North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services
NC Division of MH/DD/SAS Provider Participation Database Summary
Instructions: The NC Division of MH/DD/SAS is establishing a voluntary database of descriptive information about mental health, developmental disabilities, and substance abuse services providers in North Carolina for participation in consultation to the Department regarding various policy issues, including the adoption of new service rates. To be considered for participation in this consultation, providers are invited to complete the Excel form below, and submit to the Division of MH/DD/SAS as indicated below. Submission of this form is not an assurance that the provider will be selected for participation in this consultation. Providers will be selected on a rotating basis in relation to the issues under discussion.
E-Mail (preferred) to: Contactdmhquality@ncmail.net; or Mail to: Daisy Adams, Quality Management Team, Community Policy Management Section, DMH/DD/SAS, 3004 Mail Service Center, Raleigh, NC 27699-3004. For Assistance: Contact Daisy Adams, Quality Management Team, at (919) 733-0696 or Daisy.Adams@ncmail.net.
Hold cursor on individual item boxes below for completion instructions. Instructions also print at the end of the form.
1. Provider/Organization Name
2. Provider Federal Taxpayer Identification Number (or Soc. Sec. # ) 3. North Carolina Medicaid Provider Number (if applicable) 4. Provider Primary Physical Site Street Address 5. City 6. State 7. Zip Code 8. Provider Primary Mailing Address 9. City 10. State 11. Zip Code 12. Name of Provider Contact Person to be Considered for Participation 13. Position Title of Provider Contact Person 14. Voice Telephone Area Code and Number for Contact Person 15. Fax Area Code and Number for Contact Person 16. E-Mail Address (if available) for Contact Person 17. Name of Individual Completing This Form 18. Voice Telephone Area Code and No. for Individual Completing Form 19. Date This Form is Being Completed
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North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services
20. List all memberships of the provider in provider associations by name of the association(s).
21. List all current accreditations of the provider by a state or national accreditation group, by accreditation group name, accreditation type, and expiration date of accreditation.
a. Yes b. No
22. Are any of the provider's services currently licensed by the NC Division of Facility Services? (Check one box only)
a. Yes b. No
23. Has provider received any sanction(s), fine(s), or penalty(ies) from any national, state, or local regulatory, accreditation, or professional group within the past 10 years? (Check one box only)
a. b. Urban Statewide 100,000 or (All) More c. Rural Under 100,000
24. Indicate the counties in North Carolina where the provider has delivered services to consumers in the provider's current fiscal year. (Check all that apply)
25. List all area/county MHDDSA programs in North Carolina that the provider has a contract with in the provider's current fiscal year.
a. CMH 26. Indicate all Age/Disability Population groups currently served by the provider. (Check all that apply) d. AMH
b. CDD
c. CSA
e. ADD
f. ASA
27. Provide an unduplicated count of the estimated number of consumers that were served by the provider in the provider's last fiscal year. 28. List the amount of the provider's actual annual expenditures for the provider's last fiscal year.
$
a. NC Medicaid b. NC DMH c. All Other Sources
29. List the approximate % of the provider's revenues for the provider's last fiscal year that were derived from NC Medicaid, from NC DMH/DD/SAS, and from All Other Sources.
%
%
%
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a. Fulltime 30. List the estimated number of the provider's current fulltime (35 hours or more per week) and part time (under 35 hours per week) employees. 31. List the calendar year that the provider/organization began to operate in North Carolina. a. Public 32. Indicate the corporate tax status of the provider/organization. (Check one box only) 33. List the year ending date for the provider's last audit.
b.
Part Time
b. Private Not for Profit
c. Private For Profit
34. Enter the provider's operating fiscal year.
a. Qualified b.
