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Activation, Registration & Authorization
Authorization/UM Email Hotline
Need help with authorizations? Please email questions to:
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
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Registration
Registration is required for unmanaged benefits. Please submit the forms indicated.
MERF - Medicaid Enrolee Registration Form:
MERF (English) | MERF (Spanish)
Fax the completed MERF to 828-225-2797
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To Activate a Case
Managed Sessions, Enhanced Services
PRTF (Psychiatric Residential Treatment Facility)
TFC (Therapeutic Foster Care)
ACR - Assignment of Case Responsibility
If you have a CCIS log-in, fax to 828-225-2797 to complete documents electronically.
STR - Screening, Triage, and Referral Form if not completed by WHN in the last 60 days
Note: DCCI must also be completed with paper submission.
DCCI - Description of Consumer’s Clinical Issues
LCAD - LME Consumer Admission and Discharge Form
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MERFs and ACRs - fax to 828-225-2797 for faster entry into CCIS.
All other paper submissions - fax to 828-225-2782.
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CCIS Log-in: If you have a Care Coordination Information System (CCIS) log in through the Western Highlands Network web-based portal, submit the ACR, then complete the rest of these documents electronically through CCIS. You have the option to:
• Upload the Treatment Plan electronically through the CCIS system.
• Or fax the Treatment Plan to 828-225-2779.
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If you have not received a CCIS log-in from WHN, you may submit these documents on paper. Please see the complete list of exceptions to electronic submission in Communication Bulletin #95 (6/9/09).
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To Request Services
You will need to Activate the Case and submit the following forms:
TAR (Treatment Plan) - Treatment Authorization Request (TAR)
Read Hints for Submitting Paper TARs.
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For Hospital, Faclity-based Crisis, Mobile Crisis Management or other specialized services, refer to Communication Bulletin #107 for information on what needs to be submitted.
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Grids - Level of Care Guidelines
for Child and Adult Mental Health and Substance Abuse
| Child Level of Care Descriptions & IPRS Benefit Guidelines (12/2/11) |
PDF
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| Adult Level of Care Descriptions & IPRS Benefit Guidelines (12/2/11) |
PDF |
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| Child Level of Care Descriptions & Medicaid Benefit Guidelines (12/2/11) |
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| Adult Level of Care Descriptions & Medicaid Benefit Guidelines (12/2/11) |
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Service Authorization Codes
and Service Definitions
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| APSM 1026 Service Definitions Manual (01/03) |
PDF |
(2mb) |
| Records Management and Documentation Manual - APSM 45-2 (3/3/09) |
Link |
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| DMA Clinical Coverage Policy 8A, Enhanced MH/SA Services (8/1/11) |
Link |
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| DMA Clinical Coverage Policy 8B, Inpatient Behavioral Health Services (8/1/07) |
Link |
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| DMA Clinical Coverage Policy 8C, Outpatient Behavioral Health Services (2/1/11) |
Link |
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| DMA ClinicalCoverage Policy 8D-1, Psychiatric Residential Treatment Facilities for Children under the Age of 21 (5/1/07) |
Link |
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| DMA Clinical Coverage Policy 8D-2, Residential Treatment Services (8/1/07) |
Link |
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| DMA Fee Schedule (also onClaims & Reimbursements page) |
Link |
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| WHN Fee Schedule - 1/3/12 (also onClaims & Reimbursements page) |
Link |
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| IPRS (Integrated Payment and Reporting System) |
Link |
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Procedures Documentation
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| Instructions for Completing Notification Protocol Memo (12/05/04) |
PDF |
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| Notification Protocol (Rev. 12/05/03) |
PDF |
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| Notification Protocol Memo (12/05/03) |
PDF |
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WHN Communication Bulletins
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Bulletin #107 (12/09/11) - Medicaid Authorization Submission Guides
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PDF |
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Bulletin #87 (08/22/08) - Child Consumers Involved with Juvenile Justice:
DJJDP Consultation - Quick Reference Word
DJJDP - Juvinile Justice Court Consultation PPT
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PDF
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Bulletin #75 (01/25/08) - Case Reponsible Transfer Procedure
(This Bulletin supercedes #33) |
PDF |
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| Consumer Transfer and Notification Consent Form 1/25/08 |
PDF |
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Bulletin #41 (06/12/06) - Not applicable after 1/3/12
14-Day Limit on Pended Service Authorization Requests |
PDF |
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| Bulletin #38 (06/06/06) - Clarification of Service Authorizations for Individuals with Out of County Medicaid |
PDF |
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Bulletin #27 (03/08/06) - Not applicable after 1/3/12
Medicaid & IPRS Letter of Notification Protocol
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PDF |
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Utilization Review
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| Entitlement Resources (7/20/05) |
PDF
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| Provider Responsibility for Conducting Utilization Review (09/01/04) |
PDF
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State Hospital Child/Adolescent
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Admission/Discharge Flowchart (May 10)
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