From the CMS QPP Updates Newsletter:
North Carolina Medicaid provider reimbursement rate reductions go into effect October 1, 2025.
The reduction percentages vary from 3%, 8% or 10% and apply to procedure codes.
NC Medicaid plans to publish detailed updated fee schedules to the NC Medicaid Covered Codes and Fee Schedules Portal. You are advised to check back frequently for these updated documents.
North Carolina Division of Health Benefits officially notified Vaya Health of upcoming changes to the NC Medicaid fee schedule rates effective October 1, 2025. The new detailed fee schedule changes have not yet been provided.
Vaya Health notified network providers in their recent bulletin that it will update their systems to implement the fee schedule changes no earlier than November 1, 2025. If there is no legislative agreement by October 31, Vaya will implement the rate cuts on November 1, retroactive to the effective date of October 1. On that date they plan to update their systems to pay at the newly published rates, and will take steps to recoup the difference in reimbursement for services provided back to October 1.
Vaya indicated they will issue more detailed communications soon, and provided links to email them with questions as well as a link to join the Vaya Provider Touchpoint webinar on October 3rd.
NC Medicaid, in collaboration with the five NC Medicaid Managed Care Standard Plans, hosts the...
Fifth Annual Virtual Statewide Quality Forum
Wednesday, October 8 from noon-1:30 p.m.
Topics will include:
- Administrative Simplification Workgroup Updates
- Early Intervention and EPSDT: Proven Strategies for Success – Feedback from Providers
and Standard Plans - Key Updates from NC Medicaid
The forum is designed for providers, practice managers, and quality managers to engage in
focused discussion about how to successfully apply Medicaid Managed Care quality initiatives to
generate positive outcomes.
Please register to participate in this valuable and informative forum that will offer practical
applications to enhance and improve your services to NC Medicaid members.
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!
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!
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)
Today we bring you updates from the latest CMS QPP Newsletter for Small Practices:
CMS Proposes Policy Changes for Quality Payment Program
The Centers for Medicare & Medicaid Services (CMS) has issued its Calendar Year (CY) 2026 Medicare Physician Fee Schedule (PFS) Proposed Rule, which includes proposed policies for the Quality Payment Program (QPP).
The Notice of Proposed Rulemaking (NPRM) includes proposals for the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs), as well as several Requests for Information (RFIs).
Specifically, we’re proposing policies that:
- Continue the transformation of MIPS through MIPS Value Pathways (MVPs).
- Are responsive to feedback and concerns raised by interested parties.
- Maintain stability within the MIPS program through the established performance threshold.
2026 Policy Proposal Highlights
Key QPP policies that we are proposing in the CY 2026 PFS Proposed Rule include:
- Introducing 6 new MVPs for the 2026 performance year that are related to diagnostic radiology, interventional radiology, neuropsychology, pathology, podiatry, and vascular surgery.
- Introducing a 2-year informational-only feedback period for new cost measures, allowing clinicians to receive feedback on their score(s) and find opportunities to improve performance before a new cost measure affects their MIPS final score.
- Maintaining the current performance threshold policies, leaving the performance threshold set at 75 points through the 2028 performance year.
- Introducing Qualifying APM Participant (QP) determinations at the individual level, in addition to existing determinations at the APM entity level.
Overview of RFIs
We are also seeking feedback on RFIs about the following topics:
- Establishing Core Elements for MVPs, to require reporting on key quality measures within each MVP.
- Establishing a process to assign clinicians to an MVP, to facilitate the most relevant reporting for their scope of care.
- Transitioning to FHIR-based electronic clinical quality measure (eCQM) reporting in quality reporting programs.
- Understanding the current environment, including challenges, with collecting and exchanging high-quality healthcare data.
- Changing requirements for the Query of Prescription Drug Monitoring Program (PDMP) Measure and Performance-Based Measures in the Public Health and Clinical Data Exchange Objective.
The AHEC Standardized Onboarding and Credentialing program aims to improve the process of placing health science students in clinical placements through partnerships as well as onboarding and credentialing tools.
These tools help reduce the time and resources needed to onboard and credential students to clinical rotations. These tools, as well as support and guidance from AHEC and other partners, can make it easier for small practices to host students, helping to increase opportunities for training, and ultimately increasing clinical capacity. To get started or for more information, please contact Aubrey Delaney, Associate Director Onboarding and Credentialing at Audelaney@wakeahec.org.
Learn more: Standardized Student Onboarding and Credentialing.
Excerpt from CMS QPP Small Practices Newsletter:
2025 Consumer Assessment of Healthcare Providers Survey (CAHPS) for MIPS Survey Registration Now Open
Registration is open through June 30, 2025, at 8 p.m. ET for the CAHPS for MIPS Survey for the 2025 performance year.
Who can register?
- Groups, virtual groups, and APM Entities that intend to administer the CAHPS for MIPS Survey as 1 of their 6 quality measures for reporting traditional MIPS
- Groups, subgroups, and APM Entities that are registered to report the following MVPs and that intend to administer the CAHPS for MIPS Survey as 1 of their 4 quality measures:
- Adopting Best Practices and Promoting Patient Safety within Emergency Medicine MVP
- Advancing Cancer Care MVP
- Value in Primary Care MVP
How to Register
Groups, virtual groups, and APM Entities will register on the QPP website. You’ll need to have the Security Official role to register your organization. Please refer to the QPP Access User Guide (ZIP, 4MB) for information about obtaining a Security Official role for your organization. To register:
- Sign in to QPP.
- Click Start Registration from the landing page.
- Click Register or Edit CAHPS Registration.
Subgroups interested in administering the CAHPS for MIPS Survey as 1 of their 4 required quality measures will need to complete their MVP registration prior to registering for the CAHPS for MIPS Survey. After completing the subgroup’s MVP registration, they will need to contact the QPP Service Center by email at QPP@cms.hhs.gov, by creating a QPP Service Center ticket, or by phone at 1‑866‑288‑8292 (Monday through Friday, 8 a.m. – 8 p.m. ET) to register for the CAHPS for MIPS Survey.
You must register by 8 p.m. ET on June 30, 2025.
Additional Resource
