1. Screening, Triage, and Registration Forms, Timelines, and WHN procedures

2. What’s the difference? Registration vs. Opening Registration vs. Opening Dual funded Consumers Dual funded Consumers

3. STR Form Review

4. STR Form Page #2

5. Description of Clinical Issues Form

6. PCP Admission Form Review

7. IPRS Worksheet Review

8. Consumer Consent Form

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

10. 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. 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 STR Form complete in full “Description of Consumer Clinical Issues” form (complete sections A and B) “Description of Consumer Clinical Issues” form (complete sections A and B) WHN Consumer Consent Form ( if needed) WHN Consumer Consent Form ( if needed)

11. 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. 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 STR Form - completed in full “Description of Consumer Clinical Issues” form (complete A,B and C) “Description of Consumer Clinical Issues” form (complete A,B and C) PCP Consumer Admission Form PCP Consumer Admission Form WHN Consumer Consent Form ( if needed) WHN Consumer Consent Form ( if needed) IPRS Worksheet (only if requesting State funds) IPRS Worksheet (only if requesting State funds)

12. 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) 225- 2782 within 5 working days of initial contact. 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) 225- 2782 within 5 working days of initial contact. STR Form – completed in full STR Form – completed in full “Description of Consumer Clinical Issues” form (complete sections A, B and C) “Description of Consumer Clinical Issues” form (complete sections A, B and C) IPRS Worksheet (only required for case opening) IPRS Worksheet (only required for case opening) PCP Consumer Admission Form PCP Consumer Admission Form WHN Consumer Consent Form ( if needed) WHN Consumer Consent Form ( if needed)

13. 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. 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 STR Form - completed in full “Description of Consumer Clinical Issues” form (complete sections A,B and C) “Description of Consumer Clinical Issues” form (complete sections A,B and C) PCP Consumer Admission Form PCP Consumer Admission Form

14. State Funded (IPRS) Consumer - STR completed by WH Access WHN Access will send screening and initial authorization to provider. Provider sends: WHN Access will send screening and initial authorization to provider. Provider sends: PCP Admission Form PCP Admission Form IPRS Worksheet IPRS Worksheet WHN Consumer Consent Form WHN Consumer Consent Form fax to 225-2779 fax to 225-2779 Provider requests further authorizations via WHN Service Management Provider requests further authorizations via WHN Service Management

15. 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 fax to 225-2782

16. Incomplete or incorrect forms? WHN will pend incomplete forms and administratively deny if not corrected within 14 days. WHN will pend incomplete forms and administratively deny if not corrected within 14 days.

17. STR Frequently Asked Questions Q: What is the Western Highlands Facility Code (Question D)? Q: What is the Western Highlands Facility Code (Question D)? A: 13131 A: 13131 Q: What about the ICD 9 diagnosis code (#18 on the PCP form)? 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. 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? 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. A: Your license number (LCSW, LPC, LMFT, etc.) or your 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: https://nppes.cms.hhs.gov A: You can obtain this identifier via the following website: https://nppes.cms.hhs.gov https://nppes.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.