Provider Announcements

Beginning February 1, 2022, the following changes will be made to Outpatient Pharmacy Clinical Coverage Criteria and the accompanying prior authorization request forms:

  • Cystic Fibrosis
    • Minimum age for Trikafta changed from 12 years to 6 years, or greater. Updated criteria and form.
  • Hepatitis C
    • Clarified duration of therapy for Mavyret for treatment experienced genotype 1 & 3 patients, includes patients with liver and kidney transplant. Minimum age for Mavyret changed from 12 to 3 years of age; minimum weight requirement removed; added Mavyret pellet packs. Updated criteria and forms for Mavyret.
    • Minimum age for Epclusa changed from 6 to 3 years of age; minimum weight requirement removed; added Epclusa pellet packs. Updated criteria and forms for Epclusa and generic Epclusa, Sofosbuvir-Velpatasvir.
  • Opioid Analgesics
    • Added generic Hysingla ER. Updated criteria with no change to form.
  • PCSK9 Inhibitors
    • Added Homozygous Familial Hypercholesterolemia (HoFH) for Praluent. Updated criteria and form.
  • Zolgensma
    • Added exemption from providing (CHOP-INTEND) score or HINE score for infants initiating treatment based on Newborn Screening results indicating baby has SMA. Updated criteria and form.

Getting Started with Carolina Complete Health

Carolina Complete Health Quick Reference Guide Form (PDF)

To join our provider-led network and be a part of Carolina Complete Health Network, please complete our contract request form, call Network Relations at 1-833-552-3876, or email us at NetworkRelations@CCH-Network.com to request a participating provider agreement.

Join the CCHN Provider Engagement team on a New Provider Orientation. For instructions on how to attend, please visit our education and training site. 

New Provider Orientations will cover:

  • Carolina Complete Health overview
  • Provider Engagement and Provider Relations Support
  • Accessing the public website and secured web portal
  • Verification of Eligibility and Carolina Complete Health benefits
  • Prior Authorizations
  • Claims and billing
  • Fraud, Waste & Abuse
  • Cultural Competency

Registration is free and easy! Use the Log In button in the upper right hand corner of this webpage

  • Click create account to register​
  • Follow the prompts – once verified you will receive an email saying that you are ready to log in​
  • From there you'll navigate back to the portal and log in

Using the Secure Provider Portal (PDF), providers will be able to: 

  • Easily check patient eligibility
  • View, manage, and download your patient list​
  • View, and submit claims​
  • View and submit service authorizations​
  • Communicate with us through secure messaging​
  • Maintain multiple providers on one account​
  • Control website access for your office​
  • View historical patient health records​
  • Submit assessments to provide better patient care​
  • Update provider demographic data

Claims may be submitted in 3 ways:​

  1. The Secure Provider Portal - Available 90 days before go-live. Use the login button located on the upper right hand corner of this page​
  2. Electronic Clearinghouse​
    Three clearinghouses for Electronic Data Interchange (EDI) submission: Availity, Change Healthcare (formerly Emdeon), and Ability.  As long as the provider’s clearinghouse has a connection to one of the previously mentioned clearinghouses, then the claim can be passed on to Carolina Complete Health. Carolina Complete Health's Medical Payer ID is 68069
  3. Mail
    Carolina Complete Health
    Attn: Claims​
    PO Box 8040 ​
    Farmington MO 63640-8040

The timely filing deadline for initial claims is 180 calendar days from the Date of Service, or in the case of a health care provider facility, within one hundred eighty days after the date of the member’s discharge from the facility.​

What is a paid claim?

  • Paid in Full - The claim has been adjudicated, processed and reimbursed in accordance and with the executed provider contract on file including the coordination of benefits, as applicable per claim.

Please visit the Claims and Billing section of our Provider Resources to view our billing manual.

Setting up EFT and ERA:

Carolina Complete Health offers Payspan, a free solution that helps Providers transition into electronic payments and automatic reconciliation. Payspan will be available 30 days before implementation

 

Access the Pre-Auth Check Tool to determine whether a prior authorization is required

Emergency services, family planning, post stabilization services, and table top x-rays do not require prior authorization. 

Prior authorizations can be submitted in 3 ways: 

  1. The Secure Provider Portal 
  2. Phone​
    1-833-552-3876
  3. Fax​
    Medical PA Fax: 1-833-238-7694
    BH Inpatient Fax: 1-833-596-2768
    BH Outpatient Fax: 1-833-596-2769
    Pharmacy PA Fax: 1-866-399-0929

For Prior Authorization Form, please visit our Manuals, Forms, and Guides page.

For Behavioral Health UM Prior Authorization Guidelines, please visit our Manuals, Forms, and Guides page.

  • For Behavioral Health, please see state bulletin regarding COVID-19 flexibilities for specifics related to BH prior authorizations.

Visit the Prior Authorization section of this website as well as the Provider Manual for more information.

Carolina Complete Health will use National Imaging Associates, Inc. (NIA) to provide the management and prior authorization of non-emergent, advanced, outpatient imaging services.

Please use the Help STAT! link on the upper right hand corner of this website to quickly be connected with the Carolina Complete Health Network team. This information is routed to an internal email address, managed during business hours. 

You may also contact Network Relations by calling 1-833-552-3876 or emailing Networkrelations@cch-network.com

Advanced Medical Homes (AMHs), Hospitals, and Health Systems, are encouraged to reach out directly to their designated Provider Engagement Coordinator.