Screening, Triage, and Screening, Triage, and RegistrationRegistration

Forms, Timelines, and WHN Forms, Timelines, and WHN proceduresprocedures

What’s the difference?What’s the difference?

Registration vs. Registration vs. OpeningOpening

Dual funded Dual funded ConsumersConsumers

STR Form ReviewSTR Form ReviewNC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

Standardized Consumer STR Interview and Registration Form

First Name, M.I., and Last Name of Consumer MM DD YYYY Complete as indicated by LME, or may be assigned by LME upon receipt.

/ / A. Consumer Name ®

B. Consumer DOB ® C. LME Name ® D. LME Facility Code ®

E. LME Consumer Record No. ® Complete All Applicable Provider Identification Numbers.

F. Name of Provider Agency or LME Completing Form ®

G. Medicaid Provider Enrollment No.

® H. IPRS Attending Provider No.

® I. National Provider Identifier (NPI) No.

® J. Provider Consumer Record No.

® Instructions: The Consumer STR Interview and Registration Form is required to be completed by all LMEs operating or contracting for STR, and by all Enhanced Benefits Service providers. STR Interview items (1 - 48) are required to be completed by all facilities performing STR. STR is appropriate only for all new applicants for services, or for inactive consumers seeking services in a new

episode of care (minimum of no billable services within prior 60 days). STR is required to be conducted by a Qualified Professional (QP) as defined by NC Administrative Code. STR is designed as a brief inquiry, not an in-depth assessment, to determine need and to facilitate access to a more intensive clinical service by a provider. STR is intended to identify the nature of a presenting mh/dd/sas problem, recommend a Triage Severity of Need Determination, and facilitate referral to a provider of choice or other resource. STR is to be conducted as efficiently and effectively as possible, within the Screening method and time available, while imposing a minimum burden on the consumer or other requestor. Upon Determination of a Triage Severity of Need, prompt consumer referral to a provider of choice or other resource should be facilitated, with no delay in referral for services based on missing data. Registration items (1 & 49 - 55) are designated by “®”, and are required to be completed for all new or previously inactive consumers initiating an Enhanced Benefits Service. This form is required to be submitted to the LME within five business days of Screening or service initiation, per Division guidelines and HIPAA, 42 CFR, Part 2, and G.S. 122C regulations. Any electronic

transmittal is required to conform to HIPAA standards for electronic health care transactions, and conform to a uniform format specified by the Division, including required encryption for secure transmission of data. For further reference, see current DMHDDSAS CDW Reporting Requirements and CDW Data Dictionary at http://www.dhhs.state.nc.us/mhddsas/manuals/index.htm.

1. ® Entry Type: STR Only Registration Only STR & Registration ( One) (Items A-J & 1–48) (Items A-J & 1 & 49–55) (Items A-J & 1–55) ………………………………………………………………………………………………………… 2. Date of Consumer Screening: / / (MM/DD/YYYY) 3. Consumer Co. of Residence: or

(Enter county name or county code from CDW Data Dictionary.) Co. Code 4. Is consumer currently enrolled in Medicaid? ( One) Yes No 5. Screening Referral Source of consumer: _________________________

or

(Enter referral source name or source code from attached instructions.) Code 6. Time Screening Began: : 7. Time Screening Ended: : (Enter 24 Hr. Military Time) HH MM (Enter 24 Hr. Military Time) HH MM 8. Screening Method: ( One) Face-to-Face Telephone 9. Name of Person Initiating Request for Services and Relationship to Consumer: (May be the consumer)________________________________________________ 10. Phone # of Person Initiating Request: - - 11. Brief Description of Presenting Problem(s): (Attachment should be included) 12. Presenting Problem(s) by Consumer Age/Disability: (Not Target Population determination) 12a) 1st: ( One only) AMH CMH ADD CDD ASA CSA 12b) 2nd: ( One, if applic.) AMH CMH ADD CDD ASA CSA 12c) 3rd: ( One, if applic.) AMH CMH ADD CDD ASA CSA 13. Current Risk to Consumer Safety (especially for DD or MH consumer): ( One box for each row) NONE MILD MOD. SEV. NOT SCREENED 13a) Instability of Care Provider Supervision 13b) Safety Issues in Living Arrangement 13c) Aggression or Self-Injurious Behaviors

