Provider Monitoring

Procedures and Associated Forms/Checklists

Posted below are the procedures, forms and checklists WHN monitoring staff will use
when conducting reviews of providers.

____________________________________________ Alternative Family Living
Onsite Review Form		Link
Consumer of Concern
Consumer of Concern Procedure		PDF
Guardianship
Guardianship Personnel Review		PDF
Guardianship Record Review Tool		PDF
Guardianship Ward Interviews		PDF
Inpatient Continuity of Care
Inpatient Continuity of Care Review Tool		PDF
Medical Staff Monitoring
Nurse Practitioner Monitoring Checklist		PDF
PA Supervision Monitoring Checklist		PDF
Psychiatric Services Monitoring Checklist		PDF
Tele-psychiatry Monitoring Checklist		PDF
General Provider Monitoring Policies and Procedures
Share Provider Monitoring Results Policy		PDF
Provider Clinical Compliance Review Preparation		PDF
Provider Report Cards		Page↑
Provider Performance Profile Grid		PDF
CABHA Crosswalk		PDF
LIP Profile Grid with Attestation Letter		PDF
LIP Profile Grid		PDF
Provider Monitoring Guides & Tools
Initial On-site Health and Safety Review		PDF
WHN Routine Provider Profile Record Review Guide		PDF
WHN Routine Provider Personnel Review Guide (Updated 2/2/12)		PDF
WHN Routine Provider Profile Fund Mgmt Review Guide		PDF
WHN Routine Provider Rights Review Guide and Tool		PDF
WHN Preferred, Exceptional, Gold Provider Review Guide and Tool		PDF
Health & Safety Incident Reporting Tool		PDF
WHN Provider Self-Audit Form		PDF
Provider Self-Assessment on Quality Improvement		PDF
Licensed Independent Practitioners
WHN Licensed Independent Practitioner Site Review		PDF
WHN LIP Event Compliance Guide		PDF
WHN LIP Event Compliance Tool		PDF
Event Compliance		Page↑
WHN Provider Agency Event Compliance Guide		PDF
WHN Provider Agency Event Compliance Tool		PDF
Plans of Correction
POC Procedure		PDF
POC Review Checklist		PDF
POC Template		Word File
Sanctions
WHN Provider Sanctions Grid		PDF
WHN External Assessments Sanctions Grid		PDF
Clinical Review
Clinical Treatment Record Review		PDF
Provider Review Checklist-Case Responsible		PDF
Provider Review Checklist-Non Case Responsible		PDF
Utilization Review
Utilization Review Scoring Form		PDF
Monitoring Checklist for Contact with Individual/Legally Responsible Person		Page↑
Monitoring Checklists		PDF
Non-Contract local Routine Monitoring Review
Non-contract Local Routine Monitoring Review		PDF
Medication Review
Routine Medications Review Tool		PDF
Self Audit
WHN Self Audit Instructions		PDF
WHN Provider Self Audit Form		Excel
WHN Provider Refund Attachment		PDF
Treatment Plans/Person-Centered Plans
Complete PCP		Word File
Basic Benefit Treatment Plan - Template		Word File
Table of Service Planning Requirements		PDF
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Other Resources

Records Management and Documentation Manual for Providers of Publicly-funded MH/DD/SA Services, CAP-MR/DD Services and Local Management Entities: http://www.ncdhhs.gov/mhddsas/statspublications/Manuals/rmdmanual-final.pdf

Division of Medical Assistance Enhanced Mental Health and Substance Abuse Services - Clinical Coverage Policy No: 8A
http://www.ncdhhs.gov/dma/mp/8A.pdf

Division of Medical Assistance Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers -
Clinical Coverage Policy No: 8C
http://www.ncdhhs.gov/dma/mp/8C.pdf

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