MENTAL HEALTH AND SUBSTANCE ABUSE MANAGED CARE NETWORKS HOSPITAL INPATIENT PSYCHIATRIC CARE APPLICATION FOR BCBSM PARTICIPATION GENERAL INFORMATION
|
|
- Felicia Doyle
- 8 years ago
- Views:
Transcription
1 MENTAL HEALTH AND SUBSTANCE ABUSE MANAGED CARE NETWORKS HOSPITAL INPATIENT PSYCHIATRIC CARE APPLICATION FOR BCBSM PARTICIPATION GENERAL INFORMATION NOTE: DO NOT USE THIS APPLICATION FOR OWNERSHIP CHANGES. USE THE MORE ABBREVIATED "ADDENDUM" FORM INSTEAD. I. BCBSM's Mental Health and Substance Abuse Managed Care Networks BCBSM s Mental Health and Substance Abuse Managed Care (MHSAMC) networks are utilized by select BCBSM customer groups that have chosen a managed care program for their mental health and substance abuse benefits. For each of the two networks, all mental health and substance abuse care is currently managed (preauthorized) by vendor care managers. Members are subject to substantial out-of-network copayments, deductibles, and/or reduced benefits when they go outside of their designated mental health network without an authorization from the care manager. For some benefit plans, out-of-network referrals are not allowed. These networks include: State of Michigan Mental Health Case Management Program- This network is open to all qualified hospitals that provide inpatient (or partial) psychiatric care. It is currently used by Federal Employee Program (FEP) members, Ford Hourly National PPO Plan members, select MESSA members EDS, Blue Choice Point of Service (POS) and Chrysler Help Line serving Chrysler members (mental health) The selection of network providers is based upon the provider's demonstrated commitment to appropriate, high quality, cost-effective care and their agreement to accept the applicable discounted MHSAMC network payment as payment in full for covered hospital services, except for applicable copayments and deductibles. In support of these commitments, network providers are required to meet guidelines relative to quality of care, cost control, appropriate utilization, access, and other standards. Note: This application pertains only to the hospital s inpatient (and/or partial) psychiatric care program. If the hospital also offers outpatient psychiatric care, complete the application for Outpatient Psychiatric Care (OPC) facilities. If the hospital offers substance abuse services, complete the application for Substance Abuse facilities. Hospital MHSAMC IP Psych New WF0369 FEB03 1
2 II. Hospital Qualifications Requirements for Inpatient Psychiatric Care Psychiatric hospitals, acute care general hospitals with psychiatric care units, and hospital-based psychiatric day care (partial) units will be included in the networks. These facilities must have and maintain the following: An active Traditional Participating Hospital Agreement (PHA) with BCBSM. Full accreditation with no limitations for each site by either JCAHO or AOA. Compliance with BCBSM Psychiatric Severity of Illness/Intensity of Service Criteria. An appropriate and timely internal utilization program. Satisfactory utilization and audit history An effective and timely discharge planning program. Compliance with credentialing and recredentialing policies established by BCBSM. Psychiatric beds/units licensed by the state of Michigan. An established internal quality of care and improvement program. Professional liability insurance or funded self-insurance in the name of the hospital in the minimum amount of $1 million per occurrence and $3 million aggregate. III. Hospital Reimbursement For covered services, BCBSM will pay the lesser of the hospital s charge or the BCBSM approved amount, less copayments and/or deductibles if applicable. The BCBSM approved amount for these networks is a hospital-specific per-diem for inpatient psychiatric care and/or partial hospitalization care. Please contact Provider Contracting for rate information before completing this application. IV. Participation Agreement The Mental Health and Substance Abuse Managed Care participation agreement will be sent to the hospital if/when the hospital is approved for participation. If, however, the hospital would like to review the agreement prior to submitting the application, you may request a sample copy from BCBSM. Hospital MHSAMC IP Psych New WF0369 FEB03 2
3 MENTAL HEALTH AND SUBSTANCE ABUSE MANAGED CARE NETWORKS HOSPITAL INPATIENT PSYCHIATRIC CARE APPLICATION INSTRUCTIONS Complete this application if the hospital was not previously in one of the MHSAMC networks and is now interested in applying for network participation. If the application is being submitted in conjunction with an ownership change, you may use the more abbreviated Addendum form, instead. Please print (in ink) or type the requested application information in the space provided. Where applicable, attach complete copies of all documents requested (indicated in bold). Return the completed application, along with the requested attachments to: MHSAMC Inpatient Psychiatric Care Program Provider Contracting - B715 Blue Cross Blue Shield of Michigan West 11 Mile Road Southfield, MI Fax: Please be certain the application is complete and all requested attachments are enclosed at the time of submission to BCBSM. Refer to the checklist attached. Incomplete applications will be returned to you. This will significantly delay the review process. Upon receipt of the application, we will send you a letter of acknowledgment. It takes approximately 4-8 weeks for an application to be evaluated. After we review the application and accompanying documentation, we will most likely contact the designated representative of the hospital to set up an appointment for an on-site visit. The on-site visit includes a review of a sample of medical records to evaluate the applicant's compliance with BCBSM requirements, as outlined in this application. If the hospital is approved for MHSAMC program participation, the appropriate participation agreement will be offered. If the hospital is not approved, we will send notification in writing indicating the reason(s) for the denial. The hospital may not submit claims and is not eligible for reimbursement unless and until participation is granted by BCBSM and both parties sign the appropriate Mental Health and Substance Abuse Managed Care Network participation agreement. If the hospital is approved and offered a participation agreement, it will be asked to retain the agreement for its records and return the signed Signature Document to BCBSM. The countersigned copy of the Signature Document will be returned to the hospital, generally, within days of our receipt of the signed Signature Document. The hospital's effective date for participation in the BCBSM MHSAMC program will be 30 days from the date the Signature Document is received by BCBSM. It is not retroactive to the date we received the application. Upon completion of the application and contracting process, the hospital will be provided with the appropriate BCBSM provider manual(s) and will be added to our mailing list for the appropriate BCBSM provider publication (e.g., The Record). It is the Hospital's responsibility to be familiar with and to adhere to all BCBCM billing and benefit requirements. It is also the responsibility of the hospital to ensure the hospital s billing department (or billing agency) is compliant with all BCBSM's billing requirements. Please direct questions regarding completion of the application to Barbara Milke, Provider Contracting, at (248) or via at BMilke@BCBSM.com. Hospital MHSAMC IP Psych New WF0369 FEB03 3
