August 2026 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 in NaviNet to providers.

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You will find the following topics in this digest:

TOP NEWS

• ACNC Welcomes New Director of Provider Network Management
• Your Voice Matters

ADMINISTRATION

• Let Us Know — Member Intervention Form Now Available in NaviNet
• Vendor Transition for Retrospective Review Services

MEMBER BENEFITS SPOTLIGHT

• Updated CARE Card Rewards Promote Preventive Care

VALUE-BASED CARE

• Earn Incentives While Improving Care Gaps

ON THE ROAD WITH ACNC

• Market President’s Visit to Asheville
• Stop By and See Us at the August North Carolina Pediatric Society Annual Meeting
• Take Advantage of Provider Drop-in Hours at Our Wellness Centers

EDUCATION AND TRAINING

• Register to Attend the North Carolina Standard Plan Annual Quality Forum Webinar

QUALITY CORNER

• Understand the Prenatal Immunization Status Measure

POPULATION HEALTH

• Population Health Programs Provide Integrated Care to Members

ACNC Welcomes New Director of Provider Network Management

Robert Coble joined ACNC in July as Director of Provider Network Management. In this role, Robert develops and manages provider relationships to help optimize performance. He brings to ACNC more than 10 years of experience in provider engagement, network performance and strategic program development.

Your Voice Matters

Your practice may receive an invitation to complete our annual satisfaction survey. The online survey will take about 15 minutes to complete. Your answers will help guide administrative and operational improvements to our health plan. If you receive an invitation by mail, please scan the QR code in the letter to complete the web-based survey.

Let Us Know — Member Intervention Form Now Available in NaviNet

Providers can Let Us Know if a member requires support by completing the Member Intervention form and faxing it to our Rapid Response and Outreach Team or by submitting the form via the NaviNet provider portal. The form can be used to assist members with issues such as behavioral health needs, medication noncompliance, care management engagement, social determinants of health and other identified needs or interventions. 

To submit the Member Intervention form in NaviNet:

1. Log in to the NaviNet provider portal.
2. Go to the Forms and Dashboards section under Workflows.
3. Select the Member Intervention form link.
4. Fill out all relevant fields on the form and click Submit.
5. After submission, a confirmation message will appear: Member intervention form Submitted.

Once submitted by fax or through NaviNet, the Member Intervention form is routed directly to the Rapid Response and Outreach Team to address any identified concerns. A Care Connector will contact the provider within 48 to 72 hours to confirm receipt and to ensure understanding of the request. Outreach will then be made to the member. Upon completion of the referred intervention, the provider will be notified of the outcome.

For questions or help with completing the form, contact the Rapid Response and Outreach Team at 1-833-808-2262.

Vendor Transition for Retrospective Review Services

AmeriHealth Caritas is enhancing its retrospective review operations to improve accuracy and efficiency. As part of this effort, we are updating our vendor partnerships supporting retrospective data mining and complex chart review activities. You may begin receiving medical record requests or communications from these vendors. All vendors will operate in accordance with AmeriHealth Caritas policies and regulatory requirements. There is no change to providers’ contractual obligations.

In June 2026, ACNC began transitioning services previously performed by Cotiviti to a combination of existing and new vendor partners:

HMS Gainwell (expansion of existing services)

• Scope: Retrospective Data Mining Services (previously performed by Cotiviti)
• Effective date: June 19, 2026
• Status: Existing AmeriHealth Caritas vendor (currently supporting third-party liability [TPL]/coordination of benefits [COB] services)
• Provider impact: Minimal — This represents an expansion of services already in place.
• Customer Service: 833-907-0661

Apixio (a Machinify Company) (new vendor)

• Scope: Retrospective Complex Chart Review
• Effective date: July 17, 2026
• Status: New vendor to the AmeriHealth Caritas network
• Customer Service: 844-308-3781

Codoxo (new vendor)

• Scope: Second-Pass Retrospective Complex Chart Review and Data Mining
• Role: Provides an additional layer of review after HMS Gainwell and Apixio to support a thorough and consistent evaluation process
• Effective date: August 14, 2026
• Status: New vendor to the AmeriHealth Caritas network
• Customer Service: 866-270-1951

Reminder: Please follow the instructions in the letters and requests you receive for medical record submission.

Updated CARE Card Rewards Program Promotes Preventive Care

ACNC has updated our CARE Card incentives for members to better align with plan and provider priorities for members to get regular preventive care. The CARE Card is a prepaid debit card that members can use to purchase food, medical supplies and over-the-counter medicines at selected retailers. The new incentives include rewards for infant well visits, annual mammograms and diabetic eye exams. Based on North Carolina Department of Health and Human Services (NCDHHS) guidelines, member incentive payments cannot exceed $75 per member per year.

For the latest CARE Card incentive details, visit the CARE Card Rewards Program webpage.

