What Does the Law Mandate?

Deadline to Connect Has Passed

The mandate to connect to the state-designated health information exchange, NC HealthConnex, required that those receiving state funds for care, such as Medicaid and the State Health Plan, initiate their connection by January 1, 2023.

While the law regarding this connection mandate is complex, we hope the following will provide some clarification:

  • Signing a participation agreement demonstrates a good-faith effort to meet the connection mandate.
  • Once you have an executed agreement, meaning that both your practice and the NC HIEA have signed, you are placed in the onboarding queue where your organization will wait for an invitation to begin your technical connection.
  • Actively engaging in the onboarding process with your technical vendor and the NC HIEA also demonstrates a good-faith effort to meet the connection mandate.

At this time, thousands of provider organizations are in various stages to complete their connection. We encourage providers to begin training while they are in the onboarding queue by visiting our training page.

What Does the Law Mandate?

As a result of legislation passed in late 2015, the NC HIEA was operationalized under the N.C. Department of Information Technology and directed to build and oversee a statewide health information exchange network, now known as NC HealthConnex. Among others, the goals of the enabling legislation and the HIE Act included improving health care and patient outcomes while controlling rising health care costs. (See N.C.G.S. § 90-414.1 et seq.)

The HIE Act requires that all health care organizations that receive state funds for the provision of health services submit demographic and clinical information pertaining to services rendered to Medicaid and other state-funded health care program beneficiaries and paid for with Medicaid or other state health care funds to the network (N.C. General Statute 90-414.4).

The HIE Act provides for the mandated submission of clinical and demographic data from health care providers, but it also allows for the voluntary exchange of patient data if providers choose to send clinical and demographic data pertaining to services paid for with non-state funds.

 

What Does “Connected” Mean?

To meet the statutory mandate in the Statewide Health Information Exchange Act, a mandatory provider or entity is “connected” when its clinical and demographic information (or claims data, depending on the organization) pertaining to services paid for by Medicaid and other state-funded health care funds are being sent to NC HealthConnex, at least twice daily—either through a direct connection or via a hub (i.e., a larger system with which it participates, another regional HIE with which it participates or an EHR vendor). Similar rules apply for entities required to submit claims data to the state via NC HealthConnex. Providers’ and entities’ data feed(s) must account for and send required data from all the locations and organizations that serve state-funded patients. Having a technical connection to NC HealthConnex and submitting all required data in a timely fashion to the state are important elements of compliance with the HIE Act and other state, federal, and contractual requirements.

 

Changes Enacted July 11, 2022

Governor Cooper signed the 2022 Appropriations Act (Session Law 2022-74) into law on July 11, 2022. The new law does not change the deadline to connect to NC HealthConnex by January 1, 2023, for organizations who receive state funds for providing services (e.g., Medicaid, State Health Plan, grants).

However, the Appropriations Act has other important impacts on the Statewide Health Information Exchange Act. Specifically, enforcement of the statutory mandate for certain providers and entities to connect and submit data to NC HealthConnex as a condition of receiving state funds is temporarily suspended until the General Assembly implements enforcement reforms. This means that providers, regardless of connection status, may continue receiving payment of state funds for providing services (e.g., Medicaid, State Health Plan) at this time.

The N.C. Health Information Exchange Authority Advisory Board must report to the General Assembly by March 31, 2023, on the status of organizations that are connected and unconnected by the January 1, 2023, deadline.

 

Participation is Voluntary, Condition of Receiving State Funds for Certain Providers

Notwithstanding the voluntary nature of the HIE Network under G.S. 90-414.2 and as a condition of receiving state funds, certain entities who receive state funds for the provision of health care services are required, at a minimum, to submit demographic and clinical information pertaining to services rendered to Medicaid and other state-funded health care program beneficiaries and paid for with Medicaid or other state-funded health care funds.

These entities include:

  • Hospitals as defined in G.S. 131E-176(13)
  • Physicians licensed to practice under Article 1 of Chapter 90 of the General Statute
  • Physician assistants as defined in 21 NCAC 32S.0201
  • Nurse practitioners as defined in 21 NCAC 36.0801
  • Dentists licensed under Article 2 of Chapter 90 of the General Statutes
  • Psychiatrists
  • State Laboratory of Public Health
  • N.C. Department of Health and human Services state health care facilities
  • Pharmacies registered with the N.C. Board of Pharmacy under Article 4A of Chapter 90 of the General Statutes (claims data)
  • Physicians who perform procedures at ambulatory surgical centers
  • Prepaid health plans (claims data)
  • Local Management Entities (claims data)
  • All other providers of Medicaid and state-funded services, unless otherwise specified in law

 

Voluntary Connection for Certain Providers (G.S. 90.414.(e))

Notwithstanding the mandatory connection and data submission requirements referenced above, the following providers of Medicaid services or other state-funded health care services are not required to connect to the HIE Network or submit data but may connect to the HIE Network and submit data voluntarily:

  1. Community-based long-term services and supports providers, including personal care services, private duty nursing, home health and hospice care providers
  2. Intellectual and developmental disability services and supports providers, such as day supports and supported living providers
  3. Community Alternatives Program waiver services (including CAP/DA, CAP/C and Innovations) providers
  4. Eye and vision services providers
  5. Speech, language and hearing services providers
  6. Occupational and physical therapy providers
  7. Durable medical equipment providers
  8. Nonemergency medical transportation service providers
  9. Ambulance providers (emergency medical transportation service)
  10. Local education agencies and school-based health providers
  11. Chiropractors licensed under Article 8 of this Chapter.

 

Additional Provisions

Balance Billing Prohibition (G.S. § 90-414.4. (b1)) – The law expressly prohibits balance billing when an in-network provider or entity with the State Health Plan for Teachers and State Employees does not connect to the HIE Network. This section specifically provides that under the State Health Plan an in-network provider or entity who renders health care services, including prescription drugs and durable medical equipment, and who is not connected to the HIE Network, is prohibited from billing the State Health Plan or a Plan member more than either party would be billed if the provider was connected to the HIE Network.

Note: Providers participating in the State Health Plan network should reach out to the State Health Plan with questions regarding this provision at BCBSNC Provider Services at 1-800-777-1643 or providerupdates@BCBSNC.com. 

Exemption for Certain Records (G.S. § 90-414.4.(c)) – Providers with patient records that are subject to the disclosure restrictions of 42 C.F.R. § 2 are exempt from submitting clinical data with respect to the patient records subject to these disclosure restrictions under Part 2. Presently, the NC HIEA does not receive Part 2 data.  Providers shall comply with the requirements of the HIE Act with respect to all other patient records. 

State Ownership of HIE Network data (G.S. § 90-414.6.) – The law prohibits the NC HIEA from fulfilling requests for electronic health information from an individual, individual's personal representative, or an individual or entity purporting to act on an individual's behalf.  The Authority provides educational materials to the public and to patients about how they can access their records from other sources.

Hardship Exemption (G.S. § 90-414.4(a3)) – Directs NCDHHS to facilitate a hardship extension process.

  • Contact NCDHHS with questions about the process or if your provider/org obtained one.
  • This process still exists in practice and by statute; however, it does not allow for extension beyond the final statutory connection deadline of January 1, 2023, set in statute.