Transcript Screening, Triage, and Registration

Screening, Triage, and
Registration
Forms, Timelines, and WHN
procedures
What’s the difference?


Registration vs.
Opening
Dual funded
Consumers
STR Form Review
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
/
A. Consumer Name ®
YYYY
Complete as indicated by LME, or may be assigned by LME upon receipt.
/
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.
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)
1. ® Entry Type:
STR Only
Registration Only
STR & Registration
( One)
Agitation
Nausea and Vomiting
Sweats
Seizures
(Items A-J & 1–48)
(Items A-J & 1 & 49–55)
(Items A-J & 1–55)
…………………………………………………………………………………………………………
Tremors
Other (Describe)_____________________________________________
2.
Date of Consumer Screening:
3.
Consumer Co. of Residence:
/
/
(MM/DD/YYYY)
or
(Enter county name or county code from CDW Data Dictionary.)
( One)
Yes
Co. Code
4.
Is consumer currently enrolled in Medicaid?
5.
Screening Referral Source of consumer: _________________________
No
or
(Enter referral source name or source code from attached instructions.) Code
6.
Time Screening Began:
:
(Enter 24 Hr. Military Time) HH
MM
7. Time Screening Ended:
:
(Enter 24 Hr. Military Time) HH
MM
8.
Screening Method: ( One)
9.
Name of Person Initiating Request for Services and Relationship to Consumer:
(May be the consumer)________________________________________________
Face-to-Face
Telephone
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)
st
12a) 1 : ( One only)
AMH
CMH
ADD
CDD
ASA
CSA
nd
12b) 2 : ( One, if applic.)
AMH
CMH
ADD
CDD
ASA
CSA
rd
12c) 3 : ( 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)
13a) Instability of Care Provider Supervision
13b) Safety Issues in Living Arrangement
13c) Aggression or Self-Injurious Behaviors
NONE
MILD
MOD.
SEV.
NOT SCREENED
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 #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
/
A. Consumer Name ®
YYYY
Complete as indicated by LME, or may be assigned by LME upon receipt.
/
B. Consumer DOB ®
C. LME Name ®
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:
-
-
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)____________________________________
‘
Has the consumer or immediate family member (parent, grandparent, sibling, 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:___________________________________
40. Phone # of Legal Guardian (if applicable): (______) _______________________
41. Emergency Contact Name & Relationship: _______________________________
42. Phone # of Emergency Contact: (______) _______________________________
LME Operated or Contracted STR
LME Contracted Service Provider
Transportation
Hispanic, Cuban
Site Accessibility
Other (Describe):_________________
Hispanic, Mexican American
Hispanic, Puerto Rican
Hispanic, Other
Not Hispanic Origin
Unknown
First & Last Name of Qualified Professional (QP) who Conducted STR Interview
46. STR Staff Qualifications:
-
47.
White/Anglo/Cauc.
Amer. Ind./Native American
Asian
Native Hawaiian
Pacific Islander
Other (Describe): _________________________________
31. Is consumer proficient in English?
( One)
Yes
No
Other
English
Sign Language
None
Unknown
QP in SA
-
STR Staff Area Code, Phone No., & Extension

QP in DD
/
48.
/
Date Form Submitted to LME
CONSUMER REGISTRATION FOR ENHANCED BENEFITS PROVIDERS
/
49. ® Date of Consumer Service Initiation:
Complete ID Nos. (as applicable & available)
MM

/
DD
YYYY
-
-
(Needed for cross referencing with CNDS)
Black/Afric. Amer.
Alaska Native
Unknown
Spanish
QP in MH
-
50. ® Consumer Social Security Number:
30. Race: ( One)
32. Primary Language: ( One)
Enhanced Benefits Service Enrolled Provider
Crisis Service Provider
45.
(List name & practice of licensed MD, PA, or NP)__________________________________
28. What special arrangements were made for services access? ( All that apply)
-
43. Consumer Unique Identifier:
44. Type of Agency Hosting STR: ( All that apply)
27. Primary Care Medical Provider:
None
E. LME Consumer Record No. ®
39. Consumer’s Legal Guardian (if applicable):_______________________________
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
29. Ethnicity: ( One)
D. LME Facility Code ®
33. Gender:
Male
Female
34. Veteran Status:
Yes
No
Unk.
35. National Guard or Military Reserve (or Military Family) Status in OIF or OEF:
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
French
MM
54. ®
-
-
-
55. ®
Registration Provider Area Code, Phone No., & Ext.
DD
/
YYYY
/
Date Form Submitted to LME
Description of Clinical Issues
Form
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
5
Single/Never Married
Annulled
2
6
Married
Widowed
3
8
Separated
Domestic Partners
4
Divorced
Tobacco use
Substance abuse
Both □ Unknown □ None
□ None □ Medicare □ Health Choice □ Private Insurance _______________
Health Related Codes:
Other Insurance:
Living Arrangement:
00
10
13
16
18
Other
1
Private Residence
8
Adult Care Home 6 or fewer beds
11 Community ICF-MR
12
Homeless
14 Correctional Facility
15
Residential Facility/Not Nursing Hm
17 Foster/Alternative Family Living
Other Independent
19 Adult Care 7+ beds (Rest Home)
Highest Grade Completed___________
Employment Status:
C.
□ Unknown
Full Time
Retired
Part Time
Homemaker
Are you pregnant?
Unemployed
Armed Forces
Yes
Nursing Home (ICF, SNF)
Community ICF-MR 70+ beds
Institution
No
Student □ Unknown
Seasonal/Migrant Worker
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

