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Tailored Plans cover doctor visits, prescription drugs, and services for serious mental illness, severe substance use disorder, intellectual or developmental disabilities, and traumatic brain injury, all through a single plan rather than splitting behavioral and physical health across separate coverage. Four organizations run these plans statewide: Alliance Health, Partners Health Management, Trillium Health Resources, and Vaya Total Care. A practice serving this population needs a workflow distinct from Standard Plan billing.
WellCare of North Carolina is merging with Carolina Complete Health effective April 1, 2026, with the combined health plan retaining the Carolina Complete Health name. Practices credentialed with WellCare need to confirm how their existing contracts and claims history carry over to the surviving entity.
State lawmakers have been debating proposals to scale back hospital tax exemptions and separately considered a bill to ban facility fees in non-hospital settings, following patient complaints about facility fees charged when large systems bill physician-office visits as hospital outpatient care. Neither proposal had passed as of this writing, but both signal a direction of scrutiny that could affect what a practice affiliated with a larger system can bill going forward.
Atrium Health and Novant Health dominate the Charlotte region, while Duke Health and UNC Health anchor the Triangle. Facility-fee billing practices, tied to how these systems code office visits acquired through physician-group purchases, have drawn direct patient and legislative scrutiny, and a practice referring into any of these networks should track how that scrutiny might affect billing going forward.
Claims submission that correctly routes Tailored Plan-eligible patients and tracks the WellCare merger transition.
Learn MoreFull-cycle RCM that monitors North Carolina facility-fee legislation and Jurisdiction M requirements as distinct compliance points.
Learn MoreProvider enrollment across Carolina Complete Health, Blue Cross Blue Shield of NC, and the major hospital-affiliated networks your referrals come from.
Learn MoreA free audit that checks specifically for Tailored Plan misrouting and WellCare transition gaps.
Learn MoreFront-desk and administrative support that scales with a growing North Carolina practice without new office overhead.
Learn MoreBenchmarks your claims data against current North Carolina payer-specific denial patterns, including the Tailored Plan structure.
Learn MoreLocal visibility support built for a market split between the Charlotte and Triangle metro referral networks.
Learn More| North Carolina Regulation | The Generic Billing Trap | The MD Revenue Group Approach |
|---|---|---|
| Standard vs Tailored MCOs | Routing physical health claims for Tailored Plan members through standard Medicaid MCO channels, leading to automatic denials. | We identify Tailored Plan-eligible patients pre-visit and route all physical and behavioral claims directly to Alliance, Partners, Trillium, or Vaya. |
| WellCare Merger | Submitting claims under legacy WellCare profiles after the April 2026 Carolina Complete Health merger. | We transition all clearinghouse submitter IDs and provider contracts to the surviving Carolina Complete Health registries. |
| Opportunities Pilots | Overlooking pilot-region addresses and missing distinct HCPCS coding rules for non-medical social service reimbursement. | We verify pilot boundaries pre-visit, filing non-medical claims using pilot-specific coding guidelines. |
| Facility Fee Scrutiny | Applying outdated office-visit facility codes under Dukes or UNC hospital groups, triggering audits and non-payment. | We audit hospital facility-fee limits and align group CPT modifier codes with active legislative constraints. |
We audit your last 90 days of claims for Standard vs Tailored Plan routing errors and prepare your systems for the Carolina Complete Health merger.
A written plan targeting the specific leakage points the audit found, not a generic onboarding checklist.
Your existing vendor keeps running while we credential and build claim rules in parallel, proven on real claims first.
Real-time reporting on collections, denials, and A/R velocity, so you see the recovery as it happens, not at quarter-end.
Our local North Carolina billing experts audited regional HMO mappings, transitioned legacy WellCare contracts to the surviving Carolina Complete Health registry, and re-routed misclassified physical claims to Alliance Tailored profiles.
See What We Can Recover For YouWellCare of North Carolina merged with Carolina Complete Health. All provider contracts, clearinghouse submitter profiles, and claims routing setups must transition to the surviving Carolina Complete Health credentialing directory to prevent immediate electronic rejections.
Medicaid beneficiaries with complex behavioral health or developmental needs are enrolled in Tailored Plans covering all physical and behavioral health care. Submitting physical health claims to Standard MCOs instead of the assigned Tailored Plan will trigger immediate denials.
North Carolina runs a regional Healthy Opportunities Pilots program covering non-medical services (housing, food, transport). Specialized billing structures and criteria apply in pilot regions. Claims must route through Standard MCOs using pilot-specific coding guidelines.
We check specifically for Standard vs Tailored Plan assignments, Carolina Complete Health merger updates, and Palmetto Jurisdiction M Medicare coverage profiles.
