Partners works with a number of hospitals to provide inpatient services for enrollees. This section contains information for hospital providers.

Partners requires prior authorization for inpatient admissions. Hospitals seeking to admit a Partners’ enrollee for inpatient psychiatric treatment should call the UM Hospital Admissions Team at 704-842-6434. Staff is available 8 a.m.- 9 p.m., seven days a week.

Details regarding authorization can be located in the Partners’ Provider Operations Manual and the Hospital Behavioral Health Facility Instructions Manual.

░ Quick Links:

Emergency Department Reimbursement Form
Special Project Enrollment Form

Inpatient Document/Form Information Grid

► Hospital Behavioral Health and Acute Care Facility Instructions ◄
Document Information Frequency of Submission Forms and Document Links How to Submit to Partners
Out of Network Hospital Single Client Inpatient Application/ Agreement

This three-pages document serves as the contractual agreement for the inpatient services.

Each admission/episode of care per enrollee Out of Network Hospital Consumer Specific Agreement

Inpatient Review Form

Send via Secure email to providers@partnersbhm.org
Inpatient Review Form At admission and per benefit plan limits until discharged Inpatient Review Form Send via Secure email to providers@partnersbhm.org

OR

Information can be given via telephone interview with UM reviewers at 704-842-6434 7 days per week 8 a.m.-7 p.m.

Manual Service Authorization Request (SAR) At admission and per benefit plan limits until discharge Manual Service Authorization Form Send via Secure email to providers@partnersbhm.org

OR

Information can be given via telephone interview with UM reviewers at 704-842-6434 7 days per week 8 a.m.-7 p.m.

Copy of Certificate of insurance for General & professional liability, automobile coverage as applicable, workers comp Each admission/ episode of care per recipient. Should cover the dates of service of the admission N/A Send via Secure email to providers@partnersbhm.org
Hospital-Based Clinician Registration  Worksheet Each Admission/episode of care per recipient if attending physician services are billed as part of inpatient services by hospital Hospital-Based Clinician Registration Worksheet Send via Secure email to providers@partnersbhm.org
Trading Partners BHM Agreement – Used only if filing claims using HIPAA compliant transactions. Submitted one (1) time and kept on file unless there are changes.  If already submitted for other services such as Emergency Department services, does not have to be submitted again unless there are changes. Trading Partner Agreement

OR

Will be mailed by Finance staff with fully executed out of network agreement for the facility’s first agreement submitted

Send via Secure email to providers@partnersbhm.org

OR

Mail directly to:
Partners Behavioral Health Management
901 South New Hope Road
Gastonia, NC  28054
Attn: IT Department

W-9 Each admission/episode of care N/A
Vendor Form Submitted with first admission from facility. Not required once set up. Not required with inpatient services if already on file from Emergency Department services unless there is a change Vendor Electronic Funds Transfer (EFT) Form

OR

Will be mailed by Finance staff with fully executed out of network agreement for the facility’s first agreement submitted

Send via Secure email to providers@partnersbhm.org

OR

Mail directly to:
Partners Behavioral Health Management
901 South New Hope Road
Gastonia, NC  28054
Attn: Finance Department

ACH form – used to set up electronic payments to provider Submitted with first admission from facility. Not required once set up. Not required with inpatient services if already on file from Emergency Department services unless there is a change. Agreement for ACH Transactions Form Send via Secure email to providers@partnersbhm.org

OR

Mail directly to:
Partners Behavioral Health Management
901 South New Hope Road
Gastonia, NC  28054
Attn: Finance Department