Before completing the Practitioner Data Form, please review the following criteria required for network practitioners.

Transcription

1 Befre cmpleting the Practitiner Data Frm, please review the fllwing criteria required fr netwrk practitiners. Nte: These check-ff sheets are prvided fr yur cnvenience. Please use t ensure yu meet minimum criteria and verify required materials are included with yur cmpleted applicatin packet. AVAILABILITY The fllwing criteria applies t all practitiners serving the ValueOptins cmmercial netwrk: Accessible twenty-fur (24) hurs a day, seven (7) days a week, and agree t make appintments available within the fllwing guidelines: Extreme Emergencies Emergency Serius Risk (Urgent) Mild/Mderate Risk (Rutine) The member must be ffered the pprtunity t be seen immediately r within 30 minutes. In an emergency situatin, a member must be ffered the pprtunity t be seen within six (6) hurs f the call fr an appintment. In an urgent situatin, a member must be ffered the pprtunity t be seen within 48 hurs f the call fr an appintment. In a rutine situatin, a member must be ffered the pprtunity t be seen within 10 business days f a call fr an appintment. Please see Prvider Handbk, Participating Prvider Respnsibilities fr details ( PSYCHIATRISTS Must pssess a Dctr f Medicine (MD) degree r Dctr f Ostepathy (DO) degree frm an accredited medical schl. Bard certified in psychiatry as defined by the American Bard f Psychiatry and Neurlgy (ABPN) OR the American Ostepathic Bard f Psychiatry and Neurlgy (AOBPN); OR cmpleted a three- (3) year psychiatric residency training prgram apprved by the Accreditatin Cuncil fr Graduate Medical Educatin (ACGME) r the American Ostepathic Assciatin (AOA). Licensed t practice medicine in the state where practice is t ccur. Must pssess a current Drug Enfrcement Administratin (DEA) Certificate. State Cntrlled Substance Registratin Certificate (where applicable). Freign medical schl graduates must submit an Educatinal Cmmissin fr Freign Medical Graduates (ECFMG) Certificate. Pssess prfessinal liability cverage at minimum level f $1,000,000 per episde and $3,000,000 aggregate. The NCC, in states where the maximum amunt f cverage btainable is less than the limits abve, may make exceptins. Cpy f current face sheet must be included (must indicate applicant as the insured, plicy perid and cverage amunts and participating in the state s catastrphic lss fund, if applicable). DEVELOPMENTAL BEHAVIORAL PEDIATRICIANS Must pssess a Dctr f Medicine (MD) degree r Dctr f Ostepathy (DO) degree frm an accredited medical schl. Licensed t practice medicine in the state where practice is t ccur. Cmpleted a pediatric residency frm an Accreditatin Cuncil f Graduate Medical Educatin (ACGME) accredited residency prgram. Cmpleted a tw-year accredited Develpmental Behaviral Fellwship. Prir t availability f accreditatin, dcumentatin f an accepted applicatin t sit fr the Sub-Bard f Develpmental Behaviral Pediatrics r an attestatin frm the fellwship directr that the fellwship was cmpleted and prvided develpmental behaviral training will be sufficient. Bard certified in pediatrics as defined by the American Bard f Pediatrics (ABP). Bard certified in Develpmental Behaviral Pediatrics by the Sub-Bard f Develpmental Behaviral Pediatrics within three years f credentialing r within tw years f the first available exam, whichever is later. Revised Page 1 f 5