Unqualified
35. Was the provider's last audit, as indicated in item # 33 above, Qualified or Unqualified? (Check one box only)
36. Mark All Services That Apply to:
Child/Adolescent and/or Adult
Child/Adolescent (Under 18 years)
b. Wish to Provide This Service in Future
Adult (18 years and over)
d. Wish to Provide This Service in Future
a. Currently Provides This Service
c. Currently Provides This Service
NEW OR MODIFIED SERVICE DEFINITIONS *Assertive Community Treatment Team (ACTT) H0040 *Community Support - Adults (MH/SA) *Community Support - Children/Adolescents (MH/SA) *Community Support Team (CST) - Adult (MH/SA) *Day Treatment - Child and Adolescent (MH/SA) H2012-HA *Detoxification Services - Ambulatory Detoxification *Detoxification Services - Medically Supervised or ADATC Detoxification/Crisis Stabilization *Detoxification Services - Non-Hospital Medical Detoxification *Detoxification Services - Social Setting Detoxification YP790 *Developmental Therapy Service (DD) *Diagnostic/Assessment (MH/SA) *Inpatient Hospital Psychiatric Treatment (MH) YP820 *Inpatient Hospital Substance Abuse Treatment (SA) YP820 *Intensive In-Home Services *Mobile Crisis Management (MH/SA) *Multisystemic Therapy (MST) *Psychiatric Residential Treatment Facility (PRTF) YA230
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36. Mark All Services That Apply to:
Child/Adolescent and/or Adult
Child/Adolescent (Under 18 years)
b. Wish to Provide This Service in Future
Adult (18 years and over)
d. Wish to Provide This Service in Future
a. Currently Provides This Service
c. Currently Provides This Service
*Psychosocial Rehabilitation Services (PSR) H2017 *Substance Abuse Comprehensive Outpatient Treatment Program (SACOT) - Adult H2035 *Substance Abuse Halfway House H2034 *Substance Abuse Intensive Outpatient Program (SAIOP) H0015 *Substance Abuse Medically Monitored Community Residential Treatment *Substance Abuse Non-Medical Community Residential Treatment *Targeted Case Management for Individuals with Developmental Disabilities (DD) T1017-HE CAP (New): Adult Day Health CAP (New): Augmentative Communication CAP (New): Crisis Services CAP (New): Day Supports CAP (New): Home and Community Supports CAP (New): Home Modifications CAP (New): Individual/Caregiver Training and Education CAP (New): Personal Care Services CAP (New): Personal Emergency Response Systems CAP (New): Residential Supports CAP (New): Respite Care (general, enhanced institutional and nursing) CAP (New): Specialized Consultative Services CAP (New): Specialized Equipment and Supplies CAP (New): Supported Employment CAP (New): Transportation CAP (New): Vehicle Adaptations ADVP YP620 Assertive Outreach YP230 Behavioral Health Prevention Education Services (BHPES) H0025 CAP Waiver: Adult Day Health S5102 CAP Waiver: Augmentative Communication Device - Purchase T2028 CAP Waiver: Augmentative Communication Device - Repairs Service V5336 CAP Waiver: Case Management T2022 CAP Waiver: Crisis Stabilization H2025HQ CAP Waiver: Day Habilitation - Individual T2021 CAP Waiver: Day Habilitation Periodic Group (2 clients) T2021HQ CAP Waiver: Day Habilitation Periodic Group (over 2 clients) T2021HQ CAP Waiver: Developmental Day T2027 CAP Waiver: Environmental Access Training S5165 CAP Waiver: Family Training S5110 CAP Waiver: In-Home Aide - Level 1 S5120 CAP Waiver: Interpreter Services T1013 CAP Waiver: PERS S5161 CAP Waiver: Personal Care S5125
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36. Mark All Services That Apply to:
Child/Adolescent and/or Adult
Child/Adolescent (Under 18 years)
b. Wish to Provide This Service in Future
Adult (18 years and over)
d. Wish to Provide This Service in Future
a. Currently Provides This Service
c. Currently Provides This Service
CAP Waiver: Respite - Community Based S5150 CAP Waiver: Respite - Facility Based (24 hour awake staff) S5150 CAP Waiver: Respite - Institutional H0045 CAP Waiver: Respite Care - Nursing Bed T1005TD, T1005TE CAP Waiver: Respite Group (2-3 clients) S5150HQ CAP Waiver: Supported Employment - Group H2025 CAP Waiver: Supported Employment - Individual T1999 CAP Waiver: Supported Living - Level 1 H2016 CAP Waiver: Supported Living - Level 2 T2014 CAP Waiver: Supported Living - Level 3 T2020 CAP Waiver: Supported Living - Level 4 H2016HI CAP Waiver: Supported Living Periodic - Group H2015HQ CAP Waiver: Supported Living Periodic - Individual H2015 CAP Waiver: Therapeutic Case Consultation T2025 CAP Waiver: Transportation T2001 CAP Waiver: Vehicle Adaptations T2039 Community Rehabilitation Service YP650 CPT - Aphasia Assessment 96105 CPT - Clinical Evaluation/Intake 90801 CPT - Developmental Testing (Extended) 96111 CPT - Developmental Testing (Limited) 96110 