Provider Manuals and Forms

Manuals and guides

AmeriHealth Caritas North Carolina offers these reference materials to our providers for use when treating our members.

• Provider manual (PDF)
  This manual will help you and your office staff provide services to our members.
• Claims and billing guide (PDF)
  This manual will help you avoid delays in the processing of your claims.
• Provider reference guide (PDF)
  Keep this sheet of contact information close by for when you need to give us a call.
• Prior authorization reference guide (PDF)
  Refer to this guide for quick information about services requiring prior authorization and how to submit your request.

If you have any questions about these materials or about AmeriHealth Caritas North Carolina, call Provider Recruitment at 1-844-399-0474, or contact your Account Executive.

Forms

Advance directives

• Advance Directive for a Natural Death (PDF)
• Advance Instruction for Mental Health (PDF)
• Health Care Power of Attorney (PDF)
• Organ/Tissue Donor Card (PDF)
• Registration Form (PDF)
• Remove Directive Form (PDF)

Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

• Non-covered State Medicaid Plan Services Request Form for Recipients under 21 years old (PDF)

Let Us Know (Rapid Response and Outreach Team)

• Rapid Response and Outreach Team Member Intervention Form (PDF)

Long-Term Services and Supports (LTSS)

• Request for Independent Assessment for Personal Care Services (PCS) Attestation of Medical Need (PDF)

Maternity

• Delivery Notification Form (PDF)
• Pregnancy Medical Home Risk Screening Form (PDF)
• Pregnancy Medical Home Assessment Form — Spanish (PDF)

Prior Authorization

• Medical Necessity Prior Authorization Form (PDF)