Provider Manuals, Policies 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.
• Behavioral health utilization management guide (PDF)
  Use this guide to learn more about behavioral health services that require prior authorization.
• Care gaps response form provider guide (PDF)
  The Gaps Response Form functionality allows providers using the NaviNet portal to enter Care Gap resolution data online.
• Claims and billing guide (PDF)
  This guide will help you avoid delays in the processing of your claims.
• Jiva Provider Guide (PDF)
  This guide will help you navigate the Jiva Provider Portal.
• Prior authorization reference guide (PDF)
  Refer to this guide for quick information about services requiring prior authorization and how to submit your request.
• Provider reference guide (PDF)
  Keep this sheet of contact information close by for when you need to give us a call.

Policies

• Utilization management program description 2021 (PDF)

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)

Grievances and Appeals

• Provider Grievance Submission Form (PDF)
• Provider Appeal Submission Form (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 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)

Medical Prior Authorization

• Prior Authorization Request Form (PDF)

Pharmacy Prior Authorization

• Pharmacy Prior Authorization Requests

Provider Change

• Request for Change of Primary Care Provider (PDF)