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Provider Communication Bulletin #168

In This Bulletin:

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ID Cards and PCP Changes

Partners reminds providers of the process for member ID card and primary care provider (PCP) changes.

  • Tailored Plan (TP) Members: Members can request a new ID card or change PCPs through the MemberCONNECT portal or the Partners website. Tailored Plan ID cards are paper and arrive in envelopes with red lettering that signals important health information.
  • NC Medicaid Direct Members: Members must contact the NC Medicaid Contact Center at 1-888-245-0179 or their local DSS office for ID card or PCP changes.

Both Tailored Plan and NC Medicaid Direct members may change PCPs without cause up to two times per year. Changes with cause are allowed at any time.

PDL Changes Coming Oct. 1, 2025

GLP-1 Medications:

Effective Oct. 1, 2025, Wegovy, Zepbound and Saxenda will be removed from the Preferred Drug List (PDL) for weight management, as directed by NC Medicaid. Saxenda will no longer be covered for any indication.

  • Preferred alternatives for obesity treatment include diethylpropion, phendimetrazine and phentermine. These products do not require prior authorization.
  • Wegovy and Zepbound require prior authorization for specific FDA-approved indications:
    • Wegovy: To reduce cardiovascular risk in adults with cardiovascular disease who are obese or to treat noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced fibrosis.
    • Zepbound: To treat moderate to severe obstructive sleep apnea (OSA) in adults with obesity.

Prior Authorization Requirements:

  • All current prior authorizations for Wegovy and Zepbound will expire Sept. 30, 2025.
  • New prior authorization requests may be submitted starting Oct. 1, 2025, using clinical criteria posted on NCTracks.
  • Coverage for GLP-1 medications for diabetes is unchanged.

Read more: NC Medicaid to Change Coverage for GLP-1 Weight Management Medications

ADHD Medications:

Effective Oct. 1, 2025, the following medications will be non-preferred and require prior authorization, documenting trial and failure of two preferred products:

  • Adderall XR Capsule (brand)
  • Apetensio XR Capsule (brand)
  • Concerta Tablet (brand)
  • Focalin XR Capsule (brand)
  • Methylphenidate ER Capsules (generic for Apetensio XR)

The updated PDL will be available Oct. 1, 2025, on the NC Medicaid Preferred Drug List.

Insulin Products:

Effective Oct. 1, 2025, the following medications will be non-preferred and require prior authorization after documenting trial and failure of at least one preferred insulin:

  • Humalog U-100 Cartridge, Junior Kwikpen, Kwikpen, Vial
  • Humalog 50/50 Mix Kwikpen
  • Humalog 75/25 Vial (brand)
  • Novolog U-100 Prefill, Flexpen, Vial
  • Novolog 70/30 Mix Vial, Flexpen (brand)
  • Levemir Vial, Flexpen, Flextouch (brand)

Spravato® (Esketamine) Nasal Spray
Spravato® is indicated for treatment-resistant depression in adults (as monotherapy or with an oral antidepressant) and for depressive symptoms in adults with major depressive disorder and acute suicidal ideation or behavior.

  • Spravato® is covered through the Physician Administered Drug Program (PADP). Criteria and prescribing details are available in the PADP Catalog.
  • Authorization requests may be submitted through ProviderCONNECT or via fax to 704-772-4300. Forms are available at Partners Prior Authorization Submissions.
  • Prescribers may contact Partners’ Utilization Management team at PHUMQuestions@PartnersBHM.org for assistance.

Important REMS information
A Risk Evaluation and Mitigation Strategy (REMS) is required to ensure Spravato® is used safely. Prescribers, healthcare settings and pharmacies must be REMS certified. Only certified pharmacies may dispense the drug to certified clinics or institutions. Details are available on the Spravato® REMS Fact Sheet.

Additional Outpatient Therapy

Providers may not bill Medicaid for outpatient therapy if a member is already receiving services that include therapy, such as Level III Residential Treatment, Intensive In-Home Services, Community Support Team (CST), Substance Abuse Intensive Outpatient Treatment (SAIOP) and Substance Abuse Comprehensive Outpatient Treatment (SACOT), unless the additional therapy meetings Early and Periodic Screening, Diagnosis and Treatment (EPSDT) criteria.