CPT - Evaluation and Management (all codes 99201 - 99215) CPT - Family Therapy with patient 90847 CPT - Family Therapy without patient 90846 CPT - Group Therapy (Multiple Family Group) 90849 CPT - Group Therapy (non-multiple family group) 90853 CPT - Hospital Codes (99221 through 99263) CPT - Individual Therapy (all codes 90804 - 90829) CPT - Interactive Evaluation 90802 CPT - Medication Administration 90782 CPT - Medication Check - Individual 90862 CPT - Neurobehavioral Exam 96115 CPT - Neuropsychological Testing Battery 96117 CPT - Psychological Testing 96100 Developmental Day YP610 Drop In Center - Attendance YP690 Drop In Center - Coverage YP692 Facility Based Crisis Program S9485 Financial Support Services YM600 Guardianship YM686 H Code - Alcohol and/or Drug Group Counseling H0005 H Code - Behavioral Assessment H0001 H Code - Behavioral Health Counseling - Family Therapy with Client H0004HR
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North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services
36. Mark All Services That Apply to:
Child/Adolescent and/or Adult
Child/Adolescent (Under 18 years)
b. Wish to Provide This Service in Future
Adult (18 years and over)
d. Wish to Provide This Service in Future
a. Currently Provides This Service
c. Currently Provides This Service
H Code - Behavioral Health Counseling - Family Therapy without Client H0004HS H Code - Behavioral Health Counseling - Group Therapy H0004HQ H Code - Behavioral Health Counseling H0004 H Code - Mental Health Assessment H0031 Independent Living YM700 Individual Supports YM716 Long Term Vocational Support YM645 Opioid Treatment H0020 Partial Hospitalization - Adult H0035HB Personal Care YM050 Residential Services: Family Living - Low YP740 Residential Services: Family Living - Moderate YP750 Residential Services: Group Living - High YP780 Residential Services: Group Living - Low YP760 Residential Services: Group Living - Moderate YP770 Residential Services: Supervised Living - 1 Resident YM811 Residential Services: Supervised Living - 2 Resident YM812 Residential Services: Supervised Living - 3 Resident YM813 Residential Services: Supervised Living - 4 Resident YM814 Residential Services: Supervised Living - 5 Resident YM815 Residential Services: Supervised Living - 6 Resident YM816 Residential Services: Supervised Living - Low YP710 Residential Services: Supervised Living - Moderate YP720 Residential Treatment - Level I - Therapeutic Foster Care H0046 Residential Treatment - Level II - Family Type S5145 Residential Treatment - Level II - Program Type H2020 Residential Treatment - Level III - 4 beds or less H0019 Residential Treatment - Level III - 5 beds or more H0019 Residential Treatment - Level IV - 4 beds or less H0019 Residential Treatment - Level IV - 5 beds or more H0019 Respite Services - Community Respite YA213 Respite Services - Hourly Respite - Group YP011 Respite Services - Hourly Respite - Individual YP010 Respite Services - Hourly Respite YA125 Respite Services - Respite - Community YP730 Room and Board - Level II (Age 13+) YA236 Room and Board - Level II (Age 5 or less) YA234 Room and Board - Level II (Age 6-12) YA235 Room and Board - Level III (1-4 beds) YA232 Room and Board - Level III (5+ beds) YA233 Room and Board - Level IV (1-4 beds) YA237 Room and Board - Level IV (5+ beds) YA238 Specialized Summer Program (WM) YA370 Supported Employment: Group YP640
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North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services
36. Mark All Services That Apply to:
Child/Adolescent and/or Adult
Child/Adolescent (Under 18 years)
b. Wish to Provide This Service in Future
Adult (18 years and over)
d. Wish to Provide This Service in Future
a. Currently Provides This Service
c. Currently Provides This Service
Supported Employment: Individual YP630 Therapeutic Leave - Residential Level II: Program Type YA255 Therapeutic Leave - Residential Level II: Therapeutic Foster Care YA254 Therapeutic Leave - Residential Level III (1-4 beds) YA256 Therapeutic Leave - Residential Level III (5+ beds) YA257 Therapeutic Leave - Residential Level IV (1-4 beds) YA258 Therapeutic Leave - Residential Level IV (5+ beds) YA259 Therapeutic Leave - Room and Board Level II (Age 13+) YA267 Therapeutic Leave - Room and Board Level II (Age 5 or less) YA265 Therapeutic Leave - Room and Board Level II (Age 6-12) YA266 Therapeutic Leave - Room and Board Level III (1-4 beds) YA263 Therapeutic Leave - Room and Board Level III (5+ beds) YA264 Therapeutic Leave - Room and Board Level IV (1-4 beds) YA268 Therapeutic Leave - Room and Board Level IV (5+ beds) YA269 Wilderness Camp YA241
Thank you for your assistance in competing this form!
