Provider-Led Medical Policy

A Physician-run Medical Affairs Committee (MAC)

Carolina Complete Health (CCH) is the only Provider-Led Entity (PLE) in NC Medicaid Managed Care. CCH was established through a unique collaboration between the NC Medical Society, NC Community Health Center Association, and Centene.

Carolina Complete Health’s (CCH) Medicaid Affairs Committee (MAC) is a sub-committee of the CCH Board of Directors that consists of seven North Carolina Medicaid physicians and one Financial Matters Committee representative. The MAC has board authority to make medical policy decisions for CCH using feedback from specialty reviewers and medical policy/advisory workgroups.

Specialty Reviewers

As the PLE, we seek out experts like yourself to provide input into clinical policy that is evidenced-based and in-line with current practice. Through this process, we hope to ensure that providers have a real voice so that we can continue to do the right thing for our patients and our practices. We believe this will not only improve patient care but relieve unnecessary administrative burden.

Making a Difference

Carolina Complete Health’s Medical Affairs Committee meets monthly to review medical policies that provide clinical guidance and criteria for covered Medicaid benefits. Each month, CCH/N seeks feedback from our network of providers for input which is then shared with the Committee. This feedback can lead to revision, rejection, or retirement of policies to ensure alignment with current practice in the field.

Examples of how feedback affects policy:

Feedback received on NC Medicaid policy 11A-17 CAR T-Cell Therapy resulted in the creation of a Carolina Complete Health (CCH) specific policy, removing the absolute requirement of a bone marrow biopsy (no more than six months old). See policy NC.CP.MP.500 CAR T-Cell Therapy (PDF).
Feedback specific to policy NC.CP.MP.153 H. Pylori Serology Testing resulted in additional revisions to this CCH specific policy, adding special considerations for use of H. pylori serology testing (PDF).
Feedback received for Pancreas Transplantation resulted in the addition of Type II diabetes mellitus as part of potential medical necessity for a pancreas transplant. See policy NC.CP.MP.102 (PDF) criterion I.B.

All current clinical policies that CCH has adopted can be found on the Clinical Policy page.

View our Medical Policy Provider Guide (PDF)

Medical Policy Advisory Workgroups

Primary Care
Emergency Medicine
Behavioral Health
Pediatric
Obstetrics

Any provider (MD, DO, NP, PA) or behavioral health clinician can participate in their specialty-matched Medical Policy workgroup as long as they are a participating CCH provider. For more information on getting involved with Medical Policy, please email CCHNMedicalPolicy@cch-network.com for eligibility criteria.

Provider Advisory Workgroups

The CCHN Provider Advisory Committee (PAC) is a committee utilized to communicate Carolina Complete Health’s (CCH’s) programs and processes to its provider network allowing for collaboration and feedback through discussion with the providers. CCHN Provider Advisory Committee provides input on the CCH Provider Support Plan, Provider Training Plan, Provider Engagement Strategy, Medical Policy Strategy, Innovations Programs, Administrative simplification, and more.

The HCBS Council is dedicated to providers of Durable Medical Equipment, Personal Care Services, Home Health, and Long-Term Services and Supports providers. This group will meet with CCHN to discuss barriers and concerns as well as to brainstorm solutions..

If interested in participating, contact email CCHNMedicalPolicy@cch-network.com for eligibility criteria.