In this bulletin:
Physical Health Provider Updates
Partners’ Behavioral Health and Intellectual/Developmental Disabilities Tailored Plan collaborates with Carolina Complete Health (CCH) to support physical health providers participating in the Tailored Plan. The Partners/CCH Special Bulletin offers valuable guidance on enrollment, claims processing, authorizations and compliance requirements.
Prior Authorization Changes
Effective April 1, 2026, the following Radiology and Diagnostic Cardiology (RBM) procedures were removed from Evolent’s Utilization Review Matrix and no longer require prior authorization for participating providers. Prior authorization is still required for non-participating providers.
| Procedure | CPT |
| CT ORBIT/EAR/FOSSA WITH O DYE | 70480, 70481, 70482 |
| CT MAXLOFACE AREA; W/O CONTRAST MATL | 70487, 70488, 70486, 76380 |
| DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX W/O CNTRST | 71250, 71260, 71270, 71271 |
| CT UPPER EXTREMITY WITH O DYE | 73200, 73201, 73202 |
| MRI UPPER EXTREMITY WITH O AND WITH DYE | 73218, 73219, 73220 |
| CT LOWER EXTREMITY WITH O DYE | 73700, 73701, 73702 |
| CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST | 75557, 75561 |
| CT HRT WITH 3D IMAGE CONGEN | 75573 |
| MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL | 77046, 77047, 77048, 77049 |
| CT BONE MINERL DENSITY STUDY 1/> SITS AXIAL SKE | 77078 |
| MRI BONE MARROW BLOOD SUPPLY | 77084 |
| GATED HEART PLANAR SINGLE | 78472, 78473, 78494 |
| ECHOCARDPHRY RL TM W/2D W/WO M-MODE, TRANSOESOPHAGEAL | 93312, 93313, 93314, 93315, 93316, 93317, 93318 |
Additional prior authorization changes took effect April 1, 2026, to streamline administrative processes, reduce provider burden and improve timely access to care for members.
| Service Category | Prior Authorization Requirement | Procedure Codes/Notes |
| Durable Medical Equipment (DME) | No PA required for PAR providers | Neurostimulators: E0730 Wheelchairs: E0950, E0956 |
| DME: Nutritional Services | No PA required for members under age 21; PA required for all others | B4100 |
| Physician Services | PA required | 95700, 95711, 95718, 95720, 95721, 95722, 95723, 95724, 95725, 95726 |
| Skin Procedures | PA required after 12 visits per calendar year | 11043 |
| Skin Grafts | PA required when billed with a diagnosis of gender dysphoria; otherwise, PA required for non-PAR providers only | 14060, 14061, 15100, 15101, 15120 |
| Surgery – Musculoskeletal System | No PA required for PAR providers | 29848 |
| Surgery – Nervous System | No PA required for PAR providers | 64721 |
| Surgery – Nervous System | PA required | 64568 |
| Surgery – Respiratory System | PA required | 30130, 30140, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276 |
| Other Surgical Procedures | PA required | 30460 |
Definitive drug testing prior authorization changes took effect Feb. 1, 2026. Prior authorization is required for G0481 and for G0480 when more than twelve tests are performed for a member within a calendar year. Prior authorization continues to be required for G0482–G0483.
| Procedure code
(Number of drugs/classes tested in one encounter) |
Previous Authorization Requirements | Current Authorization Requirements
(Effective Feb. 1, 2026) |
| G0480 (1-7) | PA not required | PA required after 12 tests for PAR providers.
PA required for non-PAR for all testing. |
| G0481 (8-14) | PA not required | PA required |
| G0482 (15-21) | PA required | PA required |
| G0483 (22+) | PA required | PA required |
Please review associated clinical coverage policies from NC Medicaid and CCH for more details:
- Drug Testing for Opioid Treatment and Controlled Substance Monitoring (1S‑8)
- Drugs of Abuse: Definitive Testing (NC.CP.MP.50)
To determine if prior authorization is required and to confirm where to submit the authorization, providers should use Partners Health Management’s Prior Authorization Lookup Tool.
