GUIDELINES | FORMS | LINKS
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- Network Provider Manual (through the Provider.MyLearningCampus.org)
FORMS
Credentialing
Provider Directory, Applications & Request Forms
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
- Provider Claims Split
- Submission Address for Paper Claims
(Out-of-State Providers) - Remittance Advice (RA) Companion Guide
- Replacement-Voided-Denied Claims Process
- National Correct Coding Initiative (NCCI) Fact sheet
Contracts
Care Coordination Forms
Quality Improvement Activities
IT Information & Forms
- System Administrator Designee Request Form
- Learning Campus User Agreement
Please note: with the launch of the new site, we also have a new process to request new users for Provider.MyLearningCampus.org. - Access Provider Direct Instructions
- Request access for 837 claims submissions
- 835 Response file redirect to approved clearinghouse
- ZixMail Instructions
Operational Information & Forms
- 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 2020-21
- HIPAA Work Area Privacy Safeguards
- IRIS Resources
- 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
- Treatment Authorization Request (TAR) Form
- Worksheet for Requesting Exceptions to the Diversion Law (SB 859)
Healthy Movement Report
Links & Resources
Benefit Plan Information
Crisis Solutions
Trillium Health Resources
NC DHHS
- Family Disaster Plan
- HIPAA
- Incident Response Improvement System (IRIS) Resources and Forms
- Incident Response Improvement System (IRIS) Incident Report
- 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)
- 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
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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