When EPSDT May Apply:

Additional individual, group or family therapy may be covered if it is medically necessary to correct or improve a condition identified by a licensed practitioner. Documentation must show:

  • How additional therapy is distinct from therapy already included in another service
  • Why is it medically necessary for the member
  • How it will improve, maintain or prevent worsening of the member’s health, consistent with EPSDT criteria (scope, amount, duration and frequency may exceed standard limits when justified)

Compliance reminder:

Billing duplicate therapy without meeting EPSDT requirements may result in overpayment recovery.

Report concerns:

To report suspected fraud, waste or abuse, call the Partners Regulatory Compliance Alert Line at 1-866-806-8777 or submit a My Compliance Report.

NC-TOPPS Focus Pilot

Partners invites mental health/substance use disorder (MH/SUD) providers to participate in NC-TOPPS focus groups beginning in October 2025. These sessions are designed to gather candid feedback, answer questions and share network updates.

Session Dates (1-2 p.m.):

  • Oct. 10 and 24
  • Nov. 6 and 20
  • Dec. 1 and 15

Sessions will be held virtually via Teams. A meeting link will be emailed the day before each session. Register through Partners Training Resource and Collaborative.

GCQI Provider Participation Opportunity

Partners is seeking greater mental health/substance use disorder (MH/SUD) and intellectual/developmental disabilities (I/DD) provider participation in the Global Continuous Quality Improvement (GCQI) Committee. The GCQI Committee works to:

  • Standardize quality improvement efforts
  • Improve accessibility, effectiveness and efficiency of services
  • Develop strategies to enhance health and well-being in integrated physical and behavioral health
  • Share resources, tools and outcome measures
  • Identify service gaps and training needs

GCQI is committed to collaboration, mutual respect and a member-focused approach. Provider representatives may be anyone involved in quality initiatives who is willing to share and learn with peers.

The committee meets quarterly and is provider-led by elected MH/SUD and I/DD co-chairs. Providers are encouraged to participate in this important quality effort.

Clinical Coverage Policies

Utilization Management uses clinical coverage policies to administer benefits and determine medical necessity. Service definitions and clinical policies guide when and how services are covered for physical health, behavioral health, substance use disorders, and intellectual/developmental disabilities. Read more on the Service Definitions page on the Partners Provider Knowledge Base. For questions, email UMQuestions@PartnersBHM.org.

IRIS Incident Reporting Reminders

All providers of publicly funded services are required to submit Level II and Level III incident reports in the North Carolina Incident Response Improvement Center (IRIS) within 72 hours of becoming aware of the event. This applies to:

  • Category A Providers: Providers of publicly funded services licensed under NC General Statutes 122C, except hospitals.
  • Category B Providers: Providers of publicly funded non-licensed periodic or community-based mental health, developmentally disabled and/or substance abuse services.

Read the full requirements and access trainings here.

Claims Information

Note to Providers: Partners has observed an increase in claims status inquiries from clearinghouses. Providers using a clearinghouse for claim reconciliation must ensure that their staff have access to remittance advice.

Explanation of Benefits (EOB) Requests for Coordination of Benefits Claims

Partners requests copies of the Explanation of Benefits members/claims submitted with Coordination of Benefits. The request will be sent via email from Partners Claims staff.

  • Once requested, please submit the information via secured email prior to the date specified in the request.
  • If a response is not received, the original claim payment will be recouped.

Claims Submission Reminders

  • Each benefit plan must be submitted on separate claims.
  • Ensure all diagnosis codes are included in claims. To help Partners measure member health, identify areas of risk and evaluate the quality of care.
  • Physical Health Paper Claims – mail to:
    Partners Health Management
    Attn: Claims
    PO Box 8002
    Farmington, MO 63640-8002

Physical Health Claims Processing

Partners Health Management has partnered with Availity®, an independent company, to manage electronic data interchange (EDI) and portal transactions with Carolina Complete Health for Physical Health Claims processing:

  • This change took effect July 1, 2024
  • Providers can now access Availity® in ProviderCONNECT under the “Physical Health Claims” Quick Links box.