2 Graduates f freign medical schls must submit an Educatinal Cmmissin fr Freign Medical Graduates (ECFMG) certificate. Pssess prfessinal liability cverage at minimum level f $1,000,000 per episde and $3,000,000 aggregate. The NCC, in states where the maximum amunt f cverage btainable is less than the limits abve, may make exceptins. Cpy f current face sheet must be included (must indicate applicant as the insured, plicy perid and cverage amunts and participating in the state s catastrphic lss fund, if applicable). ADDICTIONOLOGIST (nn-psychiatrist) Must pssess a Dctr r Medicine (MD) degree r Dctr f Ostepathy (DO) degree frm an accredited medical schl. Certified by the American Bard f Psychiatry and Neurlgy (ABPN); OR the American Ostepathic Bard f Psychiatry and Neurlgy (AOBPN) with added qualificatin in addictin psychiatry, OR cmpleted a three- (3) year residency training prgram accredited by the Accreditatin Cuncil fr Graduate Medical Educatin (ACGME) r the American Ostepathic Assciatin (AOA). Certified by the American Sciety f Addictin Medicine (ASAM) as an addictins specialist. Licensed t practice medicine in the state where practice is t ccur. Must pssess a current Drug Enfrcement Administratin (DEA) Certificate. State Cntrlled Substance Registratin Certificate (where applicable). Graduates f freign medical schls must submit an Educatinal Cmmissin fr Freign Medical Graduates (ECFMG) Certificate. Pssess prfessinal liability cverage at a minimum level f $1,000,000 per episde and $3,000,000 aggregate. The NCC, in states where the maximum amunt f cverage btainable is less than the limits abve, may make exceptins. Cpy f current face sheet must be included (must indicate applicant as the insured, plicy perid, PSYCHOLOGISTS Must pssess Dctral degree (PhD, EdD, PsyD) in clinical psychlgy r cunseling psychlgy frm an accredited cllege r university AND meet ne f the fllwing: a. Dctrate was received frm a cllege prgram n the American Psychlgical Assciatin (APA) accredited list f cunseling psychlgy r clinical psychlgy prgrams at the time f graduatin, OR b. Cmpletin f a pre-dctral APA apprved clinical internship at the time f graduatin, OR c. Listed in the Natinal Register f Health Service Prviders in Psychlgy, OR d. Be a diplmat with the American Bard f Prfessinal Psychlgy (ABPP) under the clinical psychlgy r cunseling psychlgy categries. Licensed independently as a clinical psychlgist at the highest level in the state where practice is t ccur. Pssess prfessinal liability cverage at a minimum level f $1,000,000 per episde and $1,000,000 aggregate. MASTERS LEVEL PSYCHOLOGISTS Must pssess a Master s degree in mental health cunseling r allied mental health field frm an accredited cllege r university. Must be licensed r certified at the highest level f independent practice in the state where practice is t ccur. Only acceptable in thse states whse clinical experience and exam requirements equal r exceed tw (2) years r 2,000 hurs f clinical experience r 1,000 hurs f clinical cntact (face t face) under an apprved supervisr as defined by the apprpriate state regulatry agency. Must have received at least 150 hurs f face t face supervisin by an apprved supervisr (as defined by the state). All eligible prviders must have a minimum f five (5) years full-time pst-master s clinical experience in the direct prvisin f mental health and/r substance abuse care and must have cmpleted a ne- (1) year clinical training prgram supervised by a clearly designated psychlgist wh was licensed/certified by the State Bard f Examiners at the time the supervisin ccurred. This clinical training prgram must include a wide range f clinical experiences and a minimum f 1,500 hurs f clinical wrk with at least 37 hurs in direct patient cntact, at least tw (2) hurs weekly in individual supervisin, and six (6) hurs weekly in ther settings. Page 2 f 5

3 Pssess prfessinal liability cverage at a minimum level f $1,000,000 per episde and $1,000,000 aggregate. SOCIAL WORKERS Must pssess Master s degree r higher frm a graduate schl f scial wrk accredited by the Cuncil n Scial Wrk Educatin (CSWE). State licensed r certified t practice at the highest level f independent practice in the state where practice is t ccur. Pssess prfessinal liability cverage at a minimum level f $1,000,000 per episde and $1,000,000 aggregate. ADVANCED PRACTICE NURSE (APN) State licensed t practice as a nurse at the highest level f independent practice in the state where practice is t ccur. Must pssess Master's degree r higher in nursing frm an accredited cllege r university in a prgram recgnized by the Natinal League fr Nursing (NLN) r Cmmissin n Cllegiate Nursing Educatin (CCNE), OR must meet licensing requirements acceptable by the bard t practice at the highest level f independent practice in the state where practice is t ccur. Current DEA Certificate (if applicable fr prescriptive authrity). Current State Cntrlled Dangerus Substances (CDS) Registratin (if applicable fr prescriptive authrity). Rx Number r Certificatin issued t the APN in rder t prvide prescriptive authrity (if applicable fr prescriptive authrity). Certified by the American Nurses Credentialing Center (ANCC) as an APN, Bard Certified (BC). The certificatin held must be in ne f the fllwing areas: Clinical Specialist in Adult Psychiatric and Mental Health Nursing, r Clinical Specialist in Child and Adlescent Psychiatric & Mental Health Nursing, r Family Psychiatric and Mental Health Nurse Practitiner, r Adult Psychiatric and Mental Health Nurse Practitiner, r Psychiatric and Mental Health Nurse Certificatin. The APN is required t maintain cmpliance with cllabratin/supervisin licensing requirements issued by the State(s) where practice is t ccur. Where required, the APN must be supervised by a psychiatrist (MD r DO) and submit a cpy f the agreement. APNs with prescriptive authrity must pssess prfessinal liability cverage at a minimum level f $1,000,000 per episde and $3,000,000 aggregate. APNs withut prescriptive authrity must pssess prfessinal liability cverage at a minimum level f $1,000,000 per episde and $1,000,000 aggregate. The NCC, in states where the maximum amunt f cverage btainable is less than the limits abve, may make exceptins. Cpy f current face sheet must be included (must indicate applicant as the insured, plicy perid, cverage amunts and participatin in the state s catastrphic lss fund, if applicable). PROFESSIONAL COUNSELORS / MENTAL HEALTH COUNSELORS Must pssess Master's degree r higher in a mental health discipline. State licensed r certified at the highest level f independent practice in the state where practice is t ccur. Only acceptable in thse states where clinical experience and exam requirements equal r exceed tw (2) years r 2,000 hurs f clinical experience r 1,000 hurs f direct clinical cntact (face-t-face) under an apprved supervisr as defined by the apprpriate state regulatry agency. Must have received 100 hurs f face-t-face supervisin by an apprved supervisr (as defined by the state) during the first tw (2) years f pst-graduate direct clinical experience. Pssess prfessinal liability cverage at a minimum level f $1,000,000 per episde and $1,000,000 aggregate. Page 3 f 5

