October Provider Digest

AmeriHealth Caritas North Carolina (ACNC) is committed to providing the support you deserve. A Known System Issues Tracker is updated weekly and also available to providers in NaviNet.

You will find the following topics in this October digest:

QUALITY CORNER

ADMINISTRATION

MEMBER SPOTLIGHT

CYBERSECURITY

Incentive Available for UST HealthProof Provider Engagement Coordination Program

ACNC is committed to supporting providers in delivering high-quality, coordinated care. The UST HealthProof Provider Engagement Coordination (PEC) program helps ensure that chronic conditions and quality care gaps are properly documented by providing practices with clinical documentation improvement (CDI) alerts. These alerts identify potential diagnosis and quality measure gaps based on member history and can be delivered on-site, remotely, or electronically to fit the provider's workflow. For more details on the program, see our July 24 notice (PDF). 

PEC program incentive opportunity

To support providers in properly documenting chronic medical conditions and quality care gaps, ACNC is offering providers an incentive for providing back responses to CDI alerts. 

  • $50 per unique member if the practice closes 60% of the gaps identified on returned CDI alerts
  • $100 per unique member if the practice closes 90% of the gaps identified on returned CDI alerts

Updated Provider Manual Now Available

The updated Provider Manual (PDF) is available. For your convenience, a revision log is found at the back of the appendix to help identify updates. Several high-level revisions include:

  • Information has been added on the North Carolina Department of Health and Human Services (NCDHHS) tobacco-free policy — effective January 1, 2027.
  • The Pharmacy Lock-in program criteria has been updated.
  • Prior Authorization webpage is the single source of truth for requirements.
  • Retrospective/post-service utilization management review information has been added.

Pharmacy Updates

The NC Medicaid Preferred Drug List (PDL) update took effect on October 1, 2025. The update included the elimination of NC Medicaid coverage for GLP-1s for the treatment of obesity. See the NCDHHS announcement here.

Bausch Health terminated their CMS Drug Rebate Agreement on October 1, 2025. Drugs manufactured by this company are no longer covered by Medicaid nationwide. This includes popular medications like Xifaxan. Bausch Health has set up a Patient Assistance program to help eligible patients in financial need obtain prescription products. Find out more on their website.

Post-Appointment Survey Provider Scorecard in NaviNet

The Post-Appointment Member Satisfaction Survey is one of the tools ACNC uses to evaluate the member care experience. This survey evaluates the comprehensive, quality and culturally responsive care members receive. Your commitment directly contributes to improving health outcomes and experiences for our members.

Scorecards will only be generated for provider groups who have received 10 or more member responses during a given reporting period. Providers can view their member satisfaction ratings through the Post-Appointment Survey Provider Scorecard, available in the NaviNet provider portal. To access this feature, log in and navigate to: Workflows for this Plan→ Report Inquiry→ Clinical Reports→ Post-Appointment Survey Provider Scorecard.

Scorecard refresh schedule

Scorecards will be refreshed twice annually — in August and February — based on calendar year reporting periods:

  • February: Covers member responses from July to December of the previous year
  • August: Covers member responses from January to June of the current year

If you have any questions, please contact your Provider Network Account Executive.

QUALITY CORNER

Antibiotics and Acute Bronchitis

According to the American Academy of Family Physicians (AAFP), a cough is the most common illness-related reason for ambulatory visits, and this is frequently diagnosed as acute bronchitis.