14. Does Screening indicate consumer is in need of Detox due Yes No N/A to risk for acute alcohol or drug withdrawal symptoms? (If “Yes”, All that apply) Agitation Nausea and Vomiting Sweats Seizures Tremors Other (Describe)_____________________________________________ 15. Current Risk of Potential Harm to Self or Others: SCALE: NONE, no current ideation (within past 30 days) MILD, current ideation only to hurt self or others (within past 30 days) MODERATE, ideation with EITHER plan or history of attempts to hurt self or others SEVERE, ideation AND plan, with EITHER intent or means to hurt self or others ( One box for each row) NONE MILD MOD. SEV. NOT SCREENED 15a) Consumer’s Potential Risk to Self 15b) Consumer’s Potential Risk to Others 16. Triage Severity of Need Determination with Response Timeline: ( One) Determine appropriate severity of need. Clinical judgment may override criteria below to indicate higher level of need determination. All consumers presenting with a potential substance-related problem should receive at least an “Urgent” level of need determination, and be scheduled for appointment or service initiation within 48 hours. Emergent: (2 hours maximum for service initiation) a. Consumer has a moderate or severe risk related to safety or supervision, or b. Consumer is at moderate or severe risk for substance abuse withdrawal symptoms, or c. Consumer presents a mild, moderate, or severe risk of harm to self or others, or d. Consumer has severe incapacitation in one or more area(s) of physical, cognitive, or behavioral functioning related to mh/dd/sa problems. Urgent: (48 hours maximum for service initiation) Consumer presents with moderate risk or incapacitation in one or more area(s) of physical, cognitive, or behavioral functioning related to mh/dd/sa problems. Routine: (7 calendar days maximum for service initiation) Consumer presents with mild risk or incapacitation in one or more area(s) of safety, or physical, cognitive, or behavioral functioning related to mh/dd/sa problems. Non-Threshold Clinical Need: (Referral to Community Resources only) Consumer presents with a problem that does not meet any of the above minimum required thresholds of clinical need for referral to an assessment by a professional provider through the state or federally funded MH/DD/SAS system. 17. Where Consumer is Being Referred for Response After Triage: ( Best One only) B = Basic Benefits Service Provider E = Enhanced Benefits Service Provider R = Crisis Service Provider C = Community Resources (Specify Name of Community Resource)_______________________________________

STR Form Page #2STR Form Page #2

NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

Standardized Consumer STR Interview and Registration Form

First Name, M.I., and Last Name of Consumer MM DD YYYY Complete as indicated by LME, or may be assigned by LME upon receipt.

/ / A. Consumer Name ® B. Consumer DOB ® C. LME Name ®

D. LME Facility Code ® E. LME Consumer Record No. ® If Item No. 17 above is checked for “Community Resources”, skip to Item 26. 18. What initial service(s) does Screener recommend for consumer? ( All that apply) Diagnostic Assessment Community Support Targeted Case Mgt. Other Clin. Intake/Eval. (90801) Beh. Hlth. Assess. (H0001) Men. Hlth. Assess. (H0031) 19. Has provider appointment date and time (or crisis service) been offered to consumer?

Yes No N/A If “Yes”, complete Item 20. If “No” or “N/A”, skip to 26. 20. Has provider appointment (or crisis service) that was offered been accepted by the consumer? Yes No If “Yes”, complete Items 21 – 22. If “No”, skip to Item 26. 21. Provider Agency Referred to and Location: _______________________________ 22. Phone No. of Provider Referred to: - - Complete Item 23 only for Enhanced Benefits Service or Crisis Service, based on appointment or actual initiation of a service. (Enter date and time) 23. Appointment Date & Time Scheduled: / / and : (or Crisis Service Initiated) MM DD YYYY HH MM (Enter 24 Hr. ) 24. How was Provider Chosen? ( One only) Consumer Choice Family/Legal Guardian Choice Screener Decision Other Person Decision (Identify):________________________________________________ 25. Why was Provider Chosen? ( All that apply) Consumer Coverage Benefits Crisis or Urgent Access 1st Available Hours Location Cultural Reasons Reputation/Recommended by Others Provider Specialty ‘ Other Reason (Describe) ___________________________________________________ 26. Accommodation of Special Consumer Needs: ( All that apply) Not Applic. Wheelchair/Mobility Needs Interpreter (Sign Language) Deaf/Hearing Impaired Intellectual Disability Childcare Visually Impaired Physical Disability Frail Senior Other (Describe)____________________________________

33. Gender: Male Female 34. Veteran Status: Yes No Unk. 35. National Guard or Military Reserve (or Military Family) Status in OIF or OEF: Has the consumer or immediate family member (parent, grandparent, sibli ng, spouse, partner, child, or other significant person in the family constellation) served in the National Guard or Military Reserve in support of Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF)?

Yes No

36. Consumer’s St. Address/City/State:_____________________________________ 37. Consumer’s Phone # (______) ________________________________________ 38. Mailing Address/City/State/Zip Code:___________________________________ 39. Consumer’s Legal Guardian (if applicable):_______________________________ 40. Phone # of Legal Guardian (if applicable): (______) _______________________ 41. Emergency Contact Name & Relationship: _______________________________ 42. Phone # of Emergency Contact: (______) _______________________________ 43. Consumer Unique Identifier: - 44. Type of Agency Hosting STR: ( All that apply) LME Operated or Contracted STR Enhanced Benefits Service Enrolled Provider LME Contracted Service Provider Crisis Service Provider

45. First & Last Name of Qualified Professional (QP) who Conducted STR Interview 46. STR Staff Qualifications: QP in MH QP in SA QP in DD 47. - - - 48. / / STR Staff Area Code, Phone No., & Extension Date Form Submitted to LME

27. Primary Care Medical Provider: (List name & practice of licensed MD, PA, or NP)__________________________________ 28. What special arrangements were made for services access? ( All that apply) None Transportation Site Accessibility Other (Describe):_________________ 29. Ethnicity: ( One) Hispanic, Mexican American Hispanic, Puerto Rican Hispanic, Cuban Hispanic, Other Not Hispanic Origin Unknown 30. Race: ( One) Black/Afric. Amer. White/Anglo/Cauc. Amer. Ind./Native American Alaska Native Asian Native Hawaiian Pacific Islander Unknown Other (Describe): _________________________________ 31. Is consumer proficient in English? ( One) Yes No 32. Primary Language: ( One) English Sign Language French Spanish Other None Unknown

