Western Highlands Network
Western Highlands Network

Reimbursement and Claims Forms

  • CAP-MR/DD Supply/Equipment Receipt and Authorization Confirmation Form
    (PDF) (Word)
  • CCIS User Assignment Request 11/28/07
    Computer login request for DDE/CCIS access
    (PDF)
  • Claims Resolution Inquiry
    (PDF) (Word)
  • CMS-1500 (formerly HFCA-1500) Health Insurance Claim Form. Re-posted 2/16/07
    NOTE: this is a special PDF file that contains form fields you can fill in on screen, then print, save, or fax it. You MUST save this file to your own computer before using it, DO NOT fill it in online! This is not a secure website. If you fill it out online you will violate HIPAA privacy/security laws.
    (PDF)
  • Medicaid Direct Enrolled Provider Billing Registration Application (04/02/08)
    (PDF) (Word)
  • NPI Collection Form V 1
    (Excel)
  • Request to Change MRA
    (PDF) (Word)
  • State Funding Eligibility Statement 01/25/08
    (PDF) (Word)

View All WHN Forms

Reimbursement & Claims Procedures

Assistance:

Contact a Claims and Reimbursement Specialist through This e-mail address is being protected from spambots. You need JavaScript enabled to view it or phone (828) 225-2785 or 1-800-671-6560.

NPI Information:

Obtain an NPI: https://nppes.cms.hhs.gov/NPPES/Welcome.do

Workgroup for Electronic Data Interchange (WEDI): http://www.wedi.org/

Taxonomy : http://www.wpc-edi.com/taxonomy

Medicaid NPI Registration: http://www.dhhs.state.nc.us/dma/

Western Highlands NPI Registration Instructions:
See Western Highlands Communication Bulletin #54

Fee Schedules
WH Fee Schedule (10/9/2008) Excel Spreadsheet  
DMA Fee Schedule: http://www.dhhs.state.nc.us/dma/fee/fee.htm    
     
Procedures / Instructional Aides
WH Explanation of Benefits/Code Description Excel  
Western Highlands Fee Collection Policy (09/27/07) Word File PDF

Instructions for Completing CMS1500 (02/16/07)

  PDF
DMA Memorandum Re: Rounding (01/24/04) Word File PDF

NC DMA HIPAA Code Conversion

  PDF
Direct Data Entry Instructions/Users Manual (04/04/08)   PDF
     
Communication Bulletins
Bulletin #83 - 06/26/2008
Provisionally Licensed and Non-Licensed Substance Abuse Counseling Professionals
Word File PDF
Bulletin #76 - 02/11/08
National Provider Identification (NPI) Implementation Transition Assistance
Word File PDF
Bulletin #67 - 10/15/07
Claim Submission Requirements
Word File PDF
Bulletin #60 - 04/24/07
National Provider Identifier (NPI) Deadline Lifted
Word File PDF

Bulletin #57 - 03/27/07
National Provider Identifier (NPI) Clarification

Notice: Not having a properly registered NPI with Medicaid and/or Western Highlands may result in non-payment for services.

Word File PDF
Bulletin #55 - 03/05/07
Western Highlands Network IPRS Timely Filing Limits
Word File PDF
Bulletin #54 - 02/19/07
National Provider Identifier (NPI)
What is NPI, How to Register, and How to Bill
Word File PDF

WHN NPI Collection Form

Excel Spreadsheet  
Bulletin #52 - 01/10/07
Children’s Residential Treatment Level II Group (H2020)
Children Residential Treatment Level III and IV (H0019)
Medicaid Reimbursement
Word File PDF
Bulletin #51 - 01/02/07
Standardized Children in Residential Placement Room and Board Authorization/Reimbursement
Word File PDF

Standardized State Authorization of Room & Board Letter (06/08/07)

