NC State Health Plan Network

The State Health Plan is excited to partner with providers on a new strategy, which we’re calling the Clear Pricing Project, to provide quality, affordable, and transparent health care for public servants who educate our children, protect our streets, and build our roads.

The Plan’s goal is to create a provider reimbursement methodology that is fair, transparent, comparable, and predictable in an effort to preserve and protect the Plan benefit by keeping it financially sustainable. The Plan will be moving to a reference-based pricing model to reimburse providers for their services. This model will use Medicare rates as a reference point and pay providers a percentage above that rate.

The new rates will be effective Jan. 1, 2020. If a provider does not wish to participate and serve North Carolina public servants in this new network, then they will be considered a non-network provider.

Blue Cross and Blue Shield of North Carolina (Blue Cross NC), the Plan’s third-party administrator, is currently reaching out to all providers in the Blue Options network. All providers interested in participating in the new North Carolina State Health Plan Network must complete a signature page and submit it to Blue Cross NC no later than July 1, 2019.

If you are already a contracted and credentialed provider in good standing with Blue Cross NC, then you only need to download the signature page from their website, complete it and email it to NCSHPNetworkContracts@bcbsnc.com.

If you are not contracted and credentialed with Blue Cross NC, or you are in the process of terminating, you need to be credentialed to join the North Carolina State Health Plan Network. Click here to get network participation and credentialing information.

Questions regarding the methodology used for the reimbursement exhibit should be directed to NCSHPNetworkContracts@bcbsnc.com. Other questions should be submitted to the Plan via email to SHPProviderNetwork@nctreasurer.com.

HIE Update

  • House Bill 70 has passed and has been signed by the Governor.
  • NC HIEA will be working to process all agreements received and notify all providers of their status, then the NC HIEA will begin notifying Blue Cross NC of providers who are non-compliant. Blue Cross NC will then reject claims from non-compliant providers for services provided to State Health Plan members.
  • The State Health Plan values the providers who serve North Carolina Teachers, State Employees and Retirees and wants to support providers in their effort to connect to the HIE. We look forward to working with you in the coming months as we implement the requirements of the law.

Provider Frequently Asked Questions

How do I participate in the North Carolina State Health Plan Network?

How do I participate in the North Carolina State Health Plan Network?

All providers interested in participating must complete a signature page and submit it to Blue Cross NC no later than July 1, 2019.

If you are already a contracted and credentialed provider in good standing with Blue Cross NC, then you only need to download the signature page from their website, complete it and email it to NCSHPNetworkContracts@bcbsnc.com.

If you are not contracted and credentialed with Blue Cross NC, or you are in the process of terminating, you need to be credentialed to join the North Carolina State Health Plan Network. Click here to get network participation and credentialing information.

When will my contract be fully executed?

When will my contract be fully executed?

We anticipate that you should receive your executed signature page and confirmation by October 1, 2019.

What happens if I decide not to participate in the North Carolina State Health Plan Network and do not complete the contract signature page?

What happens if I decide not to participate in the North Carolina State Health Plan Network and do not complete the contract signature page?

You will be considered out-of-network for the North Carolina State Health Plan Network. Out-of-network reimbursements will be set at reimbursement rates lower than in-network reimbursements. Please note: Out-of-network payments will be made directly to members.

Out of Network Rates:

  • Inpatient will reimburse at 125% of Medicare
  • Outpatient will reimburse at 150% of Medicare
  • Professional will reimburse at 130% of Medicare
I completed the participation interest form in response to the letter of intent mailed to me in October 2018. Do I also need to sign the contract signature page in order to participate in the North Carolina State Health Plan Network?

I completed the participation interest form in response to the letter of intent mailed to me in October 2018. Do I also need to sign the contract signature page in order to participate in the North Carolina State Health Plan Network?

Yes, you must complete a signature page and email it to NCSHPNetworkContracts@bcbsnc.com to participate, even if you completed the interest form on the State Health Plan website.

Who should complete the contract signature page?

Who should complete the contract signature page?