Avoid Delays: Follow the Correct Claims Reconsideration Process
We’ve noticed an increase in claims reconsideration requests being sent to the Provider Dispute Email, which can delay processing. To ensure your request is managed quickly and correctly, follow the Claims Reconsideration Process outlined on our website.

  • Do not send reconsideration requests to the dispute inbox.
  • Follow the steps listed under the “Claims Reconsideration Process” section on the Claims and Rates Information page.

For all claims-related questions, providers are reminded to contact the Claims Department at ClaimsDepartment@PartnersBHM.org. To avoid delays in receiving a response, please do not contact individual claims staff directly.

Member/Recipient Eligibility and Enrollment

For eligibility and enrollment questions, providers are encouraged to contact the Eligibility and Enrollment Department at eligibilityenrollment@partnersbhm.org.

To request enrollment, providers should visit Alpha+ Home Page > Enrollments. For guidance, refer to University > Provider Portal Handbook > Enrollments.

If additional enrollment training is needed, email eligibilityenrollment@partnersbhm.org to schedule one-on-one training. Please note that providers will need to have Microsoft Teams screen sharing capabilities for more specific and in-depth training.

Recent Provider Alerts

Training Resource and Collaborative (TRAC)

TRAC offers a centralized cross-functional selection of required training, collaboratives and events. TRAC provides a centralized hub for cross-functional required training, collaboratives and events.

Please note: the way you register for TRAC trainings and meetings has recently changed.

Click here to view what is coming up and register.

 

Live Virtual Provider Trainings

To view the currently available training courses and register, visit the TRAC Provider Training webpage. Email Training@PartnersBHM.org for accommodation requests.

  • Acceptance and Commitment Therapy (ACT)
    Explore ACT’s six core processes for developing psychological flexibility and using the ACT Matrix to help clients’ value-driven actions. This training is approved by the North Carolina Substance Abuse Professional Practice Board (NCSAPPB) for six hours.
  • Becoming an Ally for LGBTQ Clients
    Gain knowledge and strategies to effectively support LGBTQ+ individuals and promote affirming environments.
  • CBT Learning Community
    Join us for live, virtual 90-minute trainings on the third Wednesday of each month, now featuring rotating topics that strengthen Cognitive Behavioral Therapy (CBT) skills, support self-care and improve quality of care. Training topics include Core Principles of Dialectical Behavioral Therapy (DBT), Core Principles Acceptance and Commitment Therapy (ACT), Core Principles of Trauma Informed Care and Seeking Safety, Core Principles of Mindfulness, Motivational Interviewing (MI) for Substance Use Behaviors and MI for Holistic Health and Well-being. These practical, evidence-based sessions are ideal for busy professionals.
  • Connecting Community Support Team and Permanent Supportive Housing (CST-PSH) Training
    Learn the CST-PSH evidence-based model for tenancy support services. This training fulfills North Carolina Service Definition requirements for 15 hours.
  • Dialectical Behavior Therapy (DBT) for Complex Cases
    Understand and apply DBT techniques to treat complex mental health cases. Approved for 6 NCSAPPB hours.
  • HIV & Ethics
    Stay updated on HIV diagnosis and treatment trends while exploring ethical decision-making and social determinants of health. Approved for six NCSAPPB hours (three HIV, three Ethics).
  • Illness Management and Recovery (IMR)
    Develop skills to support recovery and manage mental illness using evidence-based strategies. Approved for six NCSAPPB hours.
  • Mindfulness and Recovery Training
    Discover mindfulness techniques for stress management and recovery in mental health and substance use. Approved for six NCSAPPB hours.
  • Motivational Interviewing Training
    Learn the fundamentals of Motivational Interviewing (MI) to support client behavior change. This 13-hour training meets North Carolina Service Definition requirements.
  • NCSNAP Training
    For forms, schedules, and instructions, email Training@PartnersBHM.org.
  • Person Centered Thinking (PCT) 3-Day Training
    Engage in interactive exercises and discussions to support people with disabilities. Approved for 12 contact hours.
  • Trauma Informed Care and Seeking Safety
    Learn principles of trauma-informed care and the Seeking Safety program for addressing trauma and substance use. Approved for six NCSAPPB hours.
  • Trauma Informed Interventions for People Who Support I/DD Members
    Explore trauma’s impact on individuals with I/DD and learn trauma-informed strategies.
  • Treating SUD During the Modern Opioid Epidemic
    Examine the opioid epidemic’s scope and explore evidence-based treatments, including medication and CBT. Approved for six NCSAPPB hours.
  • Twelve Step Facilitation Training
    Review TSF principles, treatment models, and recovery pathways for substance use disorders. Approved for six NCSAPPB hours.

