Medical Billing in North Carolina

What is specific to North Carolina

North Carolina moved most Medicaid members into managed care plans while keeping NC Medicaid Direct for certain populations, and Blue Cross NC remains the largest commercial payer statewide.

North Carolina’s Medicaid programme is North Carolina Medicaid. Practices with a meaningful North Carolina Medicaid mix usually need it worked as its own queue rather than mixed into commercial follow-up, because the submission path, the timely filing window and the appeal route are all different.

What a medical billing seat does in North Carolina

Aged accounts receivable called until they close, and denials read, appealed and tracked.

In North Carolina the queue that costs the most is North Carolina Medicaid: 365 days from the first date of service (except inpatient and nursing facility claims), and a claim past that date is unpayable rather than late.

• Worklist worked from the difficult end, not the easy end
• Every call logged with the payer reference and the outcome
• Denials categorised so the same reason stops recurring
• Appeals written and submitted, not just re-bills
• Weekly written summary of what moved and what did not
• Worked during North Carolina business hours, not queued overnight

Most of the North Carolina work we see comes out of Charlotte, Raleigh and Greensboro, though nothing about a seat depends on where your office is — the queue is worked through your system, not from your building.

North Carolina borders 4 states, and practices near those lines almost always carry at least one out-of-state Medicaid enrollment. That is a separate portal, a separate filing window and a separate appeal route from North Carolina Medicaid, and it is the queue that most often goes unworked because it belongs to nobody.

What North Carolina law gives you

30 calendar days after receipt of a claim, for both electronic and paper. The receipt date differs by channel: electronic claims are deemed received the day transmitted, mailed claims the fifth business day after mailing.

Source.

North Carolina Medicaid, in practice

Managed care through Prepaid Health Plans: four Standard Plans (AmeriHealth Caritas North Carolina, Healthy Blue of North Carolina, and UnitedHealthcare of North Carolina statewide, plus Carolina Complete Health in Regions 3, 4 and 5), a statewide Children and Families Specialty Plan (Healthy Blue Care Together), four Behavioral Health/IDD Tailored Plans (Alliance, Partners, Trillium, Vaya), and the EBCI Tribal Option. Source

North Carolina carves federally recognized tribal members and other IHS-eligible patients out of the Standard Plans into the EBCI Tribal Option — a Primary Care Case Management entity created and operated by the Cherokee Indian Hospital Authority, not a commercial payer. No other state Medicaid program has a tribally operated PCCM entity of this kind, and provider questions route to Provider.Services@cherokeehospital.org rather than a PHP provider line. Source

On the commercial side the dominant Blue plan here trades as Blue Cross and Blue Shield of North Carolina (Blue Cross NC), which matters mainly because its portal and its appeal route are the ones your seat will spend the most time in. Source

How long you have to file a North Carolina Medicaid claim

365 days from the first date of service (except inpatient and nursing facility claims). Not stated on the page quoted.

“Medicaid claims, except inpatient claims and nursing facility claims, must be received by NCTracks within 365 days of the first date of service to be accepted for processing and payment.” NC Medicaid — Claims and Billing

A claim past that date is not late, it is unpayable, and no appeal recovers it. It is the one queue where a week of nobody working it is money that does not come back — which is the argument for working North Carolina Medicaid as its own queue rather than mixing it into commercial follow-up. Every state’s limit is listed here.

Working North Carolina hours

North Carolina runs on Eastern time, 10 hours behind our floor in Rawalpindi. To be at a desk for your nine to five, the shift here runs 7pm to 3am, and 6pm to 2am once the clocks go forward. Pakistan does not observe daylight saving, so the shift moves on this side rather than yours.

That is the part that decides whether follow-up happens at all: a payer’s phone lines are open on North Carolina hours and nobody else’s.

What it costs in North Carolina

$1,700

Per seat, per month, in US dollars — $20,400 a year for one full-time person, forty hours a week, on North Carolina hours. No annual contract, no percentage of collections, no setup fee and no software to buy. Seat prices across all roles in North Carolina run $1,500 to $2,500; the full list is published.

That is the entire invoice. Run your own figures against a percentage vendor or a hire rather than take ours.

Getting started in North Carolina

About a week from a signed agreement to a person working your queue, and that week of training on your workflow is not billed on top. The work happens in your own system under a login you issue, so there is nothing to migrate and nothing to install. The week, step by step, and what is signed before anyone has access.

Questions