4 MARRIAGE AND FAMILY COUNSELORS Must pssess Master's degree r higher in mental health discipline. State licensed r certified at the highest level f independent practice in the state where practice is t ccur. Only acceptable in thse states whse clinical experience and exam requirements equal r exceed tw (2) years r 2,000 hurs f clinical experience r 1,000 hurs f direct clinical cntact (face-t-face) under an apprved supervisr as defined by the apprpriate state regulatry agency. Must have received 100 hurs f face-t-face supervisin by an apprved supervisr (as defined by the state) during the first tw (2) years f pst-graduate direct clinical experience. Pssess prfessinal liability cverage at a minimum level f $1,000,000 per episde and $1,000,000 aggregate. PASTORAL COUNSELORS Must pssess Master s degree r higher in mental health discipline. Must be licensed in ne f the disciplines recgnized by ValueOptins (MD/DO, PSY, SW, RNCS, ARNP, MFT, r LPC) at the highest level f independent practice in the state where the practice is t ccur and meet the ValueOptins credentialing criteria OR must be licensed r certified as a Pastral Cunselr in the state where the practice is t ccur. Pssess prfessinal liability cverage at a minimum level f $1,000,000 per episde and $1,000,000 aggregate. ALCOHOL and DRUG COUNSELORS Must pssess Master s degree r higher in mental health discipline OR certificatin as a clinical supervisr by the Cnnecticut Certificatin Bard, Inc., prir t Octber 2, 1998, and meet all requirements fr certificatin as a certified alchl and drug cunselr. State licensed as an alchl and drug cunselr at the highest level f independent practice in the state. Pssess prfessinal liability cverage at a minimum level f $1,000,000 per episde and $1,000,000 aggregate. Page 4 f 5

5 Criteria fr Specialty Netwrks Vluntary Participatin EAP COUNSELORS Must be licensed in ne f the disciplines recgnized by ValueOptins (MD/DO, PSY, SW, RNCS, ARNP, MFT, r LPC) at the highest level f independent practice in the state where the practice is t ccur and meet ValueOptins credentialing criteria. Pssess prfessinal liability cverage at a minimum level f $1,000,000 per episde and $3,000,000 aggregate. The NCC, in states where the maximum amunt f cverage btainable is less than the limits abve, may make exceptins. Cpy f current face sheet must be included (must indicate applicant as the insured, plicy perid, Must pssess knwledge and wrk experience f EAP Cre Technlgy by: Active status as a Certified Emplyee Assistance Prfessinal (CEAP); r Tw (2) years f verifiable experience as an internal EAP cunselr and/r as an external EAP cnsultant t ther rganizatins. Examples f verifiable experience include but are nt limited t: Management and/r unin representative cnsultatin n the impact f persnal prblems n perfrmance issues, the apprpriate use f cnstructive cnfrntatin and the rle f the EAP. Direct care functins f an EAP practice including assessment and referral, shrt-term cunseling and linkages t treatment and/r cmmunity resurces. Crisis Interventin including critical incident stress management (CISM) services. Training and experience in rganizatinal dynamics/develpment, human resurce management r industrial scial wrk / psychlgy. Assessment and identificatin f drug and alchl abuse / dependency prblems and apprpriate treatment interventins. Must pssess knwledge and wrk experience in the assessment and treatment f substance abuse as indicated by: Active status as a Certified Emplyee Assistance Prfessinal (CEAP) with an acceptable level f experience in the assessment and/r treatment f chemical dependency, r Pssess ne year f experience in a substance abuse treatment facility, r Cmpleted a state-level certificatin acceptable t supprt eligibility fr the Natinal Certified Addictin Cunselr (NCAC) credential, r Pssess Internatinal Certified Alchl and Drug Cunselr Certificatin (ICADC), r Pssess a minimum f six (6) units f cntinuing educatin (CEU s, PDH s etc) in chemical dependency assessment/treatment, r Cmpleted three (3) graduate level hurs f cursewrk in chemical dependency. PRACTITIONER RIGHTS: As a netwrk practitiner, yu have the right t: review infrmatin submitted t supprt yur credentialing applicatin. crrect errneus infrmatin cllected during the credentialing prcess. be infrmed f the status f yur credentialing r recredentialing applicatin. be ntified f these rights. All requests fr dcumentatin must be submitted in writing. ValueOptins will nt release infrmatin btained thrugh the primary surce verificatin prcess when Federal r State law prhibits disclsure. Please visit t access the cmplete ValueOptins Prvider Handbk. Page 5 f 5