Provider Manuals, Policies and Forms

Manuals and guides

AmeriHealth Caritas North Carolina offers these reference materials to our providers for use when treating our members.

• Provider manual (PDF)
  This manual will help you and your office staff provide services to our members. Please see Attachment B in the appendix for the Provider Manual Revision Log for a complete list of updates.
• Behavioral health utilization management guide (PDF)
  Use this guide to learn more about behavioral health services that require prior authorization.
• Claims and billing manual (PDF)
  This guide will help you avoid delays in the processing of your claims. Please see the Claims and Billing Guide Revision Log on page 104 for a complete list of updates.
• Provider reference guide (PDF)
  Keep this sheet of contact information close by for when you need to give us a call.

Policies

• Administrative Policies Archive
• Clinical Resources
• Good Faith in Contracting Policy (PDF)
• Network Provider Credentialing/Recredentialing Policy (Effective July 2023) (PDF)
• Opioid Misuse Prevention Program (PDF)
• Provider Hardship (Advances) Policy (PDF)
• Reimbursement Policies
• Utilization Management Program Description 2021 (PDF)

If you have questions about these materials or about AmeriHealth Caritas North Carolina, ;contact your Account Executive.

Forms

Advance directives

• Advance Directive for a Natural Death (PDF)
• Advance Instruction for Mental Health (PDF)
• Claim Refund Form (PDF)
• Health Care Power of Attorney (PDF)
• Organ/Tissue Donor Card (PDF)
• Registration Form (PDF)
• Remove Directive Form (PDF)

Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

• Non-covered State Medicaid Plan Services Request Form for Recipients under 21 years old (PDF)

Grievances and appeals

• Provider Appeal Submission Form (PDF)
• Provider Grievance Submission Form (PDF)

Long-term services and supports (LTSS)

• Request for Assessment for Personal Care Services (PCS) Attestation of Medical Need (PDF)

Maternity

• Delivery Notification Form (PDF)

Medical prior authorization

• Prior Authorization Request Form (PDF)

Member Intervention Request

• Rapid Response and Outreach Team Member Intervention Form (PDF)

Pharmacy prior authorization

• Pharmacy Prior Authorization Requests

Provider change

• Request for Change of Primary Care Provider (PDF)
• Request for Change of Primary Care Provider (Spanish) (PDF)

Reproductive health

• Please visit the North Carolina Department of Health and Human Services (NCDHHS) website to download state-approved forms.