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2022 Provider Manualcarolinacompletehealth.com 2022 Carolina Complete Health. All rights reserved.
TABLE OF CONTENTSINTRODUCTION . 7Welcome to Carolina Complete Health . 7About Us: Doctors Leading the Way to Better Health Care . 7Mission . 7About this Manual (Including Billing Guidelines) . 8KEY CONTACTS. 9PRODUCT SUMMARY . 11Eligible Populations . 11Voluntary Populations . 11ENROLLMENT . 13Provider Restrictions. 13Provider Marketing Guidelines . 13VERIFYING ELIGIBILITY. 14Beneficiary Eligibility Verification . 14Beneficiary Identification Card . 15CAROLINA COMPLETE HEALTH WEBSITE . 16Carolina Complete Health Website . 16Secure Provider Portal . 16GUIDELINES FOR PROVIDERS . 18Primary Care Providers (PCPs) . 18Provider Types That May Serve As PCPs . 18Assignment of Medical Home . 18Medical Home Model . 19Primary Care Provider (PCP) Responsibilities . 20Care Management for High Risk Pregnancies (CMHRP) . 22Care Management for At-Risk Children (CMARC) . 22Vaccines for Children (VFC) Program . 22Referrals. 23Specialist Responsibilities . 232 of 1142022-03-25
Protected Health Information (PHI) . 24Mainstreaming . 25Appointment Accessibility Standards . 25Covering Providers . 26Telephone Arrangements . 2624-Hour Access . 27Provider Directory Demographic Changes . 28Hospital Responsibilities . 28Advance Directives . 29Voluntarily Leaving the Network . 29CULTURAL COMPETENCY . 31BENEFIT EXPLANATION AND LIMITATIONS. 32Carolina Complete Health Benefits . 32Non-Contracted and Non-Covered Services. 37Non-Emergent Medical Transportation . 38Value-Added Services (VAS) . 38Language Assistance . 41NETWORK DEVELOPMENT AND MAINTENANCE . 42Non-Discrimination . 43Tertiary Care. 43Network Adequacy and Access Standards . 43MEDICAL MANAGEMENT . 46Overview . 46Utilization Management . 46Self-Referrals . 47Prior Authorization and Notifications. 48Authorization Determination Timelines . 50Transplant Authorizations . 50Second and Third Opinions. 53Clinical Information . 53Clinical Decisions . 543 of 1142022-03-25
Peer to Peer Discussions . 54Medical Necessity. 55Review Criteria . 55New Technology . 56Notification of Pregnancy . 56Abortions . 57Sterilization. 57Concurrent Review and Discharge Planning . 57Retrospective Review . 57Opioid Misuse Prevention Program Policy . 57HIGH TECH RADIOLOGY . 58Advanced Diagnostic Imaging . 58Cardiac Solutions . 58EARLY PERIODIC SCREENING, DIAGNOSTIC AND TREATMENTSERVICES. 60EMERGENCY CARE SERVICES . 6324-HOUR NURSE ADVICE LINE. 64WOMEN’S HEALTHCARE. 65PUBLIC HEALTH PROGRAMS . 66Women, Infants and Children (WIC) Program . 66Parents as Teachers (PAT) . 66CARE MANAGEMENT PROGRAM . 68High Risk Pregnancy Program . 68Complex Teams . 69Member Connections Program . 70Chronic Care/Disease Management Programs. 71PROVIDER ENGAGEMENT AND PROVIDER RELATIONS ANDSUPPORT . 72Provider Orientation . 72Responsibilities . 72Top 10 Reasons to Contact a Provider Partnership Associate . 734 of 1142022-03-25
CREDENTIALING AND RECREDENTIALING . 74Right to Review and Correct Information . 75Right to Be Informed of Application Status . 75Right to Appeal Adverse Credentialing Determinations . 75Providers on Review. 75RIGHTS AND RESPONSIBILITIES . 76Member Rights . 76Member Responsibilities. 76Provider Rights . 77Interest and Penalties . 77Provider Responsibilities . 78GRIEVANCES AND APPEALS PROCESS . 82Beneficiary Grievance Process . 82Beneficiary Appeal Process . 83Expedited Appeal Process . 83How to File a Beneficiary Grievance or Appeal (Non-Claim): . 84State Fair Hearing Process . 84Continuation of Benefits . 85Reversed Appeal Resolution . 85How to File a State Fair Hearing . 85Provider Grievance and Appeals . 86Appeals on Behalf of a Member . 88Provider Ombudsman . 89FRAUD, WASTE AND ABUSE . 90Fraud, Waste and Abuse (FWA). 90Authority and Responsibility . 92QUALITY IMPROVEMENT . 93Program Structure . 93Practitioner Involvement . 94Quality Assessment and Performance Improvement Program Scope and Goals . 945 of 1142022-03-25
Patient Safety and Quality of Care . 95Performance Improvement Process . 96Healthcare Effectiveness Data and Information Set (HEDIS) . 97How Are HEDIS Rates Calculated? . 97Provider Satisfaction Survey . 99Consumer Assessment of Healthcare Provider Systems (CAHPS) Survey . 99Provider Profiling and Incentive Programs. 99PHARMACY . 101Preferred Drug List (PDL) . 101Unapproved Use of Preferred Medication . 101Prior Authorization Process . 10172-Hour Emergency Supply Policy . 102Prospective Drug Utilization Review (DUR) Response Requirements . 103Benefit Exclusions . 103Physician Administered Drug Program . 104Dispensing Limits, Quantity Limits and Age Limits . 104Mandatory Generic Substitution . 105Working With the Pharmacy Benefit Manager (PBM) . 105Online Prior Authorization . 105Pharmacy Portal and Provider Links . 106MEDICAL RECORDS REVIEW . 107Medical Records . 107Required Information . 107Medical Records Release . 109Medical Records Transfer for New Beneficiaries . 109Medical Records Audits . 109TELEMEDICINE AND TELEPSYCHIATRY . 110Telemedicine Covered Services . 110Telemedicine Appeals . 111ENVOLVE VISION HELP AT A GLANCE . 1126 of 1142022-03-25