Word File PDF

Standardized Parent Letter of Notification

  PDF

Standardized DSS Letter of Notification

  PDF
Bulletin #50 - 12/08/06
Lifting of 60-day Timely Filing Edit
Word File PDF
Bulletin #49 - 12/05/06
Electronic Claims Submission
Effective July 1, 2007
Word File PDF
Bulletin #48 - 11/07/06
Request to Change Contract Maximum
Word File PDF

Request to Change Contract Maximum Form

Word File PDF
Bulletin #47 - 08/17/06
Western Highlands Network IPRS Timely Filing Limits
Word File PDF
Bulletin #46 - 07/20/06
Guidelines for Medical/Psychiatric Consultation
Word File PDF
Bulletin #38 - 06/06/06
Clarification of Service Authorizations for Individuals with Out of County Medicaid
(see also: Service Authorization page)
Word File PDF
Bulletin #37 - 06/02/06
Room and Board Reimbursement Rates for Child Mental Health Residential Providers
Word File PDF
Bulletin #36 - 06/02/06
Purchase of Services Agreements (Contracts) for IPRS Funded Services for Fiscal Year 2007
Word File PDF
Bulletin #35 - 05/05/06
CAP-MR/DD Waiver Equipment and Supply Reimbursement Effective July 1, 2006
Word File PDF
CAP-MR/DD Supply/Equipment Receipt and Authorization Confirmation Form
Word File PDF
Bulletin #34 - 04/25/06
Level III and IV Residential Rates
Word File PDF
Bulletin #30 - 03/30/06
Enhanced Benefits Reimbursement
Word File PDF
Bulletin #23 - 02/27/06
Claim Submission Requirements for State Funded Services
Word File PDF
Deadlines for Submitting Claims for IPRS Reimbursement
  PDF
Bulletin #22 - 02/22/06
Therapeutic Leave for ADMRI Residential Services
Word File PDF
Bulletin #21 - 12/29/05
CPT 2006 Code Review
Word File PDF
Bulletin #21 Addendum (01/17/2006)
CPT 2006 Code Changes
Word File PDF
Bulletin #20 -12/28/05
Authorization and Reimbursement for CMSED Residential Treatment Room and Board.
Related Documents:
Word File PDF
Co-pay Letter to Parents
SSI Letter to Parents
Word File
Word File
PDF
PDF
Bulletin #17 - 11/01/05
Authorization & Reimbursement for Residential Treatment Room & Board
Word File PDF
Bulletin #16 - 09/30/05
DD Targeted Case Management Billing
Word File PDF
Bulletin #15 - 09/30/05
Recoupment, Reimbursement, Direct Enrollment Updates
Word File PDF
Bulletin #14 - 09/21/05
Rate Adjustments and Benefit Design Changes Respite and Room & Board
Word File PDF
Bulletin #13 - 07/21/05
Consumers With Private Insurance: A Clarification of the Coordination of Benefits Policy of 01/13/05
Word File PDF
Bulletin #12 - Updated 04/02/08
Reimbursement Business Practice Modifications and Medicaid Direct Enrolled Provider Registration
Word File PDF
Bulletin #11 - 06/02/05
Western Highlands Payment Cycles - FY 2006
Word File PDF
Bulletin #10 - 05/05/05
Western Highlands Claims/Authorization Table
Excel Spreadsheet  
Bulletin #9 - 01/14/05
Coordination of Benefits Policy
Word File PDF
Bulletin #8 - 01/14/05
Issues Related to Claims and Reimbursement
Word File PDF
Bulletin #7 - 01/12/05
Updates on important issues
Word File PDF
Bulletin #6 - 12/10/04
Updates on important issues
Word File PDF
Bulletin #4 - 11/17/04
Re: Language Translation and Interpretation
Word File PDF
Bulletin #2 - 10/14/04
Clarifications
Word File PDF
Bulletin #1 - 09/23/04
Clarifications
Word File PDF

 

Western Highlands Network | 356 Biltmore Avenue | Asheville, NC 28801

Consumers: 828-225-2800 or 1-800-951-3792 | Providers: 828-225-2785 or 1-800-671-6560 | Fax: 828-225-2784