Earn Incentives While Improving Care Gaps

With ACNC’s recently launched gaps-in-care value-based programs (VBP), providers have an opportunity to strengthen quality performance while earning incentives tied to improved member outcomes in behavioral health, maternity care and primary care.

PerformPlus^® Behavioral Health Gaps in Care
The behavioral health VBP focuses on mental health follow-up care and antipsychotic adherence and monitoring. Providers are eligible to receive a per-gap-closure incentive of $350 once a year for each member assigned to their practice who meets the population and compliance criteria.

PerformPlus^® Gaps in Care for Maternity Care
The maternity care VBP focuses on postpartum care and cervical cancer screening quality measures. Providers are eligible to receive a per-gap-closure incentive of $250 once a year for each member attributed to their practice.

PerformPlus^® Gaps in Care for Primary Care Physicians
The primary care VBP focuses on chronic disease, immunizations and well-child visit improvement measures. Eligible providers will receive a per-gap-closure incentive of $250 once a year for each member assigned to their practice who meets the population and compliance criteria.

Strong collaboration between providers and ACNC can improve patient outcomes, enhance quality performance and support success in value-based care programs. ACNC provides tools and resources to help providers close care gaps, improve HEDIS performance and maximize value-based program opportunities.

For questions or more information, please contact your Account Executive.

Stop By and See Us at the August North Carolina Pediatric Society Annual Meeting

ACNC is pleased to sponsor the Networking Lounge at the North Carolina Pediatric Society 2026 Annual Meeting, taking place August 28 – 30 in Durham, North Carolina. In addition to our Networking Lounge sponsorship, we will also have an exhibit. Stop by the Networking Lounge in the Rotunda Room for a special treat from our team, and be sure to visit our booth in the exhibit hall and register to win a gift basket!

Take Advantage of Provider Drop-in Hours at Our Wellness Centers

Get one-on-one support for your billing, claims, value-based program and other provider-related questions at monthly Provider Network Management office hours. Stop by our local regional Wellness & Opportunity Center between 10:00 a.m. and 2:00 p.m. to meet with an account executive. No appointment is needed.

For more information or questions, contact your Provider Account Executive. We hope you drop in at an upcoming session!

Register to Attend the North Carolina Standard Plan Annual Quality Forum Webinar

Join the North Carolina Department of Health and Human Services (NCDHHS) on Wednesday, October 14, from 11:00 a.m. to 1:00 p.m. for the NC Standard Plan Annual Quality Forum Virtual Webinar. This year’s forum will focus on women’s health and Early and Periodic Screening, Diagnostic and Treatment (EPSDT). The interactive webinar will feature a provider panel sharing best practices in women’s health. Even if you cannot attend live, register to receive the slides and recording when they become available.

Understanding the Prenatal Immunization Status Measure

The Prenatal Immunization Status (PRS-E) HEDIS^® measure is the percentage of deliveries in the measurement period in which persons received influenza and tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccinations.

Influenza:

• Deliveries where persons received an adult influenza vaccine on or between July 1 of the year prior to the measurement period and the delivery date, or
• Deliveries where persons had anaphylaxis due to the influenza vaccine on or before the delivery date

Tdap:

• Deliveries where persons received at least one Tdap vaccine during the pregnancy (including on the delivery date), or
• Deliveries where people had either of the following:
  • Anaphylaxis due to the diphtheria, tetanus or pertussis vaccine on or before the delivery date
  • Encephalitis due to the diphtheria, tetanus or pertussis vaccine on or before the delivery date

Best practices to meet the Prenatal Immunization Status (PRS-E) measure:

• Discuss vaccines during the first prenatal visit to create a schedule that optimizes immunization timing during pregnancy.
• Make vaccination as easy as possible for patients, ideally ensuring vaccine availability in the same location that they get prenatal care.
• Give the influenza vaccine before influenza begins circulating in the community when possible; however, vaccination is recommended at any point during flu season to help protect patients while the virus is circulating.
• Stay current on vaccine recommendations, educate and encourage patients to get vaccinated, and use office systems that make vaccination part of routine practice workflows.

For more information refer to the American College of Obstetricians and Gynecologists recently released 2026 Maternal Immunization Schedule.

Population Health Programs Provide Integrated Care to Members

ACNC’s Population Health programs utilize a person-centered approach to improve health outcomes by providing additional support to members with special health care needs, behavioral health conditions, and certain chronic conditions. Providers are encouraged to refer members to these no-cost care management programs for conditions such as asthma, diabetes, pregnancy, tobacco use or other identified needs.

These programs include interactive contact with members. Learn more about these special programs on our website or use our Member Intervention Request form to refer a member to a program. You may also call the Rapid Response and Outreach Team at 1-833-808-2262 for additional assistance.