Providers' Page

Network Management Department
CoastalCare
PO Box 4147
Wilmington, NC 28406

• Accountable Care Training (David Lloyd) Tools:
  • Access Redesign Outcomes Achieved
  • AH01a Med Checks for 2 years with averages 2/22/11
  • Back Fill Scheduling Calculator
  • Basic Cost Based Calculator with Revenue
  • Case Load Calculator Flexible
  • CBHO Benefit Design Package Mgmt Adult
  • CMHC Benefit Package 2008 C&A
  • Level of Care Guidellines ASAM Criteria Sample
  • Performance Expectations Calculator Sample
  • Sample Psychiatrist Balance Sheet
  • Weekly Service Planner
• Add a Site Form
• Add a Service Form
• AlphaMCS Provider Webportal Login Request
• Assignment of Benefits
• Authorization for Use & Disclosure of Protected Health Information
• Change Form
• Client Rights Brochure - Adult
• Client Rights Brochure - Child/Youth
• Consumer Residential Placement Change (rev. 8/10/09)
• Consumer Complaint
• Consumer Movement Acknowlegement
• Contract Checklist - Attachment/Insurance Requirements
• Crisis Diversion Bed Referral Form
• Crisis Prevention/Crisis Response
• Cultural Diversity Committee Nomination Form
• Death Review Abstract Form
• DHHS Quarterly Incident Report  
• Direct Deposit Authorization Form
• Disaster Plan Update
• EPSDT Review Request
• EPSDT Review
• Family Income  and Size-Guidelines for determining
• Health Care Registry 24-Hour Report Form
• Health Care Registry 5-Day Report Form
• HIPAA Privacy Notice
• Hospital Entrollment
• Innovations Incident Reporting For Failure to Provide Back-Up Staffing
• Innovations Short Term Goals Template
• Insurance Authorization
• IPRS Target Population Enrollment Form, Child
• IPRS Target Population Enrollment Form, Adult
• IRS Form W-9: Request for Taxpayer Identification Number and Certification
• Notification of Out of Home Placement (C/Y consumers
• Out of Network Services Enrollment form
• Out of Network Single Case Agreement
• Peer Specialist Certification
• Person-Centered Information on DMH website
• Plan of Correction Form
• Poverty Level Chart
• Provider Complaint Clarification
• Provider Health Questionaire (PHQ-9)
• QI Project 9/27/10 forms:
  • Metabolic Risk History
  • Record of Indicators
• Provider Portal User Request
• Record Retention Log
• Relative As Provider Forms
• Safety & Supervision Planning Checklist
• Service Orders
• Sliding Fee Schedule (Sample)
• STR Form (State)
• Supportive Housing Forms
• Trading Partner Agreement (TPA) Request
• Training Request Form
• Transition of IIH, CST and Day Treatment Consumers
  • Medicaid Funded Consumer Transition Plan
  • Health Choice Funded Consumer Transition Plan
  • Transition Plan Spreadsheet
• Treatment/Discharge Summary
• Utilization Review Check Sheets
• Utilization Review Initial Level of Care Eligibility Determination for NC Innovations
• Utilization Review Forms:
  • Approved CCA Template
  • LOCUS - This tool has been specifically modified and can only be used in conjunction with the CCA template listed above.
  • CALOCUS - This tool has been specifically modified and can only be used in conjunction with the CCA template listed above.
  • ASAM - This tool has been specifically modified and can only be used in conjunction with the CCA template listed above.
• Value Options Forms:
  • CAP-TCM Request for Authorization (CTCM)
    • Instructions
  • Inpatient Treatment Report (ITR)
    • Instructions
  • Outpatient Review Form (ORF2)
    • Instructions
  • Value Options Certification Letter Request Form
• Verification of Experience form template
  
  • Guide for evaluating Human Service degrees
  • Core Rules, Staff Definitions at 10A NCAC 27G.0104