H2011: Mobile Crisis Management- # of Units_______ Effective Date_____________________________
Effective Date______________________________
PCP 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
/
/
A. Consumer Name
B. Consumer DOB
Complete as indicated by LME, or may be assigned by LME upon receipt.
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.
18. Diagnosis Code(s) (ICD-9): (List up to three ICD-9 diagnoses in order of importance)
1.
2.
Name of LME responsible for receiving this Consumer’s PCP
Consumer Current Admission Date:
/
/
3.
Consumer Co. of Residence:
4.
Consumer’s Residence Zip Code:
5.
Ethnicity: ( One)
6.
Marital Status at the time of admission: ( One)
MM
DD
YYYY
7.
Co. Code
Not Applicable
Not Hispanic Origin
Unknown
/
DD
YYYY
(Enter codes from attached instructions)
20b) Age of First Use
20c) Use Frequency 20d) Route of Admin.
2) Secondary Substance
3) Additional Substance
Single
Married
Separated
Divorced
Widowed
Unknown
Domestic Partners
Complete consumer identifying numbers below (as applicable and available):
-
21. Consumer Unique Identifier:
Race: ( One)
Gender:
MM
1) Primary Substance
Hispanic, Puerto Rican
Annulled
Black/Afric. Amer.
Alaska Native
Unknown
8.
(for current episode)
20a) SA Drug Code
Hispanic, Mexican American
.
/
18c)
20. Provide information on Substance Abuse (Drug of Choice) Details:
-
Hispanic, Other
.
18b)
Not Applicable
or
(Enter county name or county code from CDW Data Dictionary.)
Hispanic, Cuban
.
18a)
19. Date Started Substance Abuse Treatment:
Male
White/Anglo/Cauc.
Amer. Ind./Native American
Asian
Native Hawaiian
Pacific Islander
Other (Describe): _________________________________
Female
9. Veteran Status:
Yes
No
22. Consumer Social Security Number:
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.)
(Enter code from attached instructions.)
(Enter code from attached instructions.)
Yes
Sign Language
French
Other
None
Unknown
16. Is consumer pregnant at the time of admission?
/
MM
Name of Provider Agency
25. Medicaid Provider Enrollment No.:
28.
First and Last Name of Provider Staff Submitting this Form to LME
No
29.
English
17. Diagnosis(es) Effective Date:
Complete provider identifying information below (as applicable and available):
24.
27. National Provider Identifier (NPI) No.:
13. Admission Referral Source of consumer to facility:
( One)
-
26. IPRS Attending Provider No.:
12. Living Arrangement (residential) at time of admission:
14. Is consumer proficient in English?
15. Primary Language: ( One)
-
(Needed for cross referencing with CNDS)
23. Consumer Medicaid Number:
/
DD
Yes
MM
No
Not Applicable
(for current episode)
YYYY
E-Mail Address of Provider Staff Submitting this Form to LME
Spanish
30.
-
-
-
Provider Area Code, Phone No., & Extension
DD
YYYY
31.
/
/
Date Form Submitted to LME
IPRS Worksheet Review
Western Highlands
Adult IPRS Target Population Worksheet
Client Name _______________________________________________________
Adult DD Client (Active only):
Western Highlands
Child IPRS Target Population Worksheet
Client Name _______________________________________________________
Child DD (Active Only):
_____ CDSN
Client ID _____________________
Adult MH Client (Active only):
(CHILD DEVELOPMENTAL DISABILITY SNAP = 1-5) From 3-17 yrs of age
_____ 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,
Child MH (Active Only):
(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.
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.
_____ CMSED
Child SA (Active Only):
_____
_____
_____
_____
_____
_____
_____
Client ID _____________________
_____ ADSN (ADULT DEVELOPMENTAL DISABILITY SNAP = 1-5)
_____ ADMRI (ADULT DEVELOPMENTAL DISABILITY MR/MI) Has co-occurring diagnosis of mental illness.
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
_____ 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.
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
WESTERN HIGHLANDS ASSIGNED ONLY
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
Additional – For All Katrina Evacuees
By: ________________________Provider ID: _______________Provider Name_____________________________________________________
_____ KTRNA (HURRICANE KATRINA) State tracking target pop for services provided to hurricane KATRINA Evacuees
Date Completed: _____________________ Entered in EMR by: (initials) __________Target Pop(s) Effective Date: _______________________ _
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: _______________________
Revision Date: July 1, 2006
Consumer 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
356 Biltmore Avenue
Asheville, NC 28801
Fax to Access Unit at 828-225-2782
The purpose of this form is to release information regarding eligibility for services.
Rev. 01/16/07
Medicaid Consumer - Registration
Only - Entering the system through
WH Access telephone screening



