Care Management Referral Form

This form addresses both State-funded and Medicaid-funded members who are potentially eligible for Local Management Entity/Managed Care Organization (LME/MCO) Care Management. Care Management is an administrative service defined by the Division of Medical Assistance (DMA) and the NC Division of Mental Health/Developmental Disabilities and Substance Abuse Services (NCDMHDDSAS).

Click on the following link to access the Partners Care Management Referral Form.

Complete the Demographic Form and the most relevant referral page ONLY.

All fields are required on both documents. Please enter NA if needed. Referral pages are as follows:

  • Page 1 – Directions
  • Page 2 – Demographics
  • Page 3 – State-funded individual with Mental Health, Substance Use, Intellectual Developmental Disability or Outpatient Commitment
  • Page 4 – Medicaid Recipient Receiving Crisis or Inpatient Services
  • Page 5 – Medicaid Recipient with an Intellectual or Developmental Disability
  • Page 6 – Medicaid Recipient- Child Mental Health
  • Page 7 – Medicaid Recipient- Adult Mental Health
  • Page 8 – Medicaid Recipient- Child or Adult Substance Dependent
  • Page 9 – Medicaid Recipient- Child or Adult co-occurring (any combination of MH/SA/IDD)

Providers, please upload all relevant clinical documents into Member/Enrollee Alpha+ record.

Examples: Comprehensive Clinical Assessments, Psychological Evaluations, medication list, Person-Centered Plan/Individual Support Plan, Hospital Discharge Paperwork, School Documentation.

Outpatient Referrals: You will be notified by the Regional Care Management Supervisor/Manager if the person qualifies for Care Management within three business days.

Psychiatric Inpatient Referrals: If the person is a Behavioral Health Inpatient Admission, you will be contacted by the assigned Care Coordinator within two business days.

You may submit a Care Management Referral in the following ways:

Click on the following link for the Care Management Referral Form.

  • Contact PartnersACCESS at 1-888-235-4673.
  • Secure email through ZixMail at MHSA_CC@partnersbhm.org (for Mental Health Substance Use [MHSU] Care Management) or IDDRegistry@partnersbhm.org (for Intellectual or Developmental Disability [I/DD] Care Management)
  • If you do not have a ZixMail account, you can learn how to create one here. This will allow Partners to communicate with you securely via email.
  • Fax: 704-884-2707, Attention: Jennifer Flynn (for MHSU Care Coordination)
  • Fax: 704-884-2704, Attention: I/DD Registry (for I/DD Care Coordination)