Live Virtual Provider Collaboratives and Meetings

To view the currently available training courses and register, visit the TRAC Provider Training webpage. Email Training@PartnersBHM.org for accommodation requests.

  • Autism Services Learning Collaborative
    Engage with Utilization Management to discuss service updates and essential information.
  • Global Continuous Quality Improvement Meeting
    Collaborate with providers, the Provider Advisory Council and stakeholders to develop quality improvement strategies and measurable outcomes that enhance integrated health services and care quality.
  • I/DD Breakout Meeting (Bi-Monthly)
    This bi-monthly meeting provides updates for contracted Intellectual/Developmental Disabilities (I/DD) providers and is a subgroup of the Partners Provider Council. All I/DD providers are welcome to attend. To submit questions or topics for discussion, please contact your Provider Council representative.
    Note: AI notetaking or recording is not permitted. Meeting presentations are shared with attendees and through the Provider Council after each session. To register, visit the Partners Training Resource and Collaborative.
  • Long Term Community Supports (LTCS) Collaborative
    Discuss the implementation of Medicaid In-Lieu of Service – Long Term Community Supports (LTCS), address barriers to service access, and ensure service continuity and quality for members.
  • Partners Provider Forum
    Stay updated with quarterly vital information and updates tailored for providers.
  • Provider DEI Collaborative
    Engage in discussions on diversity, equity, and inclusion (DEI) to promote health equity and improve outcomes. Providers’ perspectives are vital for fostering actionable strategies for integrated care.
  • Provider Open House
    A quarterly virtual event for new and existing providers to address questions and receive support, including one-on-one training opportunities. Providers with state funding contracts are encouraged to attend.

On-Demand Behavioral Health Provider Training

  • 1915(i) State Plan Amendment Training (1:09:45)
    Overview of 1915(i) services. Includes Q&A.
  • Client-Specific Training Webinar (June 2024)
    Topic-specific training for providers.
  • Crisis Response Training (3 hours)
    Comprehensive guide to crisis intervention strategies. Contact hours available.
  • Critical Incident Reporting (CIRT/IRIS) (15:20)
    Training on incident reporting procedures.
  • Community Support Team (CST) Service Definition (3 hours)
    Behavioral health support for severe mental illness. Meets CST Service Definition requirements. Three contact hours available.
  • Employer of Record Webinar (27:37)
    Covers EOR monitoring, documentation, and quality management. No CE credits available.
  • Enhanced Rate Request Webinar (25:58)
    Step-by-step ERR form completion and cost finding instructions. No CE credits available.
  • Health Disparities: A Tribal Perspective (29:12)
    Explores health disparities among tribal populations and Medicaid’s role. No CE credits available.
  • Peer Support Services (PSS) Service Definition Webinar (42:29)
  • Person Centered Plan (PCP) Documentation Training Apr 2025 (51:20)
  • Plan of Correction Webinar 2024 (10:16)
    Training on crafting effective plans of correction.
  • Tobacco-Free Recovery (4:45)
    Encourages tobacco-free practices for better health outcomes.

