May 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 May digest:

• Claims and Billing Quick Reference Guide 

PHARMACY NEWS

• Biosimilar Preferred Drug List Update

ON THE ROAD WITH OUR PROVIDERS

• North Carolina Obstetrical & Gynecological Society 2026 Annual Meeting Recap
• Provider Network Management Team Holds Provider Forum in Raleigh
• See You at These Upcoming Spring Conferences

ADMINISTRATION

• Let Us Know — Member Intervention Request Form Submission Options
• NaviNet Appeals Search Functionality Update
• ICD-10 Update
• Evidence-Based Clinical Guidelines and Utilization Management Criteria 

MEMBER BENEFITS SPOTLIGHT

• Non-Emergency Medical Transportation

QUALITY CORNER

• Providing Care for Patients Prescribed Antipsychotic Medications

Claims and Billing Quick Reference Guide 

Did you know that AmeriHealth Caritas North Carolina (ACNC) has a Claims and Billing Quick Reference Guide (PDF) on our Provider Tools and Resources webpage? This useful resource provides reminders, guidance and timelines to help you submit clean and accurate claims. By reviewing the Quick Reference Guide and providing the necessary information on your submitted claims, we can process them more quickly and efficiently, leading to prompt payment. 

Biosimilar Preferred Drug List Updates

The North Carolina Medicaid Preferred Drug List (PDL) categorizes brand name medications including Humira, Stelara and Actemra as non-preferred. The FDA-approved biosimilars and interchangeable biosimilars products (with prior authorization) are preferred medications on the NC Medicaid PDL.

Encouraging patients to use biosimilar products can save thousands of dollars per claim in the health care system while still providing high-quality, safe and effective medication to patients.

North Carolina Obstetrical & Gynecological Society 2026 Annual Meeting Recap

We enjoyed connecting with providers at the North Carolina Obstetrical & Gynecological Society (NCOGS) 2026 Annual Meeting held in Greensboro in April. Our account executives were on hand to discuss the Bright Start^® pregnancy program and other enhanced benefits we offer to pregnant members.   

Provider Network Management Team Holds Provider Forum in Raleigh

Provider office staff gathered in Raleigh on April 22 for a half-day event with our Provider Network Management (PNM) team. Attendees had the opportunity to learn about and discuss topics such as ACNC product expansion, claims and billing, quality initiatives and value-based programs. We also offered onsite claims support for attendees to resolve specific issues.

We will hold another series of Provider Forums beginning in August. Keep a lookout in upcoming issues of the Provider Digest, or visit the Provider Training webpage for registration information. 

See You at These Upcoming Spring Conferences

Find us across the state as we continue to sponsor several upcoming conferences this spring. Stop by our booth at the following conference to meet our team and register to win a gift basket. We hope to see you there!

Let Us Know — Member Intervention Request Form Submission Options

AmeriHealth Caritas North Carolina is committed to assisting health plan providers in engaging members to support their health and well-being. Our Member Intervention Request form (PDF) is an easy-to-complete, one-page form providers can use to let us know about members who need additional support for issues including, but not limited to:

• Missed appointments
• Infant car seats
• Medication noncompliance
• Understanding plan benefits
• Social determinants of health

Providers can submit the form in two ways:

1. Download the form from our website, fill it out and fax it to our Rapid Response and Outreach Team for prompt follow-up.
2. Complete and submit the form via NaviNet
   • Log in to the NaviNet Provider Portal.
   • Go to the Forms and Dashboards section under Workflows for AmeriHealth Caritas North Carolina.
   • Select the Member Intervention form link.
   • Fill out all relevant fields on the form.
   • Click Submit

Once submitted, the Member Intervention Request Form is routed directly to the Rapid Response and Outreach Team to address any identified concerns. A Care Connector from the Rapid Response and Outreach Team will contact the provider within 48 to 72 to confirm receipt and to ensure they understand the request. They will also reach out to the member.

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

NaviNet Appeals Search Functionality Update

Providers can access a status report for previously submitted appeals via the NaviNet Provider Portal. To view the report, select Report Inquiry from the Workflows for this Plan menu and then select Administrative Reports. From there, select Claims Appeal or Grievance Status Report from the dropdown menu.

ICD-10 Update

The Centers for Medicare & Medicaid Services released 80 new ICD-10 PCS codes effective April 1, 2026. These codes are for discharges and patient encounters occurring from April 1, 2026, through September 30, 2026. See the list and learn more on the CMS ICD-10 webpage.

Evidence-Based Clinical Guidelines and Utilization Management Criteria

ACNC provides comprehensive, outcome-driven health solutions for our members. Part of this approach means making it a priority to reduce unnecessary variations in care. We've used the latest scientific evidence and research to create clinical guidelines, which represent the most current professional standards.

While these guidelines are intended to inform, they aren't intended to replace a physician's clinical judgment. The physician remains responsible for determining the applicable treatment for everyone. Clinical guidelines and utilization management criteria are made available to members, practitioners and providers on the ACNC website. Members and practitioners may request copies of guidelines used for a medical necessity determination at any time using the following methods.

Utilization Management (UM) Criteria is available upon request and is most easily located on our website:

• Manuals, Policies and Forms webpage
• ACNC Clinical Resources webpage

If you are a practitioner without fax, email, or internet access:

• Call 1-833-900-2262 to reach our Utilization Management department.
• In person:
  AmeriHealth Caritas North Carolina
  5th Floor
  8041 Arco Corporate Drive
  Raleigh, NC 27617

Non-Emergency Medical Transportation

AmeriHealth Caritas North Carolina can arrange and pay for transportation to help members get to and from their appointments for Medicaid-covered care. As an added benefit, we also provide transportation to educational programming and events at our Wellness & Opportunity Centers. This service is at no cost to the member.

Members can call ACNC Member Services for help in making an appointment or use the ModivCare Mobile app. ACNC also provides gas reimbursement at current IRS rates for members who use their own car or have a caregiver, family member or friend drive them to an appointment. Find more details on the Transportation page of our website and please share with our members. Click below to watch a short video about the Transportation benefit on our YouTube Channel.

Providing Care for Patients Prescribed Antipsychotic Medications

There are three specific HEDIS^® measures that focus on antipsychotic medications with the aim of reducing and controlling symptoms while keeping side-effects at a minimum.

Best practices for measures specific to antipsychotic medications

• Ensure a baseline is collected. Then routinely refer members taking an antipsychotic medication to have their blood glucose or cholesterol checked at least annually.¹
• Educate patients and their families on the symptoms of new-onset diabetes and the importance of diabetes screening.²
• Encourage patients to engage in healthy lifestyle behaviors to help control side effects.³
• Regularly review the ongoing need for continued use of antipsychotic medications at provider visits.⁴
• Follow up with the patient’s parents/guardians to discuss diabetes screening and lab results and provide education.²

¹ “APM-E - Metabolic Monitoring for Children and Adolescents on Antipsychotics," Johns Hopkins Health Plans, 2025.
² “SSD - Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications,” Johns Hopkins Health Plans, 2026.
³ “Antipsychotic Medication," Center for Addiction and Mental Health, 2018.
^{4 “}APP - Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics,” Johns Hopkins Health Plans, 2017.