4 MENTAL HEALTH AND SUBSTANCE ABUSE MANAGED CARE NETWORKS INPATIENT PSYCHIATRIC CARE APPLICATION The hospital would like to apply for participation in one of BCBSM's mental health and substance abuse managed care (MHSAMC) networks 1.0 General Information: 1.1 Tax Name (This is name on file with the IRS and maybe different from the hospital's business name) 1.2 Business Name (This is name used when doing business, or the DBA. It will be used for directories) 1.3 Hospital's primary site address (Main Campus) Site Address City State Zip Code 1.4 Hospital's address for inpatient psychiatric services, if different from above address Site Address City State Zip Code 1.5 Inpatient Psychiatric Care Program Telephone Number (for directory) 1.6 Hospital's address for partial hospitalization psychiatric services, if different from above address Site Address City State Zip Code 1.7 Partial Psychiatric Program Telephone Number (for directory) 1.8 Hospital's Web site address (if applicable) 1.9 Date hospital began/will begin admitting patients for psychiatric care (MM/DD/YR) Hospital MHSAMC IP Psych New WF0369 FEB03 4
5 2.0 Ownership and Administration 2.1 Is the hospital's board of directors responsible for the operations of the psychiatric care unit and partial hospitalization services? Yes No 2.2 If the answer was "no" to 2.1 please provide an explanation below: 3.0 Accreditation 3.1 Check the hospital s applicable accreditation agency: JCAHO - Joint Commission on the Accreditation of Healthcare Organizations. AOA - American Osteopathic Association 3.2 What is the date of the hospital s most current accreditation survey report? (MM/DD/YY)? 4.0 Licensure 4.1 Indicate below the type of current Michigan license(s) held by the hospital. For each license checked, please attach a current copy. Psychiatric Care License Psychiatric Partial Hospitalization License 4.2 Indicate below the number of beds or treatment positions the hospital is licensed for: Type of beds Psychiatric inpatient beds - adult Psychiatric inpatient beds - minor Psychiatric partial hospitalization treatment positions- adult Psychiatric partial hospitalization treatment positions - minor Number of Beds Hospital MHSAMC IP Psych New WF0369 FEB03 5
6 5.0 Liability Insurance 5.1 Does the hospital carry professional liability insurance in a minimum amount of $1 million per occurrence and $3 million per aggregate? Yes No 5.2 If the hospital's professional liability insurance is provided by a commercial insurance carrier or if it is self-funded, attach a copy of the Face Sheet or Declaration Sheet of the insurance contract or self-funding trust agreement (which indicates the name and location of the facility and the coverage amounts). 5.3 Does the hospital require all professional (clinical) staff not covered under the hospital's professional liability policy to carry individual policies in the same $1 million/$3 million minimum amount of coverage? Yes No (Explain: ) 5.4 If some or all of the professional (clinical) staff are not covered under the hospital's policy, does the hospital maintain copies on file of the professional staff s individual professional liability insurance policies or other proof of insurance? Yes No 5.5 Does the hospital require all clinical staff not covered under the hospital s insurance coverage to carry individual insurance policies in an appropriate amount of coverage? Yes No 6.0 Psychiatric Care Utilization Evaluation A utilization evaluation system can result in improved client care and improved planning for more appropriate, effective, and efficient use of the hospital s resources and must include the following for the hospital s psychiatric care program: The program must provide in writing a utilization evaluation system designed to review the appropriateness of admissions to the program, lengths of stay, discharge practices, use of services, quality, timeliness and completeness of client records, and any other factors that may contribute to the effective utilization of program resources. Utilization evaluation must be administered by a committee that is representative of all disciplines providing direct and indirect client services. Two levels of evaluation activity are required; concurrent evaluation and retrospective evaluation studies. Concurrent evaluation uses open cases to examine client records. Retrospective evaluation studies examine services provided so patterns of care can be analyzed. These findings serve as the basis for further program planning and development. Written utilization evaluation findings and recommendations must be made available to administrative and treatment staff for study and appropriate action. Hospital MHSAMC IP Psych New WF0369 FEB03 6
7 6.1 Attach copies of policies and procedures pertaining to utilization review and program evaluation. 6.2 Attach minutes from the last two quarterly utilization review meetings. 6.3 Attach a copy of the most recent retrospective evaluation study. 6.4 Attach a copy of the clinical admission, continued stay and discharge criteria for inpatient and/or partial psychiatric care program. 6.5 What was the average length of stay for the past year? Inpatient psychiatric care program Partial hospitalization psychiatric care program 6.6 What was the number of admissions for the past year? Inpatient psychiatric care program Partial hospitalization psychiatric care program 6.7 What was the average census for the past year? Inpatient psychiatric care program Partial hospitalization psychiatric care program 6.8 What was the average patient-to-staff ratio for the past year? Inpatient psychiatric care program Partial hospitalization psychiatric care program 7.0 Staffing Each program must include a multidisciplinary staff consisting of a board-certified psychiatrist, a fully licensed psychologist and a MSW certified social worker. Additionally, limited licensed psychologists, licensed professional counselors, certified nurse practitioners and licensed marriage and family therapists may be included on staff. All professional staff must hold a Michigan license that is the permanent license that can be obtained in that discipline. The hospital must maintain proof of current licensure, registration or certification for all clinical staff. 7.1 Name of the hospital s psychiatric care program medical director: Hospital MHSAMC IP Psych New WF0369 FEB03 7