WH Access completes the screening
and sends it to the provider chosen
by the consumer.
The provider must fax the following
forms to WH Medical Records at
(828) 225-2779 within 5 working
days of initial contact with the
consumer.
STR Form – “Registration Only”
sections (A-J, 1, and 49-55)
Medicaid Consumer - “No Wrong
Door” - STR completed by the
provider
The provider must fax the following
forms to WH Medical Records at
(828) 225-2779 within 5 working
days of initial contact with the
consumer. Failure to register a
Medicaid consumer may jeopardize
reimbursement.
 STR Form complete in full
 “Description of Consumer Clinical
Issues” form (complete sections A
and B)
 WHN Consumer Consent Form ( if
needed)
Medicaid Consumer - “No Wrong
Door” - STR completed by provider
with request for H Code authorization
(Provisionally Licensed Therapist)
To register a Medicaid consumer and seek
authorization for services billed through the
LME, the following forms must be faxed to
Access at (828) 225-2782 within 5 working
days.
 STR Form - completed in full
 “Description of Consumer Clinical Issues”
form (complete A,B and C)
 PCP Consumer Admission Form
 WHN Consumer Consent Form ( if needed)
 IPRS Worksheet (only if requesting State
funds)
State Funded (IPRS) Consumers –
“No Wrong Door”, STR completed
by the provider
To open the consumer’s case in the WH
system and request authorizations for
State funded services the provider must fax
the following forms to Access at (828) 2252782 within 5 working days of initial
contact.
 STR Form – completed in full
 “Description of Consumer Clinical Issues”
form (complete sections A, B and C)
 IPRS Worksheet (only required for case
opening)
 PCP Consumer Admission Form
 WHN Consumer Consent Form ( if needed)
State Funded (IPRS) Consumers –”No
Wrong Door”- Face to face
assessment for consumers who do
not meet any Target Pop criteria
To request authorization for state
funded services when NOT opening
the case, the provider must fax the
following forms to Access at (828)
225-2782 within 5 working days.
 STR Form - completed in full
 “Description of Consumer Clinical
Issues” form (complete sections A ,B
and C)
 PCP Consumer Admission Form
State Funded (IPRS) Consumer
- STR completed by WH Access





WHN Access will send screening and
initial authorization to provider.
Provider sends:
PCP Admission Form
IPRS Worksheet
WHN Consumer Consent Form
fax to 225-2779
Provider requests further
authorizations via WHN Service
Management
State Funded (IPRS) Consumer STR completed by WH Access and
does not meet Target pop


Return only the “Description of
Consumer Clinical Issues” form
(complete sections A ,B and C)
fax to 225-2782
Incomplete or incorrect
forms?

WHN will pend incomplete
forms and administratively
deny if not corrected
within 14 days .
STR Frequently Asked
Questions










Q: What is the Western Highlands Facility Code
(Question D)?
A: 13131
Q: What about the ICD 9 diagnosis code (#18 on the PCP
form)?
A: The diagnosis codes in ICD 9 and in DSM-IV are
almost all the same, so using the DSM-IV code is OK.
Q: What do I put in the H. IPRS Provider Number boxes?
A: Your license number (LCSW, LPC, LMFT, etc.) or your
agency provider number.
Q: What about I. National Provider Identifier?
A: You can obtain this identifier via the following website:
https://nppes.cms.hhs.gov
Q: How do I complete #43 Consumer Unique Identifier?
A: Western Highlands will enter this identifier.