Provider Documents & Forms
Guidelines, Forms, and Links
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Documents & Forms
These forms should be sent to ProviderEnrollment@TrilliumNC.org
- Provider Change Form
If you are requesting site and service additions please email the specific request to NetworkServicesSupport@TrilliumNC.org - Hospital Registration Worksheet (Excel)
- TFC/IAFT Additional Site Form
- AFL/Respite Additional Site Form
- Standardized Referral Form Updated (PDF)
- Standardized Referral Form Updated (DOCX)
- 837I Institutional Health Care Claim
- 837P Professional Health Care Claim
- Authorization Agreement for Direct Deposit
- Claims Request Form Instructions
- Claims Request Form
- Claims Inquiry Form Instructions
- Claims Inquiry Form
- Deficit Reduction Act Attestation
- Known Issues Tracker
- Medicaid Direct & Tailored Plan Claims Submission Protocol
- National Correct Coding Initiative (NCCI) Fact sheet
- Request for Taxpayer - W9
- Prompt Payment Tip Sheet
- Remittance Advice (RA) Companion Guide
- Submission Address for Paper Claims (Out-of-State Providers)
- Replacement-Voided-Denied Claims Process
- Taxonomy Claim Submission Fact Sheet
- Tailored Care Management Billing Guide
- Tailored Plan Physical Health Claim Reconsideration and Grievance Form
- System Administrator Designee Request Form
- Trading Partner Agreement
- Learning Campus User Agreement
Please note: We also have a new process to request new users for Provider.MyLearningCampus.org. - Provider Direct Terms and Conditions Instructions
- Access Provider Direct Instructions
- Request access SFTP Claims Care Management
- 835 Response file redirect to approve clearinghouse
- ZixMail Instructions
- Child First® Request for Service Form
- Child with Complex Needs Referral 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-2022-24
- HIPAA Work Area Privacy Safeguards
- IRIS Resources
- Innovations Waiver Verification of Relative/Legal Guardian
- Independent Practitioner Referral Form
- LOC Eligibility Determination NC Innovations Form
- Medicaid Clinical Coverage Policies 8A-8P
- NCDHHS NC SNAP - Assessment website
- Trillium NC SNAP Training Eligibility and Registration Forms
- Trillium Physical Health Prior Authorization
- 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
- 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
- Respite Service Provider Attestation
- Treatment Authorization Request (TAR) Form
- Unlicensed Alternative Family Living Home Provider Attestation
- Worksheet for Requesting Exceptions to the Diversion Law (SB 859)
Links and Resources
- Family Disaster Plan
- HIPAA
- Incident Response Improvement System (IRIS) Resources and Forms
- Incident Response Improvement System (IRIS)
- NC Division of Health Benefit
- 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.
- Trillium FAQ for NC Tracks
- NC Innovations Incident Report for Failure to Provide Back-up Staff
- NC-TOPPS
- New Involuntary Commitment Process (effective October 1, 2019)
- PCP/Provider Request for Care Manager Name or Assignment Referral Form
- Provider Monitoring Process
- Psychiatric Recruitment Opportunities for Providers (Loan Repayment Incentives and Practice Opportunities)
- School of Government LME Programs
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