CONSUMER REGISTRATION FOR ENHANCED BENEFITS PROVIDERS

49. ® Date of Consumer Service Initiation: / / Complete ID Nos. (as applicable & available) MM DD YYYY 50. ® Consumer Social Security Number: - - (Needed for cross referencing with CNDS)

51. ® Consumer Medicaid Number:

52. ® First and Last Name of Registration Provider Staff Submitting this Form to LME 53. ® E-Mail Address of Registration Provider Staff MM DD YYYY 54. ® - - - 55. ® / / Registration Provider Area Code, Phone No., & Ext. Date Form Submitted to LME

Description of Clinical Issues Description of Clinical Issues FormForm

A. Description of Consumers Clinical Issues

(Use for documenting clinical information for initial authorizations in conjunction with the STR form. Please include information on hospitalizations, psychosis, depression, anxiety or legal problems, SA arrests and DSS involvement) Client Name:_________________________________________ DOB:___________________

_______________________________________ Signature of QP/Clinician

B. Additional CDW Information (use if NOT sending the PCP Admissions Form)

Marital Status: 1 Single/Never Married 2 Married 3 Separated 4 Divorced 5 Annulled 6 Widowed 8 Domestic Partners

Health Related Codes: Tobacco use Substance abuse Both □ Unknown □ None

Other Insurance: □ None □ Medicare □ Health Choice □ Private Insurance _______________ Living Arrangement: 00 Other 1 Private Residence 8 Nursing Home (ICF, SNF) 10 Adult Care Home 6 or fewer beds 11 Community ICF-MR 12 Community ICF-MR 70+ beds 13 Homeless 14 Correctional Facility 15 Institution 16 Residential Facility/Not Nursing Hm 17 Foster/Alternative Family Living 18 Other Independent 19 Adult Care 7+ beds (Rest Home)

Highest Grade Completed___________ □ Unknown Are you pregnant? Yes No

Employment Status: Full Time Part Time Unemployed Student □ Unknown Retired Homemaker Armed Forces Seasonal/Migrant Worker

C. Access SAR:

Requested Services

Community Support (State Funds) – 24 Units Effective Date_______________________________

Diagnostic Assessment – 1 Event Effective Date_____________________

H0001: SA Assessment – 8units Effective Date___________________

H0031: MH Assessment – 8 units AND H0004: Individual – 12 units Effective Date__________________

T1017HI: DD Case Management/State- 40 units Effective Date______________________________

H2011: Mobile Crisis Management- # of Units_______ Effective Date_____________________________

PCP Admission Form ReviewPCP Admission Form Review

NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

Person-Centered Plan (PCP) Consumer Admission Form

Last Name, M.I., and First Name of Consumer MM DD YYYY Complete as indicated by LME, or may be assigned by LME upon receipt.

/ / A. Consumer Name B. Consumer DOB C. Provider Consumer Record No. D. LME Facility Code E. LME Consumer Record No. Instructions: The Consumer Admission Form is required to be completed as a part of the Person-Centered Plan for all Enhanced Benefits Service consumers within 30 days of service initiation. The form is required to be submitted to the LME by all Enhanced Benefits providers for each new consumer, or with inactive consumers for whom they are initiating services in a new episode of care (minimum of no billable services within prior 60 days). Admission information is required to be updated periodically when new data is collected or when existing data is modified. This form is required to be submitted to the LME and to Value Options in accordance with Division guidelines and HIPAA and 42 CFR, Part 2 and GS 122C regulations. Any electronic transmittal is required to conform to HIPAA standards for electronic health care transactions, and conform to a uniform format specified by the Division, including required encryption for secure transmission of data. For further reference, see current DMHDDSAS CDW Reporting Requirements and CDW Data Dictionary at http://www.dhhs.state.nc.us/mhddsas/manuals/index.htm. 1. Name of LME responsible for receiving this Consumer’s PCP 2. Consumer Current Admission Date: / / MM DD YYYY 3. Consumer Co. of Residence: or (Enter county name or county code from CDW Data Dictionary.) Co. Code 4. Consumer’s Residence Zip Code: - 5. Ethnicity: ( One) Hispanic, Mexican American Hispanic, Puerto Rican

Hispanic, Cuban Hispanic, Other Not Hispanic Origin Unknown 6. Marital Status at the time of admission: ( One) Annulled Single Married Separated Divorced Widowed Unknown Domestic Partners 7. Race: ( One)

Black/Afric. Amer. White/Anglo/Cauc. Amer. Ind./Native American

Alaska Native Asian Native Hawaiian Pacific Islander

Unknown Other (Describe): _________________________________ 8. Gender: Male Female 9. Veteran Status: Yes No Unk. 10. Education Level at time of admission (highest grade/degee completed): (Enter code from attached instructions.)

11. Employment Status at time of admission (temporary or permanent): (Enter code from attached instructions.)

12. Living Arrangement (residential) at time of admission: (Enter code from attached instructions.)

13. Admission Referral Source of consumer to facility: (Enter code from attached instructions.) 14. Is consumer proficient in English? ( One) Yes No 15. Primary Language: ( One) English Sign Language French Spanish Other None Unknown 16. Is consumer pregnant at the time of admission? Yes No Not Applicable 17. Diagnosis(es) Effective Date: / / (for current episode) MM DD YYYY

18. Diagnosis Code(s) (ICD-9): (List up to three ICD-9 diagnoses in order of importance) 18a) . 18b) . 18c) . 19. Date Started Substance Abuse Treatment: / / Not Applicable (for current episode) MM DD YYYY 20. Provide information on Substance Abuse (Drug of Choice) Details: Not Applicable (Enter codes from attached instructions)

20a) SA Drug Code 20b) Age of First Use 20c) Use Frequency 20d) Route of Admin.

