Medicaid requirements

 

North Carolina Medicaid Managed Care

Through your contract with EyeMed, you’re an in-network provider for Healthy Blue and Healthy Blue Care Together members enrolled in North Carolina Medicaid Managed Care. These Medicaid members include most Family & Children’s Medicaid, Pregnant Women, and Non-Medicare Aged, Blind, Disabled. Medicaid members in North Carolina can choose one of the available health plans they wish to use for benefits.

Refer to the EyeMed North Carolina Medicaid Provider Manual (requires inFocus login to access) for additional details.

 

Children and Families Specialty Plan (CFSP)

The Children and Families Specialty Plan (CFSP) is a new single, statewide Medicaid Managed Care plan that will wrap Medicaid-enrolled children, youth, and families currently and formerly served by the child welfare system with seamless, integrated and coordinated health care.”

CFSP provides Medicaid-enrolled children, youth, and their families with seamless, integrated, and coordinated health care. It focuses on families currently and formerly served by the child welfare system.

 

Managed care plans

As a North Carolina provider, you are an in-network provider for members enrolled in the following managed care plans:

• Healthy Blue and Healthy Blue Care Together

 

Medicaid enrollment

To provide routine vision care services to North Carolina Medicaid members, you must enroll with both programs:

1. North Carolina Medicaid. You can enroll and check your application status via the NCTracks Provider Portal. You must ensure your Medicaid registration (type 1 NPI, type 2 NPI, location affiliations) matches how you plan to submit claims to EyeMed.
2. EyeMed Vision Care^®. You can enroll with us by completing a New Provider Application, and entering “North Carolina [state] Medicaid” in the notes section. Typical turnaround time is 10 business days. 

 

Provider requirements

In-network Medicaid providers must:

• Review and meet all requirements outlined in the  EyeMed North Carolina Medicaid Provider Manual (requires inFocus login to access), including some that are unique to this plan. 
• Provide both exams and materials to Medicaid members.

 

Frame kit and eyewear ordering 

Refer to State Optical Resources for information about covered frames and eyewear.

 

Out of network claims 

If you have engaged in a good faith contracting effort with the health plan but you have refused that contract, then the health plan, after considering all facts and circumstances surrounding your willingness to contract, may deem you as an out-of-network provider in accordance with the health plan’s Good Faith Contracting policy.

 

Coordination of Benefits (COB)

Details for how the COB process is administered in the state of North Carolina can be found in the  EyeMed North Carolina Medicaid Provider Manual. You must be logged into your account on inFocus to access the manual.

Medicaid coordination of benefits process

• Primary payer. Medicaid is considered the payer of last resort.
  • Federal regulations require you to bill all identifiable financial resources available for payment, including Medicare, prior to billing Medicaid. 
• Submitting COB claims.File COB claims in hard copy using a CMS 1500 form. You must attach a copy of the primary plan's explanation of benefits or denial. 

 

Related provider resources Provider Manual – North Carolina Medicaid (Healthy Blue) Medically Necessary Contact Lens Form – North Carolina Medicaid (Healthy Blue) Job Aid – Submitting Lab Claims for Dispensing Fees (North Carolina Medicaid)