Issued: March 21, 2023
Effective April 1, 2023, Partners Medicaid benefit plan will transition to NC Medicaid Direct. Partners is implementing NC Medicaid Direct flexibilities effective April 1-June 30, 2023 to ease administrative burden for providers.
What is happening?
Partners is relaxing prior authorization requirements for NC Medicaid Direct services for dates of service April 1-June 30, 2023.
These flexibilities do not apply to State Funded services. Services are subject to post-payment review.
When is this happening?
April 1, 2023
How is this impacting providers?
- NC Medicaid Direct prior authorization requirements will be relaxed for dates of service April 1-June 30, 2023.
- Partners will allow retrospective authorizations for NC Medicaid Direct Services* April 1-June 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 June 30, 2023 to avoid claim denials.
- Initial or concurrent authorizations for NC Medicaid Direct services starting April 1-June 30, 2023 must be entered into ProAuth by June 30, 2023 to be reviewed for medical necessity.
- Current Medicaid services authorized beyond March 31, 2023 will be transitioned by Partners UM into NC Medicaid Direct authorizations starting April 1, 2023 with prorated units and retain original end date.
- 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 June 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.