1) Primary Substance

2) Secondary Substance

3) Additional Substance Complete consumer identifying numbers below (as applicable and available): 21. Consumer Unique Identifier: -

22. Consumer Social Security Number: - - (Needed for cross referencing with CNDS) 23. Consumer Medicaid Number: Complete provider identifying information below (as applicable and available): 24. Name of Provider Agency 25. Medicaid Provider Enrollment No.: 26. IPRS Attending Provider No.: 27. National Provider Identifier (NPI) No.: 28. First and Last Name of Provider Staff Submitting this Form to LME 29. E-Mail Address of Provider Staff Submitting this Form to LME MM DD YYYY 30. - - - 31. / / Provider Area Code, Phone No., & Extension Date Form Submitted to LME

IPRS Worksheet ReviewIPRS Worksheet Review

Western Highlands Child IPRS Target Population Worksheet

Client Name _______________________________________________________ Client ID _____________________ Child DD (Active Only): _____ CDSN (CHILD DEVELOPMENTAL DISABILITY SNAP = 1-5) From 3-17 yrs of age Child MH (Active Only): _____ CMSED (CHILD MENTAL HEALTH SERIOUSLY EMOTIONALLY DISTURBED WITH OUT-OF-HOME PLACEMENT) out of home

risk/placement or meets other SED criteria. From 3-17 yrs of age. Diagnosis = 293.0, 293.81, 293.82, 293.83, 293.84, 293.89, 293.9, 294.0, 294.10, 294.11, 294.8, 294.9, 295.10, 295.20, 295.30, 295.40, 295.60, 295.70, 295.90, 296.00, 296.01, 296.02, 296.03, 296.04, 296.05, 296.06, 296.20, 296.21, 296.22, 296.23, 296.24, 296.25, 296.26, 296.30, 296.31, 296.32, 296.33, 296.34, 296.35, 296.36, 296.40, 296.41, 296.42, 296.43, 296.44, 296.45, 296.46, 296.50, 296.51, 296.52, 296.53, 296.54, 296.55, 296.56, 296.60, 296.61, 296.62, 296.63, 296.64, 296.65, 296.66, 296.7, 296.80, 296.89, 296.90, 297.1, 297.3, 298.8, 298.9, 300.00, 300.01, 300.02, 300.11, 300.12, 300.13, 300.14, 300.15, 300.16, 300.19, 300.21, 300.22, 300.23, 300.29, 300.3, 300.4, 300.6, 300.7, 300.81, 300.82, 300.9, 301.13, 302.2, 302.3, 302.4, 302.6, 302.81, 302.82, 302.83, 302.84, 302.85, 302.89, 302.9, 306.51, 306.8, 307.0, 307.1, 307.20, 307.21, 307.22, 307.23, 307.3, 307.42, 307.44, 307.45, 307.46, 307.47, 307.50, 307.51, 307.52, 307.53, 307.59, 307.6, 307.7, 307.80, 307.81, 307.89, 307.9, 308.3, 309.0, 309.21, 309.24, 309.28, 309.3, 309.4, 309.81, 309.9, 310.1, 311, 312.30, 312.31, 312.32, 312.33, 312.34, 312.39, 312.81, 312.82, 312.89, 312.9, 313.23, 313.81, 313.82, 313.89, 314.00, 314.01, 314.2, 314.9, 995.50, 995.51, 995.52 , 995.53, 995.54, 995.55, 995.59, 995.80, 995.81, 995.82, 995.83, 995.84, 995.85, 995.86, 995.89, V15.81, V15.82, V15.84, V15.85, V15.86, V15.89, V61.0, V61.10, V61.11, V61.12, V61.20, V61.21, V61.3, V61.41, V61.49, V61.5, V61.6, V61.7, V61.8, V61.9, V62.3, V62.4, V62.5, V62.6, V62.81, V62.82, V62.83, V62.89, V62.9, V65.2.

_____ CMMED (CHILD MENTAL HEALTH SERIOUSLY EMOTIONALLY DISTURBED) From 3-17 yrs of age. Diagnosis = Same as CMSED. _____ CMDEF (CHILD MENTAL HEALTH DEAF OR HARD OF HEARING) From 3-17 yrs of age. Primary Diagnosis = Same as CMSED. _____ CMECD (CHILD MENTAL HEALTH EARLY CHILDHOOD DISORDER) From 3-5 yrs of age who demonstrates significantly atypical

