AmeriHealth Caritas North Carolina
Provider Stabilization Assistance Application

Applications must be received by December 16, 2024.

Medicaid providers impacted by Hurricane Helene must use this one-time application and attestation to request assistance from AmeriHealth Caritas North Carolina (ACNC).

Application requirements include:

• Be in one of the 28 severely impacted disaster counties, which include the Eastern Band of Cherokee Indians territory.
• Need urgent assistance to relieve financial distress resulting from Hurricane Helene-related lost revenue.
• Be enrolled in NCTracks.
• Be a contracted provider participating in the ACNC network.
• Have treated and billed claims for an ACNC member in the last 12 months.
• Be unable to access sufficient relief through other means, such as business continuity insurance or government programs.

Please note that applications are limited to one per Taxpayer Identification Number (TIN). If there are multiple practices under a single TIN, one application should be submitted on behalf of all practices.

Question Title

* 1. Provider/Practice Name

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* 2. Taxpayer Identification Number (TIN) - limited to one application per TIN

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* 3. National Provider Identifier (NPI)

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* 4. Service location (please provide complete address: address, city, state, zip)

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* 5. Service location county

Alexander

Alleghany

Ashe

Avery

Buncombe

Burke

Caldwell

Catawba

Cherokee

Clay

Cleveland

Gaston

Graham

Haywood

Henderson

Jackson

Lincoln

Macon

Madison

McDowell

Mitchell

Polk

Rutherford

Swain

Transylvania

Watauga

Wilkes

Yancey

Question Title

* 6. Authorized Practice Representative (This representative must be authorized to make the request for stabilization payments on behalf of any/all practices under this TIN.)

Name

Title (i.e. Practice Manager)

Phone

Direct email

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* 7. I attest that our practice is contracted as a network provider with AmeriHealth Caritas North Carolina Medicaid managed care plan.

Yes

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* 8. Are you registered to receive payments from AmeriHealth Caritas North Carolina via Electronic Funds Transfer (EFT)?

Yes, our practice is registered for EFT

No, our practice is not registered for EFT but would like to be

No, our practice is not registered for EFT and does not wish to be

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* 9. Number of Full-Time Equivalents (FTEs) employed within this TIN

1-10

11-20

21 or more

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* 10. Current operational status of your practice (please check as many as applicable)

Operating in primary location

Operating in alternate location

Operating on a limited/reduced schedule

Operating with limited providers available

Offering telehealth services

Other (please specify)

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* 11. What percent of operation is this practice/TIN in today?

25%

50%

75%

100%

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* 12. Date disruption began

Date

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* 13. Estimated timeline to resume normal operations

1-3 weeks

4-8 weeks

8-12 weeks

12 weeks or more

not applicable, our practice has resumed operations

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* 14. Are you currently accepting new patients?

Yes

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* 15. Please describe efforts your practice is taking to restore operations and resume services for Medicaid members.

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* 16. Have you applied for and/or received Hurricane Helene disaster funding from the Federal Emergency Management Association (FEMA) or other government organizations?

Yes

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* 17. Have you received, or do you expect to receive payments from a business continuity insurance policy?

Yes

If yes, describe how much of the impact you expect insurance payments to cover.

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* 18. Please explain why stabilization payments are needed. Include specific details about impact on operations, lost volume, additional costs and ability to provide services to Medicaid patients.

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* 19. How will the stabilization funds be utilized?

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* 20. By completing this form, the Authorized Practice Representative represents and warrants (indicate by checking each box):

The individual submitting this form is duly authorized to submit this request on behalf of all entities sharing the Taxpayer Identification Number listed on this form;

The receipt of any post stabilization payment will not result in any increased utilization, unnecessary services or payments by third party payors, including Federal healthcare programs. Any post stabilization payment is in no way intended as an incentive for referrals of government healthcare program business;

All statements and information provided are true;

Provider acknowledges that AmeriHealth Caritas North Carolina is relying on the veracity of the submitted information to determine a bona fide need for stabilization assistance;

Provider acknowledges that submission of its request is not a guarantee of payment and that decision, including the amount of stabilization assistance, will be made by AmeriHealth Caritas North Carolina.

AmeriHealth Caritas North CarolinaProvider Stabilization Assistance Application

Applications must be received by December 16, 2024.

Question Title

* 1. Provider/Practice Name

Question Title

* 2. Taxpayer Identification Number (TIN) - limited to one application per TIN

Question Title

* 3. National Provider Identifier (NPI)

Question Title

* 4. Service location (please provide complete address: address, city, state, zip)

Question Title

* 5. Service location county

Question Title

* 6. Authorized Practice Representative (This representative must be authorized to make the request for stabilization payments on behalf of any/all practices under this TIN.)

Question Title

* 7. I attest that our practice is contracted as a network provider with AmeriHealth Caritas North Carolina Medicaid managed care plan.

Question Title

* 8. Are you registered to receive payments from AmeriHealth Caritas North Carolina via Electronic Funds Transfer (EFT)?

Question Title

* 9. Number of Full-Time Equivalents (FTEs) employed within this TIN

Question Title

* 10. Current operational status of your practice (please check as many as applicable)

Question Title

* 11. What percent of operation is this practice/TIN in today?

Question Title

* 12. Date disruption began

Question Title

* 13. Estimated timeline to resume normal operations

Question Title

* 14. Are you currently accepting new patients?

Question Title

* 15. Please describe efforts your practice is taking to restore operations and resume services for Medicaid members.

Question Title

* 16. Have you applied for and/or received Hurricane Helene disaster funding from the Federal Emergency Management Association (FEMA) or other government organizations?

Question Title

* 17. Have you received, or do you expect to receive payments from a business continuity insurance policy?

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* 18. Please explain why stabilization payments are needed. Include specific details about impact on operations, lost volume, additional costs and ability to provide services to Medicaid patients.

Question Title

* 19. How will the stabilization funds be utilized?

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* 20. By completing this form, the Authorized Practice Representative represents and warrants (indicate by checking each box):

AmeriHealth Caritas North Carolina
Provider Stabilization Assistance Application