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Service Authorization Procedures
If you need assistance:
Please see the Access and Services Management page for a list of personnel you can contact.
Available online documents:
Open them directly by clicking on them, or save them to disk (the easiest way on a PC is by right-clicking your mouse.) The files are in Word 2000, Excel 2000, and Adobe Acrobat 5.0 PDF files. Each document link is set to open in a new window. Some of these files are large and may take a few minutes to load or save - larger files are noted in the table.
| Procedures | ||
Access Fax Number
|
Word File | |
Services Management Fax Number
|
Word File | |
| Instructions for Completing Notification Protocol Memo (12/05/04) | Word File | |
| Notification Form for Out Of Home Community Placement, Children/Adolescents 11/03 | Word File | |
| Notification Protocol (Rev. 12/05/03) | ||
| Notification Protocol Memo (12/05/03) | ||
| Transition of Consumers Procedure (01/25/08) | Word File | |
| Web Links for Notification Protocol (12/15/04) | Word File | |
| Communications | ||
| Bulletin #75 - 01/25/08 Case Reponsible Transfer Procedure This Bulletin Supercedes#33 |
Word File | |
|
Word File | |
| Bulletin #51 - 01/02/07 Standardized Children in Residential Placement Room and Board Authorization/Reimbursement |
Word File | |
|
Word File | |
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| Bulletin #41 - 06/12/06 14-Day Limit on Pended Service Authorization Requests |
Word File | |
| Bulletin #38 - 06/06/06 Clarification of Service Authorizations for Individuals with Out of County Medicaid |
Word File | |
| Bulletin #31 - 03/30/06 Medicaid Authorization Process during transition to state-wide vendor |
Word File | |
| Bulletin #27 - 03/08/06 Medicaid & IPRS Letter of Notification Protocol |
Word File | |
| Forms | ||
| Assignment of Case Reponsibility/1st Responder | Word File | |
| NC Div. of MH/DD/SAS Regional Referral Form for Admission to a State Psychiatric Hospital or ADATC (01/31/08) | Word File | |
| ADATC Rehab Referral Form Instructions (6/05/07) | Word File | |
| PCP Admission Form (6/02/08) | Word File | |
| STR Registration Form (6/02/08) | Word File | |
| PRTF Cert. of Need: Medicaid Inpatient Psych. Serv. Under 21 | ||
| State Funding Eligibility Statement (01/25/08) | Word File | |
| Unit of Service Cheat Sheet | Word File | |
| Service Authorization Requests | ||
| Authorization Procedure for SA IOP Consumers Funded With IPRS Dollars (04/13/06) |
Word File | |
| Services REQUIRING Authorization Effective (11/01/05) | Word File | |
| Services NOT Requiring Authorization Effective (11/01/05) | Word File | |
| Service Authorization Tracking Sheet (06/13/05) | Word File | |
Service Authorization Request Form (10/03/07) While this document can be filled out "electronically", providers still need to FAX the document to WHN. Emailing Protected Health Information (PHI) violates the federal HIPAA security rule. |
Word File |
|
| Description of the Initial Clinical Evaluation (9/01/04) | Word File | |
| Value Options Forms | ||
| Value Options forms can be obtained from their website at: www.valueoptions.com. From their home page, select "For Providers", then select "Regional Focus", then select "North Carolina Medicaid Account." | ||
| Service Authorization Codes and Service Definitions | ||
| Adult Service Authorization (01/12/05) | Word File | |
| Child and Family Service Authorization (04/01/05) | Word File | |
| DD Service Authorization (01/12/05) | Word File | |
| Substance Abuse Service Authorization (01/12/05) | Word File | |
| Specialized Adult Services and Substance Abuse Programs (02/17/05) | Word File | |
| Description of Coding for Crisis Intervention (09/11/04) | Word File | |
| APSM 1026 Service Definitions Manual (01/03) | PDF (2 Mb) | |
| APSM 45 Service Records Manual (09/03) | PDF (440 Kb) | |
| Substance Abuse Service Definitions | Word File | |
| Substance abuse outpatient definitions are available at www.dhhs.state.nc.us/mhddsas/medicaid/index.htm. The document is entitled "Substance Abuse Outpatient Codes" (6/02) | ||
| Utilization Review | ||
| Child Utilization Review - Frequently Asked Questions (04/04/07) | Word File | |
| Child Utilization Review - Initial Request Worksheet (04/04/07) | Word File | |
| Child Utilization Review - Reauthorization Worksheet (04/04/07) | Word File | |
| Adult Services Utilization Review Narrative (02/09/06) | Word File | |
| Adult Services Utilization Review Form (02/09/06) | Word File | |
| Entitlement Resources (7/20/05) | Word File | |
| Provider Responsibility for Conducting Utilization Review (09/01/04) | Word File | |
| Standard Care Guidelines for Disability Areas and Levels of Care | ||
| Adult Mental Health - State Funded (09/21/07) | Word File | |
| Adult Substance Abuse - State Funded (09/21/07) | Word File | |
| Child Mental Health - State Funded (09/21/07) | Word File | |
| Child Substance Abuse - State Funded (09/21/07) | Word File | |
| Developmental Disabilities - State Funded (09/21/07) | Word File | |
| Developmental Therapy Excess Unit Override Instructions (07/11/07) | Word File | |
| Residential Treatment Room and Board Tools | ||
| Standardized State Authorization of Room & Board Letter | Word File | |
| Standardized Parent Letter of Notification | ||
| Standardized DSS Letter of Notification | ||
| Co-pay letter to Parents | Word File | |
| SSI Letter to Parents | Word File | |