behavioral, socio-emotional, motor or sensory development. Diagnosis = 291.0, 291.1, 291.2, 291.3, 291.5, 291.81, 291.89, 291.9, 292.0, 292.11, 292.12, 292.81, 292.82, 292.83, 292.84, 292.89, 292.9, 293.0, 293.81, 293.82, 293.83, 293.84, 293.89, 293.9, 294.0, 294.11, 294.8, 294.9, 295.10, 295.20, 295.30, 295.40, 295.60, 295.70, 295.90, 296.00, 296.05, 296.20, 296.21, 296.22, 296.23, 296.24, 296.25, 296.26, 296.30, 296.31, 296.32, 296.33, 296.34, 296.35, 296.36, 296.40, 296.41, 296.42, 296.43, 296.44, 296.45, 296.46, 296.50, 296.51, 296.52, 296.53, 296.55, 296.56, 296.60, 296.61, 296.62, 296.63, 296.64, 296.65, 296.66, 296.7, 296.80, 296.89, 296.90, 297.1, 297.3, 298.8, 298.9, 299.00, 299.10, 299.80, 300.00, 300.01, 300.02, 300.11, 300.12, 300.13, 300.14, 300.15, 300.16, 300.19, 300.21, 300.22, 300.23, 300.29, 300.3, 300.4, 300.6, 300.7, 300.81, 300.82, 300.9, 301.13, 301.20, 301.22, 301.4, 301.50, 301.51, 301.6, 301.7, 301.81, 301.82, 301.83, 301.84, 302.70, 303.00, 303.90, 304.00, 304.10, 304.20, 304.30, 304.40, 304.50, 304.60, 304.80, 304.90, 305.00, 305.20, 305.30, 305.40, 305.50, 305.60, 305.70, 305.90, 306.51, 307.0, 307.1, 307.20, 307.21, 307.22, 307.23, 307.46, 307.47, 307.50, 307.51, 307.52, 307.53, 307.59, 307.6, 307.7, 307.80, 307.81, 307.89, 307.9, 308.3, 309.0, 309.21, 309.24, 309.81, 309.9, 310.1, 311, 312.30, 312.31, 312.32, 312.33, 312.34, 312.39, 312.81, 312.82, 312.89, 312.9, 313.23, 313.81, 313.82, 313.9, 314.2, 314.9, 315.31, 315.9.

Child SA (Active Only):

_____ CSSAD (CHILD SUBSTANCE ABUSE DISORDER) Child in need of treatment for a primary substance abuse disorder. From 3 -17 yrs of age. Primary Diagnosis = 291.0, 291.1, 291.2, 291.3, 291.5, 291.81, 291.89, 291.9, 292.11, 292.12, 292.81, 292.82, 292.83, 292.84, 303.00, 303.90, 304.00, 304.10, 304.20, 304.30, 304.40, 304.50, 304.60, 304.80, 304.90, 305.00, 305.20, 305.30, 305.40, 305.50, 305.60, 305.70.

_____ CSWOM (CHILD SUBSTANCE ABUSE WOMEN) Pregnant or have dependent children under 18 and who are in need of treatment for a primary substance abuse disorder. From 3-17 yrs of age. Primary Diagnosis = Same as CSSAD.

_____ CSIP (CHILD SUBSTANCE ABUSE INDICATED PREVENTION) Using alcohol or drugs at a pre-clinical level and meets the specified IP criteria. From 3-17 yrs of age. Diagnosis = V65.42.

_____ CSSP (CHILD SUBSTANCE ABUSE SELECTIVE PREVENTION) At elevated risk for substance abuse and who meet the specified SP criteria. From 3-17 yrs of age. Diagnosis = Same as CSIP.

_____ CSCJO (CHILD SUBSTANCE ABUSE CRIMINAL JUSTICE OFFENDER) In need of treatment for a primary substance abuse disorder with Services Authorized by TASC Only and meet the specified CJO criteria. From 3-17 yrs of age. Primary Diagnosis = Same as CSSAD.

_____ CSDWI (CHILD SUBSTANCE ABUSE DWI TREATMENT) In need of treatment for a primary SA disorder and arrested for DWI, had DWI assessment, paid $125 and income less than 200% of federal poverty level. From 3-17 yrs of age. Primary Diagnosis = Same as CSSAD.

_____ CSMAJ (CHILD in the MAJORS SA/JJ PROGRAM) Treatment for a primary SA disorder. From 3-17 yrs of age. Primary Diagnosis = Same as CSSAD Additional - For All Katrina Evacuees _____ KTRNA (HURRICANE KATRINA) State tracking target pop for services provided to hurricane KATRINA Evacuees Competency Status (choose one): C Competent M Minor I Incompetent U Unknown

**If client meets CMSED criteria the case responsible person's supervisor must sign below. Signature indicates criteria for this population has been thoroughly

reviewed; client meets all criteria and is eligible for CTSP funding. Supervisor's Signature________________________ Date ________________ Form Completed

By: ________________________Provider ID: _______________Provider Name_____________________________________________________

Date Completed: _____________________ Entered in EMR by: (initials) __________Target Pop(s) Effective Date: ________________________

Revision Date: July 1, 2006

Western Highlands Adult IPRS Target Population Worksheet

Client Name _______________________________________________________ Client ID _____________________ Adult DD Client (Active only): _____ ADSN (ADULT DEVELOPMENTAL DISABILITY SNAP = 1-5) _____ ADMRI (ADULT DEVELOPMENTAL DISABILITY MR/MI) Has co-occurring diagnosis of mental illness. Adult MH Client (Active only): _____ AMSPM (ADULT MENTAL HEALTH SEVERE AND PERSISTENT MENTAL ILLNESS) Exhibits functioning so impaired that it interferes

substantially with their capacity to remain in the community and has or has ever had a GAF of 40 or below. Primary Diagnosis = 295.10, 295.20, 295.30, 295.40, 295.60, 295.70, 295.80, 295.90, 296.00, 296.01, 296.02, 296.03, 296.04, 296.05, 296.06, 296 .20, 296.21, 296.22, 296.23, 296.24, 296.25, 296.26, 296.30, 296.31, 296.32, 296.33, 296.34, 296.35, 296.36, 296.40, 296.41, 296.42, 296.43, 296.44, 296.45, 296.46, 296.50, 296.51, 296.52, 296.53, 296.54, 296.55, 296.56, 296.60, 296.61, 296.62, 296.63, 296.64, 296.65, 296.66, 296.7, 296.80, 296.89, 296.90, 298.9.

