"Targeted Case Management Application Checklists & Attestations" - North Dakota

Targeted Case Management Application Checklists & Attestations is a legal document that was released by the North Dakota Department of Human Services - a government authority operating within North Dakota.

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  • Released on May 1, 2021;
  • The latest edition currently provided by the North Dakota Department of Human Services;
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North Dakota Medicaid
Targeted Case Management
Application Checklists & Attestations
You must fill out the checklist for your application entirely and attach the
documents indicated on the checklist along with signed signature pages for the
packet to be considered complete.
The department does not retain incomplete documents. If this packet is
incomplete when it is received, the entire packet will be deleted and you will
receive an email notification at the contact email address entered on the
checklist.
Published by:
Medical Services Division
Provider Enrollment
600 E. Boulevard Ave., Dept.
325 Bismarck, ND 58505
May 2021
North Dakota Medicaid
Targeted Case Management
Application Checklists & Attestations
You must fill out the checklist for your application entirely and attach the
documents indicated on the checklist along with signed signature pages for the
packet to be considered complete.
The department does not retain incomplete documents. If this packet is
incomplete when it is received, the entire packet will be deleted and you will
receive an email notification at the contact email address entered on the
checklist.
Published by:
Medical Services Division
Provider Enrollment
600 E. Boulevard Ave., Dept.
325 Bismarck, ND 58505
May 2021
North Dakota Department of Human
Services Targeted Case
Management Application Checklists
& Attestations
Contents
TCM
Checklists
Individual Practitioner Checklists
Child Welfare ................................................................................................................ 3
High Risk Pregnant Women & Infants.......................... ..................................................5
Long Term Care ........................................................................................................... .8
SMI/SED .....................................................................................................................11
Group Provider Checklist .............................................................................................14
TCM Attestations
Individual Practitioner Attestations
Individual High Risk Pregnant Women & Infants.......... ...................................................7
Long Term Care ............................................................................................................10
SMI/SED ....................................................................................................................... 13
Group Provider Attestations
Child Welfare .................................................................................................................16
Long Term Care .............................................................................................................17
High Risk Pregnant Women & Infants............................ ................................................1 8
SMI/SED ........................................................................................................................19
TCM Application FAQs .........................................................................................................20
Reset
Page 1 of 2
TCM Child Welfare
Individual Practitioner Application - Formset
New Application
Reactivation
Have Questions?
Click Here
for FAQs and More Resources
Application Tracking #
Practitioner Name
Individual NPI #
Street
Primary Service Address
City
State
Zip
Street
Facility Mailing Address
City
State
Zip
Who will be billing for this individual provider's services?
Enrolled Billing Group (Affiliation)
Billing Group
Facility Phone
Medicaid ID
Name
Billing Group
Facility Phone
Medicaid ID
Name
Unenrolled Billing Group. Please Provide Application Tracking Number and/or NPI:
No Billing Group - Practitioner is enrolling as an Ordering or Referring provider only and will not
have affiliations with a billing group. Check this option only if claims will not be submitted for services
rendered by this practitioner – only enrolling to order, refer, or prescribe.
Contact Name
Contact Phone
Ext
Contact Email
Date form was completed
Name
Who is filling out this form?
PROVIDER TYPE 017-Other Service Providers
SPECIALTY
335-Case Manager/Care Coordinator
TAXONOMY
171M00000X
Page 2 of 2
Please coordinate with your billing department and any other applicable area to determine the correct
enrollment effective date. The Department will not make changes to that date once the application is
approved and any claims submitted with a date of service prior to the enrollment effective date will deny. A
retroactive enrollment effective date is limited to no more than ninety (90) days* prior to the date a complete
application packet is received by the Department. If the date requested is outside the 90 day timeframe, the
enrollment effective date assigned will be 90 days from the date the complete application packet was received.
Click Here to find more information on Effective Dates and Retro Effective Date Policies
What is the Enrollment Effective Date you are requesting?
*If this application is associated with an emergency service, the Department may consider a date more than 90
days prior to the date a complete application packet is received.
You must include a copy of the claim and medical
notes with your application documents.
A Copy of the Claim/Claims is attached to my documents.
A Copy of the Medical Notes is attached to my documents.
Submitted
Required Documents
Fax/Email Coversheet
This Formset
Degree*
Field:
Issued:
Wraparound Certificate**
Issued:
Expires:
Printout of Individual NPI
Enumeration
from the
NPPES Website
Date
Page 4 of the SFN 615 form must be signed & dated by the Individual
SFN 615 (6-2020)
Provider who is applying.
Proof of Insurance is not required for any application. If proof of insurance is submitted with an application, it will be
deleted from the file. It remains the provider’s responsibility to ensure that the necessary insurance is in place, but
proof of insurance is not required to be submitted for any application.
*Degree must be Bachelor's or above and be in one of the following fields:
10. Human Resource Management
1. Social Work
6. Elementary Education
(human-service track)
7. Early Childhood Education
2. Psychology
11. Criminal Justice
8. Special Education
3. Sociology
12. Human Services - Child & Family
9. Child Development and Family
4. Counseling
Welfare
Science
5. Human Development
**If enrolling before Wraparound Certificate is issued, Wraparound Certificate must be obtained and submitted
within 12 months.
Revision
12/29/2020
Reset
Page 1 of 2
TCM High Risk Pregnant Women & Infants
Individual Practitioner Application - Formset
New Application
Reactivation
Have Questions?
Click Here
for FAQs and More Resources
Application Tracking #
Practitioner Name
Individual NPI #
Street
Primary Service Location
City
State
Zip
Street
Facility Mailing Address
City
State
Zip
Who will be billing for this individual provider's services?
Enrolled Billing Group (Affiliation)
Billing Group
Facility Phone
Medicaid ID
Name
Billing Group
Facility Phone
Medicaid ID
Name
Unenrolled Billing Group. Please Provide Application Tracking Number and/or NPI:
No Billing Group - Practitioner is enrolling as an Ordering or Referring provider only and will not
have affiliations with a billing group. Check this option only if claims will not be submitted for services
rendered by this practitioner – only enrolling to order, refer, or prescribe.
Contact Name
Contact Phone
Ext
Contact Email
Date form was completed
Name
Who is filling out this form?
PROVIDER TYPE 017-Other Service Providers
SPECIALTY
335-Case Manager/Care Coordinator
TAXONOMY
171M00000X