Claims and Billing Frequently Asked Questions

• Carolina Complete Health is working as a delegate to both Trillium and Partners Tailored Plans to support the physical health provider networks. This includes contracting, physical health claims processing, provider network support, and more. For dates of service beginning 7/1/24, instead of submitting physical health claims to Medicaid Direct for Partners or Trillium Tailored Plan members, providers should submit using one of the methods outlined on the CCH Provider Guide for Tailored Plan Billing (PDF). These methods will result in a claim being submitted to Carolina Complete Health for processing.

• Known Issue Description: On January 27, 2025, Carolina Complete Health identified gaps within the hierarchy logic associated with Behavioral Health/Physical Health Claims routing that caused Trillium Claims to inappropriate pay lines when they should have been rejected to submit to Trillium for behavioral Health Processing. Additional updates to hierarchy logic required due to revised guidance from NC DHHS received 05/01/25, to ensure that Trillium Behavioral Health Claims appropriately reject with message to submit to Trillium for behavioral Health Processing.
• Resolution: System configuration logic is being updated. Claims impacted will be identified and will be reprocessed once the system fix is completed. Providers should continue to submit future Physical Health claims for continued processing.
• For updates and estimated fix dates, providers can review the Known Issues Tracker (PDF) which is updated weekly, by Friday mornings, or reach out to CCHN Provider Relations via NetworkRelations@cch-network.com.

• Carolina Complete Health attests to NC Medicaid Clinical Policy 1H: Telehealth, Virtual Communications and Remote Patient Monitoring. Billing for telehealth should follow the guidelines and modifiers outlined in this policy. Providers should submit claims on a nationally accepted format as outlined in the CCH Billing Manual (PDF). Electronic claims submission is preferred: Electronic Submission Methods for CCH, Partners, and Trillium (PDF).

• Providers should use the Synchronous Audio-Only Codes outlined in Attachment A C. 2. Virtual Communication Services of NC Medicaid Clinical Policy 1-H. 
• Virtual communications is the use of technologies other than video to enable remote evaluation and consultation support between a provider and a beneficiary or a provider and another provider. 
• As outlined in Attachment A and program specific clinical coverage policies, covered virtual communication services include: telephone conversations (audio only); virtual portal communications (secure messaging); and store and forward (transfer of data from beneficiary using a camera or similar device that records (stores) an image that is sent by telecommunication to another site for consultation).
• Modifier GT "should not be used for virtual patient communications (including telephonic evaluation and management services) or remote patient monitoring" per clinical policy 1H.

• An example of a CMS 1500 form can be found in the CCH Billing Manual (PDF), page 46. 
• Box 24 contains six claim lines. Each claim line is split horizontally into shaded and unshaded areas. Within each un-shaded area of a claim line, there are 10 individual fields labeled A-J. Within each shaded area of a claim line there are four individual fields labeled 24A-24G, 24H, 24J, and 24Jb. Fields 24A through 24G are a continuous field for the entry of supplemental information. Instructions are provided for shaded and unshaded fields. The shaded area for a claim line is to accommodate the submission of supplemental information, EPSDT qualifier, and Provider Number. Shaded boxes 24 a-g is for line-item supplemental information and provides a continuous line that accepts up to 61 characters. Refer to the instructions listed below for information on how to complete. The un-shaded area of a claim line is for the entry of claim line-item detail. 

• Source: Outpatient Specialized Therapies, 10A (PDF)
• Source: PT/OT/ST Frequently Asked Questions Guide (PDF)
• “The provider’s type and specialty determine the outpatient setting allowed. For independent practitioner providers: office, private residence, school, Head Start program, and childcare (regular and developmental day care) settings.”    
• Place of Service 99 – Other, may be used in the daycare setting
• Place of service 03 – School, may be used in the preschool setting.

• Source: Outpatient Specialized Therapies, 10A (PDF)
• "Outpatient Specialized Therapy (OST) services are covered in all settings except hospital and rehabilitation inpatient facilities.“
• "The provider’s type and specialty determine the outpatient setting allowed. For independent practitioner providers: office, private residence, school, Head Start program, and childcare (regular and developmental day care) settings. Telehealth claims should be filed with the provider’s usual place of service code(s).”
  
  
• Source: Carolina Complete Health Billing Manual (PDF)
• Claim form instructions for CMS 1500:  In field 24 B Unshaded, providers should enter the Place of Services using the appropriate 2-digit CMS Standard Place of Service (POS) Code. A list of current POS Codes may be found on the CMS website.