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North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services
Cell: B7 Comment: Item # 1: Enter the complete corporate name of the provider/organization.
Cell: B8 Comment: Item # 2: Enter the provider's 9-digit United States federal Taxpayer Identification Number (often referenced as an "Employer ID Number"). If the provider is an individual and there is no federal Taxpayer Identification Number assigned, enter the individual provider's Social Security Number.
Cell: B9 Comment: Item # 3: If the provider is a Medicaid provider, enter the Medicaid Provider Number assigned by the North Carolina Division of Medical Assistance. If not, enter "NA".
Cell: B10 Comment: Item # 4: Enter the provider's primary physical site street address.
Cell: B11 Comment: Item # 5: Enter the city of the provider's primary physical site address.
Cell: B12 Comment: Item # 6: Enter the state of the provider's primary physical site address.
Cell: B13 Comment: Item # 7: Enter the zip code of the provider's primary physical site address.
Cell: B14 Comment: Item # 8: Enter the primary mailing address of the provider.
Cell: B15 Comment: Item # 9: Enter the city of the primary mailing address of the provider. Cell: B16 Comment: Item # 10: Enter the state of the primary mailing address of the provider. Cell: B17 Comment: Item # 11: Enter the zip code of the primary mailing address of the provider.
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Cell: B18 Comment: Item # 12: Enter the first and last name of the provider contact person that is to be considered for participation.
Cell: B19 Comment: Item # 13: Enter the position title of the provider contact person that is to be considered for participation in meetings with DHHS staff.
Cell: B20 Comment: Item # 14: Enter the voice telephone area code and number of the provider contact person. Cell: B21 Comment: Item # 15: Enter the fax area code and number of the provider contact person. Cell: B22 Comment: Item # 16: Enter the e-mail address of the provider contact person. Cell: B23 Comment: Item # 17: Enter the first and last name of the individual completing this form. Cell: B24 Comment: Item # 18: Enter the voice telephone area code and number of the individual completing this form. Cell: B25 Comment: Item # 19: Enter the month, date, and full year that this form is being completed. Example: 11/15/2004
Cell: B26 Comment: Item # 20: List the association name(s) of all provider groups that the provider/organization is a member of. If none, enter "None".
Cell: B29 Comment: Item # 21: List all current accreditations of the provider by the name of the accreditation group, the type of accreditation, and the expiration date of the accreditation. If none, enter "None". Cell: B32 Comment: Item # 22 a: Check "Yes" if any of the provider's services are licensed by the North Carolina Division of Facility Services.
Cell: C32 Comment: Item # 22 b: Check "No" if none of the provider's services are licensed by the North Carolina Division of Facility Services.
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Cell: B35 Comment: Item # 23 a: Check "Yes" if the provider has received any sanction(s), fine(s), and/or penalty(ies) from any regulatory, accreditation, or professional organization within the past 10 years. Cell: C35 Comment: Item # 23 b: Check "No" if the provider has received no sanction(s), fine(s), and/or penalty(ies) from any regulatory, accreditation, or professional organization within the past 10 years.
Cell: B38 Comment: Item # 24 a: Check this "Statewide (All)" box if services were available to be provided to consumers in all counties statewide in the provider's current fiscal year. If 24a is checked, skip 24b and 24c. Cell: C38 Comment: Item # 24 b: Check this "Urban 100,00 or More" box if services were provided to consumers in counties that had a residential population of 100,000 or more persons in the provider's current fiscal year.
Cell: D38 Comment: Item # 24 c: Check this "Rural Under 100,000" box if services were provided to consumers in counties that had a residential population of less than 100,000 persons in the provider's current fiscal year.
Cell: B40 Comment: Item # 25: List all area/county MHDDSA programs in North Carolina that the provider/organization has a contract with during the provider's current fiscal year. If none, enter "None". Cell: B43 Comment: Item # 26 a: Check this "CMH" box if services are currently provided to children and/or adolescents under 18 years of age who have a primary disability of Child Mental Health (CMH). Leave blank if no services are provided to this population. Cell: C43 Comment: Item # 26 b: Check this "CDD" box if services are currently provided to children and/or adolescents under 18 years of age who have a primary disability of Child Developmental Disabilities (CDD). Leave blank if no services are provided to this population.
