North Carolina
Effective April 1, 2023, NC Health Choice beneficiaries automatically moved to the NC Medicaid program.
Beneficiaries ages 0-3 and fully qualified legal immigrants who are in NC Medicaid Direct will be enrolled in the Local Management Entities/Managed Care Organizations (LME/MCOs). LME/MCOs manage the care of NC Medicaid Direct beneficiaries who receive behavioral health services (services for mental health, developmental disabilities or substance use disorders).
Contact information:
North Carolina (NC) Health Choice Provider Services:
800-753-3224
Carelon Behavioral Health Automated Faxback Service:
877-339-8758
Please note that faxes sent to any other number will not be honored by NC Health Choice.
Forms and information:
NC Medicaid is Moving to Managed Care
For guidance on navigating this transition, including how to submit a Prior Authorization for members served under NC Medicaid Managed Care, please visit the NC Department of Health and Human Service (DHHS) Providers webpage .
For additional resources regarding NC Medicaid policies, procedures and services:
Division of Mental Health, Developmental Disabilities and Substance Abuse Services
Program Specific Clinical Coverage Policies
Additional resources
Effective April 1, 2023, beneficiaries ages 0-3 and fully qualified legal immigrants who are in NC Medicaid Direct will be enrolled in the Local Management Entities/Managed Care Organizations (LME/MCOs). LME/MCOs manage the care of NC Medicaid Direct beneficiaries who receive behavioral health services (services for mental health, developmental disabilities or substance use disorders).
As a result of this change, most prior authorizations for behavioral health services for these beneficiaries (except for Cumberland Hospital and Children’s Development Services Agency (CDSA) services) will no longer be submitted to Carelon Behavioral Health.
Contact information:
North Carolina (NC) Medicaid Provider Services, NC Public Sector Provider Service Department, and Carelon Behavioral Health’s Customer Service:
Monday to Friday, 8:00 a.m. to 6:00 p.m. Eastern time
888-510-1150
Carelon Behavioral Health Automated Faxback Service
866-409-5958
Information and resources:
ProviderConnect
Authorization requests must be submitted via ProviderConnect . Providers are encouraged to submit any current clinical information to support the medical necessity of the request, in addition to the required documentation outlined by the North Carolina Division of Health Benefits. Additional documentation may consist of Child and Family Team notes, summary of Care Review, copies of assessments/evaluations, etc.
NC Medicaid is Moving to Managed Care
For guidance on navigating this transition, including how to submit a Prior Authorization for members served under NC Medicaid Managed Care, please visit the NC Department of Health and Human Service (DHHS) Providers webpage .
Outpatient Services
For beneficiaries under 21, the first 16 visits of the fiscal year are unmanaged and do not require preauthorization. For beneficiaries 21 and over, the first 8 visits of the fiscal year are unmanaged and do not require preauthorization.
When it is not known if a beneficiary has used all of the unmanaged visits, submit a request for authorization to Carelon Behavioral Health. Service Orders are required to be submitted with all outpatient service requests. The service order is required to be updated annually.
Retrospective Reviews
Carelon Behavioral Health conducts retrospective reviews for individuals who do not have verifiable, active Medicaid at the time of admission to a service, but who subsequently are approved for Medicaid covering the date of service. Applicable medical records must be either attached to the Retrospective ProviderConnect request or sent to Carelon Behavioral Health by mail to:
Carelon Behavioral Health
Retrospective Review Department
P.O. Box 13907
RTP, NC 27709-13907
Carelon Behavioral Health has 60 days to review the request upon receipt of complete information. To ensure prompt processing, please provide both the beginning date and the ending date of the period you would like reviewed.
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services
Carelon Behavioral Health conducts medical necessity reviews for beneficiaries under the age of 21, when services are requested that are not covered in the North Carolina State Plan. Service limitations on scope, amount, or frequency described in the coverage policy may not apply if the service is medically necessary.
A Person-Centered Plan is required to be updated for EPSDT requests.
Customer Service/Provider Relations
Providers may submit consumer-specific inquiries to Customer Service 24 hours a day, seven days a week via ProviderConnect. Such inquiries will receive an electronic response that will appear in the Inbox of Your Message Center on ProviderConnect.
Regarding inquiry escalation, a provider not satisfied with a response to, or the handling of, an inquiry should gather pertinent information, call Customer Service, and simply ask to speak to a Customer Services supervisor to resolve the issue.
Other forms and links:
Provider Change Attestation Form
Use the Provider Change Attestation Form to request provider change only for those Medicaid beneficiaries who have appealed an adverse decision, or whose provider agency is going out of business, or are changing providers for another service with an authorization period of six months or more.
For additional resources regarding NC Medicaid policies, procedures and services:
Division of Mental Health, Developmental Disabilities and Substance Abuse Services
Today we are Carelon Behavioral Health, but when some of these materials were developed, we were Beacon Health Options.