INTRODUCTIONWelcome to Carolina Complete HealthThank you for being part of the Carolina Complete Health network of participating physicians,hospitals, and other healthcare professionals committed to serving Medicaid members in NorthCarolina. As a Provider-Led Medicaid Managed Care plan, we value our partnerships withproviders to support Medicaid Transformation in North Carolina in Regions 3, 4 and 5. We arecommitted to improving quality, cost-efficiency, and patient and provider satisfaction. CarolinaComplete Health is locally-based with offices in Charlotte, Durham, and Wilmington to serve theunique needs of each region and community.About Us: Doctors Leading the Way to Better Health CareCarolina Complete Health is a Prepaid Health Plan (PHP) contracted with the N o r t hC a r o l i n a Department of Health and Human Services ( N C D H H S ) . What makes CarolinaComplete Health different is that we are a designated Provider-Led Entity (PLE) through aninnovative joint venture among the Centene Corporation (Centene), the North Carolina MedicalSociety (NCMS), and the North Carolina Community Health Center Association (NCCHCA). Centene Corporation: With over 30 years of Managed Care experience, Centene is aFortune 50 company serving over 25 million members across 50 states with the missionto transform the health of the communities it serves, one person at a time. North Carolina Medical Society: The NCMS is the oldest professional memberorganization in North Carolina, representing physicians and physician assistants whopractice in the state, providing leadership in medicine by uniting, serving andrepresenting physicians and their health care teams to enhance the health of NorthCarolinians. North Carolina Community Health Center Association: The NCCHCA is a private,non-profit membership association that represents Federally-Qualified Health Centers(FQHCs) and aspiring health centers across North Carolina.We believe that physicians are the key to success for Medicaid Transformation andshould have a leadership role in developing and approving the plan’s medical policies toensure they are in the best interest of patients and providers. That’s why you will seelocal provider representation within our leadership team and board of directors, investedin every decision we make.MissionAt Carolina Complete Health, our mission is to transform the health of our community, oneperson at a time. Working with providers, we do this by: Ensuring access to primary and preventive care servicesEnsuring care is delivered in the best setting to achieve an optimal outcomeImproving access to all necessary healthcare servicesEncouraging quality, continuity, and appropriateness of medical careProviding medical coverage in a cost-effective manner7 of 1142022-03-25
Partnering with doctors, hospital systems, specialists and other providers to ensure thatour health plan benefits, services, network, and support truly meet the needs of NorthCarolina Medicaid beneficiaries.About this Manual (Including Billing Guidelines)Carolina Complete Health is committed to working with our provider community andbeneficiaries to provide a high level of satisfaction in delivering quality healthcare benefits.We are committed to providing comprehensive information through this Provider Manual as itrelates to Carolina Complete Health operations, benefits, and policies and procedures. ThisProvider Manual is posted on the Carolina Complete Health website where it can be reviewedand printed free of charge. Providers are notified via bulletins and notices posted on theprovider website and in our weekly Explanation of Payment notices, of material changesto the Manual. For hard copies of this Provider Manual please contact the Provider Servicesdepartment at 1-833-552-3876 or if you need further explanation on any topics discussed in themanual.Billing GuidelinesBilling guidelines and instructions are located in the dedicated Carolina Complete Health BillingManual. The Billing Manual includes comprehensive information about claims and payments,including details on timely claim payments, which may be found in the “Prompt Pay” section ofthe Carolina Complete Health Billing Manual. The Billing Manual is located in the “Resources”section of our website at: www.network.carolinacompletehealth.com. The Billing Manualincludes information on: Encounter data submission guidelinesClaims submission protocols and standards; including timeframe requirementsInstructions/information for Clean ClaimsClaims Dispute ProcessPayment policiesClient Participation RequirementsCost Sharing RequirementsThird Party Liability and Other Instructions8 of 1142022-03-25