• Source: Outpatient Specialized Therapies, 10A (PDF)
• “The provider’s type and specialty determine the outpatient setting allowed. For independent practitioner providers: office, private residence, school, Head Start program, and childcare (regular and developmental day care) settings. Telehealth claims should be filed with the provider’s usual place of service code(s).”
  
  
• Source: Carolina Complete Health Billing Manual (PDF)
• Claim form instructions for CMS 1500:  In field 24 B Unshaded, providers should enter the Place of Services using the appropriate 2-digit CMS Standard Place of Service (POS) Code. A list of current POS Codes may be found on the CMS website.

• Source: Telehealth, Virtual Communications and Remote Patient Monitoring, 1-H (PDF)
• “Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio- isual communication. This modifier should not be used for virtual patient communications (including telephonic evaluation and management services) or remote patient monitoring” 

• Source: Core Services Provided in FQHC and Rural Health Clinics, 1D-4 (PDF)
• Carolina Complete Health attests to NC Medicaid Clinical Coverage Policy 1D-4. This policy states to “use modifier SC to bill non–behavioral health visits that occur after the first encounter in which the beneficiary appears with, presents with, or suffers illness or injury requiring additional diagnosis or treatment.” 
• The SC modifier is for a subsequent sick, after the first encounter, when the member has a non-behavioral health illness or injury. 

• Known Issue Description: On 12/19/2024, CCH identified an issue with FQHC/RHC claims which is causing claims billed with procedure code T1015 and a HI modifier to be denied for yJ: DUPLICATE CLAIMS BILLING SAME/SIMILAR CODE(S) FOR DATE OF SERVICE, yQ: SAME OR MULTIPLE PROVIDERS BILLING EXACT OR SIMILAR CODE(S), and yq: DUPLICATE CLAIMS OR MULTIPLE PROVIDERS BILLING SAME/SIMILAR CODE(S).
• Resolution: System configuration logic is being updated. Impacted claims have been identified for reprocessing. No further action from providers is needed at this time.
• For updates and estimated fix dates, providers can review the Known Issues Tracker (PDF), which is updated weekly by Friday mornings. You can also reach out to CCHN Provider Relations via NetworkRelations@cch-network.com

• Source: Carolina Complete Health Billing Manual (PDF). Section: “Provider Claim Corrections,Reconsiderations, and Claim Grievances”
• Source: Carolina Complete Health Standard Plan: Claim Reconsideration and Grievance Form (PDF).

Submission:

• Secure Provider Portal (preferred). For instructions, view page three of the Claim Dispute Form (PDF).
• Paper: Complete the Claim Dispute Form (PDF) and submit along with the EOP to the mailing address listed on the form or fax to 833-641-0206. If faxing, please only submit one claim per form submission, with a maximum of 400 pages.

• Mutually Exclusive Editing: These are combinations of procedure codes that may differ in technique or approach but result in the same outcome. The procedures may be impossible to perform anatomically. Procedure codes may also be considered mutually exclusive when an initial or subsequent service is billed on the same date of service. The procedure with the highest RVU is considered the reimbursable code. 

• Source: Carolina Complete Health Billing Manual (PDF). Section: “Provider Claim Corrections,Reconsiderations, and Claim Grievances”
• Source: Carolina Complete Health Standard Plan: Claim Reconsideration and Grievance Form (PDF).

Submission:

• Secure Provider Portal (preferred). For instructions, view page three of the Claim Dispute Form (PDF).
• Paper: Complete the Claim Dispute Form (PDF) and submit along with the EOP to the mailing address listed on the form or fax to 833-641-0206. If faxing, please only submit one claim per form submission, with a maximum of 400 pages.

• Source: CCH Billing Manual (PDF)
• If an enrollee has other insurance that is primary, you must submit your claim to the primary insurance for consideration and submit a copy of the Explanation of Benefits (EOB) or Explanation of Payment (EOP), or rejection letter from the other insurance when the claim is filed. If this information is not sent with an initial claim filed for an Enrollee with insurance primary to Medicaid, the claim will pend and/or deny until this information is received. If an Enrollee has more than one primary insurance (Medicaid would be the third payer), the claim cannot be submitted through EDI or the secure web portal and must be submitted on a paper claim.
• Providers have 365 calendar days from the primary payer EOP to submit a COB claim to Carolina Complete Health. If using the Carolina Complete Health Secure Provider Portal, you can follow the instructions outlined here: Coordination of Benefits Walkthrough (PDF). These instructions also apply to providers using the Trillium Physical Health Portal for physical health claims.
•  Additional resource: Provider FAQ- Pended Claims Requiring Additional Information (PDF)