New Attestation Form Required for NC Medicaid Community Behavioral Health Taxonomy

Effective March 26, 2023, providers completing an initial enrollment, re-enrollment, or re-verification application with taxonomy 251S00000X - NC Medicaid Community Behavioral Health, or a manage change request (MCR) to add it, will be required to complete an attestation form to identify the services they use. By completing this form, providers will attest that:

  • Their services correspond with a procedure code within this taxonomy 
  • They are fully able to provide these services in the NC Medicaid program
  • They are or will be contracting with at least one NC Behavioral Health Intellectual/Developmental Disabilities Tailored Plan
  • They comply with all applicable requirements within NC Clinical Coverage Policies

NC Medicaid Community Behavioral Health providers will select the intended service(s) on the Community Behavioral Health Attestation Form prompting the selection of taxonomy 251S00000X; or, if they are not a Community Intervention Services (CIS) provider, indicate so by marking the appropriate box. 

  • This form must be downloaded from the Provider Policies, Manuals, Guidelines and Forms page, completed, signed and dated by the Office Administrator (OA). 
  • The form must then be uploaded to the upload page presented directly after submission of the application or uploaded afterwards on the Upload Documents page under Status & Management. Providers are encouraged to upload the form in a timely manner to prevent delays in application processing.

Any material misrepresentation made to NC Medicaid regarding the attestation may result in an investigation by NC Medicaid and/or impact the organization’s eligibility to participate in the NC Medicaid program.

The form will be available on the Provider Policies, Manuals, Guidelines and Forms page on the effective date.