KEY CONTACTSThe following chart includes several important telephone and fax numbers available to youroffice. When calling Carolina Complete Health, please have the following information available: NPI (National Provider Identifier) number Tax ID Number (“TIN”) number Beneficiary’s ID numberHealth Plan InformationCarolina Complete Health10101 David Taylor Dr. Suite 300Charlotte, NC mentProvider ServicesMember ServicesAuthorization RequestTelephone NumberFax Number1-844-915-04591-833-552-3876TDD/TYY: YY: 800-735-2962Concurrent Review1-833-238-7692Care Management1-833-238-7689Envolve (24/7 Availability)1-833-552-38761-866-399-0929TDD/TYY: 800-735-2962Face Sheets1-833-238-7690Behavior Health PriorAuthorization Inpatient1-833-596-2768Behavioral Health PriorAuthorization Outpatient1-833-596-2769Census cal Records1-833-238-76939 of 1142022-03-25
North Carolina Department ofHealth and Human ServicesMedical ClaimsCarolina Complete HealthPO Box 8040Farmington, MO 63640-80401-919-855-4800Reimbursement Rate DisputeCarolina Complete HealthPO Box 8040Farmington, MO 63640-80401-919-715-4645Medical NecessityAppealCarolina CompletePO Box 8040Farmington, MO 63640-8040Electronic Claims SubmissionCarolina Complete Healthc/o Centene EDI Department 1-800-225-2573, ext. 25525or by e-mail to: EDIBA@centene.com10 of 1142022-03-25
PRODUCT SUMMARYThe Medicaid Managed Care population is comprised of beneficiaries who fall into one of thecategories of eligibility listed below:Eligible PopulationsEligibility of Parents/Caretakers, Children, Pregnant Women, and Refugees: Parents/Caretakers of Children eligible Children eligible for Poverty Level Children Pregnant women and women up to sixty (60) days post-partum Individuals eligible under Participants of Refugee Individuals who are eligible under the above groups and are Autism orDevelopmental Disabilities (DD) waiver participantsEligible Children in the Care and Custody of the State and Receiving Adoption SubsidyAssistance: All children in the care and custody of the North Carolina Department of Healthand Human Services, Division of Social Services All children placed in a not-for-profit residential group home by a juvenile court All children receiving adoption subsidy assistance All children receiving non-medical assistance (i.e., living expenses) that are in thelegal custody of the North Carolina Department of Health and Human Services,Division of Social Services shall remain the responsibility of the North CarolinaDepartment of Health and Human Services, Division of Social ServicesState Child Health Plan: North Carolina has an approved combination State Child Health Planunder Title XXI of the Social Security Act (the Act) for the Children's Health Insurance Program(CHIP).Voluntary PopulationsMedicaid Managed Care eligible members in the above specified eligibility groups mayvoluntarily disenroll from the Medicaid Managed Care Program or choose not to enrollin the Medicaid Managed Care Program if they: Are eligible for Supplemental Security Income (SSI) under Title XVI of the Act Are described in Section 501(a)(1)(D) of the Act Are described in Section 1902 (e)(3) of the Act11 of 1142022-03-25
Are receiving foster care or adoption assistance under part E of Title IV of the Act Are in foster care or otherwise in out-of-home placement Meet the SSI disability definition as determined by the North Carolina Department ofHealth and Human Services, Division of Social Services12 of 1142022-03-25
ENROLLMENTThe Department of Health and Human Services, Division of Social Services is responsible foreligibility determinations. The state agency will conduct enrollment activities for MedicaidManaged Care eligible members.Provider RestrictionsProviders shall not conduct or participate in health plan enrollment, disenrollment, or transfer oropt-out activities, or attempt to influence a beneficiary’s enrollment. Prohibited activities include: Requiring or encouraging the beneficiary to apply for an assistance category Requiring or encouraging the beneficiary and/or guardian to use the opt out as an optionin lieu of delivering health plan benefits Mailing or faxing enrollment forms Aiding the beneficiary in filling out health plan enrollment forms Aiding the beneficiary in completing on-line health plan enrollment Photocopying blank health plan enrollment forms for potential beneficiaries Distributing blank health plan enrollment forms Participating in three-way calls to the enrollment helpline Suggesting a beneficiary transfer to another health plan Other activities in which a provider attempts to enroll a beneficiary in a particular healthplan or in any way assisting a beneficiary to enroll in a health planProvider Marketing GuidelinesParticipating providers may conduct marketing activities to beneficiaries subject to DSSguidelines.13 of 1142022-03-25