8 7.2 Attach evidence that the psychiatric care program medical director is board certified in psychiatry. 7.3 For treating psychiatrists (other than the medical director) attach evidence that they are board eligible or board certified in psychiatry. 7.4 Attach a roster of all clinical staff and indicate full time equivalents. 7.5 Attach copies of current state of Michigan licensure or certifications for each clinician. 7.6 For certified social workers, attach a copy of their Masters degree in social work. 7.7 For clinical nurse practitioners, attach a copy of their American Nurses Association (ANA) certification as a nurse practitioner in either Adult Psychiatric and Mental Health Nursing or Child and Adolescent Psychiatric and Mental Health Nursing. 8.0 Policies and Procedures 8.1 Attach copies of all policies and procedures pertaining to the following services: Psychosocial intake assessment Psychiatric evaluation Medication review Individual psychotherapy Family psychotherapy Group psychotherapy 8.2 Attach copies of all patient treatment/activity schedules 9.0 Contact Person for Application 9.1 Please give the following information for a contact person for any questions BCBSM may have regarding this application: Name: Title: Telephone number: Hospital MHSAMC IP Psych New WF0369 FEB03 8
9 10.0 Attestation I certify by my signature below that: I have reviewed the information in this application and to the best of my knowledge it is a complete and accurate representation of this hospital s psychiatric care operations. I understand that BCBSM may choose to do an onsite survey after review of this application to verify program compliance and to verify the accuracy of any information provided. All licenses for this hospital are current and valid in Michigan. All licenses and certifications for clinical staff who provide psychiatric care for this hospital are current and valid. The hospital s accreditation and insurance coverage is current and valid. The enclosed policies and procedures have been implemented and are enforced by this hospital. The hospital maintains financial records that conform with generally accepted accounting principles and practices. I understand the effective date of participation, if granted, will be 30 days from the date the signed agreement s Signature Document is received by BCBSM and is not the date the application was sent or received. Note: This application must be signed by the person who is responsible for the overall administration of the hospital and/or for the administration of its psychiatric care services. Authorized hospital representative By Name Title Date X (signature - required) (print or type) (print or type) Return completed application with all attachments to: MHSAMC Inpatient Psychiatric Care Program Provider Contracting Mail Code B715 Blue Cross Blue Shield of Michigan West 11 Mile Road Southfield, MI Hospital MHSAMC IP Psych New 1-03.doc Hospital MHSAMC IP Psych New WF0369 FEB03 9
10 Checklist for Application Attachments Current state of Michigan psychiatric care license and/or psychiatric partial hospitalization license, as applicable. Copy of the Face Sheet or Declaration Sheet of the insurance contract or self-funding trust agreement (which indicates the name and location of the facility and the coverage amounts). Copy of policies and procedures pertaining to utilization review and program evaluation. Copy of minutes from the last two quarterly utilization review meetings. Copy of the most recent retrospective evaluation survey. Copy of the clinical admission, continued stay and discharge criteria for each program. Evidence that the psychiatric care program medical director is board certified in psychiatry. Evidence of treating psychiatrists' board eligibility or board certification in psychiatry. Copy of roster of all clinical staff with full time equivalent indicated. Copy of current state of Michigan licensure or certifications for each clinician. Copy of Masters degree in social work for certified social workers. Copy of clinical nurse practitioners' American Nurses Association certificate for Adult Psychiatric and Mental Health Nursing, or Child and Adolescent Psychiatric and Mental Health. Copy of policy and procedures for psychosocial intake assessment, psychiatric evaluation, medication review, individual, family and group psychotherapy Copy of all patient treatment/activity schedules. Hospital MHSAMC IP Psych New 1-03.doc Hospital MHSAMC IP Psych New WF0369 FEB03 10
SUBSTANCE ABUSE FACILITY GENERAL INFORMATION
SUBSTANCE ABUSE FACILITY GENERAL INFORMATION I. BCBSM s Substance Abuse Facility Programs Traditional The Traditional BCBSM Substance Abuse Program provides benefits for the treatment of substancerelated
HALFWAY HOUSE FACILITY APPLICATION FOR PARTICIPATION IN BCBSM S MENTAL HEALTH AND SUBSTANCE ABUSE MANAGED CARE NETWORK(S) GENERAL INFORMATION
HALFWAY HOUSE FACILITY APPLICATION FOR PARTICIPATION IN BCBSM S MENTAL HEALTH AND SUBSTANCE ABUSE MANAGED CARE NETWORK(S) GENERAL INFORMATION I. BCBSM s Halfway House Facility Program for the State of
OUTPATIENT PHYSICAL THERAPY FACILITY APPLICATION FOR BCBSM PARTICIPATION FOR THE TRADITIONAL PROGRAM AND/OR THE MEDICARE SUPPLEMENTAL PROGRAM AND BCN
OUTPATIENT PHYSICAL THERAPY FACILITY APPLICATION FOR BCBSM PARTICIPATION FOR THE TRADITIONAL PROGRAM AND/OR THE MEDICARE SUPPLEMENTAL PROGRAM AND BCN GENERAL INFORMATION I. BCBSM s (Freestanding) Outpatient
BCBSM MENTAL HEALTH AND SUBSTANCE ABUSE MANAGED CARE PROGRAM
BCBSM MENTAL HEALTH AND SUBSTANCE ABUSE MANAGED CARE PROGRAM Professional Provider Participation Agreement This agreement (Agreement) is between Blue Cross Blue Shield of Michigan (BCBSM), and the provider
Frequently Asked Questions (FAQs) from December 2013 Behavioral Health Utilization Management Webinars