UM Vendor Changes
As a reminder, on April 1, 2026, Partners and CCH updated utilization management vendors for the following services. Review the information below for details that may affect your practice for Partners Tailored Plan members.
| Service | Current Vendor | Future Vendor | Vendor Information |
| Radiation Oncology | None | Evolent: Effective no earlier than May 1, 2026 | RADMD | Radiation Oncology |
| Musculoskeletal Surgery | None | Evolent: Effective April 1, 2026 | RADMD | Musculoskeletal Surgery (MSK) |
| Interventional Pain Management | None | Evolent: Effective April 1, 2026 | RADMD | Interventional Pain Management (IPM) |
| Cardiovascular Procedures | None | TurningPoint: Effective May 1, 2026 | My Turning Point Healthcare |
| Genetic Testing | None | EviCore: Effective no earlier than May 1, 2026 | Homepage | EviCore by Evernorth |
| Advanced Imaging | Evolent | Evolent (no change) | Radiology | Evolent |
New ICD-10 Codes Introduced
The Centers for Medicare and Medicaid Services (CMS) implemented 80 new ICD‑10 procedure codes effective April 1, 2026. Providers are required to use the updated ICD‑10 codes for applicable discharges and encounters on or after this date to avoid potential claim delays or denials.
The complete list of new ICD‑10‑PCS codes is available on the CMS ICD‑10 webpage.
Interoperability Update
Partners will implement CMS-required changes effective July 1, 2026, as outlined in the UM Update: Partners to Implement SAR Changes to Better Align with CMS, published Sept. 5, 2025.
CMS published the Interoperability and Prior Authorization Final Rule (CMS-0057-F). The rule establishes new timeframes for prior authorization decisions in state Medicaid and Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs. The CMS requirements mandate that:
- Expedited (urgent) requests must receive a decision within 72 hours.
- Standard (non-urgent) requests must receive a decision within seven calendar days.
To support timely processing and meet turnaround time requirements, providers are expected to submit complete, accurate and error-free Service Authorization Requests (SARs). Doing so helps ensure a smooth Utilization Management review and allows the services needed to be implemented without delay.
Providers are encouraged to review Partners Provider Communication Bulletin #148 for more background on requests for additional information expectations.
Provider Training and Office Hours
Partners and CCH host office hours for Partners Tailored Plan physical health providers on the first Tuesday of each month at noon.
Providers are encouraged to register and submit questions in advance.
Archived sessions are available on CCH’s Partners Tailored Plan Provider Resources page.
Questions
For more information related to Physical Health Utilization Management, contact PHUMQuestions@PartnersBHM.org.
Xifaxan Update
Effective Oct. 1, 2025, Xifaxan (rifaximin) is no longer covered by NC Medicaid because the manufacturer no longer participates in the Medicaid Drug Rebate Program. Providers are encouraged to review the NC Medicaid update for more information and alternative options.
Prescribers with patients who are currently taking Xifaxan may request access through the patient assistance program on the Bausch Health Companies, Inc. website. Because the application requires clinical information, providers should work with members to complete the application.
Current Service Needs
Partners has identified the following service gaps. Providers are needed across our 15-county service area. For details, forms and updates, visit the Current Service Needs page.
Priority Service Gaps
Substance Abuse Non-Medical Community Residential Treatment (Adult): This service provides a 24-hour structured, safe and stable living environment for adults with substance use disorders (SUD) who have significant social and psychological challenges affecting recovery. Services are tailored to a beneficiary’s level of readiness to change and focus on developing recovery skills to prevent relapse and support transition to a less intensive level of care. Beneficiaries may present with justice system involvement, co-occurring mental illness and impaired functioning. This service is needed for NC Medicaid Direct, Tailored Plan and State-Funded Services.
Clinically Managed Residential Withdrawal Services (Adult): Clinically managed residential withdrawal services, also referred to as a social setting detoxification, are organized, facility-based services that provide 24-hour supervision, observation and support for adults who are intoxicated or experiencing withdrawal. Services are delivered by appropriately trained staff and focus on monitoring, stabilization and referral to ongoing treatment as needed. This service is needed for NC Medicaid Direct and Tailored Plan.
