Forms
| CATEGORY | FORM DESCRIPTIONS |
|---|---|
| Abortion | Physician statement for therapeutic abortion services |
| Adult Care Homes | Plan, serve and document quality of care for individuals residing in adult care homes |
| Ambulance | Prior approval and state-to-state medical transportation |
| Auditory Processing | Prior approval for auditory implant sound processors |
| Behavioral Health | Mental health and substance use targeted case management, certificates of need, individual service needs and discharge planning |
| Breast and Cervical Cancer | Breast and cervical cancer, including application for coverage, certification and verification of the condition |
| Care Management | Forms related to Care Management for Medicaid Managed Care |
| CMEP Form | CMEP Form |
| Community Alternative Programs (CAP) | CAP for Children (CAP-C) and CAP for Disabled Adults (CAP-DA) |
| Community Care of NC/Carolina ACCESS (CCNC/CA) | CCNC/CA, including office visit enrollment, medical exemption request, hospital admitting agreement and confidentiality agreement |
| County Forms | Medicaid forms required by the North Carolina Departments of Social Services |
| Dental and Orthodontic | Dental/orthodontic services, including prior approval, treatment extension, treatment termination and post-treatment summaries |
| Direct Enrolled Outpatient Behavioral Health | Independent mental health and substance use provider reviews |
| Durable Medical Equipment (DME) | Durable medical equipment, including prior approval for general and specialized products |
| Early and Periodic Screening, Diagnosis and Treatment (EPSDT) | Request non-covered Medicaid plan services for beneficiaries under the age of 21 |
| Hearing Loss | Providing hearing aids |
| HIV Case Management | Targeted case management for beneficiaries living with HIV/AIDS |
| Home Health | Prior approval home health, and HCPCS Code Addition Medicaid Home Health Fee Schedule |
| Hospice | Hospice services, including prior approval, documentation and coordination with personal care service provision |
| Hysterectomy | Hysterectomy informed consent |
| Medical Transportation | Ambulance and Non-Emergency Medical Transportation (NEMT) |
| Mental Health/Developmental Disabilities/Substance Abuse | Forms related to behavioral health, direct enrolled outpatient behavioral health and mental health/substance use targeted case management |
| Non-Emergency Medical Transportation | Provider request for reimbursement of services rendered |
| Nursing Facilities | Plan, serve and document quality of care for individuals residing in skilled nursing facilities |
| Orthodontics | Orthodontic services, including prior approval, treatment extension, treatment termination and post-treatment summaries |
| Orthotics and Prosthetics | Orthotic and prosthetic equipment, including prior approval for general and specialized products |
| Personal Care Services | Plan, serve and document quality of care for individuals obtaining personal care services |
| Pregnancy Medical Home | Pregnancy risk assessment |
| Presumptive Eligibility | Hospital presumptive eligibility, giving temporary Medicaid or CHIP coverage to those likely to qualify for benefits |
| Private Duty Nursing | Plan, serve and document quality of care for individuals getting private duty nursing |
| Radiology | Retroactive eligibility for radiology services request |
| Reproductive Health | Abortion, hysterectomy, pregnancy medical home and sterilization |
| Request for Coverage | Request for Coverage Form |
| Retainer Payments | Retainer payment attestation forms for providers |
| Sterilization | Sterilization informed consent |
| Third-Party Liability | Third-party insurance |
Transition of Care: Consent to Share Confidential Information | TOC beneficiary consent to share confidential information between health plans |
| TOC Warm Handoff Summary |