VERIFYING ELIGIBILITYBeneficiary Eligibility VerificationTo verify beneficiary eligibility, please use one of the following methods:1. Log on to the secure provider portal at https://provider.carolinacompletehealth.com.Using our secure provider website, you can check beneficiary eligibility. You can searchby date of service and either of the following: beneficiary name and date of birth.2. Call our automated beneficiary eligibility IVR system. Call 1-833-552-3876 fromany touch tone phone and follow the appropriate menu options to reach ourautomated beneficiary eligibility-verification system twenty-four ( 24) hours a day.3. Call Carolina Complete Health Provider Services. If you cannot confirm abeneficiary’s eligibility using the methods above, call our toll-free number at 1-833-5523876. Follow the menu prompts to speak to a Provider Services Representative toverify eligibility before rendering services. Provider Services will need the beneficiaryname to verify eligibility.Through the Carolina Complete Health secure provider web portal, primary care providers(PCPs) are able to access a list of eligible beneficiaries who have selected their services orwere assigned to them. The patient list reflects all changes made within the last twenty-four(24) hours. The list also provides other important information including date of birth and indicatorsfor patients whose claims data show a gap in care, or a missed Early Periodic Screening. Inorder to view this list, log on to https://provider.carolinacompletehealth.com. Since eligibilitychanges can occur throughout the month and the beneficiary list does not prove eligibility forbenefits or guarantee coverage, please use one of the above methods to verify beneficiaryeligibility on date of service.All new Carolina Complete Health beneficiaries receive a Carolina Complete Health beneficiaryID card. A new card is issued only when the information on the card changes, if a beneficiaryloses a card, or if a beneficiary requests an additional card. Since beneficiary ID cards are nota guarantee of eligibility, providers must verify beneficiary’s eligibility on each date of service.Providers must have a policy in place regarding the provision of non-emergency services to anadult Medicaid Managed Care beneficiary, including requesting and inspecting the adultbeneficiary’s health plan beneficiary ID card. If the adult beneficiary does not produce their healthplan beneficiary ID card, and the provider verifies eligibility and health plan enrollment, theprovider may provide service if they have notified the health plan that the beneficiary has nohealth plan ID card. The provider must document this verification in the beneficiary's medicalrecord.14 of 1142022-03-25
Beneficiary Identification CardProviders are required to implement a policy of requesting and inspecting an adult beneficiary’shealth plan beneficiary ID card, prior to providing non-emergency services. If you suspectfraud, please contact Provider Services at 1-833-552-3876 immediately. Beneficiaries mustkeep the beneficiary ID card in order to receive benefits not covered by Carolina CompleteHealth, such as Pharmacy services. Beneficiaries are directed to present both identificationcards when seeking non-emergency services.15 of 1142022-03-25
CAROLINA COMPLETE HEALTH WEBSITECarolina Complete Health WebsitePlease use the Carolina Complete Health website to find information. Utilizing the website allowsimmediate access to current provider and beneficiary information twenty-four (24) hours, seven(7) days a week. Please contact your Provider Relations Representative or our Provider Servicesdepartment at 1-833-552-3876 with any questions or concerns regarding the website. CarolinaComplete Health website is located at https://www.carolinacomplete
practice in the state, providing leadership in medicine by uniting, serving and representing physicians and their health care teams to enhance the health of North Carolinians. North Carolina Community Health Center Association: The NCCHCA is a private, non-profit membership association that represents Federally-Qualified Health Centers