_____ AMSMI (ADULT MENTAL HEALTH SERIOUS MENTAL ILLNESS) Has or has ever had a GAF score of 50 or below. Primary Diagnosis = 290.0, 290.10, 290.11, 290.12, 290.13, 290.20, 290.21, 290.40, 290.41, 290.42, 290.43, 293.83, 295.10, 295.20, 295.30, 295.40, 295.60, 295.70, 295.80, 295.90, 296.00, 296.01, 296.02, 296.03, 296.04, 296.05, 296.06, 296.20, 296.21, 296.22, 296.23, 296.24, 296.25, 296.26, 296.30, 296.31, 296.32, 296.33, 296.34, 296.35, 296.36, 296.40, 296.41, 296.42, 296.43, 296.44, 296.45, 296.46, 296.50, 296.51, 296.52, 296.53, 296.54, 296.55, 296.56, 296.60, 296.61, 296.62, 296.63, 296.64, 296.65, 296.66, 296.7, 296.80, 296.89, 296.90, 297.1, 297.3, 298.9, 300.01, 300.14, 300.21, 300.3, 30 1.20, 301.83, 302.2, 302.4, 307.1, 307.51, 309.81, 312.30, 312.33, 312.34.

_____ AMDEF (ADULT MENTAL HEALTH DEAF OR HARD OF HEARING) Diagnosis = 290.0, 290.10, 290.11, 290.12, 290.13, 290.20, 290.21, 290.3, 290.40, 290.41, 290.42, 290.43, 293.0, 293.81, 293.82, 293.83, 293.84, 293.89, 293.9, 294.0, 294.10, 294.11, 294.8, 294.9, 295.10, 295.20, 295.30, 295.40, 295.60, 295.70, 295.80, 295.90, 296.00, 296.01, 296.02, 296.03, 296.04, 296.05, 296.06, 296.20, 296.21, 296.22, 296.23, 296.24, 296.25, 296.26, 296.30, 296.31, 296.32, 296.33, 296.34, 296.35, 296.36, 296.40, 296.41, 296.42, 296.43, 296.44, 296.45, 296.46, 296.50, 296.51, 296.52, 296.53, 296.54, 296.55, 296.56, 296.60, 296.61, 296.62, 296.63, 296.64, 296.65, 296.66, 296.7, 296.80, 296.89, 296.90, 297.1, 297.3, 298.8, 298.9, 300.00, 300.01, 300.02, 300.11, 300.12, 300.13, 300.14, 300.15, 300.16, 300.19, 300.21, 300.22, 300.23, 300.29, 300.3, 300.4, 300.6, 300.7, 300.81, 300.82, 300.9, 301.0, 301.13, 301.20, 301.22, 301.4, 301.50, 301.51, 301.6, 301.7, 301.81, 301.82, 301.83, 301.84, 301.9, 302.2, 302.3, 302.4, 302.6, 302.70, 302.71, 302.72, 302.73, 302.74, 302.75, 302.76, 302.79, 302.81, 302.82, 302.83, 302.84, 302.85, 302.89, 302.9, 307.0, 307.1, 307.20, 307.21, 307.22, 307.23, 307.3, 307.42, 307.44, 307.45, 307.46, 307.47, 307.50, 307.51, 307.52, 307.53, 307.59, 307.6, 307.7, 307.80, 307.81, 307.89, 307.9, 308.3, 309.0, 309.21, 309.24, 309.28, 309.3, 309.4, 309.81, 309.9, 310.1, 311, 312.30, 312.31, 312.32, 312.33, 312.34, 312.39, 312.81, 312.82, 312.89 , 312.9, 799.9, 995.80, 995.81, 995.82, 995.83, 995.84, 995.85, 995.86, 995.89.

_____ AMSRE (ADULT MENTAL HEALTH STABLE RECOVERY POPULATION) Eligible for AMSPM or AMSMI; stable clients moving toward recovery within the community. Diagnosis = Same as AMSMI and AMPAT

Adult SA Client (Active only): _____ ASCDR (ADULT SUBSTANCE ABUSE INJECTION DRUG USER/COMMUNICABLE DISEASE) IV drug user or infected with

HIV/TB/Hepatitis or enrolled in Opioid treatment for a primary substance abuse disorder and meets specified CDR criteria. Primary Diagnosis = 291.0, 291.1, 291.2, 291.3, 291.5, 291.81, 291.89, 291.9, 292.11, 292.12, 292.81, 292.82, 292.83, 292.84, 292.89, 303.00, 303.90, 304.00, 304.10, 304.20, 304.30, 304.40, 304.50, 304.60, 304.80, 304.90, 305.00, 305.20, 305.30, 305.40, 305.50, 305.60, 305.70, 305.90.

_____ ASWOM (ADULT SUBSTANCE ABUSE WOMEN) Pregnant or has dependent children or seeking custody of a child under 18 and who are in need of treatment for a primary substance abuse disorder. Primary Diagnosis = Same as ASCDR.

