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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Provider Manual
Network Provider Manual
Applications & Request Forms
Provider Change Form Removal of a Clinically Licensed Practitioner Respond to RFP/RFA/RFI Hospital Registration Worksheet (Excel) Trillium Additional Site Form Request to Add Licensed Practitioner For use to affiliate a practitioner with a group/agency. Practitioners must be credentialed in order to provide services. Licensed Practitioner Credentialing Application (New Providers must have approval from Network Development to be Credentialed and/or Contracted.) Practitioner Application (Complete this application to obtain credentialed status with Trillium. To be used by all Licensed Practitioners.) Provider Evaluation Form (To be completed as part of the Trillium credentialing process and attached to the application.)
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 Submission Address for Paper Claims (Out-of-State Providers) Request for Taxpayer - W9	Direct Deposit Request Form Provider Claims Split EOB Denial Codes Final Accounting Form Remittance Advice (RA) Companion Guide Replacement-Voided-Denied Claims Process
Contracts
Contracts Documents
Care Coordination Form
Child-Adolescent Discharge/Transition Plan Criterion 5 Health Safety Checklist Out of State Travel Form Spreadsheet for Residential Service Information (xls)	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 Project (QIP)
Provider QIP Template	Provider QIP Evaluation Form - Blank Tool
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 Independent Practitioner Referral Form Innovations Waiver Verification of Relative/Legal Guardian LOC Eligibility Determination & Medical Assessment Form Medicaid Clinical Coverage Policies 8A-8P Records Management & Documentation Management NC SNAP - Assessment Form NC SNAP Training Calendar 2019 NC SNAP Eligibility and Registration Form Training	NC-SNAP - Summary Report Coversheet NC-TOPPS: Services Requiring It NC-TOPPS: Important Users Link NC-TOPPS Implementation Guidelines FY 2017-2018 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 Regional Referral Form for Admission to a State Psychiatric Hospital or ADATC Treatment Authorization Request (TARs) (docx) ValueOptions Authorization Letter Request Form Worksheet for Requesting Exceptions to the Diversion Law (SB 859)
Links & Resources
Trillium Health Resources
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 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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GUIDELINES | FORMS | LINKS

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