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

To ensure beneficiaries can seamlessly receive care on day one, the North Carolina Department of Health and Human Services (NCDHHS) is delaying the implementation of the NC Medicaid Managed Care Behavioral Health and Intellectual/ Developmental Disabilities Tailored Plans (Tailored Plans) scheduled for Oct. 1, 2023, but will now go forward at a date still to be determined.

Contract Request Form

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

View more information in the NC DHHS Press Release.