NC CCH - Medicaid - PPA 060119 - Practitioner Version

Sep 16, 2026

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Participating Provider Agreement establishes a contractual relationship between the Provider and Carolina Complete Health, Inc. for delivering covered health care services to individuals enrolled in specified products. The agreement defines key terms such as affiliated entities, attachments, covered persons and services, compensation schedules, cost-sharing amounts, and participation standards. It also clarifies roles for payors and payor contracts, including how governmental contracts may function as coverage agreements, setting a framework for provider participation and service delivery.

LanguageEnglish

CategoryLetters

FormatPDF

Pages93

Reading Time33 min

AccessFree to download

ARTICLE 1 - DEFINITIONS

Affiliate

Attachment

Clean Claim

Company

Compensation Schedule

Contracted Provider

Cost-Sharing Amounts

Coverage Agreement

Covered Person

Covered Services

Governmental Contract

Medically Necessary

Participating Provider

Payor

Payor Contract

Product

PARTICIPATING PROVIDER AGREEMENT This Participating Provider Agreement (together with all Attachments and amendments,“Agreement”) is made and entered into by and between Test Provider (“Provider”) and Carolina Complete Health, Inc. (“Health Plan”) (each a “Party” and collectively the “Parties”). This Agreement is effective as of the date designated by Health Plan on the signature page of this Agreement (“Effective Date”) . WHEREAS, Provider desires to provide certain health care services to individuals enrolled in Products offered by or available from or through a Company or Payor (as defined herein), and Provider desires to participate in such Products as a “Participating Provider,” as set forth herein; and WHEREAS, Health Plan desires for Provider to provide such health care services to individuals enrolled in such Products, and Health Plan desires to have Provider participate in certain of such Products as a Participating Provider, as set forth herein. NOW, THEREFORE, in consideration of the recitals and mutual promises herein stated, the Parties hereby agree to the provisions set forth below. ARTICLE 1-DEFINITIONS When capitalized in this Agreement, the following terms have the meanings set forth below. 1.1 Affiliate means, at any time during the Term hereof, an entity directly or indirectly controlling, controlled by or under common control with the applicable Party. 1.2 Attachment means any attachment, addendum, schedule or exhibit that is attached to this Agreement as of the Effective Date or thereafter, each of which is incorporated in this Agreement by reference and may beamended from time to time as provided herein. References to this “Agreement” include references to all Attachments. 1.3 Clean Claim has, as to each particular Product, the meaning set forth in the applicable Product Attachment or, if no such definition exists, the Provider Manual. 1.4 Company means (collectively or individually, as appropriate in the context) Health Plan and/or one or more of its Affiliates that choose to participate in the rights and benefits of this Agreement. 1.5 Compensation Schedule means, at any given time, the then-effective schedule(s) of maximum rates payable to Provider or Contracted Providers for Covered Services provided to Covered Persons with respect to a particular Product, as set forth in an Attachment. 1.6 Contracted Provider means a physician, hospital, health care professional or any other provider of Covered Services that has a downstream relationship with Provider (i.e., is employed by or has a direct or indirect contractual relationship with Provider) and that was listed on the immediately preceding Roster Report (as such term is defined in Section 2.2.3). For the purposes of this Agreement, to the extent that Provider provides Covered Services under this Agreement, the term “Contracted Provider” also includes Provider. 1.7 Cost-Sharing Amounts means any amounts payable by a Covered Person, such as copayments, costsharing coinsurance, deductibles or other amounts that are the Covered Person’s financial responsibility under the applicable Coverage Agreement, if applicable. 1.8 Coverage Agreement means any agreement or program entered into, issued or agreed toby Company or Payor, under which Company or Payor furnishes administrative or other services in support of a health care program for an individual or group of individuals, which may include or reference a list of benefits to which Covered Persons are entitled and which may include access to one or more of Company’s provider networks or vendor arrangements, except those excluded by Health Plan. 1.9 Covered Person means any individual entitled to receive Covered Services pursuant to the terms of a Coverage Agreement. 1.10 Covered Services means those services and items that Company determines are Medically Necessary, payable and covered under the applicable Coverage Agreement. 1.11 Governmental Contract means the Company’s or

FAQs

Who are the parties to the Participating Provider Agreement?

The agreement is made between the Provider and Carolina Complete Health, Inc., with each referred to as a “Party” and collectively as the “Parties.”

What does “Participating Provider” mean in this agreement?

It refers to a physician, hospital, ancillary, or other health care provider that contracted with Health Plan to provide covered services, approved for participation by Company, and designated by Company as a participating provider for a product.

How are “Covered Services” defined?

“Covered Services” are those services and items that the Company determines are medically necessary, payable, and covered under the applicable coverage agreement.

Sep 16, 2026

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