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
- 2022-2023 End-of-the-Year Letter from the Finance Director
- 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
- Sandhills Center JIVA authorization system training - video link
- Logging in to Jiva
- Submitting an Initial Behavioral Health Outpatient Request
- Submitting an Initial Physical Health Inpatient Request
- Submitting an Initial Behavioral Health Inpatient Request - for use by Psychiatric Hospitals/Units and Alcohol Drug Abuse Treatment Centers (ADATCs) only
- All Service Codes to be Used on Authorization Requests in Jiva
- 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
- Service Authorization Request Form
- Non-Covered Medicaid Service Request Form
- Sandhills Center IPRS Benefit Plan
Network Operations
- Provider Contract Information Form
- Disputes Resolution Flowchart
- Notice of Change Request
- Provider Communications Plan
- Glossary of Terms and Acronyms
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
- 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