Good Faith Contracting Efforts
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Procedural guidelines for documenting and executing good faith efforts to contract with providers for Carolina Complete Health's Medicaid products; applies to CCH Contracting Department and subcontractors involved in provider contracting.
No material clinical or coverage changes in this revision.
Good Faith Contracting Coverage Criteria
Good Faith Contracting Criteria
Stance on contracting and reimbursement after good faith efforts:
ALL of the following
- Minimum of three (3) contract offering attempts (the initial contract offering counts as the first effort).
See timeline requirements for spacing between attempts.
- There must be at least ten (10) calendar days between the 1st and 2nd attempts and at least ten (10) calendar days between the 2nd and 3rd attempts.
- The overall good faith contracting effort period must be at least thirty (30) calendar days, though CCH may allow additional time if discussions are ongoing, revisions are being negotiated, or the provider's legal review requires more time.
ALL of the following
- If CCH has made the required good faith efforts but the provider refuses to contract, CCH shall not reimburse the out-of-network provider more than 90% of the Medicaid Fee-for-Service rate, except for out-of-network emergency services, post-stabilization services, and services provided during transitions in coverage.
ALL of the following
- All attempts and outcomes must be logged in the Good Faith Contracting Effort tracker capturing provider demographics, contact attempts, contracting representative, final determination and the sent date of the final determination letter.
- A Final Determination letter must be sent within 10 calendar days after the final decision and must include the reason for the determination, appeal rights, and instructions on how to request an appeal.
(See provider actions and documentation requirements.)
Reimbursement and Coding Guidance
| No codes listed |
Provider Actions and Operational Rules
Good Faith Contracting Attempts and Timeline
The initial contract offering is counted as the first good faith effort. If the provider does not execute, CCH will make a second effort at least 10 calendar days after the first, and if still not executed a third and final effort at least 10 calendar days after the second. The overall good faith contracting effort period must be at least 30 calendar days (additional time may be allowed if negotiations, revisions, or legal review are ongoing). If after at least 30 days and the three attempts the provider fails to respond verbally or in writing, the request to join the network is considered rejected.
- Initial contract offering = first effort
- Second and third attempts occur ≥ 10 calendar days after prior attempt
- Minimum good faith period = 30 calendar days; CCH may extend if discussions or reviews continue
- After ≥30 days and three attempts with no response, request considered rejected
Reimbursement Cap After Good Faith Efforts
When CCH has made good faith efforts to contract but the provider refuses to execute a contract, CCH is prohibited from reimbursing the out-of-network provider more than 90% of the Medicaid Fee‑for‑Service rate, except for out‑of‑network emergency services, post‑stabilization services, and services provided during transitions in coverage.
- Reimbursement cap = 90% of Medicaid FFS rate after good faith efforts
- Exceptions: out‑of‑network emergency services, post‑stabilization services, services during transitions in coverage
Tracking and Communication of Final Determination
If after the third and final effort no mutual agreement is reached, CCH will send a Good Faith Contracting Effort Final Determination letter to the provider’s address within 10 calendar days of the final decision; the letter will state the reason for the decision, the provider’s right to appeal, and how to request an appeal. All efforts must be logged on the CCH Good Faith Contracting Effort tracker capturing provider demographics, contracting representative, final determination, and sent date of the final determination letter.
- Final Determination letter sent within 10 calendar days and must include reason, appeal rights, and how to request an appeal
- Good Faith Contracting Effort tracker must record provider location, specialty, TIN, NPI, requesting contact, CCH contracting representative, final determination, and sent date of final determination letter
Definitions Related to Good Faith Efforts
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