 On-Demand Physical Health Provider Training

  • Partners-CCH Physical Health Office Hours April 2025 (1:08:35)
  • Partners-CCH Physical Health Office Hours March 2025 (1:07:24)
  • Partners-CCH Physical Health Office Hours September 2024 (24:34)
    Handout available at registration
  • June 2024 Tailored Plan EVV Info Session (11:32)
    Covers Electronic Visit Verification requirements. Includes FAQ.
  • May 2024 Physical Health Providers Update (40:36)
    Updates on tailored plans and care management. Includes FAQ.
  • March 2024 Physical Health Providers Update (56:31)
    Collaboration strategies between providers and Partners Health Management.

ProviderCONNECT On-Demand Trainings

  • ProAuth Demonstration Video April 2024
    The new system requires providers to log in to ProviderCONNECT to submit authorization requests. Since launch, Partners has identified some common questions among providers on how to access or use the system.
  • User Navigation Guide Video
    Introduction to ProviderCONNECT portal features.
  • LA Non-Utilizer Report Video
    Guides administrators on maintaining user accounts.
  • Secure Messages Video
    Instructions on secure communication via ProviderCONNECT.
  • Document Manager Video
    Guide to using the Document Manager for file sharing and management.
  • SysAid2 Service Ticket Overview Video (8 minutes)
    Overview of the service ticket system.

Tailored Plan Provider On-Demand Trainings

The North Carolina Department of Health and Human Services (NCDHHS) requires the listed training courses to be available for providers. This applies to Tailored Plan, Medicaid Direct and State-funded providers. Registering is easy. You will be prompted to enter simple registration information. The on-demand training will then be available immediately or when your schedule allows. Note: Training Reciprocity Among Tailored Plans. NCDHHS is allowing the six LME/MCOs reciprocity for some Tailored Plan-required training courses.

All on-demand training courses can be accessed through PartnersTraining.org.

  • CLAS Standards (35:55)
    Reviews culturally and linguistically appropriate services (CLAS) standards for health equity and cultural competence. No CE credits available.
  • Due Process (33:07)
    Covers four dispute types: Medicaid appeals, non-Medicaid appeals, Provider disputes, and Grievances. No CE credits available.
  • EPSDT (18:26)
    Explores EPSDT requirements, periodicity schedules, diagnostic/treatment components, and service coordination. No CE credits available.
  • Fraud, Waste, and Abuse (20:47)
    Overview of compliance, regulatory programs, and the impact of fraud, waste, and abuse on healthcare. No CE credits available.
  • Into the Mouths of Babes (4:10)
    Focuses on oral health services for Medicaid-insured children. Required for reimbursement eligibility. No CE credits available.
  • Hand Washing & PPE (12:40)
    Infection control training emphasizing handwashing and personal protective equipment (PPE). No CE credits available.
  • Infection Control: Community Care Settings (8:53)
    Focus on infection transmission, precautions, and member education in community care. No CE credits available.
  • Infection Control: Home Care Settings (9:55)
    Highlights infection control procedures in home care settings. No CE credits available.
  • Prevention & Population Health Management (18:52)
    Discusses Partners’ health improvement approach, program goals and provider expectations. No CE credits available.

Community Training

All Trainings are Virtual via Zoom and are two hours unless otherwise specified. Participants may not be admitted to the training if joining more than 15 minutes after training begins. Participants who request a certificate will need to be on-camera during the training.

For more information contact: Amber Matthews, AMatthews@PartnersBHM.org.

Trauma Part 1: Introduction to Trauma and Resilience  
Oct. 1, 2025 | 10 a.m.–noon (Register)
Most of us have experienced trauma at some time. This can have a lasting effect on our learning, behavior and health. Learn about trauma, how to address the effects and develop resilience.

Nutritional Impact on Mental Health      
Oct. 3, 2025 | 10 a.m.–noon (Register)
Join us for an insightful training on the intricate relationship between eating behaviors and mental health. This interactive training will explore how our dietary choices and habits can profoundly influence our mental well-being, emphasizing the crucial connection between nutrition and mental health.

Human Trafficking: Keeping Our Children Safe   
Oct. 7, 2025 | 10 a.m.–noon (Register)
Human Trafficking is a global problem, even in the United States. Children may be susceptible to online predators. Learn about trafficking around the world and some ideas about how to keep our children safe. This training addresses sexting briefly.

