Prior Authorization

All services are subject to benefit coverage, limitations, and exclusions as described in applicable plan coverage guidelines. For details, view the Clinical Coverage Policies.  All medical services performed, even if a Prior Authorization is not required, must be medically necessary and may not be experimental in nature.

Medical necessity is defined for Carolina Complete Health beneficiaries as healthcare services, supplies or equipment provided by a licensed healthcare professional that are:

  • Appropriate and consistent with the diagnosis or treatment of the patient’s condition, illness, or injury;
  • In accordance with the standards of good medical practice consistent with evidence based and clinical practice guidelines;
  • Not primarily for the personal comfort or convenience of the beneficiary, family, or provider;
  • The most appropriate services, supplies, equipment, or level of care that can be safely and efficiently provided to the beneficiary;
  • Furnished in a setting appropriate to the patient’s medical need and condition and, when supplied to the care of an inpatient, further mean that the beneficiary’s medical symptoms or conditions require that the services cannot be safely provided to the beneficiary as an outpatient service;
  • Not experimental or investigational or for research or education.
  • For information on the medical necessity “EPSDT Guarantee” please see the “Early Periodic Screen, Diagnostic and Treatment Services” section

Experimental studies and related guidance is found in the following:

See Provider Manual for additional details.

All medical services performed must be medically necessary and may not be experimental in nature. Experimental is defined as medical care that is investigatory or an unproven procedure or treatment regimen that does not meet generally accepted standards of medical practice in North Carolina.

In evaluating whether a particular service is or is not experimental the agency will consider safety, effectiveness and common acceptance as verified through:

  1. Scientifically validated clinical studies
  2. Medical literature research and
  3. Qualified medical experts.

Experimental studies and related guidance is found in the following:

See Provider Manual for additional details.

Prior Authorization Forms

Pharmacy Prior Authorizations

  • For Pharmacy Prior Authorization forms, please visit our Pharmacy page.
Fax Number Reference Guide
833-238-7690 Carolina Complete Health Medicaid Face Sheets
833-238-7691 Carolina Complete Health Medicaid Assessments
833-238-7692 Carolina Complete Health Medicaid Inpatient Requests
833-238-7693 Carolina Complete Health Medicaid Medical Records
833-238-7694 Carolina Complete Health Medicaid Prior Authorization
844-975-1325 Carolina Complete Health Medicaid Census Reports
833-596-2768 Carolina Complete Health Inpatient Behavioral Health PA
833-596-2769 Carolina Complete Health Outpatient Behavioral Health PA

Non-emergent, Advanced, Outpatient Imaging Services

  • In an effort to continue promotion of quality improvement for services provided to Carolina Complete Health members, effective July 1, 2021, Carolina Complete Health will use National Imaging Associates, Inc. (NIA) to provide the management and prior authorization of non-emergent, advanced, outpatient imaging services.
  • Services managed and authorized by NIA include outpatient:
    • CT/CTA
    • CCTA
    • MRI/MRA
    • PET Scan
    • MUGA Scan
    • Myocardial Perfusion Imaging (MPI)
    • Stress Echocardiography
    • Echocardiography
  • Please visit NIA's website for Carolina Complete Health to download policies and procedures specific to both ordering providers and imaging facilities. These include quick reference guides and FAQs. You can also view information designed to assist you in using the RadMD Website to obtain and check authorizations