Prior Authorization/Referral
Some covered services or medications may need approval from Carolina Complete Health, and this is called a Prior Authorization (PA). You do not need a paper referral from Carolina Complete Health to see a doctor but your doctor may need to request a prior authorization from Carolina Complete Health for a service to be approved.
The Prior Authorization Reform Act is helping us make our services even better. This bill took effect January 1, 2022.
Our prior authorization process will see many improvements. We will be clearer with processes and we will reduce wait times for things like tests or surgeries. You will also see improved fairness with our PA process.
For clinical standards, please see the information linked below. To request PA information or receive additional support, please contact us at 1-833-552-3876 (TTY: 711).
Below is a list of services that require prior authorization from Carolina Complete Health before your doctor can proceed with treatment.
| SERVICES THAT REQUIRE A PRIOR AUTHORIZATION | PRIOR AUTHORIZATION REQUIRED FOR SOME OR ALL OF THE SERVICES? |
| Ambulatory Surgery Center | Some services require prior authorization |
| Bariatric Surgery (Certain restrictions and limitations may apply) | Yes |
| Birthing Centers | Yes |
| Durable Medical Equipment (DM) | Some items require prior authorization |
| High Cost Radiology | Yes |
| Home Health Care Services | Yes |
| Hospice Care | Yes |
| Hospital Services Inpatient | Yes |
| Hospital Services Outpatient | Some services require prior authorization |
| Laboratory Services (HPP): All services necessary for the diagnosis, treatment and prevention of disease, and for the maintenance of health. | Some services require prior authorization |
| Maternity Services (HPP) | Some services require prior authorization |
| Medical Services Clinic | Yes |
| Orthotics & Prosthetics (O&P): Braces (non-dental) and other mechanical or molded devices to support or correct any defect of form or function of the human body. | Yes |
| Oxygen & Respiratory Services (HPP) | Some services require prior authorization |
| Pain Managment | Some services require prior authorization |
| Substance Use Disorder Services (HPP_) | Some services require prior authorization |
| Therapy (OT,PT,ST) Services (Outpatient) | Yes |
| Transplant Services | Yes |
All such services determined by North Carolina Medicaid to be medically necessary shall constitute a Carolina Complete Health covered service. See the Carolina Complete Health Member Handbook for more information on coverage out-of-network and out of the North Carolina Medicaid service area.