Provider Grievances and Appeals

A Provider Grievance is a verbal or written complaint or dispute by a Provider over any aspect of the operations, activities, or behavior of AmeriHealth Caritas North Carolina, except for any dispute over which the Provider has appeal rights. It is an opportunity for the Provider to bring issues to the Plan.

Examples of Provider grievances include, but are not limited to:

  • Service issues with AmeriHealth Caritas North Carolina including failure by AmeriHealth Caritas North Carolina to return a Provider's calls, frequency of site visits by AmeriHealth Caritas North Carolina's Provider Account Executives and lack of Provider Network orientation/education by AmeriHealth Caritas North Carolina.
  • Issues with AmeriHealth Caritas North Carolina processes, including failure to notify Providers of policy changes, dissatisfaction with AmeriHealth Caritas North Carolina's Prior Authorization process, dissatisfaction with AmeriHealth Caritas North Carolina's referral process and dissatisfaction with AmeriHealth Caritas North Carolina's Formal Provider Appeals Process
  • Contracting issues, disputes and differences, including dissatisfaction with AmeriHealth Caritas North Carolina's reimbursement rate, and incorrect information regarding the Provider in AmeriHealth Caritas North Carolina's Provider database.

Providers may file a grievance using the following reason codes:

  • 500 Claim Denial
  • 510 Health Plan Policy
  • 520 Health Plan Information System
  • 530 Network Adequacy/Availability
  • 540 Health Plan Staff Behavior
  • 550 Interpreter Services
  • 560 Member Behavior
  • 570 Member Compliance with Treatment plan
  • 580 Member Missed/Late Appointments (appointment log required)
  • 590 Member Communication
  • 600 Referral Process
  • 610 Service Denial
  • 620 Health Plan Prior Authorization Process
  • 630 Timeliness of Payment (proof of original submission date required)
  • 640 Fraud and Abuse Services
  • 650 Transportation
  • 660 Other (Please be prepared to explain if not listed in the above options.)

Providers are encouraged to resolve grievances by phone or in person with their dedicated Account Executive, or by calling Provider Services at 1-855-738-0004.

Providers may also file online by completing the online Provider Grievance Submission form along with any supporting documentation.

Providers may also submit a provider grievance by mail. Download and complete the Provider Grievance Submission form (PDF) found in the Forms section of this website, attach any supporting documentation and mail to:

Provider Grievances Department
AmeriHealth Caritas North Carolina
PO Box 7379
London, KY 40742-7379

Time Frame for Resolution

AmeriHealth Caritas North Carolina will investigate, conduct an on-site meeting with the provider (if one was requested), and issue written resolution of a formal grievance within thirty (30) calendar days of receipt of the grievance from the Provider.

Providers may appeal most grievances not resolved through the Provider Grievance process to the provider's satisfaction.

AmeriHealth Caritas North Carolina maintains a Formal Provider Appeals Process by which Providers may challenge certain decisions of AmeriHealth Caritas North Carolina. Providers may appeal for the following reasons:

Network Providers Out-of-Network Providers
  • 500 Program Integrity related findings or activities
  • 510 Finding of fraud, waste, or abuse by the Plan
  • 520 Finding of or recovery of an overpayment by the Plan
  • 530 Withhold or suspension of a payment related to fraud, waste, or abuse concerns
  • 540 Termination of, or determination not to renew, an existing contract based solely on objective quality reasons outlined in the Plan’s Objective Quality Standards*
  • 550 Termination of, or determination not to renew, an existing contract for local health department care/case management services
  • 560 Determination to lower an Advanced Medical Home (AMH) provider's Tier Status
  • 570 Violation of terms of the provider contract between the Provider and AmeriHealth Caritas North Carolina
  • 599 Other for in-network providers – Be prepared to explain if not listed in above options
  • 700 A determination not to initially credential and contract with a provider based on objective quality reasons outlined in the Plan's Objective Quality Standards
  • 710 An out-of-network payment arrangement
  • 720 Finding of waste or abuse by the Plan
  • 730 Finding of or recovery of an overpayment by the Plan
  • 799 Other for out-of-network providers. Please be prepared to explain if not listed in the above options

* Provider terminations based on quality of care reasons may be appealed in accordance with the AmeriHealth Caritas North Carolina Provider Sanctioning Policy outlined in Section VIII of the provider manual.

Appeals must be made in writing.

Providers can file an appeal online by completing the AmeriHealth Caritas North Carolina Provider Appeals Submission form (PDF) and submitting with the required documentation here.

Or providers can submit in writing with required documentation to:

Provider Appeals Department
AmeriHealth Caritas North Carolina
P.O. Box 7379
London, KY 40742-7379

For providers wishing to submit multiple claims for the same reason code, a grid has been created for both the online form and the physical form found in the Forms section of this website.

AmeriHealth Caritas North Carolina will acknowledge receipt of each appeal request within five (5) calendar days of receipt of the request.

Timeframe for Resolution

AmeriHealth Caritas North Carolina will provide written notice of the decision of the appeal within thirty (30) calendar days of receiving a complete appeal request. If an extension is granted to the provider to submit additional evidence, written notice of the decision of the appeal will be received within thirty (30) calendar days of the date on which the additional evidence is submitted.

For more information regarding Provider Grievances and Appeals consult your AmeriHealth Caritas North Carolina provider manual (PDF).