| APPLICATIONS |
Document Description |
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ECBH Provider Network Application Request
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Form to request an application to become a contracted provider in ECBH Network |
| Add Licensed Practitioner Request Revised Jan 18, 2013 |
Form to request additional licensed practioner |
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| DIRECTORIES & MANUALS |
Document Description |
| ECBH Provider Network Directory - May 2013 |
Current listing of contracted providers operating at sites within ECBH catchment area |
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February 2013 Update
|
Responsibilities of contracted providers and the LME/MCO |
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| CLAIMS / FINANCE INFO & FORMS |
Document Description |
| 837 Institution Companion Guide |
Document to create 837I Requirements for CI |
| 837 Professional Companion Guide |
Document to create 837P Requirements for CI |
| 999 and 824 Response File Reading Instructions |
How to read the response files received after submission of an 837. |
| Replacement-Voided-Denied Claims Process Revised December 4, 2012 |
Instructions for submitting replacement, voided and denied claims |
| 2013 ECBH Check Write |
ECBH Check Writing Schedule 2013 |
| 2013 Medicaid Check Write |
Medicaid Check Writing Schedule 2013 |
| Accounting Form |
Calculate expenses against revenues received |
| Claims Request Form |
Claims Request Form |
| Claims Request Instructions |
Instructions for Claims Request |
| Clinical Coverage Policy 8D-2: Residential |
Explains correct HCPCS codes to use for billing |
| Direct Deposit Form |
Direct Deposit Request Form |
| EOB Codes for Providers |
Action needed to correct claim |
| EOB Denial Codes |
Denial Codes for Providers |
| Medicaid Rates - B3 Services |
ECBH Medicaid Rates for B3 Services |
| Medicaid Rates - CPT Fee Schedule Revised 04/2013 |
ECBH Medicaid Rates for CPT Fee Schedule |
| Medicaid Rates - EM & ER ServicesRevised 04/2013 |
ECBH Medicaid Rates for EM & ER Services |
| Medicaid Rates - HCSPC |
ECBH Medicaid Rates for HCSPC |
| Medicaid Rates - Innovations Services |
ECBH Medicaid Rates for Innovations Services |
| Medicaid Rates - Provisionally Licensed |
ECBH Medicaid Rates for Provisionally Licensed |
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For credentialing New Employees as Relative or Legal Guardian as Provider
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For credentialing Existing/Previously Credentialed Employees as Relative or Legal Guardian as Provider
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For requesting more than 40 hours/week as Relative or Legal Guardian As Provider
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| State Service Rates |
ECBH State Service Rates for FY11-12 |
| State Service Rates (Revised 04/17/2013) |
ECBH State Service Rates for FY12-13 |
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| IT INFORMATION & FORMS |
Document Description |
| Provider Direct User Agreement |
User Agreement for Provider Direct System |
| ZixMail Instructions |
Secure Email Manual |
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| OPERATIONAL INFORMATION & FORMS |
Document Description |
| Critical Incident Form |
Incident Form |
| Consumer Handbook Acknowledgement |
SAMPLE for receipt of handbook by consumer from provider |
| Discharge Plan-Child/Adolescent Form |
Used prior to Level III / IV / PRTF Admission
|
| ECBH Consent to Release |
Consent to Release PHI |
| ECBH Record Retention Form |
ECBH Record Retention Log |
| HIPAA Privacy Incident Reporting |
HIPAA Reporting Form |
| HIPAA Work Area Privacy Safeguards |
HIPAA Work Area Privacy Safeguards |
| Independent Practitioner Referral Form |
Use when consumer is referred to an LIP |
| NC SNAP Registration Form 2013 |
NC SNAP Examiner Training Registration Form |
| NC SNAP 2013 Training Calendar Updated 04/01/13 |
NC SNAP Training Calendar Jan-Dec 2013 |
| NC TOPPS Change of QP Request Form Updated 01/31/13 |
Transfer NC TOPPS from Agency to Agency |
| NC TOPPS Implementation Guidelines |
SFY 2011-2012 Implementation Guidelines |
| Notification of Out-of-Home Placement Form |
Form to submit to LME/MCO when child is placed out-of-home in a community setting |
| Plan of Correction |
Plan of correction |
| Personnel Checklist |
Checklist of documentation and training required for provider staff per 2011 IU #82 |
| Provider Change Form Revised 12/04/2012 |
To be submitted when change occurs in the agency |
| Provider UAFL |
CAP-MR/DD Unlicensed AFL Health and Safety On-Site Review Form
|
| Provider Transition Spreadsheet |
Provider Transition Spreadsheet |
| QM Report 2010-2011 |
2010-2011 Annual QM Board Report |
| Services Requiring NC-TOPPS |
Listing of required NC-TOPPS Services |
| STR Form |
Screening, Triage, Referral Form |
| Technical Assistance Request Form |
Used to Request Technical Assistance from ECBH |
