Provider Service Application

Medicaid Service Needs

This recruitment is being used as a means to expand the network of qualified, approved NC Medicaid providers that are experienced to provide high quality services to Trillium Members. Please only apply for designated counties in the application.

Interested providers must submit an application to apply for consideration for the following service needs:


  • Partial Hospitalization
  • Opioid Treatment Program
  • Psychosocial Rehabilitation
  • Substance Abuse Comprehensive Outpatient Treatment (SACOT)
  • Substance Abuse Intensive Outpatient Program (SAIOP) for Youth


Important Information

> Provider MUST meet all qualifications of the service and NC Medicaid to be eligible for a contract award.

> Separate forms must be submitted for each service of interest.

> Recruitment is for Medicaid services only.

> No start-up funding available from Trillium. Provider must be fiscally sound and have capital to start programs independently.

> Application does not guarantee a contract. Providers are advised to wait until official contract award prior to implementing programs.

> Provider must be an approved NC Medicaid provider and enrolled in NC Tracks.

> More than one provider may be selected for a service if warranted based on member need.


This recruitment should not be interpreted as a contract (implicit, explicit, or implied), nor does it imply any form of an agreement to any potential candidate. In addition, no inference should be made that Trillium will purchase and/or implement in the future any of the programs or services proposed by the respondents.

 

Please enter name as enrolled with NC Tracks.

 
 
 

Please provide the NPI intended for use in billing for services.

 

Enter all taxonomies as enrolled in NC Tracks.

 
 
 
 
 
 
 
 

Provider should review all requirements for the service of interest in the applicable clinical coverage policies located in those listed above.

 

All applicants must be in good standing with all applicable oversight entities.


This means that the applicant is in compliance with the standards and requirements of all applicable oversight entities; has submitted all required documents, payments and fees to the U.S. Internal Revenue Service, the N.C. Department of Revenue, N.C. Secretary of State, the N.C. Department of Labor, and the N.C. Department of Health and Human Services (DHHS) and its Departments and Divisions; has not filed for or is not currently in Bankruptcy; and has not had any sanctions imposed against it, including, but not limited to the following:

  • Any Local Management Entity/Managed Care Organization (LME/MCO): Contract Termination or Suspension, Referral Freeze, non-compliance with a Plan of Correction, Past Due Overpayment, Prepayment Review, Payment Suspension
  • NC Department of Health and Human Services
  • NC Medicaid/NC Division of Health Benefits: Contract Termination or Suspension, Payment Suspension, Prepayment Review, Outstanding Final Overpayment.
  • DMH/DD/SAS: Revocation, Unresolved Plan of Correction.
  • DHSR: Unresolved Type A or B penalty under Article 3, Active Suspension of Admissions, Active Summary Suspension, Active Notice of Revocation or Revocation in Effect.
  • U.S. Internal Revenue Service: Unresolved tax or payroll liabilities.
  • NC Department of Revenue: Unresolved tax or payroll liabilities.
  • NC Department of Labor: Unresolved payroll liabilities.
  • NC Secretary of State: Administrative Dissolution, Revocation of Authority, Notice of Grounds for other reason, Revenue Suspension; providers organized as a corporate entity must have a “Current – Active” registration with the NC Secretary of State.
  • Boards of Licensure or Certification for the applicable Scope of Practice
  • Provider’s Selected Accrediting Body.


Please confirm that you are in good standing with the above requirements.

 
Drop your files here