Member AMH/PCP Assignment

*WCNC follows all NC Medicaid rules and regulations.

How can I help a member change their AMH/PCP assignment to my practice?

There are three ways to do this.

1. Encourage the member to call the WellCare NC Customer Service number on the back of their Medicaid ID card to request to change their AMH/PCP assignment to your practice.
2. AMH/PCP providers can assist members wanting to be assigned to their practice, by faxing the PCP Change Request Form for Prepaid Health Plans (PHPs) (PDF).
3. For requests for multiple members, AMH/PCP providers can email the PCP Assignment Changes Spreadsheet (xlsx) with the required information and attestation to your Provider Relations Representative.

All AMH/PCP assignments are sent to the State for confirmation. Once WCNC receives State confirmation, the member will be notified by the receipt of a new ID card with your AMH/PCP practice name. If you faxed in the PCP change request form, you will receive a fax confirming the change. If you sent a spreadsheet, the Provider Relations Representative will notify you of the change.

NOTE: AMH/PCP assignment is to the practice or group location, not an individual provider. It is NOT necessary to submit a PCP change for a member that is seeing a different individual provider at the same AMH/PCP practice location.

Can I remove members that are assigned to my practice?

If you have *discharged a member from your practice and need to request that a member, be re-assigned to another AMH/PCP, there are three options for submitting this information:

1. Complete the transfer on the secure provider portal by choosing “Request Member Transfer” under “Select Action” when you have entered a member ID on the “Check Member Eligibility” page
2. Fax the PCP Transfer Request Form (PDF)
3. For requests for multiple members, AMH/PCP providers can email the PCP Assignment Changes Spreadsheet (xlsx) with the required information and attestation to your Provider Relations Representative.

*What does “discharged a member from practice” mean?

• The Member is non-compliant with the physician’s treatment plan or plan of care.
• There is evidence of abusive or inappropriate behavior.
• If the physician is unable to adequately address the member’s needs.

In these situations, you must follow your process for discharging the member from your practice and have documentation of this.

The following are NOT valid reasons for discharging a member from your practice: 

• Members you are unable to contact.
• Members you have never seen.

Please continue to work to engage these members. You can reach out to your Provider Relations Representative if additional support is needed.

All AMH/PCP assignments are sent to the State for confirmation. Once WCNC receives State confirmation, the member will be notified by the receipt of a new ID card with their new AMH/PCP practice name. If you faxed in the member transfer form or submitted on the secure portal, you will receive a fax confirming the change. If you sent a spreadsheet, the Provider Relations Representative will notify you of the change.

What if I have members that have moved out of my service area or are seeing another PCPs?

If you have evidence that a member has relocated or moved their care to another primary care practice, please contact your Provider Relations Representative. You will be asked to submit the PCP Assignment Changes Spreadsheet (xlsx) with the required information and attestation to your Provider Relations Representative. You will need to include a description of why the member should be transferred including:

• New address that is out of service area of PCP
• Name and TIN/NPI of AMH/PCP that member is seeing.
• Other details supporting request such as medical record transfer request or documentation of a discussion with the member in the patient’s medical record.

The documents with the evidence should be submitted in the spreadsheet.

Once this information is received by WCNC, if no documentation is provided, WellCare will review claims and outreach to the member to confirm their AMH/PCP preference. If there is no claims evidence or the member is unable to be reached, the member will remain assigned to your practice. The Provider Relations Representative will notify you if the change was unable to be validated.

If documentation is provided, WCNC will re-assign the member. All AMH/PCP assignments are sent to the State for confirmation. Once WellCare NC receives a confirmation 834 from the State the Provider Relations Representative will notify you of the change, and the member will be notified by receipt of a new ID card.

NOTE: It is NOT necessary to submit requests to have members reassigned due to age or gender. WCNC has a monthly process to review member assignments as compared to the age ranges and gender seen for your practice as documented in NC Tracks and re-assigning members that don’t match the information in NC Tracks for your practice.

What if I have members that have moved out of State?

If you have evidence that a member has moved out of State, please contact your Provider Relations Representative and provide the out of state address so WellCare can share it with the State. Per the State, members can remain eligible for Medicaid while OOS for up to 12 months. The member will stay assigned to your practice since the State requires that all members be assigned to an AMH/PCP. If/when the member is determined to be ineligible, the member will no longer be active with WellCare and won’t be assigned to your practice.

When will a PCP change take effect?

The effective date of an AMH/PCP assignment will be the 1st of the following month when received on or before the 16th of the month. The effective date will be the 1st of the month following the next month if received after the 16th day of the month.

Do I need authorizations to provide primary care for a member not assigned to me?

Members do NOT need an authorization to see an in-network PCP even if that PCP is not the assigned PCP.  Members WILL need a prior authorization to see a PCP who is NOT in network.

NOTE: A member can see any PCP in network with WellCare, they do not need to be listed on the member’s Medicaid ID card.

Additional Important AMH/PCP Assignment Information

AMH/PCP assignment is to the practice or group location, not an individual provider. It is NOT necessary to submit a PCP change for a member that is seeing a different individual provider at the same AMH/PCP practice location.

1. It is NOT necessary to submit requests to have members reassigned due to age or gender. WCNC has a monthly process to review member assignments as compared to the age ranges and gender seen for your practice as documented in NC Tracks and re-assigning members that don’t match the information in NC Tracks for your practice.
2. Members are notified of AMH/PCP assignment when they receive their WellCare NC ID card, which includes the AMH/PCP group name, address and telephone number.
3. Members can see any PCP in network with WellCare, they do not need to be listed on their Medicaid ID card.
4. Per State contract, members are allowed to change their AMH/PCP without cause twice per year. Members shall be given thirty (30) days from receipt of notification of their AMH assignment to change their AMH/PCP without cause (1st instance) and shall be allowed to change their AMH/PCP without cause up to one time per year thereafter (2nd instance).
5. Providers can review assigned members on the WellCare NC provider portal. For Tier 3 AMH/PCPs this information also appears in beneficiary assignment files received from WellCare. The State also includes assigned members in NC Tracks.
6. If you do not know your practices PR Representative email, please contact WCNC PR at: NCProviderRelations@Wellcare.com

NOTE: There may be discrepancies between NC Tracks and the WellCare provider portal typically due to timing related to data exchange.