NC State Health Plan Provider Network Information

Important information for all of our NC providers!

Currently, the State Health Plan (Plan) through its third-party administrator, Blue Cross and Blue Shield of North Carolina (Blue Cross NC), utilizes a commercial network, Blue Options, to reimburse providers in North Carolina. However, because provider contracts are marked confidential, the Plan has no easy way to confirm that claims are being paid according to the contract. The Plan knows how much money we’re spending for health care, but not how much it costs.

As a government payer of health care, the Plan has the fiduciary responsibility to its members and taxpayers to ensure that providers are not over-compensated for their services or subsidizing other books of business at the expense of our members and taxpayers. Our goal is to create a provider reimbursement methodology that is fair, transparent, comparable and predictable in an effort to preserve and protect the State Health Plan benefit by keeping it financially sustainable.

The health of our members is our priority. To that end, we need to provide healthcare benefits that members can actually afford so they maintain their best health by getting the care they need. The Plan can’t control the cost of the care its members are getting, which is why this effort has to include the partnership of the provider community.

The Plan, with assistance from Blue Cross NC, will be moving to a reference-based pricing model to reimburse providers and hospitals for their services. This model will use Medicare rates as a reference point and pay providers a percentage above that rate. Medicare provides a standard reimbursement measurement that is publicly available and adjusts for differences in providers. Reference-based pricing is transparent and stabilizes the rates different providers get paid for the same services, and will allow the Plan to compare provider pricing to better project expenses from year to year.

The Plan will work alongside Blue Cross NC and providers to secure provider contracts based on this new reimbursement strategy, with a goal of having this effort complete by July 1, 2019. The new rates will be effective Jan. 1, 2020.

If providers do not agree to this approach, they will be considered out-of-network. Please complete the form below to indicate your interest in partnering with the Plan on this effort.

The Plan is excited to continue our partnership with you on a new strategy to provide quality, affordable and transparent health care for those public servants who educate our children, protect our streets, and build our roads.

Questions can be submited to the Plan via email to: SHPProviderNetwork@nctreasurer.com.

Click HERE for more information.

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