_____ ASDSS (ADULT SUBSTANCE ABUSE DSS INVOLVED) DSS involved parents who are substance abusers and who (1)have legal custody of a child under 18 yrs and are under active investigation/supervision by Child Protective Services or receive Work First Asst. or (2)have been convicted of a Class H or I Controlled Substance felony in NC and who are applicants for or a recipient of Food Stamps. Primary Diagnosis = Same as ASCDR.

_____ ASDWI (ADULT SUBSTANCE ABUSE DWI TREATMENT) Who is in need of treatment for a primary substance abuse disability, arrested for DWI, had DWI assessment, paid $125 and income less than 200% of federal poverty level. Primary Diagnosis = Same as ASCDR.

_____ ASHMT (ADULT SUBSTANCE ABUSE HIGH MANAGEMENT) Who is in need of treatment for a primary substance abuse disorder and have had chronic SA treatment or involuntary commitment to SA treatment. Primary Diagnosis = 303.00, 303.90, 304.00, 304.10, 304.20, 304.30, 304.40, 304.50, 304.60, 304.80, 304.90.

_____ ASCJO (ADULT SUBSTANCE ABUSE CRIMINAL JUSTICE OFFENDER) Services authorized by TASC Only and who are in need of treatment for a primary substance abuse disorder. Primary Diagnosis = Same as ASCDR.

_____ ASHOM (ADULT SUBSTANCE ABUSE HOMELESS) Meets criteria for ASCDR or ASCJO or ASDSS or ASDWI or ASHMT or ASWOM or ASDHH; and who are homeless and who need treatment for a primary substance abuse disorder. Primary Diagnosis = Same as ASCDR.

_____ ASDHH (ADULT SUBSTANCE ABUSE DEAF AND HARD OF HEARING) Who are in need of treatment for a primary substance abuse disorder. Primary Diagnosis = Same as ASCDR.

Cross Disability (any case type): _____ TANF (CROSS DISABILITY TEMPORARY ASSISTANCE FOR NEEDY FAMILIES) Household income less than 200% of federal poverty

level, legal custodian or guardian of child less than 18, US citizen or TANF-eligible immigrant, and resident of NC. _____ AMOLM (ADULT OLMSTEAD PLAN IMPLEMENTATION) Adult identified as a participant in the AMH Olmstead Plan Implementation.

WESTERN HIGHLANDS ASSIGNED ONLY Additional – For All Katrina Evacuees _____ KTRNA (HURRICANE KATRINA) State tracking target pop for services provided to hurricane KATRINA Evacuees

Competency Status (choose one): C Competent M Minor I Incompetent U Unknown Assessment Score: GAF___________ Form Completed By: ___________________________Provider ID: ____________Provider Name:______________________________________

Date Completed: _____________________ Entered in EMR by: (initials) __________Target Pop(s) Effective Date: _______________________

Consumer Consent FormConsumer Consent Form

Western Highlands Network

Consumer Consent Form New consumer Transfer from another provider Previous agency_____________ I ________________________________ request my services/supports Consumer or Guardian from______________________________________________________________

Provider/Agency Name and I authorize Western Highlands Network to disclose/release information regarding potential eligibility for services/benefits. This includes releasing alcohol and drug abuse information according to the Federal regulations (42 CFR Part 2) and/or information about communicable diseases. for __________________________________ , DOB:_____________ and Consumer’s Name SS#_________________________ . This does not prohibit me from transferring providers through Western Highlands Network in the future. ___________________________________________ __ ______________ Consumer or Guardian Name (print & sign) Date ___________________________________________ __ ______________ Provider Clinician and title (print & sign) Date ___________________________________________ Provider/ Agency Name (please print) This form is to be completed by consumer and/or guardian and returned to the provider at your first meeting with that provider. The provider will mail or fax the form to Western Highlands Access Dept. with the appropriate screening/registration information. Ask your provider for assistance. As you know, a written Release of Information must be delivered to the old/previous provider in order to obtain past treatment/supports information. Western Highlands Network - Access Unit OR Fax to Access Unit at 828-225-2782 356 Biltmore Avenue Asheville, NC 28801 The purpose of this form is to release information regarding eligibility for services.

Rev. 01/16/07

Medicaid Consumer - Registration Medicaid Consumer - Registration Only - Entering the system through Only - Entering the system through WH AccessWH Access t telephone screeningelephone screening

WH Access completes the screening WH Access completes the screening and sends it to the provider chosen and sends it to the provider chosen by the consumer. by the consumer.

The provider must fax the following The provider must fax the following forms to WH Medical Records at forms to WH Medical Records at (828) 225-2779 within 5 working (828) 225-2779 within 5 working days of initial contact with the days of initial contact with the consumer. consumer.

STR Form – “Registration Only” STR Form – “Registration Only” sections (A-J, 1, and 49-55)sections (A-J, 1, and 49-55)

Medicaid Consumer - “No Wrong Medicaid Consumer - “No Wrong Door” - STR completed by the Door” - STR completed by the

providerprovider

The provider must fax the following The provider must fax the following forms to WH Medical Records at forms to WH Medical Records at (828) 225-2779 within 5 working (828) 225-2779 within 5 working days of initial contact with the days of initial contact with the consumer. Failure to register a consumer. Failure to register a Medicaid consumer may jeopardize Medicaid consumer may jeopardize reimbursement. reimbursement.