Acute bronchitis is mostly caused by viruses such as rhinovirus or enterovirus, where antibiotic management is not recommended for treatment.1 The National Committee for Quality Assurance (NCQA) Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB) measure states that “antibiotics are not indicated in clinical guidelines for treating with acute bronchitis who do not have a comorbidity or other infection for which antibiotics may be appropriate.”2

The Centers for Disease Control (CDC) provides guidance and talking points when speaking with patients about antibiotic use for acute bronchitis:

More information and educational resources on prescribing and using antibiotics can be found here: https://www.cdc.gov/antibiotic-use/index.html

[1] Scott Kinkade and Natalie Long, “Acute Bronchitis,” Am Fam Physician., Vol. 94, No. 7, 2016, pp. 560 - 565 https://www.aafp.org/pubs/afp/issues/2016/1001/p560.html

[2] “Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB),” NCQA, https://www.ncqa.org/report-cards/health-plans/state-of-health-care-quality-report/avoidance-of-antibiotic-treatment-for-acute-bronchitis-bronchiolitis-aab/#ref-3

Data Exchange Opportunities

ACNC strives to meet providers where they are and offers various methods to exchange quality data that supports care gap closure and top performance:

  • Data aggregator integration
  • Flat file submission
  • Direct EHR access
  • Clinical documentation upload via NaviNet

If you are interested in learning more about how you can share clinical quality data with us, please complete our 5-question survey at this link.

FREE CME for ECHO Behavioral Health Bootcamp

All types of providers are invited to participate in our No Cost ECHO Behavioral Health Boot Camp training series focused on engaging patients and members needing extra support. Sessions continue through December 10, 2025. Family practice clinicians, OB/GYNs, local health departments and/or federally qualified health centers (FQHCs) are encouraged to register.

Major topics include Differential Diagnosis and Treatment of Narcissistic Personality Disorder, Borderline Personality Disorder and Bipolar Disorder; Substance Use in the Adolescent Population; and Evidence-Based Treatment Models for Trauma in Children.

Find out more on our Behavioral Health webpage or register via email projectecho@amerihealthcaritas.com.

Exact Sciences Cologuard Now Available to Members

ACNC is working with Exact Sciences to offer Cologuard Test Kits for colorectal cancer screening to eligible members 45 or older at average risk for colon cancer who have gaps in care. This program aims to improve access to preventive screenings and help members manage their health proactively. Members will be identified based on their eligibility and need for screening and then sent a kit. Providers will receive test results directly from Exact Sciences.

ADMINISTRATION

Expectations for Home Health Electronic Visit Verification Are in Effect

As of October 1, 2025, home health care services (HHCS) providers offering the following services: home health aide services, physical therapy, occupational therapy, speech therapy, and skilled nursing visits are required to use EVV. As a reminder, claims submitted without the required EVV criteria are being denied. Providers can locate Service Codes Crosswalk with HCPCS (PDF) and Revenue Codes on our Home Health Electronic Visit Verification (EVV) website. 

The latest NCDHHS bulletin provides reminders and specific expectations. Visit our Provider Training webpage to register for office hours on Wednesday evenings for support.

Reminder to Include Prenatal and Postpartum Care (PPC) F Codes on Claims Submission

In accordance with NCDHHS policy 1E-5, claims are being denied if the 0500F code has not been submitted with the delivery claim or within 270 days prior to the delivery date.

NC Medicaid’s Obstetrical Services Clinical Coverage Policy No: 1E-5 (PDF) requires the use of two CPT billing codes for prenatal and postpartum care. These codes will assist in capturing information about the timeliness of prenatal and postpartum care provided to NC Medicaid members. The two F codes are 0500F for initial prenatal visits and 0503F for postpartum care visits. Both codes are defined in the NCQA HEDIS value sets and are meant to support more accurate and complete data collection around prenatal and postpartum care delivery in North Carolina.

After July 1, 2025, delivery claims (including global or package billing codes) submitted to NC Medicaid Direct and managed care plans will be denied without a code for 0500F (initial prenatal care visit) in the patient’s history, as defined by the revised NC Medicaid Obstetrical Services Clinical Coverage Policy.

Review the PPC F Codes Fact Sheet (PDF) and PPC F Codes Frequently Asked Questions (PDF) documents published by NCDHHS in July of 2024 for more detailed information or contact your Provider Network Management Account Executive.

