Provider Documents & Forms

GUIDELINES | FORMS | LINKS

Trillium requires priority admission to all women who are pregnant and injecting drugs, pregnant and using substances and other individuals who are injecting drugs.

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Network Provider Manual

Credentialing
Licensed Practitioners Removal of a Clinically Licensed Practitioner Request to Add Practitioner - Used to affiliate a currently credentialed practitioner with a group or agency. Credentialing - New Providers must have approval from Network Development to be Credentialed and/or Contracted. Practitioner Credentialing Application Provider Evaluation Form - To be completed as part of the Trillium credentialing process and attached to the application. Additional Required Documents - Only to be completed if the practitioner is approved for a contract directly with Trillium and not associated with a group or agency. Re-Credentialing - All practitioners must re-credential within 3 years. If credentialing expires practitioner must complete the Practitioner Credentialing Application. Practitioner Re-credentialing Provider Network Directory - Only to be completed if the practitioner is approved for a contract directly with Trillium and not with a group/agency. Providers (Groups/Agencies) Credentialing - New Providers must have approval from Network Development to be Credentialed and/or Contracted. Provider Credentialing Application Additional Required Documents - Only to be completed if the practitioner is approved for a contract directly with Trillium and not associated with a group or agency. Re-Credentialing Provider Re-credentialing Provider Network Directory - Only to be completed if the practitioner is approved for a contract directly with Trillium and not with a group/agency.
Applications & Request Forms
Provider Change Form Respond to RFP/RFA/RFI Hospital Registration Worksheet (Excel) Trillium Additional Site Form
Benefit Plan Information
Benefit Plans \| Service Definitions
Claims/Finance Information & Forms
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
Contracts Documents
Care Coordination Form
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
Crisis Solutions
Comprehensive Crisis Prevention & Intervention Plan (CCP) Crisis Solutions Initiative	Crisis Solutions North Carolina Flyer Crisis Prevention & Intervention Plan Training
Quality Improvement Activities
Provider QIP Template Provider QIP Evaluation Form - Blank Tool	Provider Performance Project
IT Information & Forms
System Administrator Designee Request Form Learning Portal User Agreement ZixMail Instructions	Request access for 837 claims submissions 835 Response file redirect to approved clearinghouse
Operational Information & Forms
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
Trillium Health Resources
Global Quality Improvement Committee	Provider Council
NC DHHS
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
SAMHSA
Disaster Planning Handbook for Behavioral Health Treatment Programs (SAMHSA)

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