The Hardship: The End of Continuity of Care
In 2026, North Carolina's Tailored Plans (LME/MCOs like Alliance, Vaya, and Trillium) have moved past the initial "grace period" for out-of-network providers. The flexibility that allowed providers to bill without a full contract or a specific Service Authorization Request (SAR) is gone.
RCM Insight: The "Authorization Missing" Surge
Providers are currently facing a surge in denials for "No Valid Authorization" even when a member has a valid Innovations Waiver slot. The disconnect often lies in the Tailored Care Management (TCM) hand-off. If the Care Manager hasn't updated the SAR in the new 2026 portal interface, the provider's claim will auto-deny. RCM departments must move from a "reactive" billing model to a "proactive" one, verifying SAR numbers 72 hours before the start of each service week.