The signature page should be completed by the entity or practice that is contracted with Blue Cross NC for Commercial PPO contracts, and who has contract signature authority. All provider entities, rosters, and locations associated with your existing Commercial PPO contracts with Blue Cross NC will be duplicated for purposes of participation in the North Carolina State Health Plan Network.

If you are a provider who is not currently contracted or credentialed with Blue Cross NC, click here to get network participation and credentialing information.

How do I know if my contract signature page has been received?

How do I know if my contract signature page has been received?

When you send your completed signature page to NCSHPNetworkContracts@bcbsnc.com you will receive an auto-reply email confirmation. Keep the auto-reply email as your receipt, along with your completed signature page. Blue Cross NC will process submitted signature pages and will send a final confirmation to you prior to October 1, 2019.

I do not have a contract with the Plan and the Plan has never reimbursed me. How does this apply to me?

I do not have a contract with the Plan and the Plan has never reimbursed me. How does this apply to me?

Blue Cross NC is the Plan’s third-party administrator (TPA) for claims and related services. One of the services provided by Blue Cross NC is a provider network. Currently, the Plan utilizes the Blue Cross NC Blue Options Network. It’s also important to note that the Plan is a self-funded health plan, which means the Plan, not the TPA, funds claims reimbursements.

Beginning January 1, 2020, the Plan will begin using a new Plan-specific provider network contracted by Blue Cross NC, called the North Carolina State Health Plan Network. Blue Cross NC will continue to process claims and provide medical management, which means the Plan will be following Blue Cross NC medical policies.

How does this impact my Commercial PPO contract?

How does this impact my Commercial PPO contract?

The North Carolina State Health Plan Network is a unique network that does not impact the commercial lines of business or other benefits within your Commercial PPO contract (e.g., Blue Options PPO). Pricing within the North Carolina State Health Plan Network is effective January 1, 2020. Providers currently participating in the Blue Options PPO network will continue to see State Health Plan members as in-network until December 31, 2019.

Those who decide to be part of the North Carolina State Health Plan Network in 2020 will be considered in-network for State Health Plan members. Those who decide not to accept this contract by completing the signature page will be considered out-of-network for State Health Plan members as of January 1, 2020.

When are signed contracts due?

When are signed contracts due?

Executable contracts were made available to providers for signature beginning May 13, 2019. If you wish to participate in the North Carolina State Health Plan Network, you must sign the contract by July 1, 2019. To review the contract and download the signature page please visit this website.

Will the reimbursement for January 2020 be using 2019 Medicare rates or 2020 Medicare rates, and do you know what they will be at that time?

Will the reimbursement for January 2020 be using 2019 Medicare rates or 2020 Medicare rates, and do you know what they will be at that time?

For professional services: The “Current North Carolina Medicare Part B Physician Fee Schedule,” as referenced in the Reimbursement Exhibit, will be the first Medicare fee schedule file published by CMS for an effective date of January 1. The Medicare Part B Physician Fee Schedule can be accessed at https://www.cms.gov/apps/physician-fee-schedule/overview.aspx.

For inpatient and outpatient services: As stated in the Reimbursement Exhibit, reimbursement will be based on the “then current” Medicare rates, to the extent that rate information is available and implemented.

I am not a Medicare participating provider. Will I be subject to the new State Health Plan reimbursement methodology?

I am not a Medicare participating provider. Will I be subject to the new State Health Plan reimbursement methodology?

Yes. All providers in the new North Carolina State Health Plan Network are subject to the new reimbursement methodology. We will be working with providers in this situation to address particular services that are non-Medicare related.

Will these new reimbursement rates apply to active employees and retired members?

Will these new reimbursement rates apply to active employees and retired members?

The North Carolina State Health Plan Network reimbursement rates will apply to any Plan members on a plan administered by Blue Cross NC who receive services from providers located in North Carolina. This will include both active and retired employees and their dependents who participate in plans administered by Blue Cross NC.

What if the services that I provide are not covered by Medicare?

What if the services that I provide are not covered by Medicare?

For services that are not priced/covered by Medicare, please refer to the pricing policies posted on the Blue Cross NC website.