Contract Request Form

Thank you for your interest in becoming a Carolina Complete Health Network provider.

In addition to our Standard Plan contracting, Carolina Complete Health is also currently contracting providers for physical health services with two Tailored Plans – Partners Health Management and Trillium Health Resources. View our Tailored Plan Information Guide (PDF)

Please complete the below information and one of our team members will contact you within the next 5 business days.

We look forward to working with you to improve the health of the community.

Required fields are marked with an asterisk (*)

Please indicate the network(s) you would like to join: *

Carolina Complete Health Standard Plan Trillium Tailored Plan (Physical Health Providers) Partners Tailored Plan (Physical Health Providers)

First Name *

Last Name *

Phone Number *

Email Address *

Entity Tax ID *

Entity Billing NPI *

Entity Medicaid Number

Legal Entity Name *

Attention – Name/Title *

Provider Mailing Address *

City *

State *

Zip *

County *

Facility Type *

Facility/Agency Type *

W9 Form

NCDHHS Delays Implementation of the NC Medicaid Managed Care Behavioral Health and I/DD Tailored Plans

Tailored Plans are scheduled to launch in October 2023 (delayed from April 1, 2023).

While the launch of Tailored Plans has been delayed until October 2023, Carolina Complete Health remains focused on contracting providers for physical health.

Contract Request Form

NCDHHS Delays Implementation of the NC Medicaid Managed Care Behavioral Health and I/DD Tailored Plans

Tailored Plans are scheduled to launch in October 2023 (delayed from April 1, 2023).

While the launch of Tailored Plans has been delayed until October 2023, Carolina Complete Health remains focused on contracting providers for physical health.

View more information in the NC DHHS Press Release.