Cell: D43 Comment: Item # 26 c: Check this "CSA" box if services are currently provided to children and/or adolescents under 18 years of age who have a primary disability of Child Substance Abuse (CSA). Leave blank if no services are provided to this population.
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Cell: B46 Comment: Item # 26 d: Check this "AMH" box if services are currently provided to adults 18 and over who have a primary disability of Adult Mental Health (AMH). Leave blank if no services are provided to this population.
Cell: C46 Comment: Item # 26 e: Check this "ADD" box if services are currently provided to adults 18 years and over who have a primary disability of Adult Developmental Disabilities (ADD). Leave blank if no services are provided to this population.
Cell: D46 Comment: Item # 26 f: Check this "ASA" box if services are currently provided to adults 18 years and over who have a primary disability of Adult Substance Abuse (ASA). Leave blank if no services are provided to this population.
Cell: B48 Comment: Item # 27: Provide an unduplicated count of the estimated number of consumers served by the provider in the provider's last fiscal year. Cell: B50 Comment: Item # 28: List the estimated dollar amount of the provider's actual annual expenditures for the provider's last fiscal year.
Cell: B53 Comment: Item # 29 a: Enter the % of the provider's last fiscal year's revenues which were derived from NC Medicaid funding.
Cell: C53 Comment: Item # 29 b: Enter the % of provider's last fiscal year's revenues which were derived from NC DMHDDSAS funding. Cell: D53 Comment: Item # 29 c: Item # 29 c: Enter the % of the provider's last fiscal year's revenues which were derived from all other funding sources. This includes revenues from all other sources including grants, payments, and donations from other federal, state, and local public and private agencies, consumer insurance and fees, and all other revenues.
Cell: B56 Comment: Item # 30 a: Enter the provider's current fulltime employees (actual or estimated) who work 35 or more hours per week.
Cell: C56 Comment: Item # 30 b: Enter the provider's current part time employees (actual or estimated) who work under 35 hours per week. NC Division of MH/DD/SAS Provider Database Summary: 11/03/04 Rev. Page 11 of 13
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Cell: B58 Comment: Item # 31: Enter the calendar year that the provider/organization first began to provide services to consumers in North Carolina. Example: 1995
Cell: B61 Comment: Item # 32 a: Check "Public" box if provider has a public agency tax status.
Cell: C61 Comment: Item # 32 b: Check "Private Not for Profit" box if provider has a private not for profit agency tax status.
Cell: D61 Comment: Item # 32 c: Check "Private For Profit" box if provider has a private for profit agency tax status.
Cell: B63 Comment: Item # 33: List the year ending date for the provider's last audit.
Cell: B66 Comment: Item # 34: Enter the provider's fiscal year, e.g., July 1 - June 30; Jan. 1 - Dec. 31, etc.
Cell: B68 Comment: Item # 35 a: Check "Qualified" box if provider received a qualified opinion on the provider's last audit as indicated in Item # 33 above.
Cell: C68 Comment: Item # 35 b: Check "Unqualified" box if provider received an unqualified opinion on the provider's last audit as indicated in Item # 33 above.
Cell: B71 Comment: Item # 36 a: Enter an "X" in each box below if the provider currently provides this service to children and adolescents, under 18 years of age, as described in the service definitions that are posted on the web sites of the NC DMH/DD/SAS and DMA.
Cell: C71 Comment: Item # 36 b : Enter an "X" in each box below if the provider wishes to provide this service in the future to children and adolescents, under 18 years of age, as described in the service definitions that are posted on the web sites of the NC DMH/DD/SAS and DMA. NC Division of MH/DD/SAS Provider Database Summary: 11/03/04 Rev. Page 12 of 13
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Cell: D71 Comment: Item # 36 c: Enter an "X" in each box below if the provider currently provides this service to adults, ages 18 years and older, as described in the service definitions that are posted on the web sites of the NC DMH/DD/SAS and DMA.
Cell: E71 Comment: Item # 36 d: Enter an "X" in each box below if the provider wishes to provide this service in the future to adults, ages 18 years and over, as described in the service definitions that are posted on the web sites of the NC DMH/DD/SAS and DMA.
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