Frequently Asked Questions (FAQs) from December 2013 Behavioral Health Utilization Management Webinars 1. In the past we did precertifications for Residential Treatment Centers (RTC). Will this change
Hospital Application
Hospital Application Thank you for interest in participating in Blue Cross Blue Shield of Michigan (BCBSM) and/or Blue Care Network (BCN) hospital provider networks/programs! Please review the Requirements
Facility/Organizational Providers Approval Signatures: Available Upon Request
12/04/2006, 7/2/2007, Page 1 of 20 I. Purpose: A. To ensure facility/organizational provider applicants meet ValueOptions of California (VOC) credentialing criteria. B. This policy replaces ValueOptions,
STATE OF CONNECTICUT
STATE OF CONNECTICUT DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES A Healthcare Service Agency DANNEL P. MALLOY GOVERNOR PATRICIA A. REHMER, MSN COMMISSIONER CONNECTICUT DEPARTMENT OF MENTAL HEALTH
Organization/Facility Environmental Site Review (FESR)
Organization Name: Contact Person: Address City State Zip Phone Number Fax Number Phoenix Number MHS Number Reason for Review (please check one) --------- Recredentialing Credentialing Quality Review Action
Professional Criteria and Medicaid Reimbursable Outpatient Services by Professionals
Professional Criteria and Medicaid Reimbursable Outpatient Services by Professionals The purpose of this document is to clarify who can provide which outpatient services to Iowa Plan Medicaid members.
MENTAL HEALTH INPATIENT INITIAL CERTIFICATION APPLICATION Chapter DHS 61.71 and 61.79
DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Quality Assurance Chapter DHS 61.71 and 61.79, Wis. Admin. Code Page 1 of 9 MENTAL HEALTH INPATIENT INITIAL CERTIFICATION APPLICATION Chapter
Psychiatric Rehabilitation Clinical Coverage Policy No: 8D-1 Treatment Facilities Revised Date: August 1, 2012. Table of Contents
Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 2.0 Eligible Recipients... 1 2.1 Provisions... 1 2.2 EPSDT Special Provision: Exception to Policy Limitations for Recipients
Department of Mental Health and Addiction Services 17a-453a-1 2
17a-453a-1 2 DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES General Assistance Behavioral Health Program The Regulations of Connecticut State Agencies are amended by adding sections 17a-453a-1 to 17a-453a-19,
6002 Credentialing Mental Health Screeners and Payment for Voluntary Admissions
6002 Credentialing Mental Health Screeners and Payment for Voluntary Admissions 1.0 Mental Health Screener Credentialing Title 16, Chapter 51 of the Delaware Code states that only psychiatrists and professionals
Provider Selection Criteria for PreferredOne Participating Mental Health Practitioners
Provider Selection Criteria for PreferredOne Participating Mental Health Practitioners General Criteria 1. Practitioner must serve a specialty and/or geographic need for the good of the PreferredOne product
Cenpatico Facility/Agency Credentialing Application INSTRUCTIONS
Cenpatico Facility/Agency Credentialing Application INSTRUCTIONS Please complete the application thoroughly in its entirety. The checklist below may not be exhaustive of all materials, but is provided
Consumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan
ConneCtiCut insurance DePARtMent Consumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan What consumers need to know about seeking approval for behavioral
Organization Profile and Credentialing Application
Organization Profile and Credentialing Application Initial Profile and Application Re-credentialing Application and Profile Review Mark all areas of the application NA for any item not applicable I. Certification,
Magellan Health Services Request for Proposal Psychiatric Residential Treatment Facility
Magellan Health Services Request for Proposal Psychiatric Residential Treatment Facility Magellan Health Services is seeking a provider interested in developing and operating a Psychiatric Residential
EFFECTIVE DATE: 10/04. SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31
SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31 EFFECTIVE DATE: 10/04 Applies to all products administered by the plan except when changed by contract Policy Statement:
Facility Enrollment Required Document Checklist
Facility Enrollment Required Document Checklist Facility Classification Ambulatory Infusion Center (AIC) Ambulatory Surgical Facility (ASF) End Stage Renal Disease Facility (ESRD) - Accreditation Commission
Consumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan
CONNECTICUT INSURANCE DEPARTMENT Consumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan What consumers need to know about seeking approval for behavioral
104 CMR: DEPARTMENT OF MENTAL HEALTH 104 CMR 33.00: DESIGNATION AND APPOINTMENT OF QUALIFIED MENTAL HEALTH PROFESSIONALS
104 CMR 33.00: DESIGNATION AND APPOINTMENT OF QUALIFIED MENTAL HEALTH PROFESSIONALS Section 33.01: Legal Authority to Issue 33.02: Authorization to Apply for Hospitalization Pursuant to M.G.L. c. 123,
Professional Treatment Services in Facility-Based Crisis Program Children and Adolescents
Professional Treatment Services in Facility-Based Crisis Program Children and Adolescents Medicaid and North Carolina Health Choice (NCHC) Billable Service WORKING DRAFT Revision Date: September 11, 2014
Professional Criteria and Medicaid Reimbursable Outpatient Services by Professionals
IOWA PLAN F BEHAVIAL HEALTH RE: Professional Criteria and Medicaid Reimbursable Outpatient Services by Professionals The purpose of this document is to clarify who can provide which outpatient services
TRICARE MANAGEMENT ACTIVITY (TMA) APPLICATION FOR TRICARE MENTAL HEALTH FACILITY CERTIFICATION
TRICARE MANAGEMENT ACTIVITY (TMA) APPLICATION FOR TRICARE MENTAL HEALTH FACILITY CERTIFICATION FACILITY: Please check one appropriate facility/program: Psychiatric Partial Hospitalization Program (PHP)
GENESEE COUNTY Date Issued: 01-1999 COMMUNITY MENTAL HEALTH Date Revised: 08-2011 PIHP POLICY MANUAL SUBJECT:
GENESEE COUNTY Date Issued: 01-1999 COMMUNITY MENTAL HEALTH Date Revised: 08-2011 PIHP POLICY MANUAL SUBJECT: Page 1 of 7 WRITTEN BY: T. Deeghan, COO TECHNICAL REVIEW BY: T. Deeghan, S. Mason AUTHORIZED
Mental Health/Substance Abuse Provider Orientation
Mental Health/Substance Abuse Provider Orientation Blue Cross Blue Shield of Vermont (BCBSVT) Welcome to Blue Cross Blue Shield of Vermont Our Vision A transformed health system in which every Vermonter
CHAPTER 59A-23 WORKERS COMPENSATION MANAGED CARE ARRANGEMENTS 59A-23.001 Scope. 59A-23.002 Definitions. 59A-23.003 Authorization Procedures.
