The North Carolina Department of Health and Human Services (DHHS), Division of Health Benefits may have a requirement for the North Carolina Tracks (NCTracks) component of North Carolina’s Medicaid Management Information System (MMIS).

The following information was sourced from the Request for Information (RFI) document and is subject to change upon the release of a formal solicitation.

North Carolina’s Medicaid program serves a total of 3,122,249 beneficiaries, distributed across several plan types:

• Standard Managed Care Plans: 2,263,530 enrollees
• Tailored Plans: 257,207 enrollees
• Tribal Plans: 5,683 enrollees
• Medicaid Direct: 585,829 enrollees

At the heart of North Carolina’s Medicaid infrastructure is the state’s Medicaid Management Information System (MMIS). Developed and managed by the North Carolina Department of Health and Human Services (NCDHHS), the MMIS serves as the centralized platform for administering Medicaid and other state-funded health programs. It supports multiple divisions, including:

• NC Medicaid (Division of Health Benefits)
• Mental Health Services
• Developmental Disabilities Services
• Substance Abuse Services
• Public Health
• Office of Rural Health

The MMIS is essential for a wide range of operational functions, including:

• Claims processing – approximately 5 million claims per month
• Provider enrollment and recredentialing – approximately 2,580 enrollment applications per month
• Prior authorization (PA) management – approximately 35,000 per month
• Payment issuance
• Performance monitoring and federal reporting

A key component of the MMIS is its Central Data Repository (CDR), which consolidates provider and recipient data to enhance data accuracy, reduce billing errors, and streamline operations across NCDHHS programs. The MMIS supports over 1,200 system integrations, with approximately 1,000 interfaces where the MMIS is the data source and 260 interfaces where it is the target system. Participation in Medicaid requires providers to register with the MMIS, making it a foundational system for provider engagement and compliance.

The following information was sourced from the Request for Information (RFI) document and is subject to change upon the release of a formal solicitation.

The solution should have the capability to provide the following functionality:

1. Enhanced Reporting
   1. Support for federal and state reporting, performance monitoring, and data-driven decision-making.
2. Interoperability and System Integration
   1. Ensure seamless integration with external systems, including NC FAST, Health Information Exchanges (HIEs), and Managed Care Organizations (MCOs).
   2. Comply with federal interoperability standards, including those outlined in the Medicaid Information Technology Architecture (MITA) framework.
3. Equity and Access Monitoring
   1. Incorporate tools to monitor and address health disparities and geographic access gaps.
4. Quality and Performance Measurement
   1. Integrate performance metrics across modules to support continuous improvement and accountability.
5. System Reliability and User Support
   1. Improve system uptime, responsiveness, technical stability, and provide notifications of system errors or interruptions.
6. Compliance and Certification Readiness
   1. Ensure full compliance with HIPAA, CMS certification requirements, and other applicable federal and state regulations.
   2. Design the system to be adaptable to future mandates and certification updates.
7. Financial Management
   1. Support all aspects of financial management and reporting related to the claims payment process, including check write processing and lockbox integration.
   2. Provide robust, configurable, self-service reporting, including the ability for providers to inquire on payment status.
   3. Support for Third Party Liability, including cost avoidance through integrated payer hierarchy logic, Buy-in, estate recovery and claims recovery.
   4. Support state fair hearings and testify in court on all Fiscal Agent activities relevant to the hearing, generate and send adverse determination letters for prior authorization decisions, and meet with the Department monthly.
8. Claims Management
   1. Support all aspects of Medicaid claims processing (professional, institutional, dental, pharmacy, etc.), including new claims and adjustments based on edit and audit business rules.
   2. Accept batch system claims as well as manually submitted claims through a provider portal.
   3. Upload claims-related documentation (medical records, consent forms, etc.) and match them to the corresponding claim.
   4. Manage and expose all aspects of the claim through a portal, EDI transactions, and APIs.
   5. Support industry-standard infrastructure functions such as real-time and batch integration, document management, HIPAA X12 compliant transactions, IAM integration, configurable groups and roles, and a cloud-hosted model.
9. Provider Management
   1. Manage all aspects of the provider, such as taxonomy, specialties, locations, etc.
   2. Allow a provider to self-enroll in NC Medicaid using an intuitive workflow, pre-populated screens wherever possible, and online help.
   3. Credential a provider using as much automation as possible, including credential verifications, background checks, and data verification.
   4. Manage vendors, including:
      • Alerting the Provider Operations team to bad actors using internal factors and external data feeds
      • Proactively alerting Providers to actions needed to manage their enrollment
   5. Provide reporting as needed by the Provider Operations team to manage the provider population.
   6. Offer a broad set of configurable reports, including the ability for Provider Operations to configure and generate reports through self-service.
   7. Modify the system through configuration rather than coding, to the extent possible.
   8. Support industry-standard infrastructure functions such as real-time and batch integration, document management, IAM integration, configurable groups and roles.
   9. Ability to host a Provider Portal that includes functions to the provider as described above.
10. Member Management
    1. Display member Medicaid enrollment data, including assigned benefit plans, patient monthly liability, category of eligibility, and living arrangement assignment.
    2. Capture and display all aspects of a member’s demographics, including household composition, authorized representatives, and both current and historical demographics for all members within a case.
    3. Track enrollment over time, leveraging spans to identify enrollments, dis-enrollments, and changes in circumstances resulting in enrollment changes.
    4. Interface with the North Carolina eligibility system, which manages all member functions and sends member data to the MMIS system each night to ensure current and accurate data.
    5. Host a Member Portal that provides features such as provider lookup, benefit plan details, and access to personalized health and enrollment information.
11. Fiscal Agent Functions (includes Technical and Business Operations)
    1. Support all aspects of technical operations, including operational support, full software development lifecycle support, including appropriate development and test environments and staff. This includes any infrastructure support needed.
    2. Support all aspects of business services, including business input to technical designs, policy input, processes, and domain-specific knowledge, such as expertise in Medicaid provider processes and state and federal rules and regulations. This also includes expertise in CMS policy and Medicaid rules in general.
    3. Provide clinical expertise to support activities such as utilization management, claims review, and clinical policy development.
    4. Deploy a call center to support all inquiries related to claims submissions, provider enrollment, prior authorization, financial transactions, and recipient enrollment.
    5. Support change Management activities including defect reporting, maintenance updates, and enhancements.
       • Host an Operations Portal, which includes different roles and levels of access for state staff, the fiscal agent, and vendors to view reports, manage claims codes, view current and historical claims data, manage and view prior approvals, and third-party liability.
12. Operations Portal The solution shall include an Operations Portal designed to support day-to-day administrative and oversight functions. The portal must provide secure, role-based access for State staff, the fiscal agent, and authorized vendors.
    1. Key capabilities include access to claims data, prior authorizations, third-party liability, financial transactions, and provider management tools.
    2. The portal should also support reporting, system monitoring, and configuration management to facilitate operational transparency and efficiency.
13. Prior Authorization This includes all aspects of utilization management, including prior authorizations (PA) for out-ofstate services, surgery, orthodontics, dental, hearing aid, optical, DME, private duty nursing, and EPSDT services. All other PA types such as PCS, CAP, Outpatient Behavioral health, specialized therapy services, and PASRR Level 2 are handled by different vendors and out of scope for this RFI.
    1. Capability to Receive PA request in various formats, including X12 transaction, portal submissions, fax, or paper.
    2. Apply PA specific edits and capability to modify existing authorizations.
    3. Ability to upload documentation and match it to the PA request.
    4. Meet turnaround timelines for review and decision response.
    5. Notify all responsible parties (member, auth reps, provider) of PA changes, such as rejections, reductions, or modifications, through a letter process with hearing and appeal language.