To challenge a denied, reduced, or terminated service, submit the Carolina Complete Health appeal form to the plan’s Appeals and Grievance Department within 60 calendar days of the date printed on your Adverse Benefit Determination notice. The plan has 30 calendar days to decide a standard appeal, or 72 hours if waiting could seriously harm your health. The sections below walk through what the form asks for, what to attach, how to file, and how to keep your current services going while the review is underway.
When You Need the Form
Use the appeal form after you receive a written Adverse Benefit Determination from Carolina Complete Health. That notice is the plan’s formal decision to deny a service you or your provider requested, reduce the scope of an approved service, or stop or suspend services you already receive. Typical triggers include a denied surgery, a rejected prescription, a cut in therapy visits, or a termination of home-health hours. The notice itself must explain the reasons for the decision, your right to appeal, how to request an expedited review, and how to keep benefits running during the appeal.
One boundary worth knowing: an appeal is not the same as a grievance. Complaints about wait times, staff conduct, or difficulty reaching a provider go through the grievance channel, not this form. The appeal form is for decisions that stop, limit, or refuse the medical care itself.
Getting the Form
The appeal form is available through Carolina Complete Health’s Member Handbook and member portal. You can also request a copy by calling Member Services at 1-833-552-3876 (TTY: 711), Monday through Saturday, 7 a.m. to 6 p.m. Eastern.
You are not strictly required to use the printed form. A written letter containing the same information will open an appeal. But the form is laid out to make sure nothing is missing, and using it speeds up intake.
What to Put on the Form
Member Identification
Start with your full legal name, date of birth, and Member ID number from the front of your Carolina Complete Health card. Write down the date printed on the Adverse Benefit Determination notice. That date is the plan’s mail date and it controls your 60-day filing window.
The Disputed Service
Name the service, medication, or equipment the plan denied or reduced. Then explain, in your own words, why the decision was wrong. Reference your diagnosis, your symptoms, and your treatment history. If your doctor has told you the requested procedure is the standard approach for your condition, say so. “I need this service” gives a reviewer nothing to work with; specific detail about how the denial affects your health gives them a reason to overturn it.
Provider Information
List the name, office address, and phone number of the provider who ordered or requested the service. Medical reviewers will likely contact that provider for clinical context, and bad contact information slows the review.
Authorized Representative
If you want a family member, advocate, or attorney to handle the appeal for you, complete the Designation of Authorized Representative Form (DMA-5202C-IA), available through Carolina Complete Health member materials or NC Medicaid, and submit it with your appeal. Without this form on file, the plan cannot discuss your protected health information with anyone but you.
Contact Information
Give a current mailing address and phone number for you or your representative. The plan mails its final decision, so an outdated address can cost you a deadline.
Documents to Attach
The form by itself rarely carries an appeal. The clinical evidence you attach is what gives reviewers grounds to reverse the denial. Pull together documents that directly answer the reasons stated in the Adverse Benefit Determination:
- A letter of medical necessity from your treating physician explaining why the denied service is needed for your condition, ideally citing clinical guidelines or peer-reviewed evidence.
- Recent medical records: office visit notes, hospital discharge summaries, or specialist consultations documenting your diagnosis and treatment history.
- Lab and imaging results that support the medical need for the requested service.
- Prior authorization records, if the service was previously approved and is now being reduced or terminated.
Put the attachments in date order so the reviewer can follow how your condition has progressed. Match each document to a specific denial reason in the notice. If the plan said there was insufficient evidence of your diagnosis, the records proving the diagnosis go on top.
You also have the right to request, at no charge, copies of all documents the plan used to make its decision, including the medical necessity criteria and any internal guidelines applied to your case. Ask for these before or during the appeal so you know the standard the reviewers are measuring you against.
Where to Send It
Submit the completed form and supporting documents to the Appeals and Grievance Department by mail, phone, or in person:
- Mail: Carolina Complete Health, ATTN: Appeals and Grievance Department, P.O. Box 10353, Van Nuys, CA 91410-0353
- Phone: Member Services at 1-833-552-3876 (TTY: 711), Monday through Saturday, 7 a.m. to 6 p.m. Eastern
- In person: Carolina Complete Health, 1701 North Graham Street, Suite 101, Charlotte, NC 28206
If you mail the appeal, send it certified with return receipt requested. The receipt is your proof of the date the plan received the filing, which matters if there is ever a dispute over the 60-day deadline. Remember that your 60 calendar days run from the date printed on the Adverse Benefit Determination notice, not the date it arrived in your mailbox.
Keep Your Services Running During the Review
If the denial stops, reduces, or suspends a service you are already receiving under an existing authorization, you can ask the plan to continue that service while the appeal is reviewed. The request must reach Carolina Complete Health within 10 calendar days of the date on the Adverse Benefit Determination notice, or before the effective date of the change, whichever is later.
You can make the request at the same time you file the appeal, in writing or by calling Member Services. Win the appeal and the plan covers those continued services. Lose it and the plan may require you to pay back the cost of services you received during the review. For members whose health depends on uninterrupted care, that risk is often worth taking.
What Happens After You File
Carolina Complete Health must acknowledge receipt of the appeal. During the review, the plan may contact you or your provider for additional records if the initial submission is thin on clinical detail. A standard appeal must be decided and mailed to you within 30 calendar days of receipt. The plan can take a 14-day extension if it needs more information, and you can request an extension yourself if you have more evidence to add.
Expedited Appeals
If waiting 30 days could seriously harm your health, such as an urgent surgery or a time-sensitive medication, you or your provider can request an expedited appeal. The plan must decide an expedited appeal within 72 hours of receiving the request. If Carolina Complete Health decides the situation does not meet the threshold for expedited review, it will shift the appeal to the standard 30-day track and notify you.
If the Plan Upholds the Denial
If the plan reviews the appeal and sticks with the original decision, you will receive a written notice explaining the result and your next steps. That notice opens the door to a State Fair Hearing, an independent review by the North Carolina Office of Administrative Hearings. You have 120 calendar days from the date on the appeal decision notice to request a hearing. The State Fair Hearing Request Form comes with the notice, and the addresses, fax numbers, and help line for the Office of Administrative Hearings are printed on the form itself. Return the form to both OAH and Carolina Complete Health within the 120-day window.
Free Help With the Appeal
Two resources help NC Medicaid members at no cost:
- NC Medicaid Ombudsman at 1-877-201-3750 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m. The Ombudsman answers questions about notices, helps resolve problems with your health plan, and can route you to the right department when an issue is stuck.
- Legal Aid of North Carolina at 866-219-5262, or through the JusticeHub portal online. Legal Aid helps members whose services have been denied, reduced, or terminated, and can represent you in the appeal if you qualify.
Reaching out before you submit the form, rather than after, tends to improve the filing and heads off mistakes that would delay the review.