Ongoing Needs
- Multidisciplinary Evaluation (MDE) Court-ordered, comprehensive assessments for guardianship proceedings (medical, psychological, social work; other disciplines as needed).
- Psychological Evaluation and Interpretation Standardized testing and interpretation to inform treatment selection and planning; may include psychosocial assessments and goal-directed psychotherapy for children and adolescents.
How to Participate
- Review requirements and next steps on the Current Service Needs page.
- Already in Partners’ network? Complete the Provider Change Form.
- Not yet in the network? Submit the Request for Consideration Form.
- NCTracks required: Your agency, NPI, taxonomy, sites and clinicians must be enrolled in NCTracks to contract with Partners and make contract changes.
Pop Health Survey
Providers are encouraged to help promote the new Population Health Member Survey and help members to participate. Reponses will help Partners better understand member needs and improve our programs and services.
For more information, visit the Prevention and Population Health webpage.
NC-TOPPS Survey
Last month, Partners emailed a brief follow-up survey to providers who registered for one of the NC-TOPPS Focus Groups held from October through December 2025.
This is a reminder to complete the survey before the end of April, even if you registered for a focus group but were unable to attend. The survey should take less than five minutes to complete. If you did not receive the survey, you may access the NC-TOPPS Focus Group survey 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 the Partners Claims staff.
- Once requested, 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 seen an increase in claims reconsideration requests 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, 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 must have Microsoft Teams screen-sharing capabilities for more specific and in-depth training.
State Benefit Health Plans
Providers now have the option to request appropriate State Benefit Health Plans (AMI, ASTER, etc.) with a future date. Providers may request this 60 days prior to the current end date.
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 (SUD) and intellectual/developmental disabilities (I/DD). 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 the trainings here.
Recent Provider Alerts
- April 13, 2026: PH UM Update: PA Changes for Certain Radiology and Diagnostic Cardiology Procedures
- April 8, 2026: Physical Health UM Update: Reminder of Definitive Drug Testing Prior Authorization Updates Effective Feb. 1, 2026
- April 7, 2026: UM Update: SARs for SAIOP and Ambulatory Withdrawal Management Services
- April 6, 2026: Important Rate Information Effective July 1, 2026
- March 27, 2026: IRIS System down April 1
- March 26, 2026: Issues with March 24 Remittance Advice
- March 23, 2026: UM Update: Late Submissions on Service Authorization Requests (SARs)
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.
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 the 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.
Hypertension
May 1, 2026 | 10 a.m. – noon (Register)
This training provides an 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.
Darkness to Light: Child Safety Foundations
The Darkness to Light training provides education about child sexual abuse and the steps you can take to prevent, recognize and react responsibly to child sexual abuse; participants learn proactive steps to protect children from this significant risk.
- Conversations About Safety from Abuse
May 1, 2026 | noon – 1 p.m. (Register)
This evidence-informed training discusses preventing, recognizing and reacting responsibly to child sexual abuse. Learn ways to confidently talk with children and listen to their concerns about sexual abuse and personal safety. This training is one hour. - Consent, Healthy Touch and Boundaries
May 8, 2026 | noon – 1 p.m. (Register)
This evidence-informed training helps participants learn healthy affection and touch are key in protecting children from sexual abuse, especially from parents, caregivers and family members. Learn appropriate guidelines for healthy touch and how to interact with children in safe, respectful ways. This training is one hour. - From Bystanders to Upstanders
May 15, 2026 | noon – 1 p.m. (Register)
Learn to become an upstander who chooses to act when they see warning signs, boundary violations or moments where children may be vulnerable. This training teaches participants practical skills for protecting children. This training is one hour. - Preventing Child Sex Trafficking
May 22, 2026 | 10 a.m. – noon (Register)
Child sex trafficking, also known as commercial sexual exploitation of children (CSEC), is any sexual activity involving a child for which something of value is given or promised. This training teaches participants about the root cause of CSEC and why preventing sexual abuse is important to reducing the risk of children being sexually trafficked. This training is for 1.5 hours.
Human Trafficking
May 5, 2026 | 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 resources to keep our children safe.
Mental Health 101
May 6, 2026 | 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. The training also includes information about treatment and what to do in a crisis.
