If your organization participates in the Aetna State Plan, we advise you to confirm your participation ahead of the January 1, 2025 launch date!

Effective January 1, 2025, Aetna will replace Blue Cross Blue Shield NC for the NC State Health Plan coverage.

Which plans are included?

• Enhanced PPO Plan (80/20)
• Basic PPO Plan (70/30)
• High Deductible Health Plan (HDHP)

This change does NOT impact members enrolled in the Humana Medicare Advantage plans.

The current pharmacy benefit manager (CVS Caremark®) will not change.

Humana Military's claim processor will switch from Wisconsin Physicians Service (WPS) to PGBA LLC, effective January 1, 2025.

Key Changes:

EDI Claims:

• The 2025 TRICARE East Payer ID is 99727

Claims and Document Submissions:

• Starting January 1, 2025, use XPressClaims via provider self-service

Clearinghouse Requirements:

• New submitters must file a Trading Partner Agreement and Enrollment Form to obtain a          mailbox/submitter ID
• Confirm Payer ID 99727 is enabled if your clearinghouse already files claims to PGBA
• If your clearinghouse does not submit to PGBA, files can be uploaded directly if they meet ANSI     X12 standards.
• Batch claims processing is available through the EDI Gateway mailbox system.
• Complete a PGBA EDI Provider Agreement to submit claims electronically

Claims with 2024 Dates of Service (DOS)

• WPS will process claims with 2024 DOS until April 30, 2025
• After April 30, 2025, submit 2024 claims via XPressClaims or the clearinghouse.
• Ensure all documentation and disputes are submitted promptly before April 30, 2025.

ERA/EFT Enrollment:

• Re-enroll in ERA/EFT by January 1, 2025 even if currently enrolled. (click 'I am staying in East Region'). 
• Note: T17 EFT/ERA applications will no longer be accepted after this date.

Source: Tricare EFT Changes Coming in 2025

LUNCH n' LEARN

NC HealthConnex: New Look for Easier Navigation

South Piedmont AHEC's Maria Goergen will host an informative Lunch n' Learn session on December 17th from noon - 1 p.m.  See the latest updates and improvements to NC HealthConnex (NCHIE) that will make navigation simpler and more efficient for your practice.

We hope you take advantage of this learning opportunity. 

Click below to register (there is no fee for this event).

We look forward to connecting with you!

Register for Lunch n' Learn

Effective January 1, 2025, Aetna will replace Blue Cross Blue Shield NC for the NC State Health Plan coverage.

Which plans are included?

• Enhanced PPO Plan (80/20)
• Basic PPO Plan (70/30)
• High Deductible Health Plan (HDHP)

This change does NOT impact members enrolled in the Humana Medicare Advantage plans.

The current pharmacy benefit manager (CVS Caremark®) will not change.

You know the health of your patients.

Do you know the financial health of your practice?

• Where does your practice stand related to financial benchmarks like days in accounts receivable?
• Do you understand your payer mix?
• What is your process for auditing for lost revenue?

North Carolina AHEC has a free tool that you can use to track your practice's financial health.

The role of Nurse Practitioners (NPs) in North Carolina is integral to the health care system.  As advanced practice registered nurses, NPs are trained to provide high-quality care, often serving as primary care providers.  This overview will delve into the regulations governing NP practice in North Carolina, address common questions regarding their scope of practice, prescriptive authority, collaboration requirements, and documentation.  The speaker will also dispel a few myths related to NPs!

Medicaid Managed Care Virtual Office Hours

The Centers for Medicare & Medicare Services (CMS) has released Merit-based Incentive Payment System (MIPS) performance feedback and final scores for the 2023 performance year and associated MIPS payment adjustment information for the 2025 payment year.

Medicaid Managed Care Back Porch Chat

The administrative complexities of providing care to your patients now covered under Tailored Plans can be frustrating. NC Medicaid hopes to ease provider administrative burden in the transition period, and ensure that beneficiaries receive uninterrupted care.