North Country Community Mental Health
Contractor Provider Manual
Residential and Professional Services
Introduction and How to Contact Us
Financial Services
o W-9 Request for Taxpayer Identification Number and Certification (1/11)
o HCFA 1500 Form and Instructions
o Monthly Residential Occupancy Reports and Invoices (3806 Reports)(12/16/10)
o Community Living Support Weekly Activity & Progress Log (SIP providers only) (1/10/12)
o Home Census Reporting Sheet (12/16/10)
o Personal Care and Comprehensive Community Support Time Study Log (12/16/10)
o Instructions for Time Study (6/27/08)
o Mileage Log (12/16/10)
Contract Services
o Acknowledgement of Training Material (12/10/10)
o Subcontractors Notice on Workers’ Compensation (11/4/09)
o Direct Service Provider Training Requirements (3/1/2012)
o Active Engagement Report (11/30/10)
o NCCMH Infection Control and Safety Manual, Chapter 2, Sections I-V (12/8/10)
o NCCMH Health Professional Credentialing Checklist (1/10)
o Hand Washing Poster
o Member Handbook
o Reducing Your Risk, Bloodborne Pathogens Handbook
(Please contact Jocelyn Sneller for an additional copy of the handbook at )
o Your Rights Handbook
(Please contact Jocelyn Sneller for a copy an additional copy of the handbook at or download an MDCH copy at http://www.michigan.gov/documents/RightsBooklet_9716_7.pdf)
Regulatory Requirements
o Advance Directives in Michigan tri-fold brochure (5/09)
o Advance Directives Education (9/17/07)
o Regulatory Compliance Plan (11/18/10)
o Cultural Competency and Limited English Proficiency Plan (5/05)
o HIPAA – 2 page summary
o Incident Report Form (1/30/12)
o Title 42(1)(A)(2) DHS Confidentiality of… Patient Records (10/1/00)
o Mental Health Code, Chapter 7, Sections 300.1700-1758 (12/28/06)
o MDCH Mental Health & Substance Abuse Services Rights of Recipients (12/08/10)
o Medicaid Provider Manual-Mental Health/Substance Abuse, Table of Contents (11/1/11)
To access the Michigan Medicaid Provider Manual, type the address below into your web browser:
http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf
o 2009 Application For Renewal and Recommitment, Section 5, Expanding Opportunity for Integrated Employment (2/1/09
To access type the address below into your web browser: http://www.michigan.gov/documents/mdch/ARR_final_2_10_09_266727_7.pdf
o NCCMH Preventing Sexual Harassment in the Workplace (4/1/03)
o Medicaid False Claims Act (through PA 109 and Acts 111-117 of 2006)
o Medicaid False Claims Attestation Form )10/06)
o Whistleblower’s Protection Act and Poster
o NCCMH Provider Disclosure Information (2/20/12)
o NCCMH Recipient Rights Poster (1/20/12)
o NCCMH Summary of Abuse and Reporting Requirements (11/10)
NCCMH Policies and Procedures
o NCCMH Members Rights(1/1/11)
o NCCMH Code of Ethics (11/1/11)
o NCCMH Risk Management Policy (9/1/07)
o NCCMH Risk Management Procedure (3/1/12)
o NCCMH Advance Directives Policy (11/1/07)
o NCCMH Person Centered Planning Protocols and Guidelines
o NCCMH Grievance and Appeal Procedure (8/1/09)
o NCCMH Claims Validation and Record Review (12/1/10) and Tool (3/1/09)
o NCCMH Contract Site Review Procedure (3/1/09) and Tool (2/11/10)
o NCCMH Quality Improvement (5/1/10)
* Please sign and return those items highlighted in yellow.
* Please post those items highlighted in blue in an area commonly accessed by our clients.
Rev 0312-V25