Prior Authorization Lookup Tool

ACNC updates our prior authorization requirements based on guidance from the Centers for Medicare & Medicaid Services (CMS). Please note that our Prior Authorization Lookup Tool is updated quarterly as a convenient way to find out if a service needs prior authorization.  

MEMBER SPOTLIGHT

ACNC Adds Extra Benefits for Members

In response to member feedback, ACNC has added several offerings to our list of extra benefits for members. These benefits are offered in addition to their regular Medicaid benefits. Certain terms and conditions may apply. Visit our Extra Benefits webpage for more details.

The following items are now available for new moms and babies: 

  • Monthly rewards loaded to their CARE Card to purchase baby formula and diapers
  • Support for purchasing cribs or sheets
  • A free infant car seat, requested via the Member Intervention Request Form (PDF)

ACNC also offers $50 per school-age child (ages 5 – 18) per year for families to use to purchase school supplies.

Member Intervention Request Form for Specialty Referrals

ACNC’s Let Us Know program offers our providers an additional resource for member support with missed appointments, transportation services, education on a treatment plan or chronic condition, and assistance with value-added benefits. It also can be used to request assistance in locating a specialty provider.

Specialty providers include but are not limited to providers who offer care in behavioral health, cardiology, dermatology, hospice and palliative medicine, neurology and orthopedics. You can find member guidance on the How to Get Specialty Care on our website. Providers can complete a Member Intervention Request Form (PDF) form and fax to our Rapid Response Outreach Team at 1-833-816-2262.

Wellness & Opportunity Center Events in November

In addition to ongoing activities and educational programs for our members and the general community, our Wellness & Opportunity Centers located in Asheville, Greensboro, Charlotte, Fayetteville and Greenville, along with our Mobile Wellness and Opportunity Center will be supporting the Great American Smoke Out through a variety of events. Check out their event calendars in the Community section of our website.

Watch Demetrius’ Story About Smoking Cessation, and Share It With Your Patients*

In this video provided by NCDHHS, Demetrius talks about his journey with commercial tobacco addiction and pursuing tobacco-free recovery. What worked for him? Making connections and being honest with himself. ACNC offers the Quit for Life program to support members with tools, support and medication. Find out more at the Quit For Life website.

*Reprinted with permission from NCDHHS, Tobacco Ripple Effect Newsletter, September 5, 2025 

CYBERSECURITY

Avoid Scams: Can You Spot the Phish?

More than 3.4 billion phishing emails are sent out each day worldwide. But one factor can make life much harder for scammers: You. As the first line of defense, it is important that you are able to recognize and report a suspected phishing email.

What is phishing?

Phishing scams are emails that look real, but they are designed to steal important information. A phishing email with malicious software can allow cybercriminals to take control of your computer and put protected health information (PHI) and personal identifiable information (PII), as well as your organization’s confidential and proprietary information, at risk.

Beware of ransomware

In addition to stealing information, phishing scams can lead to ransomware attacks. Ransomware is a form of malware designed to encrypt files on a device, rendering them unusable until a ransom is paid. It may be a phishing email if it:

  • Promises something of value (e.g., “Win a free gift card!”)
  • Asks for money or donations
  • Comes from a sender or company you don’t recognize
  • Links to a site that is different than the company the sender claims to be from
  • Asks you for personal information, such as your username and password/passphrase
  • Includes misspelled words in the site’s URL address or subject line
  • Has a sense of urgency for you to act now

What you should do

If you receive a suspicious email:

  • Do not click any links in the email.
  • Do not provide your username and password; you should never share your username or password, even if you recognize the source. Phishing scams frequently mimic well-known companies, such as banks or retailers like Target or Amazon.
  • Do not reply/respond to the email or forward it to anyone else within your organization.
  • Familiarize yourself with your organization’s process for reporting suspicious emails. If you suspect an email is a phishing attempt, report it immediately.
  • Your organization's information security department may have additional information and guidance on how to protect yourself from phishing scams.