CCHP Provider Manual

View the CCHP Provider Manual

Change Notifications

• 10/29/25 – Updated page 83 under claims with link to UB-04 & CMS-1500 Billing Guidelines
• 10/13/25 – Updated Member Discharge Practice section on page 34
• 10/1/25 – Added Care Plus specific content

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)
  • Member Consent for Provider to File an Appeal (Chinese)

  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

  Appendix N

  • Face to Face Interpreter Request Form
  • Video Virtual Interpreter or ASL Request Form

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