Provider Announcements

Three new Carolina Complete Health specific policies were developed based on feedback obtained from specialists in the CCH network and approved for use in the January Medical Affairs Committee. 

• NC.CP.MP.144: Mechanical Stretching Devices for Joint Stiffness and Contracture: CCH policy developed to allow use of bi-directional static progressive stretch (SPS) devices for elbows.  View the policy to read all criteria.
• NC.CP.MP.109: Panniculectomy: CCH policy developed to allow for a panniculectomy prior to some surgical procedures in order to prevent wound complications/infections. View the policy to see full medical necessity criteria.
• NC.CP.MP.145: Electric Tumor Treating Fields (Optune): Policy changed to keep in line with Optune’s recommendation that standard treatment with surgery AND radiation be used prior to initial use of the device. View the policy in full.

The North Carolina Department of Health and Human Services (DHHS) provided directives to Prepaid Health Plans (PHPs) to pend skilled nursing facility (SNF) claims submitted prior to patient monthly liability (PML) determination. PML is determined by the Department of Social Services (DSS) for North Carolina Medicaid.

Directives for processing claims

Claims received by Carolina Complete Health prior to PML determination will pend as an unclean claim for 90 calendar days. If the claim is clean as cited in section 3.41 of Managed Care Billing Guidance to Health Plans, version 24 and the PML is received within the 90 calendar days, we will pay the claim. If the PML is not received within 90 calendar days of receipt of the claim, we will deny the claim as consistent with North Carolina General Statute § 58-3-225(d). If the missing additional information (i.e., the PML) is received within 1 year after the date of the denial notice closing the claim, Carolina Complete Health is required to reopen and process the claim in accordance with North Carolina General Statute § 58-3-225(d).

Please view our Provider FAQ on the pended unclean claims for additional information (PDF).

Further, as required by North Carolina General Statute § 58-3-225(d), Carolina Complete Health will inform providers in the denial notice that the claim will be reopened if the PML is received within 1 year of the date of the denial notice closing the claim.

Reprocessing denied claims

DHHS requires PHPs to reprocess claims with dates of service from July 1, 2021, to present day that were previously denied for timely filing where the PML was delayed by DSS.

What this means for you

There’s nothing you need to do for us to reopen and process claims from this timeline. We’ll notify you of any affected claims.

Questions?

Contact Provider Services by calling 1-833-552-3876 or reach out to Network Support team directly via email: NetworkRelations@cch-network.com

We are pleased to announce that, effective January 1, 2024, Express Scripts® will begin processing pharmacy claims for our plan members.

Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.

Members have been notified in advance and will receive a new ID card with updated pharmacy information, so that they are prepared to begin having their prescriptions filled at participating network pharmacies when this change occurs.

Providers can direct members to call the Member Services phone number listed on their ID card should they have questions about this change.

Please contact your Provider Relations Representative with any additional questions.

Thank you for the care you provide to our members.