Provider Forms and Documents
Sandhills Center assists affiliated care providers as much as we can. Listed below are helpful provider forms you can access and use.
Customer Services - Member Eligibility & Enrollment (ME&E)
- Advance Directive
- Alpha Slot Scheduler
- CDW Required Fields on Enrollment
- Patient Search
- Client Update
- Enrollment
- Discharge Process
- 2021-2022 Rate Sheet
- 2020-2021 Rate Sheet
- 2019-2020 Year-End Closing Process (posted 5/20/2020)
- Sandhills Center Retainer Payment Fee Schedule (posted 4/29/2020)
- Temporary Rate Increases, effective 4/1/2020
- 2019-2020 Reimbursement Rates (updated 3/23/2020)
- 2021 Check-Write Schedule (updated 12/16/2020)
- 2018-2019 Year-End Closing Process
- 2018-2019 Reimbursement Rates (posted 3/29/2019)
- 2017-2018 Reimbursement Rates (updated 11/16/2017)
- MCO Accepted Taxonomies (July 2017)
- 2019 Check-Write Schedule
- Potential Payment Impact: Implementation of New Taxonomy Claim Edit
- Announcement to Providers: ACTT Billing Changes Effective Nov. 1, 2016
- Revised PPA Application and Instructions
- PPA Checklist
- Timely Filing Letter 2019
- Sandhills Center Refund Check
- Health Insurance Information Notification Form
- Claims Inquiry/Resolution Form
- ACH Direct Deposit Application for Providers
- Place of Service Crosswalk
- 837P Companion Guide Version 1
- 837I Companion Guide Version 1
- 835 Companion Guide Version 1
- Trading Partner Agreement
For any claims and billing issues please e-mail the following: billing@sandhillscenter.org
Care Management/ Utilization Management
- State-Funded IDD Systems Review: Service and Eligibility Requirements
- UM Master Grid
- LOC FORM SANDHILLS CENTER
- Revised Process for ICFMR
- DMA Plan for Service Authorizations March Update
- Sandhills Center Certification of Need Form
- Interstate Compact Process on the Placement of Children
- Interstate Compact Process on the Placement of Children Form
- Interstate Compact Process on the Placement of Children Instructions
- ICFMR UR Request Form
- Person-Centered Crisis Prevention Intervention Plan
- Person-Centered Plan Instructional Manual
- Person-Centered Plan Manual Updates
- Person-Centered Plan Form
- Person-Centered Plan Update - Revision Form
- Service Authorization Request Form
- Non Covered Medicaid Service Request Form
- Sandhills Center IPRS Benefit Plan
Network Operations
- Disputes Resolution Flowchart IPRS
- Sandhills Center Dispute Resolution Form
- Disputes Resolution Flowchart Medicaid
- Notice of Change Request
- Provider Communications Plan
Quality Management
Network Provider Monitoring Process
- Opioid Treatment Assessment Tool
- Suicide Prevention Assessment Monitoring Tool
- PTSD Assessment Monitoring Tool
- Bipolar Disorder Assessment Monitoring Tool
- Autism Spectrum Disorders Assessment Monitoring Tool
- ADHD Assessment Monitoring Tool
- Major Depressive Disorder Monitoring Tool - Clinical Self-Report Instructions
- Major Depressive Disorder Monitoring Tool -- Clinical Self-Report
- Major Depressive Disorder Monitoring Tool
- Coordination Between the LME-MCOs and the DHSR Mental Health Licensure and Certification Section
- Network Provider Monitoring with Tools and Training Presentations DHHS
- Alcohol and Other Drug Use Disorder Monitoring Tool
- Alcohol and Other Drug Dependence Clinical Monitoring Tool Instructions
- Alcohol and Other Drug Dependence Clinical Monitoring Self Report Tool
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