CCHP Provider Manual

CCHP Provider Manual

Appendices

Appendix A - Abuse Reporting Forms

• Child Abuse Form & Instructions
• Domestic Violence Legal Requirements for Reporting
• Elder Abuse Report Form 

Appendix B

• Advanced Health Care Directive

Appendix C - Claims

• Corrected Claim Submission Guide & Cover Sheet
• Provider Appeal and Dispute Form

Appendix D 

• Confidential Morbidity Report

Appendix E

• Fraud/Waste and Abuse Training for Providers

 Appendix F - Pharmacy

• Medication - Prior Authorization Request
• Request for Formulary Review

Appendix G - Member Services 

• Member Grievance and Appeal Form
  • Member Grievance and Appeal Form (Spanish)
• Member Consent for Provider to File an Appeal
  • Member Consent for Provider to File an Appeal (Spanish)

  Appendix H -

• Prior Authorization (PA) Form
• Minor Consent Form Transportation-NEMT
• Disclosure of UM Criteria or Guidelines Request Form
• Physician Certification Statement (PCS) for NEMT

 Appendix I 

•  Provider and Member Call Centers

 Appendix J

•  Provider Complaint Form

 Appendix K

• Seniors and Persons with Disabilities Cultural Sensitivity Training

Appendix L- WIC Referrals

• WIC Referral for Postpartum Woman
• WIC Referral for Pregnant Woman
• WIC Infant Pediatric Referral

 Appendix M

• CPN PCP Orientation
• CPN Specialist Orientation
• CPN Urgent Care Orientation
• CPN Organizational Provider Orientation
• CCRMC Orientation
• Community Health Worker Provider Training
• Skilled Nursing ICF DD Sub Acute Final

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