CHAPTER 59A-23 WORKERS COMPENSATION MANAGED CARE ARRANGEMENTS 59A-23.001 Scope. 59A-23.002 Definitions. 59A-23.003 Authorization Procedures. 59A-23.004 Quality Assurance. 59A-23.005 Medical Records and
Provider Selection Criteria for PreferredOne Participating Home Health Care Agencies
Provider Selection Criteria for PreferredOne Participating Home Health Care Agencies General Criteria 1. Practitioner must serve a specialty and/or geographic need for the good of the PreferredOne product
Arkansas Medicaid Inpatient Psychiatric for Individuals Under Age 21 Providers
Arkansas Department of Human Services Division of Medical Services Donaghey Plaza South P.O. Box 1437 Little Rock, Arkansas 72203-1437 Internet Website: www.medicaid.state.ar.us Telephone (501) 682-8292
Behavioral Health (MAPSI) Utilization Management Program Components
Behavioral Health (MAPSI) Utilization Management Program Components Payer Name: Printed Name of Payer Representative: Phone: Is this document applicable to all groups? Yes No If no, please indicate specific
Board Certified Behavior Analyst and Approved Autism Evaluation Centers. Blue Cross Blue Shield of Michigan Blue Care Network Provider Outreach
Board Certified Behavior Analyst and Approved Autism Evaluation Centers Blue Cross Blue Shield of Michigan Blue Care Network Provider Outreach September 2015 Enrollment Process 2 Enrollment Available networks:
Optum/OptumHealth Behavioral Solutions of California 1 Facility Network Request Form/Credentialing Application INSTRUCTIONS
Optum/OptumHealth Behavioral Solutions of California 1 Facility Network Request Form/Credentialing Application INSTRUCTIONS Read these instructions carefully. It is strongly recommended that an administrative
MGHS CREDENTIALS MANUAL
MGHS CREDENTIALS MANUAL POLICY FOR MEMBERSHIP TO THE MARQUETTE GENERAL HEALTH SYSTEM (MGHS) MEDICAL STAFF Applications for Medical Staff membership to MGHS shall be provided to physicians, dentists, podiatrists,
ENROLLMENT PACKET FOR THE LOUISIANA MEDICAL ASSISTANCE PROGRAM (Louisiana Medicaid Program) CLINICAL NURSE
LOUISIANA Department of HEALTH and HOSPITALS ENROLLMENT PACKET FOR THE LOUISIANA MEDICAL ASSISTANCE PROGRAM (Louisiana Medicaid Program) CLINICAL NURSE SPECIALIST (Enrollment Packet is subject to change
Outpatient Medical Rehab Center. Facility Demographics Legal Business Name (as reported to the IRS): Federal Tax Identification Number:
Facility Credentialing and Recredentialing Application Please complete each section leaving no blank spaces. Clearly state if information requested is not applicable. Attach additional sheets when necessary.
Type of Facility (As listed on License or Accreditation) Facility Demographics. Legal Business Name (as reported to the IRS):
Facility Credentialing and Recredentialing Application Please complete each section leaving no blank spaces. Clearly state if information requested is not applicable. Attach additional sheets when necessary.
Early Intervention Service Coordination Public and Private Insurance Use Determination
Early Intervention Service Coordination Public and Private Insurance Use Determination POLICY 1. Families whose children are enrolled under private insurance plans are required to use their child s benefits
Patient Information Form Trinity Wellness Center. Insurance Information
Patient Information Form Trinity Wellness Center Last Name, First Name, MI* Date of Birth* / / Social Security # -- -- Sex* : Female / Male Student Status (circle one): Full-time / Part-time / not a student
Dental Provider Application
Dental Provider Application Dental Application Instructions To apply for participation, please fill out the enclosed application, completing all appropriate sections and providing all required materials.
