of the October 1, 2025 rate reductions, are scheduled to be posted on January 5, 2026.
These updated fee schedules apply to:
- NC Medicaid Direct (Fee‑for‑Service)
- NC Medicaid Managed Care (PHP) plans
Updated schedules will be available through the NC Medicaid Fee Schedules and Covered Codes Portal.
When PHPs Will Implement Corrected Rates
Once the updated fee schedules are posted:
- Prepaid Health Plans (PHPs have 45 days) to update their systems with the corrected rates.
This places PHP system implementation between January 5 and February 19, 2026, depending on the plan.
What this means for your practice
Providers should expect to begin seeing corrected Medicaid Managed Care (PHP) payments:
- Mid‑February through early March 2026, depending on the PHP
Reprocessing of Previously Paid Claims
PHPs are required to reprocess all claims affected by the October 1, 2025 rate reductions for dates of service on or after October 1, 2025.
- After implementing the corrected rates, PHPs have an additional 30 days to complete claim reprocessing.
Based on the required timelines, claim reprocessing is expected:
- Late February through late March 2026
- Some adjustments may extend into early April, depending on the PHP
Providers do not need to resubmit claims for reprocessing unless directed otherwise by their PHP.
NC Medicaid Direct (Fee‑for‑Service) Timeline
For comparison, NC Medicaid Direct (FFS) follows a different payment timeline.
Corrected payments for NC Medicaid Direct began appearing in the January 13, 2026 check write, following system updates tied to the January 5 fee schedule posting.
This differs from PHP timelines, which must follow the 45‑day system update period plus a 30‑day reprocessing window.
What Providers Should Expect — At a Glance
Medicaid Managed Care (PHPs):
- Corrected payment amounts: Mid‑February through early March 2026
- Reprocessed claim adjustments: Late February through March 2026
- Some remittances may extend into early April, depending on the PHP
NC Medicaid Direct (FFS):
- Corrected payments began January 13, 2026
What Practices Should Do Now
✅ Continue submitting claims as usual✅ Monitor remittance advice carefully for adjustments and reprocessed claims
✅ Prepare billing and finance staff for increased remittance activity over several weeks
✅ Avoid duplicate resubmissions unless specifically instructed by the PHP
PHPs have indicated that providers do not need to take action for affected claims to be reprocessed.
Who This Applies To
This guidance applies to:
- NC Medicaid Direct
- NC Medicaid Managed Care (PHPs)
How Northwest AHEC Can Help
Your Northwest AHEC Practice Support Team is here to help practices navigate these changes. We can assist with:
- Understanding remittance advice and claim adjustments
- Preparing staff talking points and internal communications
- Workflow planning during high‑volume claim reprocessing periods
If your practice has questions or would benefit from one‑on‑one support, please reach out to your local AHEC practice support coach.
