March 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 March digest:

PROVIDER UPDATES

• Plan Now for Participation in Our 2026 Value-Based Programs

PHARMACY NEWS 

• Medicaid Direct Pharmacy Benefit Manager Change Effective May 2

TRAINING AND LEARNING OPPORTUNITIES

• Registration Is Now Open for 2026 ACNC Provider Support Forums

MEMBER BENEFITS SPOTLIGHT

• New Member Benefit — Gym Membership
• Expectant Moms and Families Are Welcome at Regional Baby Showers

OPERATIONS AND ADMINISTRATION

• Circumcision Coverage Guidance

• Reminder: CMS Final Rule to Hasten Prior Authorization 

• Member Rights, Responsibilities and Privacy 

ON THE ROAD WITH OUR PROVIDERS

• Find Us Out and About During Spring Conference Season

QUALITY CORNER

• Colorectal Cancer Screenings

Plan Now for Participation in Our 2026 Value-Based Programs  

A new suite of value-based payment programs will kick off on July 1 for in-network providers. ACNC’s PerformPlus^® programs offer financial incentives to participating providers to deliver high-quality, cost-effective and timely care to our members. Providers are required to submit health data for specific quality measures so we can track members’ health outcomes. In 2025, ACNC recognized more than 800 distinct providers through value-based programs.

The 2026 programs include:

1.  PerformPlus^® Shared Savings Program — Primary Care Providers (PDF) (underway)

2. PerformPlus^® Gaps in Care for Maternity Care (PDF) (beginning July 1, 2026)

3. PerformPlus^® Gaps in Care for Behavioral Health Providers (PDF) (beginning July 1, 2026)

4. PerformPlus^® Gaps in Care for Primary Care Physicians (PDF) (beginning July 1, 2026)

For more information about how your practice can benefit, visit the Value-Based Program webpage or contact your Provider Account Executive. 

Medicaid Direct Pharmacy Benefit Manager Change Effective May 2 

The NC Department of Health and Human Services has awarded a contract to Prime Therapeutics, LLC., to implement a new Pharmacy Benefits Administrator (PBA) solution for NC Medicaid Direct. The PBA will go live on Saturday May 2, 2026. Beginning on this date, all NC Medicaid Direct Pharmacy claims will be adjudicated through Prime’s system.

NC Medicaid is encouraging pharmacies to participate in pre-go-live testing before April 17, 2026. To register and receive test claim information, please email PharmacyTesting@primetherapeutics.com and include contact name, phone number, Pharmacy National Provider Identifier (NPI), and switch vendor information.

Please note: this transition applies only to NC Medicaid Direct and does not impact NC Medicaid Managed Care

Registration Is Now Open for 2026 ACNC Provider Support Forums  

We are excited to kick off our 2026 Provider Support Forum spring series with half-day events in Charlotte, Asheville and Raleigh. These sessions are hosted by our Provider Network Management team and are a great opportunity for in-person support for your office staff to learn about policies, benefits and quality initiatives, as well as ACNC product expansion and value-based programs. We also offer on-site claims support to help with resolving issues you may be experiencing. A second round of Provider Forums will begin in August. 

Sessions are held from 9:00 a.m. until noon. Register now! 

New Member Benefit — Gym Membership

ACNC is now offering a standard monthly fitness club membership to eligible members 18 years and older. Members must have had a wellness visit with their primary care provider and have completed a care needs screening in the past 12 months to be eligible. The Active&Fit network includes locations across the state. For more details, visit our Extra Benefits for Members webpage under Wellness and Care Management or contact your Provider Account Executive.

Expectant Moms and Families Are Welcome at Regional Baby Showers 

ACNC continues to focus on improving maternal health outcomes, especially among moms of color, by hosting regional community baby showers for hundreds of moms and families across the state. Our Quality Team partners with our Wellness & Opportunity Centers and other community agencies to host events to educate, empower and support expecting and new moms and their families.

We encourage you to promote these events among your patients and are happy to provide you with flyers or registration information. If your practice is interested in partnering with us or participating in one of the baby showers, please reach out your Provider Account Executive or call the Provider Services department at 1-888-738-0004.

Circumcision Coverage Guidance 

While circumcision coverage under Medicaid has changed over time, circumcision is currently a covered benefit without prior authorization when deemed medically necessary. ACNC covers circumcision in ambulatory surgery centers, inpatient, outpatient and office settings in compliance with NC Medicaid Policy 1 A-22, “Medically Necessary Circumcision (PDF). Please contact your Provider Account Executive if you have questions or encounter issues with circumcision claims or reimbursement.

