Manuals, Forms, and Guides

To streamline processes for nursing facility admissions and the determination of long-term care financial eligibility, NC Medicaid created a new standardized PHP Notification of Nursing Facility Level of Care Form (NC Medicaid-2039) for PHPs and nursing facilities to communicate with local Departments of Social Services (DSS). 

The standardized form includes all information a local DSS needs to begin the financial determination for long-term care as required by the Centers for Medicare and Medicaid Services (CMS).  Once counties conduct the financial determination and establish the patient monthly liability (PML), the PML will be shared with health plans and allow payments to proceed to nursing facilities.

To further clarify how this process works, NC Medicaid created stakeholder-specific fact sheets for counties, for health plans, and for providers (including hospitals and nursing facilities). The fact sheets outline the information flow, timelines and requirements for the long-term care financial eligibility determination process.

• County Fact Sheet
• Provider Fact Sheet

A provider is required to promptly notify Carolina Complete Health when prenatal care is rendered. Early notification of pregnancy allows the health plan to assist the beneficiary with prenatal care coordination of services.

To notify CCH of pregnancy, please complete the Pregnancy Risk Screening Tool from NC DHHS available through the link below and fax to Carolina Complete Health Care Management Notification of Pregnancy: 833-417-0446. 

• NC DHHS Provider Forms: Reproductive Health Forms 
• For billing guidance on the Pregnancy Screening Tool, view the NC DHHS Medicaid Clinical Coverage Policy 1E-6: Pregnancy Management Program

A provider can also complete the NOP in the Secure Provider Portal under Assessments in the member's health record.

Review the CCH Notification of Pregnancy and Maternal Health Programs Provider Guide (PDF) for additional support and resources!

Primary Care Provider (PCP) Change Fax Form (PDF)

• Providers can also continue using the PCP Change Form to add a member to their panel.

• CCH Personal Care Services 3051 Request Form (PDF) 
  • For more information, visit our PCS Page

Prior Authorization Forms

• Prior Authorization Fax Form: CCH Standard Plan (PDF) 
• Prior Authorization Fax Form: Trillium Physical Health Tailored Plan (PDF)
• Prior Authorization Tip Sheet (PDF)