Attention: MCOs and Behavioral Health Providers Recoupment of Funds with Retroactive Change in MCO Enrollment

As of May 1, 2016, NCTracks will begin a new process of handling retroactive enrollment in a Managed Care Organization (MCO.) When new or updated eligibility and enrollment records are received from NC FAST, NCTracks will create new capitation claims or void and recoup previously paid capitation claims, based on the retroactive change in MCO enrollment. Although there will not be a time limit as to how far back the NCTracks records will be updated, the newly created or voided/recouped capitation claims will only be allowed to go back at most 24 months prior to the payment-processing month from when the updates are received.

Fee for service claims will be impacted by this change when a beneficiary is retroactively enrolled in an MCO. In this situation, the fee for service claims for behavioral health services that are covered by the MCO, which paid during the time the recipient was retroactively enrolled in the MCO, will be systematically voided and the payment recouped.

Voided claims will be reported on the providers’ Remittance Advice (RA) with Explanation of Benefits (EOB) 06038 – CLAIM RECOUPED BASED ON RECENT ELIGIBILITY UPDATE. SERVICE IS COVERED BY BEHAVIORAL HEALTH MANAGED CARE PLAN. SUBMIT CHARGES TO RECIPIENT'S LME MCO.

If a provider has fee for service claims systematically voided and recouped due to retroactive enrollment in an MCO, the provider can submit charges to the recipient’s MCO for reimbursement.

If a retroactive change in eligibility results in a recipient moving from an MCO to fee for service, no reprocessing of previously denied claims will be performed. The expectation is that the provider will submit a claim to NCTracks, if and when the MCO recoups payment from the provider.