Looking for a form or document? You can view a list of forms and documents by clicking below or use the search in the upper right of this site. 

Please refer to the following forms, tools and other resources to help you perform your functions as a network provider. For additional assistance, call 1-866-990-9712 or email

Alphabetical list of documents and forms

837i 5010 Data Clarification Manual 
837p 5010 Data Clarification Manual
837p and 837i Steps For Testing and Approval 
AlphaMCS RA Steps to Export into Excel 
ASAM Worksheet for Adolescents 
ASAM Worksheet for Adults 
Authorization and Release for Background Checks 
Authorization for Release of Information 
CANS Assessment 0-4 Years Rating Sheet
Checkwrite Schedule (2022) 
Claims Adjudication Codes and Actions 
Clinical Practice Guidelines, Leveling Tools and HEDIS Measures
Community Guide (b)(3) Waiver Service 
Criterion 5 Form 
CSV RA Conversion Template 
Diversion Law Exception Worksheet 
Downloading And Importing AlphaMCS Detail Files
EDI Enrollment Form 
EFT Authorization Agreement for Automatic Deposit 
Enrollment Initiation Form: Licensed Practioner (LP)
EPSDT Non-Covered Services Request Form
Geriatric Team Referral Form 
Good Faith Contracting Policy
High-Volume Claim Inquiry Form 
Independent Assessment for Personal Care Services (PCS) (Start date: 30 days prior to Tailored Plan Launch)
Initial Level of Care Eligibility Determination: NC Innovations Waiver
Innovations Freedom of Choice Acknowledgement
Innovations Out-Of-State Travel Form Out-of-State Travel Common Questions and Answers
Innovations Waiver Health Plan Transfer Form
Innovations Waiver Participant Responsibilities
Innovations Waiver Self-Review Tool 
>> Self-Review of Innovations Member Record Job Aide
Inpatient Concurrent Review Form 
IRIS Incident Report Form 
Job Aid: Provider Portal Security Access Administrator
Local Barriers Committee Request Form
Long Term Community Supports (LTCS) in lieu of Service Definition 
Medicaid Covered Diagnoses
Medicaid Covered Diagnoses: Special Populations
NC Medicaid Provider Satisfaction Survey (2021)
Network Adequacy and Accessibility Analysis (2021)
Network Provider Participation Agreement
Network Provider Systems Access Administrator Designation
Non-Medicaid-Funded ACT Policy 
Non-Medicaid-Funded Critical Time Intervention 
Non-Medicaid-Funded Developmental Therapy Service 
Non-Medicaid-Funded Facility-Based Crisis Child 
Non-Medicaid-Funded Inpatient Behavioral Health Services 
Non-Medicaid-Funded IPS-SE For AMH-ASA
Non-Medicaid-Funded MH/DD/SA Service Definitions 
Non-Medicaid-Funded MHSA Enhanced Service Definitions 
Non-Medicaid-Funded Transition Management Services 
Non-Medicaid Residential Services Referral Profile 
Non-UCR Invoice Template
PCS Assessment Request Form
Physician Consultation (b)(3) Waiver Service
Program Integrity Incident Reporting Backup Staffing Form 
Provider-Based TCM Innovations Waiver Emergency Slot Form
Provider Contract Request Form
Provider Operations Manual
Provider Self-Audit Overpayment Workbook 
Provider Self-Audit Protocol For Paid Claims Audits
Psychological Testing Authorization Request Form 
Quarterly Provider Level I Incident Report 
Rate Request – Enhanced Rate Budget Worksheet
Rate Request – Existing Service Rate Request
Rate Request – Member- and/or Recipient-Specific Rate Request
Regional Referral Form 
Request for Claims Denial Reconsideration (Level 1)
Short-Range Goal Template For N.C. Innovations Providers 
Supported Employment (b)(3) Waiver Service 
Tailored Care Management Referral Form 
TBI Funding Request Form
TCL Community Monthly Update Form Link
The Assertive Community Treatment Transition Readiness Scale©
Universal Child and Adolescent Residential Placement Referral Form En Español
Use of Antipsychotic Medications and Monotherapy (1/24/2020)
Vaya Health-Tested Clearinghouses 

External links

Related to payment and billing

» ICD-10 Code Search

» NCTracks Website

N.C. DHHS/DHB/DMH Resources

» N.C. Division of Mental Health, Developmental Disabilities and Substance Abuse Services

» NC Medicaid

» N.C. DHHS Person-Centered Planning forms

» Medicaid Clinical Coverage Policies

» N.C. Division of Health Benefits Clinical Coverage Policy No: 8P

» N.C. Division of Mental Health, Developmental Disability and Substance Abuse Services (DMH/DD/SAS) Service Definitions

» NC-SNAP (NC Support Needs Assessment Profile)

Network participation

» Letter of Support Request

» Out-of-Network Agreement Request

» Provider Advisory Council

» Provider Nomination Form

» Provider Operations Manual

» RaDSE DocuSign® Form

Performance and quality

» AFL Update Form

» Fraud Prevention Toolkit

» Incident Response Improvement System

» NC-TOPPS website

» N.C. Department of Health and Human Services (DHHS)

» N.C. DHHS Agency Monitoring Tools for Providers

» N.C. DHHS Audit Information

» N.C. DHHS Consumer Perceptions of Care reports

» N.C. DHHS Monitoring Changes FAQ

» N.C. DHHS Home and Community Based Settings (HCBS) Self Assessment (Paper Version)

» N.C. DHHS New Unlicensed Site Review Tool for Providers

» N.C. DHHS Review Tool for LIPs/ Group Practices and Agencies Billing Outpatient Services Only

» N.C. DHHS Unlicensed AFL Review Tool for Provider