Partial Hospitalization - MH - Adult (Managed Medicaid only Service)
Partial Hospitalization - MH - Adult (Managed Medicaid only Service) Definition Partial hospitalization is a nonresidential treatment program that is hospital-based. The program provides diagnostic and
OSCAR Health Insurance Frequently Asked Questions/General Information
Q: What is the relationship between Oscar and ValueOptions? A. ValueOptions administers the mental health and substance abuse benefits for Oscar Health Insurance. They have contracted with ValueOptions,
MEDICAL MANAGEMENT OVERVIEW MEDICAL NECESSITY CRITERIA RESPONSIBILITY FOR UTILIZATION REVIEWS MEDICAL DIRECTOR AVAILABILITY
4 MEDICAL MANAGEMENT OVERVIEW Our medical management philosophy and approach focus on providing both high quality and cost-effective healthcare services to our members. Our Medical Management Department
State of Michigan. Mental Health & Substance Abuse Information Guide
State of Michigan Mental Health & Substance Abuse Information Guide Table of Contents Introduction....2 How to Use Your Information Guide.... 2 How to Use Magellan s Toll-Free Help Line.... 2 Steps for
1. Legal Name of the Primary Applicant: 3. Corporate Contact Name: 4. Corporate Contact Phone:
PSIC RPG Association Large Group Dental Application A. APPLICANT Information 1. Legal Name of the Primary Applicant: 2. of Incorporation or Formation: MO/DAY/YR 3. Corporate Contact Name: 4. Corporate
BH RESIDENTIAL TX OPTIONS Quick Reference Guide 4.9.12 Therapeutic Group RESIDENTIAL REHAB <21
Psychiatric Residential Treatment Facility (PRTF)
CareLink Network Provider Application
COMPLETION OF THIS APPLICATION DOES NOT GUARANTEE A CONTRACT WITH CARELINK NETWORK Instructions: Please complete one application for each organization and include unique service information for each site
HealthCare. HealthCare. HealthCare News. Title font is: Wiesbaden Swing LT Std. Table of Contents. Coding and Billing
#352 March 2013 THORConnect.org Table of Contents Coding and Billing Psychiatric and Substance Abuse Services Institutional... 1 Psychiatric Services... 1 Inpatient... 2 Residential Treatment Centers (RTC)...
Subacute Inpatient MH - Adult
Subacute Inpatient MH - Adult Definition Subacute Inpatient hospital psychiatric services are medically necessary short-term psychiatric services provided to a client with a primary psychiatric diagnosis
1) How does my provider network work with Sanford Health Plan?
NDPERS FAQ Summary Non-Medicare Members Last Updated: 8/5/2015 PROVIDER NETWORK 1) How does my provider network work with Sanford Health Plan? Sanford Health Plan is offering you the same PPO network you
Credentialing and Provider Maintenance
Anthem Blue Cross and Blue Shield Credentialing and Provider Maintenance Stacy Smith stacy.smith@bcbswi.com May 25, 2011 Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of
Treatment Facilities Amended Date: October 1, 2015. Table of Contents
Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 2.0 Eligibility Requirements... 1 2.1 Provisions... 1 2.1.1 General... 1 2.1.2 Specific... 1 2.2 Special
Facility Classification
Facility Classification Facility Enrollment Required Document Checklist To avoid processing delays gather these items before you get started. If applying to network, complete the application signature
DEPARTMENT OF PSYCHIATRY. 1153 Centre Street Boston, MA 02130
DEPARTMENT OF PSYCHIATRY 1153 Centre Street Boston, MA 02130 Who We Are Brigham and Women s Faulkner Hospital (BWFH) Department of Psychiatry is the largest clinical psychiatry site in the Brigham / Faulkner
MISCELLANEOUS HEALTH CARE HOME HEALTH PROFESSIONAL AND GENERAL LIABILITY APPLICATION
U.S. Risk Underwriters, Inc. Boston (617.227.1310) Dallas (800.232.5830) Houston (800.833.8803) MISCELLANEOUS HEALTH CARE HOME HEALTH PROFESSIONAL AND GENERAL LIABILITY APPLICATION CLAIMS MADE AND REPORTED
WRAPAROUND MILWAUKEE Policy & Procedure
WRAPAROUND MILWAUKEE Policy & Procedure Wraparound Wraparound-REACH FISS Project O-Yeah I. POLICY Date Issued: 11/15/07 Effective Date: 1/1/15 Reviewed: 10/20/14 By: WA Last Revision: 10/20/14 Subject:
211 CMR: DIVISION OF INSURANCE 211 CMR 52.00: MANAGED CARE CONSUMER PROTECTIONS AND ACCREDITATION OF CARRIERS
211 CMR: DIVISION OF INSURANCE 211 CMR 52.00: MANAGED CARE CONSUMER PROTECTIONS AND ACCREDITATION OF CARRIERS Section 52.01: Authority 52.02: Applicability 52.03: Definitions 52.04: Accreditation of Carriers
CHAPTER 7: UTILIZATION MANAGEMENT
OVERVIEW The Plan s Utilization Management (UM) program is collaboration with providers to promote and document the appropriate use of health care resources. The program reflects the most current utilization
