September 25, 2024
The North Carolina Department of Health and Human Services has announced the extension of Tailored Plan launch flexibilities.
The following flexibilities have been extended:
| Policy Flexibility | Time Frame |
| Relax Medical Prior Authorization requirements* | July 1, 2024-Jan. 31, 2025 |
| Relax Pharmacy Prior Approval requirements | July 1, 2024-Jan. 31, 2025 |
| Non-Participating Providers Paid at Participating Rates | July 1, 2024-Jan. 31, 2025 |
| Non-Participating Providers Follow In-Network Prior Authorization Rules | Feb. 1, 2025-May 31, 2025 |
What is happening?
The NCDHHS announced extension of Tailored Plan launch flexibilities:
- Relax Medical Prior Authorization requirements*; time period July 1, 2024-Jan. 31, 2025This only applies to medical health services (physical, behavioral health and intellectual/developmental disability [I/DD] services), not pharmacy services.Partners Health Management will extend the No Prior Auth period for medical services (physical, behavioral health and I/DD services) rendered between July 1, 2024, and Jan. 31, 2025.This No Prior Auth period pertains to Partners behavioral health and intellectual/developmental disability providers, as well as physical health providers who have contracted with Partners through our physical health partner, Carolina Complete Health.*This exception does not apply to reviews for inpatient hospitalizations, Electroconvulsive Therapy (ECT) for Inpatient and Outpatient Children only, Personal Care Services requiring Electronic Visit Verification, and initial ICF-IID or Innovations, which should still occur during this time period. Refer to Partners Benefit Page for more information regarding prior authorization requirements.Providers are required to continue to maintain all required documentation per the applicable clinical coverage policy or service definition. If behavioral health claims have not been submitted for the services provided during the no-prior authorization period by Jan. 31, 2025, retroactive authorizations will need to be in place prior to Jan. 31, 2025.These flexibilities do not apply to NC Medicaid Direct or State-funded services. All services are subject to post-payment review.
Prior authorizations may be submitted through ProAuth, fax, email or phone:
- Behavioral Health Service Authorization Requests
Submit via ProAuth by selecting Behavioral diagnosis type
Email: BHIDDManualAuthorizations@PartnersBHM.org
Phone: 1-877-398-4145
- Physical Health Service Authorization Requests
Submit via ProAuth by selecting Physical diagnosis type
Fax:
Inpatient physical health fax: 336-527-3208.
Outpatient physical health fax: 704-884-2613.
Transplant fax: 866-753-5659.
Physician Administered Drug Program (PADP) fax: 704-772-4300
Email: PHManualAuthorization@PartnersBHM.org
Phone: 1-877-398-4145
- Relax Pharmacy Prior Approval requirements; time period July 1, 2024-Jan. 31, 2025
This only applies to pharmacy services, not medical services. For this requirement, plans are expected to:
-
- Honor existing Pharmacy Prior Approvals for the life of the Prior Approval
- Consider previous Prior Approval and current drug therapy when making coverage determinations
- NCDHHS and other vendors will send prior approvals to Tailored Plans.
- Non-Participating Providers Paid at Participating Rates; time period July 1, 2024-Jan. 31, 2025This applies to all medical (physical health, behavioral health and I/DD) providers and pharmacy providers.Medically necessary services will be reimbursed at 100% of the NC Medicaid fee-for-service rate for both in- and out-of-network providers through the end of this period.
- Non-Participating Providers Follow In-Network Prior Authorization Rules; time period from Feb. 1, 2025-May 31, 2025This applies to all medical (physical health and Tailored Plan) providers and pharmacy providers.Tailored Plans may not require any additional requirements (i.e., prior authorization and/or referral requirements) for out of network providers to provide services to Tailored Plans members. This means that the Tailored Plan must have mechanisms for out-of-network providers to provide services and to be paid for those services rendered.
Additional Flexibilities:
The following Tailored Plan flexibilities also will remain in effect through Jan. 31, 2025:
- Ability to Switch Primary Care Provider (PCP), from July 1, 2024-Jan. 31, 2025Members have an extended time to switch PCP without cause, which is longer than what is outlined in the TP contract.Tailored Plans must also notify members when their previous PCP joins the Tailored Plan’s network.
- Continuity of Care for Ongoing Course of Treatment, from July 1, 2024-Jan. 31, 2025Tailored Plans must continue medically necessary services for members in an ongoing course of treatment without any form of prior approval and without regard to whether such services are provided by in-network or out-of-network providers for at least six months.Tailored Plans are required to continue services for members in an ongoing course of treatment for at least six months unless the member/family has opted to discontinue such services or selects a provider that is in-network.
Who can providers contact if they have questions?
If providers have questions about prior authorizations, contact Partners Utilization Management department:
Behavioral Health, I/DD and TBI questions: UMQuestions@PartnersBHM.org
Physical Health questions: PHUMQuestions@PartnersBHM.org.
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