Documentos y Formularios para Proveedores

• Credentialing Forms

• Provider Change Form
• Respond to RFP/RFA/RFI
• Hospital Registration Worksheet (Excel)
• Trillium Additional Site Form

• Benefit Plans | Service Definitions

• 837I Institutional Health Care Claim
• 837P Professional Health Care Claim
• Claims Request Form
• Claims Request Form Instructions
• Claims Request Form Purpose
• Request for Taxpayer - W9
• Submission Address for Paper Claims (Out-of-State Providers)

• Direct Deposit Request Form
• Provider Claims Split
• EOB Denial Codes
• Remittance Advice (RA) Companion Guide
• Replacement-Voided-Denied Claims Process
• National Correct Coding Initiative (NCCI) Fact sheet

• Contracts Documents

• Child-Adolescent Discharge/Transition Plan
• Criterion 5
• Health Safety Checklist
• Out of State Travel Form
• QI-7 Screening Programs

• Out-of-Home Request Form
• Short Range Goals Templates (docx)
• Typical Weekly Schedule  (docx)
• Typical Weekly Schedule Sample
• Universal Application for Youth Residential Placement Needs

• Comprehensive Crisis Prevention & Intervention Plan (CCP)
• Crisis Solutions Initiative

• Crisis Solutions North Carolina Flyer
• Crisis Prevention & Intervention Plan Training

• Provider QIP Template
• Provider QIP Evaluation Form - Blank Tool

• Provider Performance Project

• System Administrator Designee Request Form
• Learning Portal User Agreement
• ZixMail Instructions

• Request access for 837 claims submissions
• 835 Response file redirect to approved clearinghouse

• Bed Occupancy-Licensed/Unlicensed-Quarterly Report
• Child First^® Request for Service Form
• Consent for Release of Member Information
• Consent for Release of Member  Information (Español)
• Critical Incident / DHHS Incident and Death Report
• Cultural Competency Plan FY 2018-19
• Cultural and Linguistic Competency Action Plan Recommendations 
• HIPAA Work Area Privacy Safeguards
• Incident Response Manual & Reporting Manual
• Innovations Waiver Verification of Relative/Legal Guardian 
• Independent Practitioner Referral Form
• LOC Eligibility Determination & Medical Assessment Form 
• Medicaid Clinical Coverage Policies 8A-8P
• NC SNAP - Assessment Form
• NC SNAP Training Calendar 2020
• NC SNAP Training Eligibility and Registration Forms
• NC-SNAP - Summary Report Coversheet

• NC-TOPPS: Services Requiring It
• NC-TOPPS: Important Users Link
• NC-TOPPS Implementation Guidelines
• Non-Covered State Medicaid Plan Services Request Form for Recipients under 21 Years Old
• Notification of Out-of-Home Placement Form
• Opioid Use Disorder Medication Assisted Treatment Resource Manual
• Person-Centered Forms & Publications
• Plan of Correction
• Record Retention Form
• Records Management & Documentation Management
• Regional Referral Form for Admission to a State Psychiatric Hospital or ADATC
• ValueOptions Authorization Letter Request Form
• Worksheet for Requesting Exceptions to the Diversion Law (SB 859)

Links & Resources

• Global Quality Improvement Committee

• Provider Council

• Family Disaster Plan
• HIPAA
• Incident Response Improvement System (IRIS) Resources and Forms
• Incident Response Improvement System (IRIS) Incident Report
• Incident Response Manual & Reporting Manual
• NC Division of Medical Assistance
• NC Division of Mental Health, Developmental Disabilities & Substance Abuse Services
• NC Tracks
  • Trillium FAQ for NC Tracks
  • The “NCTracks Q and A” listserv is designed for LME/MCO use only, not for provider agencies. Provider agencies should call 1-800-688-6696 for technical assistance.

• NC Innovations Incident Report for Failure to Provide Back-up Staff
• NC-TOPPS
• New Involuntary Commitment Process (effective October 1, 2019)
• Provider Monitoring Process
• Psychiatric Recruitment Opportunities for Providers  (Loan Repayment Incentives and Practice Opportunities) 
• School of Government LME Programs
• Training on - CMS Condition of Participation for PRTFs - March 16, 2016

• Disaster Planning Handbook for Behavioral Health Treatment Programs  (SAMHSA)