Maternal Mental Health
Oct. 8, 2025 | 10 a.m.–noon (Register)
This training delves into the nuances of maternal mental health, perinatal mood disorders and practical tools for support. Explore the essential intersection of mental health, pregnancy/postpartum care and social determinants of health while gaining insights that contribute to creating a nurturing environment for mothers.

Mental Health 101
Oct. 9, 2025 | 10 a.m.–noon (Register)
Learn about mental wellness, potential signs and symptoms of mental health challenges and some of the common behavioral health disorders. This training also includes information about treatment and what to do in a crisis.

Diabetes 101
Oct. 9, 2025 |2-4 p.m. (Register)
The Diabetes 101 training provides a comprehensive overview of diabetes, including its types, signs, symptoms, risk factors and potential complications. Participants will gain knowledge about diabetes prevention, self-management strategies and valuable resources to support those affected by the condition.

Stress Management
Oct. 10, 2025 | 10 a.m.–noon (Register) 
We’re all stressed! Many of us are balancing jobs, school, family, finances and more. Let’s get together and talk about ways we can manage our stress and have a little fun.

Question, Persuade, Refer (QPR) Suicide Prevention  
Oct. 13, 2025 |2-4 p.m. (Register)
This evidence-based training teaches the skills to recognize warning clues of suicide and intervene in a suicide crisis. “Ask a question, safe a life.” *The maximum number of people allowed to participate in a virtual QPR training at one time is 30; registration is on a first-come, first-served basis.

Partners Member Café
Oct. 14, 2025 | 1-2 p.m. (Register)
Partners Member Café is held the second Tuesday of each month. Grab a cup of coffee, sit down, and join us virtually to get to know us and learn how we can help you. Ask us questions about the resources and services you need and who to call. We look forward to seeing you!

Hypertension                   
Oct. 14, 2025 | 2-4 p.m. (Register)
This training provides overview of high blood pressure, including prevention, early detection, risk factors and complications. Participants learn self-management strategies and how to use community and online resources to support heart health.

Active Listening/De-Escalation   
Oct. 15, 2025 | 10 a.m.–noon (Register)
This training focuses on active listening skills, empathy, and habits to keep yourself and other people safe. There will be a discussion about how our own experiences impact our ability to assist others in high-stress situations.

Non-Suicidal Self-Injury
Oct. 21, 2025 | 10 a.m.–noon (Register)
Learn about Non-Suicidal Self-Injury, what causes people to injure themselves, warning indicators and what we can do when we encounter someone who self-injures.

Community Resiliency Model (CRM)®
Oct. 21, 2025 | 2-4 p.m. (Register)                                         
The Community Resilience Model (CRM)® teaches participants about the impact of trauma and chronic stress on the nervous system, behavior and long-term health. Participants learn how to reset the nervous system with easy-to-learn, concrete coping skills. One of the goals of CRM is to create trauma-informed and resilient communities.

Partners Community Café     
Oct. 22, 2025 | 10 a.m.–11 a.m. (Register)
We will recognize Breast Cancer Awareness Month this month. A variety of speakers will address diagnosis, treatment options and support for those are affected by breast cancer.

Understanding Grief
Oct. 24, 2025 |10 a.m.–noon (Register)
Are you experiencing grief, or do you know someone who is grieving? In this training, you will learn about the various causes, phases and other information related to the grieving process.

Substance Use Disorder: Overview, Recovery and Resources
Oct. 28, 2025 | 2-4 p.m. (Register)
This training provides an overview of substance use disorder, including its effects on mental and physical health, while identifying specific substances and their impacts. Participants will gain valuable insights into recognizing substance-related challenges and accessing helpful resources. Join us to explore practical strategies for supporting individuals impacted by substance use disorder.

Trauma Part 2: Trauma-Informed Care       
Oct. 30, 2025 | 10 a.m.–2 p.m. (Register)
We will look at how our behavior affects others who have a history of trauma. Learn about the elements of trauma-informed care. A childcare-specific version is available on request.

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