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

Finance, Billing, and Claims

• 2023 Behavioral Health Checkwrite Schedule
• Medicaid Fee Schedule
• State-Funded Fee Schedule Spreadsheet (Excel spreadsheet)
• Claims Inquiry/Resolution Form- New Process for Claims Inquiries (6/13/2022)
• 2022-2023 Year-End Letter from the Finance Director
• ICD-10 Information
• Direct Care Worker Wage Increase Information
• EVV Rate Increase Information
• 2022 Check-Write Schedule
• 2021-2022 Rate Sheet
• Sandhills Center Retainer Payment Fee Schedule (posted 4/29/2020)
• Temporary Rate Increases, effective 4/1/2020
• MCO Accepted Taxonomies (July 2017)
• Revised PPA Application and Instructions
• PPA Checklist
• Sandhills Center Refund Check
• Health Insurance Information Notification 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 claims and billing issues, please refer to the Provider Support Portal.

The Finance/Claims department is located at 1120 Seven Lakes Drive (P.O. Box 9), West End, NC 27376. The office is open from 8:30 a.m. to 5 p.m., Monday through Friday. For more information, call 910-673-9111.

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
• Sandhills Center Dispute Resolution Form
• Notice of Change Request
• Provider Communications Plan

Quality Management

• Incident & Death Reporting (Includes links to manuals, instructions & forms)

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