NC Medicaid Managed Care plans and NCCRA

As you may be aware the NC Medicaid Managed Care plans kicked off on July 1st.  We wanted to share some information about cardiovascular and pulmonary rehab coverage for these plans but encouraged you to contact your business office regarding your organizations participation with each plan.

In contacting United Healthcare Community Care for a patient we were told that both Cardiac (93797/93798)  and Pulmonary Rehabilitation (G0424/G0239) allow up to 15 sessions of therapy and no pre-authorization was needed.

In contacting Healthy Blue we were told that Cardiac rehabilitation must be pre-authorized and that we could suggested the number of therapy sessions we think are needed and that Clinical Review would either except or indicate the number of sessions allowed.  We were told there is no coverage for Pulmonary or Respiratory therapy.

In contacting WellCare we were told that Cardiac Rehabilitation(93797 and 93798) and Pulmonary Rehabilitation must be pre-authorized but Respiratory Therapy (G0239) did not require pre-authorization.

In contacting AmeriHealth Caritas they tell us that Cardiac Rehabilitation(93797/93798) does not require pre-authorization for participating providers but would require pre-authorization for non-participating providers. They could find no information for either Pulmonary Rehabilitation (G0424) or Respiratory Therapy (G0239) and suggested that those services would require pre-authorization.

We did not check with Carolina Complete Health or EBCI Tribal Option.

And NC Medicaid Direct is continuing with the traditional plan as it has been.

Below is are the links to the Health Plans.

Health plans
For health plan questions, or to learn more about covered services, contact the health plan.

This health plan is offered statewide.

UnitedHealthcare Community Plan
This health plan is offered statewide.

Healthy Blue
This health plan is offered statewide.

AmeriHealth Caritas
This health plan is offered statewide.

Carolina Complete Health
Carolina Complete Health is a provider-led entity offered to people who live in these counties: Alamance, Alexander, Anson, Bladen, Brunswick, Cabarrus, Caswell, Catawba, Chatham, Cleveland, Columbus, Cumberland, Durham, Franklin, Gaston, Granville, Harnett, Hoke, Iredell, Johnston, Lee, Lincoln, Mecklenburg, Montgomery, Moore, Nash, New Hanover, Orange, Pender, Person, Richmond, Robeson, Rowan, Sampson, Scotland, Stanly, Union, Vance, Wake, Warren, Wilson.

The Eastern Band of Cherokee Indians (EBCI) Tribal Option
The EBCI Tribal Option is for federally recognized tribal members or others who qualify for services through Indian Health Service (IHS) and live in Cherokee, Haywood, Graham, Jackson or Swain County or in a neighboring county of the 5-county region. As a member of the EBCI Tribal Option, you can still get services from any Medicaid or NC Health Choice provider.

NC Medicaid Direct
NC Medicaid Direct is for members who qualify.