North Carolina’s behavioral health and IDD system has undergone a major structural transformation with the launch of Tailored Plans, which shifted management of services for individuals with significant behavioral health needs, IDD, and traumatic brain injury from Local Management Entities/Managed Care Organizations (LME-MCOs) to a new managed care structure. Understanding how this transition affects billing is essential for every IDD agency operating in North Carolina.
The Tailored Plan Transition
North Carolina launched Tailored Plans in December 2022, transitioning individuals with IDD and other significant needs from LME-MCO management to a new set of Tailored Plan managed care organizations. For IDD agencies, this change affected billing relationships, prior authorization processes, and claims submission workflows.
Agencies should ensure they understand which Tailored Plan or LME-MCO manages services for each individual they serve, as billing and authorization processes vary between managed care entities. NC Medicaid publishes provider guidance on Tailored Plans through the NC Medicaid provider portal.
NCTracks and Electronic Claim Submission
North Carolina processes Medicaid claims through NCTracks, the state’s Medicaid Management Information System. IDD agencies must maintain active provider enrollment in NCTracks and ensure billing staff are proficient with claim submission, prior authorization requests, and remittance advice review through the portal.
North Carolina EVV Requirements
North Carolina has implemented EVV for personal care and home health services under its Medicaid program. The state uses a state-managed EVV system, and agencies delivering covered services must ensure their EVV implementation meets NC Medicaid’s technical requirements for data capture and transmission.
Vertex EVV Manager is configured to support North Carolina EVV requirements. Explore Vertex’s North Carolina-specific billing support for more detail on state-specific compliance requirements.
Prior Authorization Under Tailored Plans
Prior authorization requirements under Tailored Plans can differ from the requirements that existed under LME-MCO management. Agencies should verify current authorization requirements with each Tailored Plan or LME-MCO they work with and ensure their authorization tracking processes reflect any changes from the transition.
Documentation Standards for NC IDD Services
North Carolina requires detailed clinical and service documentation for IDD services, including person-centered plans, individual support plans, and service notes that demonstrate medical necessity and connection to the individual’s goals. Maintaining this documentation in an organized, audit-ready format is essential for both billing accuracy and Tailored Plan compliance reviews.
