Manuals, Forms, and Guides

• Massage Therapy Acknowledgement Form (PDF)
• Massage Therapy Assessment Checklist (PDF)

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 Provider Guide for Pregnant Members (PDF) for additional support and resources!

• Primary Care Provider (PCP) Change Fax Form (PDF)
  • Use the PCP Change Form when a member requests to change their PCP. This is used to add a member to the provider's panel.

• Member Reassignment Form (PDF)
  • The Member Reassignment Form is used by the PCP to request reassignment of a member away from their panel due to:
    • Member aged-out of practice
    • Member relocated
    • Or with-cause (per NC Medical Board guidelines) 
  • Please refer to the PCP Initiated Member Reassignment (PDF) Policy.

Reach out to your Provider Engagement Coordinator for support for either of these forms.

• 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)

• YMCA Diabetes Prevention Program and Blood Pressure Self-Monitoring Program (BPSM) Physician Referral Form (PDF)

The four-month YMCA BPSM program offers personal support for members to build skills that help them manage high blood pressure, notice and control triggers that raise blood pressure, and eat healthier. Studies show that taking your blood pressure at least twice a month for four months lowers your blood pressure. Twice a month, participants attend the program and receive personal coaching, as well as attend monthly nutrition meetings.

Eligibility Requirements: The program is available to Carolina Complete Health members age 18 years or older who have been diagnosed with high blood pressure. Participants cannot have had a recent cardiac event, have atrial fibrillation or other arrhythmias, or be at risk for lymphedema.

• YMCA Diabetes Prevention Program and Blood Pressure Self-Monitoring Program (BPSM) Physician Referral Form (PDF)

The YMCA DPP is a one-year program to help adults lower their risk of diabetes by learning about physical activity and nutrition leading to weight loss and risk reduction. A trained Lifestyle Coach will teach a small group of members how healthy eating, exercise, and behavior changes can help lower their risk for diabetes and improve their overall health.

Eligibility Requirements: The program is available to Carolina Complete Health members age 18 years or older with prediabetes, a Body Mass Index (BMI) of 25+ (Asian individual(s) with BMI of 23+) and have an A1c between 5.7% - 6.4. Members who currently have diabetes would not be eligible since this program is preventative.

Note: For the DPP Program, members who currently have diabetes are not eligible because this program is preventative.