Issued: June 21, 2024

Partners Health Management is providing clarifying information on how providers should submit some claims when Tailored Plan goes live on July 1, 2024. This provider alert provides information on submitting professional and institutional claims.

What is happening?

Partners is clarifying how providers should submit professional and institutional claims on or before July 1, 2024.

This impacts claims types:

  • CMS1500 (professional claims)
  • UB04 (institutional codes)

When is this happening?

July 1, 2024.

What must Tailored Plan providers do?

Providers must make sure claims are not submitted with dates of service that cross over benefit plans for NC Medicaid Direct and the Tailored Plan.

  • Professional claims (CMS1500):
    • Claims with dates of service on or before June 30, 2024, should be submitted on a separate claim than claims with dates of service beginning on July 1, 2024.
    • Example: If a provider has a claim with dates of service on or before June 30, 2024, that claim will be submitted and processed as a claim under NC Medicaid Direct. Claims submitted beginning July 1, 2024, that are for individuals in the Tailored Plan will be processed as a claim under the Tailored Plan.
  • Institutional claims (UB04):
    • Claims will be processed by the benefit plan the member has on the date of admission.
    • Example: If a member is admitted on June 30, 2024, and is discharged on July 3, 2024, the claim would be processed against the NC Medicaid Direct benefit plan and not the Tailored Plan benefit plan which begins July 1, 2024.

What must State-Funded providers do?

For both Professional claims (CMS1500) and Institutional claims (UB04), providers must make sure claims are not submitted with dates of service that cross over benefit plans for the State Benefit Fiscal Year. Claims with dates of service on or before June 30, 2024, should be submitted on a separate claim than claims with dates of service beginning on July 1, 2024.

What if providers have questions? 

If providers have questions, they can email ClaimsDepartment@PartnersBHM.org or call 1-704-842-6486.