In order to streamline and make the DHB auditing process more efficient, all providers will be required to upload their NC Medicaid 3136 and NC Medicaid 3085 forms to the QiReport portal. When conducting compliance audits, this will be the only database used to verify the submission of these forms. As outlined in Clinical Coverage Policy 3L, all PCS providers should comply with certain documentation requirements. The Quality Improvement Attestation Form (NC Medicaid 3136) is due each year by December 31 for each NPI. This form is to be submitted by all providers to attest to their compliance with Clinical Coverage Policy 3L, Section 7.7, Internal Quality Improvement Program. Providers can find instructions using form NC-3136 I.

Additionally, providers who are serving beneficiaries seeking additional hours under Session Law 2013-306 must also submit Session Law 2013-306 PCS Training Attestation Form (NC Medicaid 3085) to NC Medicaid before serving these beneficiaries. NC Medicaid’s Personal Care Services (PCS) program committee requires that providers attest to their aide training curriculum by submitting this completed form. Providers can access PCS Training Attestation Form instructions using form NC Medicaid-3085 I. This form should only be submitted by providers who are serving beneficiaries seeking additional hours under Session Law 2013-306. As a reminder, this is not an annual form; it is due before the provider provides care for beneficiaries seeking additional hours under Session Law 3013-306, and only needs to be submitted once per agency.

NC Medicaid 3136 and 3085 Form Upload Instructions. Below we describe how to electronically upload the NC Medicaid 3136 and 3085 forms using QiRePort.

This submission will allow NC Medicaid to electronically store and maintain completed forms received for each provider. The NC Medicaid 3136 and 3085 forms will be uploaded by the provider following the same rules used by the supporting document functionality. (Note: The difference between this process and the supporting document functionality is the 3136 and 3085 forms are uploaded for each provider and are not beneficiary specific.)

To upload forms electronically, providers with administrative rights should start at the PI Setup Menu:

• Click “Documents” and find your Provider Name/NPI#. (Note: Only providers with administrative rights will have access to the Setup menu to add the forms.)
• Select the Provider Name hyperlink, then select “Add Document,” which will bring up the “Upload Record” screen.
• From there, select Document Type, Document Year and the Record. (Note: The NC Medicaid 3136 and/or 3085 forms(s) must first be saved to the computer or an external device to complete the upload.)
• Select “Done” and the system will place the uploaded document into the Provider Documents table for storage.
• Select “Save” to save the record and complete the upload.

For additional questions, providers should contact:
– NC Medicaid at PCS_Program_Questions@dhhs.nc.gov or 919-855-4360