STR Form complete in full STR Form complete in full ““Description of Consumer Clinical Description of Consumer Clinical

Issues” form (complete sections A Issues” form (complete sections A and B)and B)

WHN Consumer Consent Form ( if WHN Consumer Consent Form ( if needed)needed)

Medicaid Consumer - “No Wrong Medicaid Consumer - “No Wrong Door” - STR completed by provider Door” - STR completed by provider with request for H Code authorizationwith request for H Code authorization (Provisionally Licensed Therapist)(Provisionally Licensed Therapist)

To register a Medicaid consumer and seek To register a Medicaid consumer and seek authorization for services billed through the authorization for services billed through the LME, the following forms must be faxed to LME, the following forms must be faxed to Access at (828) 225-2782 within 5 working Access at (828) 225-2782 within 5 working days.days.

STR Form - completed in fullSTR Form - completed in full ““Description of Consumer Clinical Issues” Description of Consumer Clinical Issues”

form (complete A,B and C)form (complete A,B and C) PCP Consumer Admission FormPCP Consumer Admission Form WHN Consumer Consent Form ( if needed)WHN Consumer Consent Form ( if needed) IPRS Worksheet (only if requesting State IPRS Worksheet (only if requesting State

funds)funds)

State Funded (IPRS) Consumers – State Funded (IPRS) Consumers – “No Wrong Door”, STR completed “No Wrong Door”, STR completed by the providerby the provider To open the consumer’s case in the WH To open the consumer’s case in the WH

system and request authorizations for system and request authorizations for State funded services the provider must fax State funded services the provider must fax the following forms to Access at (828) 225-the following forms to Access at (828) 225-2782 within 5 working days of initial 2782 within 5 working days of initial contact.contact.

STR Form – completed in fullSTR Form – completed in full ““Description of Consumer Clinical Issues” Description of Consumer Clinical Issues”

form (complete sections A, B and C) form (complete sections A, B and C) IPRS Worksheet (only required for case IPRS Worksheet (only required for case

opening)opening) PCP Consumer Admission FormPCP Consumer Admission Form WHN Consumer Consent Form ( if needed)WHN Consumer Consent Form ( if needed)

State Funded (IPRS) Consumers –”No State Funded (IPRS) Consumers –”No Wrong Door”- Face to face Wrong Door”- Face to face assessment for consumers who do assessment for consumers who do not meet any Target Pop criterianot meet any Target Pop criteria

To request authorization for state To request authorization for state funded services when NOT opening funded services when NOT opening the case, the provider must fax the the case, the provider must fax the following forms to Access at (828) following forms to Access at (828) 225-2782 within 5 working days.225-2782 within 5 working days.

STR Form - completed in fullSTR Form - completed in full ““Description of Consumer Clinical Description of Consumer Clinical

Issues” form (complete sections A ,B Issues” form (complete sections A ,B and C)and C)

PCP Consumer Admission FormPCP Consumer Admission Form

State Funded (IPRS) Consumer State Funded (IPRS) Consumer - STR completed by WH Access- STR completed by WH Access

WHN Access will send screening and WHN Access will send screening and initial authorization to provider. initial authorization to provider. Provider sends:Provider sends:

PCP Admission FormPCP Admission Form IPRS WorksheetIPRS Worksheet WHN Consumer Consent FormWHN Consumer Consent Form fax to 225-2779 fax to 225-2779 Provider requests further Provider requests further

authorizations via WHN Service authorizations via WHN Service ManagementManagement

State Funded (IPRS) Consumer - State Funded (IPRS) Consumer - STR completed by WH Access and STR completed by WH Access and does not meet Target popdoes not meet Target pop Return only the “Description of Return only the “Description of

Consumer Clinical Issues” form Consumer Clinical Issues” form (complete sections A ,B and C)(complete sections A ,B and C)

fax to 225-2782fax to 225-2782

Incomplete or incorrect Incomplete or incorrect forms?forms?

WHN will pend incomplete WHN will pend incomplete forms and administratively forms and administratively deny if not corrected deny if not corrected within 14 dayswithin 14 days . .

STR Frequently Asked STR Frequently Asked QuestionsQuestions

Q: What is the Western Highlands Facility Code (Question Q: What is the Western Highlands Facility Code (Question D)?D)?

A: 13131A: 13131 Q: What about the ICD 9 diagnosis code (#18 on the PCP Q: What about the ICD 9 diagnosis code (#18 on the PCP

form)?form)? A: The diagnosis codes in ICD 9 and in DSM-IV are A: The diagnosis codes in ICD 9 and in DSM-IV are

almost all the same, so using the DSM-IV code is OK.almost all the same, so using the DSM-IV code is OK. Q: What do I put in the H. IPRS Provider Number boxes?Q: What do I put in the H. IPRS Provider Number boxes? A: Your license number (LCSW, LPC, LMFT, etc.) or your A: Your license number (LCSW, LPC, LMFT, etc.) or your

agency provider number.agency provider number. Q: What about I. National Provider Identifier?Q: What about I. National Provider Identifier? A: You can obtain this identifier via the following website: A: You can obtain this identifier via the following website:

https://https://nppes.cms.hhs.govnppes.cms.hhs.gov Q: How do I complete #43 Consumer Unique Identifier?Q: How do I complete #43 Consumer Unique Identifier? A: Western Highlands will enter this identifier.A: Western Highlands will enter this identifier.