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
- 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
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Special announcement: Effective May 11, 2023, the clinical policy flexibilities that were instituted as part of the federal Public Health Emergency will end. This includes flexibilities for authorizations, staffing ratios, sites of service, training requirements and others. For more information, please see Special Bulleting #265. Please note that this does not apply to Innovations Appendix K flexibilities. Appendix K flexibilities will end Nov. 11, 2023.
- 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
- 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
- Provider Contract Information Form
- Disputes Resolution Flowchart
- Sandhills Center Dispute Resolution Form
- 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
- 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
All content copyright © Sandhills Center 2023