UNITED BEHAVIORAL HEALTH (UBH) PROVIDER NETWORK PARTICIPATION FREQUENTLY ASKED QUESTIONS Release Date: 12-13-10
UNITED BEHAVIORAL HEALTH (UBH) PROVIDER NETWORK PARTICIPATION FREQUENTLY ASKED QUESTIONS Release Date: 12-13-10 Q1: Who is United Behavioral Health and what does it offer? A1: United Behavioral Health
Participating Provider Manual
Participating Provider Manual Revised November 2011 TABLE OF CONTENTS 1. INTRODUCTION Page 5 Psychcare, LLC s Management Team Mission statement Company background Accreditations Provider network 2. MEMBER
MEDICAL POLICY No. 91608-R1 MENTAL HEALTH RESIDENTIAL TREATMENT: ADULT
MENTAL HEALTH RESIDENTIAL TREATMENT: ADULT Effective Date: June 4, 2015 Review Dates: 5/14, 5/15 Date Of Origin: May 12, 2014 Status: Current Summary of Changes Clarifications: Pg 4, Description, updated
Riverside Physician Network Utilization Management
Subject: Program Riverside Physician Network Author: Candis Kliewer, RN Department: Product: Commercial, Senior Revised by: Linda McKevitt, RN Approved by: Effective Date January 1997 Revision Date 1/21/15
N A S W National Association of Social Workers ~ California Chapter
N A S W National Association of Social Workers ~ California Chapter Steps to a California LCSW for Out-of-State LCSWs Prior to Jan 1, 2016 BBS Announcement: LCSW Exam Restructure Scheduled January 1, 2016
Network Provider. Physician Assistant. Contract
Network Provider Physician Assistant Contract Updated 10/1/02 HCPACv1.0 TABLE OF CONTENTS I. RECITALS...1 II. DEFINITIONS...1 III. RELATIONSHIP BETWEEN THE INSURANCE BOARD AND THE PHYSICIAN ASSISTANT...3
Anthem Credentialing Programs Standards
Anthem Credentialing Programs Standards A. Eligibility Criteria Health Care Practitioners Initial applicants must meet the following criteria in order to be considered for participation: 1. Possess a current,
To Apply for BlueCross BlueShield of South Carolina and BlueChoice HealthPlan
To Apply for BlueCross BlueShield of South Carolina and BlueChoice HealthPlan 1. Complete the SC Uniform Managed Care Provider Credentialing Application. 2. Enclose copies of the following items: A. State
Behavioral Healthcare, Inc. 155 Inverness Drive West Suite 201 Englewood, CO 80112
1 of 21 I. Policy: To maintain a quality provider network, Behavioral Healthcare Inc. (BHI) will establish credentialing and recredentialing criteria and processes to evaluate and determine participation
Mental Health. HP Provider Relations
Mental Health Guidelines and Billing Practices HP Provider Relations July 2011 Agenda Session Objectives Outpatient Mental Health Medicaid Rehabilitation Option (MRO) Risk-Based Managed Care (RBMC) Eligibility
1) How does my provider network work with Sanford Health Plan?
NDPERS FAQ Summary Non-Medicare Members Last Updated: 7/20/2015 PROVIDER NETWORK 1) How does my provider network work with Sanford Health Plan? Sanford Health Plan is offering you the same PPO network
CLINICAL SOCIAL WORKER LICENSURE APPLICATION
P.O. Box 110806, Juneau, Alaska 99811-0806 Telephone: (907) 465-2551 E-mail: license@alaska.gov Website: www.commerce.alaska.gov/occ CLINICAL SOCIAL WORKER LICENSURE APPLICATION READ THESE INSTRUCTIONS
Legacy Medigap SM. Plan A and Plan C. Outline of Medigap insurance coverage and enrollment application for
2015 Medicare Supplement Coverage offered by Blue Cross Blue Shield of Michigan Legacy Medigap SM Outline of Medigap insurance coverage and enrollment application for Plan A and Plan C LEGM_S_LegacyMedigapBrochure
APPLICATION FOR CERTIFICATION TO PRACTICE AS A NURSE PSYCHOTHERAPIST IN INDEPENDENT PRACTICE INFORMATION SHEET CRITERIA FOR CERTIFICATION
APPLICATION FOR CERTIFICATION TO PRACTICE AS A NURSE PSYCHOTHERAPIST IN INDEPENDENT PRACTICE INFORMATION SHEET CRITERIA FOR CERTIFICATION APPLICANTS APPLYING FOR CERTIFICATION TO INDEPENDENTLY PRACTICE
other caregivers. A beneficiary may receive one diagnostic assessment per year without any additional authorization.
4.b.(8) Diagnostic, Screening, Treatment, Preventive and Rehabilitative Services (continued) Attachment 3.1-A.1 Page 7c.2 (a) Psychotherapy Services: For the complete description of the service providers,
Healthcare Coordination
SERVICE DEFINITION Healthcare Coordination Healthcare Coordination consists of overall health assessment, education and assistance provided by a registered nurse to those waiver participants with identified
Counseling Associates of Southern Illinois 1669 Windham Way, Suite B O Fallon, Illinois 62269 P: 618-622-2579 F: 618-624-8506 www.casicounseling.