Reminder: CMS Final Rule to Hasten Prior Authorization Process 

The Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS0057F) established updated prior authorization standards to advance timely access to care, streamline data exchange and reduce administrative burden across the health care system. As such, ACNC is required to send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests for medical items and services as of January 1, 2026. 

Providers will continue to be responsible for obtaining prior authorizations for services prior to scheduling by submitting clinical information, as needed, to support medical necessity of the requests. We can help you save time and receive quicker determinations for prior authorization requests when you complete the prior authorization form completely and submit all pertinent patient information and doctor notes that support the request. Requests will not be processed if they are missing clinical information or CPT and ICD-10 codes. As a reminder, authorization is not a guarantee of payment; payment is subject to benefit coverage rules, including member eligibility and any contractual limitation in effect at the time of service.

Please contact your Provider Account Executive with questions.

Member Rights, Responsibilities and Privacy 

As a reminder, ACNC, our network providers, and other service providers may not discriminate against members based on race, color, national origin, age, disability, creed, religious affiliation, ancestry, sex, gender identity or expression, sexual orientation or any other basis prohibited by law. Please review the Your Rights, Responsibilities and Privacy section on our website or the Member Rights and Responsibilities section on page 54 of the AmeriHealth Caritas North Carolina Member Handbook.

Find Us Out and About During Spring Conference Season 

The weather is warming up, and we are hitting the road! We are sponsoring several conferences this spring, and we hope to see you there. Stop by our booth at the following conference to meet our team and register to win a gift basket!

Colorectal Cancer Screenings 

In recognition of National Colorectal Cancer Awareness Month observed in March, providers are encouraged to educate patients on the importance of early detection through routine screenings. The Colorectal Cancer Screening (COL-E) measure assesses the percentage of adults ages 45 to 75 who had an appropriate screening for colorectal cancer. Colorectal cancer typically “develops from precancerous polyps (abnormal growths) in the colon or rectum.”¹

Colorectal cancer screenings should start at age 45. “Regular screenings can lead to the detection and removal of polyps before they develop into cancer.”¹

Best practices for the COL-E measure: ^2,3,4 

• Share educational materials on the importance of early detection and regular screenings. 
• Provide information on other screening options other than a colonoscopy, such as fecal occult blood test (FOBT), fecal immunochemical test (FIT) and multiple-target stool DNA test (mt-sDNA).
  • Cologuard (mt-sDNA) can be performed every three years, whereas FIT can be performed annually.
• Assist with scheduling appointments for screening at time of referral.
• Deploy automated interventions, such as reminder calls or text messages.
• Submit claims and documentation in a timely manner.
• Consider electronic medical records (EMR) reminders for preventive health maintenance.
• Use the reports available to you in NaviNet, such as the Gap Closure Reports, to identify patients in need of colorectal cancer screening.

Common chart deficiencies:⁵

• Member-reported data not captured within history in chart with sufficient information to show the screening was completed in the measurement year time frame.
• Not documenting correct billing codes. 
• Failure to track previous screenings.
• Documentation is not clear about screening type.
• Insufficient team-based approaches to help with screening, such as using nurses or medical assistants to trigger reminders, which limits the ability to prompt patients to schedule screenings.

For questions, please contact your Provider Account Executive. If you are interested in partnering with ACNC on improving quality outcomes, please contact ACNC Quality Management at  ACNCQualityManagement@amerihealthcaritas.com.

¹ Cho, Samantha, "HEDIS Measures for Health Plans: Colorectal Cancer Screening," Let’s Get Checked, February 18, 2026.
² “American Cancer Society Guideline for Colorectal Cancer Screening," American Cancer Society, February 18, 2026.
³ Shailavi Jain et al., "Optimal Strategies for Colorectal Cancer Screening," Current Treatment Options in Oncology, Vol. 23, No. 4, March 22, 2022.
⁴ "North Carolina’s Medicaid Quality Measurement Technical Specifications Manual: Measurement Year 2026," North Carolina Department of Health and Human Services, February 18, 2026.
⁵ Carmen Guerra, "Barriers of and Facilitators to Physician Recommendation of Colorectal Cancer Screening," Journal of General Internal Medicine, Vol. 22, No. 12, October 16, 2007.