To submit this form, you can choose one of the following methods: Online: Visit the Provider Grievance and Appeals page in the Provider section of the AmeriHealth Caritas North Carolina website (www.amerihealthcaritasnc.com) and follow the link to the secure provider portal. Mail: Complete the form and mail it with any supporting documentation to AmeriHealth Caritas North Carolina, Provider Grievances, P.O. Box 7379, London, KY 40742-7379. If you have questions on how to complete this form, please call your Account Executive or Provider Services at 1-888-738-0004.

There are no specific dates applicable to this form for 2024 and 2025.

The AmeriHealth Caritas North Carolina Provider Grievance Submission Form serves as a crucial tool for healthcare providers to address grievances related to their interactions with health plans and members. This form allows providers to formally document issues such as claim denials, health plan policies, network adequacy, staff behavior, and member compliance. By submitting this form, providers ensure their concerns are reviewed and resolved in a timely manner, contributing to better healthcare service delivery.

• 1. Today's date: Fill in the current date.
• 2. Provider name: Enter the name of the provider.
• 3. Contact name: Enter the contact name if different from the provider name.
• 4. Phone: Enter the contact phone number.
• 5. Fax: Enter the fax number.
• 6. Tax ID: Enter the provider's Tax ID.
• 7. NPI: Enter the National Provider Identifier (NPI).
• 8. Mailing address: Enter the provider's mailing address.
• 9. City: Enter the city of the provider's address.
• 10. State: Enter the state of the provider's address.
• 11. ZIP code: Enter the ZIP code of the provider's address.
• 12. Member name: Enter the member's name if the grievance involves a claim.
• 13. Member's ID: Enter the member's ID from their Medicaid card.
• 14. Claim Identification Number: Enter the claim identification number.
• 15. CPT/HCPCS Codes: Enter the relevant CPT/HCPCS codes.
• 16. NDC Code: Enter the National Drug Code (NDC) if applicable.
• 17. Reason code for submission: Select the primary reason code for your grievance from the provided list.
• 18. Supporting documentation: Attach any supporting documentation related to the grievance.

Failing to submit this form may result in unresolved grievances and ongoing issues with health plan interactions.

• Unresolved Claim Denials: Issues related to claim denials may remain unaddressed.
• Policy Disputes: Disputes related to health plan policies may continue without resolution.
• Network Adequacy Issues: Concerns about network adequacy may not be addressed.
• Behavioral Issues: Problems with health plan staff or member behavior may persist.
• Compliance Problems: Issues with member compliance to treatment plans may remain unresolved.

• 1. Claim Denial: Submit this form if your claim has been denied.
• 2. Policy Dispute: Use this form to address disputes related to health plan policies.
• 3. Network Adequacy: If experiencing network adequacy issues, submit this form.
• 4. Staff Behavior: Report problems with health plan staff behavior using this form.
• 5. Member Compliance: Address member compliance with treatment plans using this form.