The Provider Monitoring process is designed for:

• Entry into the provider network
• The review of service providers in accordance with State and Federal Requirements.

The provider monitoring process is outlined in all the workbooks, and LME-MCO #J254 – Changes to the Agency Monitoring Process serves as the primary guidance moving forward. 

Electronic communication provided on 7/31/2017 will provide information specific to the DHHS Provider Review Database Process.

Special Announcements

• 7/1/2019 – Communication with LME-MCO CEO and Waiver Contract Managers
  • Update: Update to the Generic Tool and LIP Tool Guidelines – follow up to 4/22/2019 Clarification
  • Effective: 4/22/2019 – Posted:  7/1/2019 
• 4/22/2019 – Communication with LME-MCO CEO and Waiver Contract Managers
  • Update: Clarification to Staff Qualification Worksheets and LIP Monitoring Tool effective 12/10/2018
  • Effective: 4/22/2019 – Posted:  4/24/2019 
• 11/30/2018 – Communication with LME-MCO CEOs and Waiver Contract Managers
  • Update: Revision to LIP/Group Practices and Agencies Billing Outpatient Services Only (BH) – Guidelines and Workbook
  • Effective: 12/10/2018 – Posted: 11/30/2018
• 6/25/2018 – LME-MCO Communication Bulletin #J292
  • Changes to DHHS LIP/Agency Practice Provider Monitoring Review Process
• 5/2/2018 – Communication with LME-MCO CEOs and Waiver Contract Managers
  • Update: Revisions to Provider Monitoring Tools
• 7/31/2017 – Communication with LME-MCO CEOs and Waiver Contract Managers
  • Update: DHHS Provider Review Database Process, October 2015
• 6/17/2017 - LME-MCO Communication Bulletin #J254 
  • Changes to the Agency Monitoring Process
• Frequently Asked Questions
  • Effective: 5/3/2018 – Posted: 5/2/2018

The revised Provider Monitoring Tools are effective as of April 22, 2019

• DHHS Monitoring Tools for Providers
  • Effective: 4/22/2019 – Posted:  7/1/2019
  • Guidelines revised.
• DHHS Review Tool for LIPs/ Group Practices and Agencies Billing Outpatient Services Only (BH)
  • Effective: 4/22/2019 – Posted: 7/1/2019
  • Guidelines revised

The revised Provider Monitoring Tools are effective as of May 3, 2018 

• DHHS New Unlicensed Site Review Tool for Providers
  • Effective: 5/3/2018 – Posted: 5/2/2018
  • Clinical Coverage Policies updated May 3, 2018.
• DHHS Unlicensed AFL Review Tool for Providers
  • Effective: 5/3/2018 – Posted: 5/2/2018
  • Guidelines revised and Clinical Coverage Policies updated effective May 3, 2018.

Review Information and Tools

Monitoring Consists of the Following:

• For Licensed Independent Practitioners/Group Practices and Agencies Billing Outpatient Services Only (BH) – the Post Payment Tool will be utilized.
• For Unlicensed AFLs – the Unlicensed AFL Review Tool will be utilized.
• Providers that are Nationally Accredited – the appropriate Post Payment Tool will be utilized and is based on the combination of services included in the sample.
• For services that DHSR -MHL surveys on an annual basis only a post-payment review is done.
• Refer to the Instructions and Overview sections in each workbook for a detailed description of how the workbooks are organized and for more information on how all the component parts of the review fit together.

Contact

Email us at provider.monitoring@dhhs.nc.gov with questions or comments. Please include the issue in the subject line of the email.