Issued: July 27, 2023
As previously announced in a Provider Alert issued on March 21, 2023, Partners implemented NC Medicaid Direct flexibilities to ease the administrative burden for providers. The flexibilities went into effect on the launch date for NC Medicaid Direct (April 1, 2023) and were to end on June 30, 2023. Partners extended the flexibilities to July 31, 2023. Partners is now extending the flexibilities to September 30, 2023.
What is happening?
Partners is extending the date relaxing prior authorization requirements for NC Medicaid Direct services to September 30, 2023.
These flexibilities do not apply to State Funded services. Services are subject to post-payment review.
When is this happening?
The flexibilities began April 1, 2023, and will now run through September 30, 2023.
How is this impacting providers?
NC Medicaid Direct prior authorization requirements will be relaxed for dates of service April 1-September 30, 2023.
- Partners will allow retrospective authorizations for NC Medicaid Direct Services* April 1- September 30, 2023. (There are some exceptions to the flexibilities. See list below.)
- These flexibilities will allow claims to pay during this time before authorizations are in the system. Authorizations must be in place by October 1, 2023 to avoid claim denials.
- Initial or concurrent authorizations for NC Medicaid Direct services starting April 1- September 30, 2023 must be entered into ProAuth by September 30, 2023 to be reviewed for medical necessity.
- Manual authorization requests for NC Medicaid Direct services (non-Innovations) can be submitted but are not required during this time. Manual UM determinations (non-Innovations) made prior to September 30, 2023 will be entered electronically by the UM Department. This is the current process; no changes are needed.
What are the exceptions to the NC Medicaid Direct flexibilities?
*The following levels of care will continue to follow the posted benefit guidelines and standard UM procedures:
- Inpatient initial and concurrent review.
- Electroconvulsive Therapy (ECT) inpatient only.
- Innovations – all requests will continue to require prior approval to allow for ISP approval and updates as needed:
- Innovations Initial ISP requests.
- Innovations Annual ISP requests.
- Innovations ISP revisions.
- Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) Initial request. Concurrent requests must maintain a valid level of care to cover the dates of services.
Providers are required to continue to maintain all required documentation per the applicable clinical coverage policy or service definition.
What if providers have questions?
Please contact UMQuestions@partnersbhm.org with any questions related to prior authorization.