Counseling Associates of Southern Illinois 1669 Windham Way, Suite B O Fallon, Illinois 62269 P: 618-622-2579 F: 618-624-8506 www.casicounseling.org I. Initial Client Information Date: Social Security
Handbook for Home Health Agencies
Handbook for Home Health Agencies Chapter R-200 Policy and Procedures For Home Health Agencies Illinois Department of Public Aid CHAPTER R-200 Home Health Agency Services TABLE OF CONTENTS FOREWORD R-200
Ambulance. Provider Participation Agreement
Ambulance Provider Participation Agreement BLUE CROSS AND BLUE SHIELD OF MICHIGAN AMBULANCE PROVIDER PARTICIPATION AGREEMENT THIS AGREEMENT is made by and between Blue Cross and Shield of Michigan (BCBSM)
INSTRUCTIONS FOR COMPLETING AN APPLICATION FOR A LICENSE TO OPERATE A DRUG ABUSE TREATMENT AND EDUCATION PROGRAM
INSTRUCTIONS FOR COMPLETING AN APPLICATION FOR A LICENSE TO OPERATE A DRUG ABUSE TREATMENT AND EDUCATION PROGRAM No governing body shall operate a drug abuse treatment and education program in the state
Ohio Mental Health Parity Law - Frequently Asked Questions
Ohio Department of Insurance Mental Health Parity - Frequently Asked Questions The main provisions of the Ohio Mental Health Parity law can be found in sections 1751.01, 3923.28, 3923.281 and 3923.282
Medical and Rx Claims Procedures
This section of the Stryker Benefits Summary describes the procedures for filing a claim for medical and prescription drug benefits and how to appeal denied claims. Medical and Rx Benefits In-Network Providers
Psychiatric Residential Treatment Facility (PRTF) Providers Frequently Asked Questions
Psychiatric Residential Treatment Facility (PRTF) Providers Frequently Asked Questions Information for Providers Serving Medicaid Members in the Georgia Families 360 Program Georgia Families 360, the state
PROVIDER MANUAL AMBULATORY BEHAVIORAL HEALTH CARE FOR ADULTS. Published By:
PROVIDER MANUAL AMBULATORY BEHAVIORAL HEALTH CARE FOR ADULTS Published By: North Dakota Department of Human Services Medical Services Division 600 East Boulevard, Dept. 325 Bismarck, ND 58505-0261 JANUARY
Critical Access Hospital Designation in Nevada
Critical Access Hospital Designation in Nevada Revised: January 2015 A key role played by the Nevada Rural Hospital Flexibility Program (Nevada Flex Program) based in the Nevada Office of Rural Health
Application for Individual Health Insurance
Application for Individual Health Insurance (For plans effective 1/1/2015 and after) PO Box 5023 Sioux Falls, South Dakota 57117-5023 DIRECTIONS If you are applying for a new policy during Open Enrollment,
TRICARE Behavioral Health Benefits. April 2012
TRICARE Behavioral Health Benefits April 2012 As published in the July 16, 2009 online edition of the American Journal of Public Health: Since the start of the Iraq war, mental health problems increased
Keweenaw Holistic Family Medicine Patient Registration Form
Keweenaw Holistic Family Medicine Patient Registration Form How did you first learn of our Clinic? Circle one: Attended Lecture Internet KHFM website Newspaper Sign in window Yellow Pages Physician Friend
ADMINISTRATIVE RULES FOR CLINICAL SOCIAL WORKERS TABLE OF CONTENTS
ADMINISTRATIVE RULES FOR CLINICAL SOCIAL WORKERS TABLE OF CONTENTS PART 1. GENERAL INFORMATION ON LICENSURE OF CLINICAL SOCIAL WORKERS 1.1 THE PURPOSE OF LICENSURE...1 1.2 BUSINESS LOCATION...1 1.3 ADVISORS
North Carolina Medicaid Special Bulletin
North Carolina Medicaid Special Bulletin An Information Service of the Division of Medical Assistance Please visit our Web site at www.ncdhhs.gov/dma JULY 2006 Attention: All Mental Health/Substance Abuse
CHAPTER 5 SERVICE DESCRIPTIONS. Inpatient Hospital Psychiatric Services. Service Coverage
CHAPTER 5 SERVICE DESCRIPTIONS Inpatient Hospital Psychiatric Services Service Coverage Inpatient psychiatric care involves skilled psychiatric services in a hospital setting. The care delivered includes
Keep Your Mind and Body Healthy: Understanding Mental Health Providers, Care and Coverage
Keep Your Mind and Body Healthy: Understanding Mental Health Providers, Care and Coverage Our mental health is a vital part of our overall well-being. It affects how we think, how we feel, and how we act.
Psychotherapy Professional Services
Status Active Reimbursement Policy Section: Behavioral Health Section Policy Number: RP - Behavioral Health - 001 Psychotherapy Professional Services Effective Date: June 1, 2015 Psychotherapy Professional
INSTRUCTIONS FOR SUBMISSION OF AUDIT DOCUMENTATION CHECKLIST AUDIT MATERIALS FOR INITIAL CERTIFICATION
INSTRUCTIONS FOR SUBMISSION OF AUDIT DOCUMENTATION 1. Provide completed forms as necessary to document that at the time of application you met the discipline and professional practice experience requirements
In addition to the completed application, we will need the following:
Thank you for your interest in becoming a Consociate Care Network Provider. In addition to the completed application, we will need the following: Copy of CV Copy of medical license Copy of DEA license
NEW YORK STATE MEDICAID PROGRAM MANAGED CARE MANUAL: STOP-LOSS POLICY AND PROCEDURE
NEW YORK STATE MEDICAID PROGRAM MANAGED CARE MANUAL: STOP-LOSS POLICY AND PROCEDURE Version 2011 1 (01/31/11) Page 1 of 23 TABLE OF CONTENTS Section I Purpose Statement... 3 Section II Stop-loss Policy
Group Health Plans. Information to help you administer your group health insurance program
Group Health Plans Employer s Administrative Guide Information to help you administer your group health insurance program Group Health Plans Administrative Instructions for Employers Welcome! Your administrative
Credentialing CREDENTIALING
CREDENTIALING Based on standards set forth by the National Committee for Quality Assurance (NCQA) all Providers listed in literature for Molina Healthcare will be credentialed. All designated practitioners,
United States Fire Insurance Company: International Technological University Coverage Period: beginning on or after 9/7/2014
or after 9/7/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual Plan Type: PPO This is only a summary. If you want more detail about your coverage and
Provider Selection Criteria for PreferredOne Participating Physicians
Provider Selection Criteria for PreferredOne Participating Physicians General Criteria 1. Practitioner must serve a specialty and/or geographic need for the good of the PreferredOne product for which they
TABLE OF CONTENTS. Medical Management. BCBSIL Provider Manual Rev 10/13 1
TABLE OF CONTENTS Medical Management... 2 Benefit Pre-certification... 2 Benefit Pre-certification for Inpatient and Ancillary Medical Services... 2 Benefit Pre-certification for Outpatient Medical/Surgical