Non-Suicidal Self-Injury Lunch and Learn
May 7, 2026 | 2 – 4 p.m. (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.
Women’s Health
May 8, 2026 | 10 a.m. – noon (Register)
During this training we will discuss women’s health topics across the lifespan from adolescent to senior years. The focus of this training is to highlight the cumulative experience of reproductive, physical and mental health for women.
Nutritional Impact on Mental Health
May 12, 2026 | 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.
Partners Member Café
May 12, 2026 | 1 – 2 p.m. (Register)
Partners Member Café is held the second Tuesday of each month. The topic will be the National Day for Awareness of Missing and Murdered Indigenous Women and Girls and Domestic Violence. Join us for this virtual event to learn about the importance of this national awareness day and how it impacts our tribal communities from subject matter expert, Shelby Holland. Pam Navey will be with us to share her expertise on domestic violence and how it touches our communities.
Understanding Grief
May 12, 2026 | 2 – 4 p.m. (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.
Active Listening/De-escalation
May 13, 2026 | 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.
Trauma Part One: Introduction to Trauma and Resilience
May 13, 2026 | 2 – 4 p.m. (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 its effects and develop resilience.
Maternal Mental Health
May 14, 2026 | 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.
Diabetes 101
May 15, 2026 | 10 a.m. – noon (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.
Question, Persuade, Refer (QPR) Suicide Prevention
May 18, 2026 | 2 – 4 p.m. (Register)
This evidence-based training teaches the skills to recognize warning signs of suicide and intervene in a suicide crisis. “Ask a question, save a life.” *Disponible en Español.
Emotional Intelligence (EQ) Essentials
May 20, 2026 | 10 a.m. – noon. (Register)
This training introduces the core components of emotional intelligence and teaches practical skills to manage emotions, improve communication and build strong relationships in daily life and work.
Substance Use: Overview, Recovery & Resources
May 20, 2026 | 2 – 4 p.m. (Register)
This training explains substance use disorder, its health impacts and the effects of common substances. Participants learn how to recognize signs, support recovery and connect people with helpful local and online resources.
Domestic Violence: How to Help
May 13, 2026 | 10 a.m. – noon (Register)
Many of us are still at home more than usual, and the risk for domestic violence is high. Learn how to spot the warning signs of domestic violence and how to help someone in a violent situation. This training is for three hours.
Deinfluencing Social Media: Connected, Not Consumed
May 21, 2026 | 10 a.m. – noon (Register)
This training explores how social media influences mental health, relationships, communication and community well-being. Participants will examine the positive and negative impacts of social media use, including misinformation, comparison culture, polarization and emotional regulation, along with practical strategies for healthier engagement.
Community Resiliency Model (CRM)®
May 21, 2026 | 2 – 4 p.m. (Register)
The Community Resiliency Model® (CRM) teaches participants about the impact of trauma and chronic stress on the nervous system, behaviors and long-term health. Participants learn how to reset the nervous system with easy-to-learn, concrete coping skills, resulting in resilient communities.
Partners Community Café
May 27, 2026 | 10 – 11 a.m. (Register)
Join us for our monthly Community Café: The Stories We Carry: Trauma Across a Lifetime. The café will host a panel discussion about the impact of trauma across our lifetimes. Panelists will answer questions about the impact of trauma and what can be done to lessen that impact.
Caring for the Caregiver
May 28, 2026 | 10 a.m. – noon (Register)
Caring for a loved one can be meaningful, but it can also be physically and emotionally exhausting. This training explores the signs and symptoms of burnout, common stressors and the impact of prolonged stress on overall well-being. Participants will gain practical tools for setting healthy boundaries, managing stress and sustaining themselves while continuing to care for others.
Introduction to Child and Family Team (CFT)
June 17, 2026 | 9 a.m. – 4 p.m. & June 18, 2026 | 9 a.m. – 4 p.m. (Register)
This System of Care training is a two-day, 11-hour experiential training. Child and Family Team training provides an overview from the family’s perspective. The training seeks to reinforce the idea of “one family, one plan” by addressing CFT through the lens of multiple systems. Offered quarterly either virtually or in-person.