Provider Agency/Facility Application For IPRS (State Funds ...

Managing Mental Health, Intellectual/Developmental Disabilities and Substance Abuse Services

910-673-9111 (FAX) 910-673-6202 www.sandhillscenter.org Victoria Whitt, CEO

Provider Agency/Facility Application

For IPRS (State Funds) and Medicaid Services

Please email application to:

[email protected]

SHC Agency/Facility Credentialing Application (IPRS & Medicaid) Qmcappd 03/24/2020 of 28

Instructions for SHC Provider Credentialing Application A provider agency/facility must apply for and be credentialed with Sandhills Center to qualify for reimbursement of services provided to Sandhills Center members. Additionally, agencies must have a signed contract with Sandhills Center to qualify for reimbursement of services provided to Sandhills Center members. A. This application must be completed in its entirety, with all questions addressed and required

information submitted. An application is considered to be invalid and will be returned to the provider for correction and/or for additional information if: The version date on any of the documents that comprise the provider application packet is prior to March 2020. Older versions are not accepted. Any spaces in the application are not completed. (Please indicate “N/A” or “None” if the question is not applicable.) The “Attestation Statement” Signature is not original/scanned and dated.

The text has been altered, highlighted, struck through, or obstructed through the use of correction fluids.

The contact person’s name and title is not completed.

The signatures are not by the individual applicant or, where applicable, an authorized agent for the group or entity. The responses are illegible.

Any of the documents or pages that comprise the “Provider Agency/Facility Credentialing Application” are missing. Any of the requested information in any of the documents that comprise the “Provider Agency/Facility Credentialing Application” is missing, with the exception of the fax number and e-mail address.

B. Sandhills Center shall notify the provider within ten (10) business days of receipt of the completed application or if materials are missing. The application and materials will be returned if incomplete.

NOTE: There must be an approved executed contract between the Agency/Facility and Sandhills Center prior to service delivery. If the Agency/Facility has Licensed Practitioners (LP’s) or Provisional Licensed Practitioners (PLP’s) it is the responsibility of the Agency/Facility to ensure that each Practitioner completes and submits the “Uniform Application to Participate as a Health Care Practitioner.” Upon approval of the Practitioner’s Credentialing status by the Sandhills Clinical Advisory Committee the Agency/Facility can submit claims for services provided by the LIP or PLP back to the Board Approval Date.

Before submitting the Credentialing Application, make sure you have completed the following:

Include an answer in all spaces. Indicate “N/A” or “None”, if the question is not applicable. The Authorized agent for the group or entity has signed and dated all pages requiring signature. Any requested information in any of the documents that comprise the Credentialing Application is not missing, with the exception of the fax number. Any of the required accreditation documentation is not missing. Copy of the Certificate of Insurance for your current commercial general, professional liability, and workers’ compensation (if there is more than three employees) indicating by name, provider(s)/practitioners covered, coverage amounts, effective date, expiration date, policy numbers and Sandhills Center should be listed as certificate holder. (Sandhills Center cannot accept Notice of Intent as proof of insurance), stating liability amounts equal or greater than $1,000,000 / $3,000,000 aggregate. Submit proof of automobile insurance for company vehicles, and employee vehicles that are used to transport members include contracted employees. Completed Insurance Attestations form regarding all liability insurance coverages. Completed W-9 Form signed and dated Current valid NC Tracks enrollment, active status in Medicaid Health Plan, and appropriate affiliation to employment agencies. Submit written documentation of source of authority through charter, constitution and/or by-laws or articles of incorporation.


Instructions for SHC Provider Credentialing Application (continued)

If an out-of-state Organization, submit a certificate of authority that shows eligibility to do business in NC (obtained from the Secretary of State’s office).

If an Organization is privately owned, submit listing of duties of Owner/CEO/COO. Provide documentation of qualifications via resume/curriculum vitae.

Completed Attestation Letter signed and dated (included in this application). Submit an Organization Chart. This chart will include any major programs, program heads/supervisors

as well as staffing patterns for the Agency. The chart will also show the Organizations standing committees and their reporting structure as well as any ancillary positions.

Submit an annualized budget and the most recent certified audit or most recent board approved financial statement.

Submit CFO statement of financial capacity (for profit only). Submit list of board of directors (names, titles and contact). Provide documentation of the Board by-laws

that includes required qualifications of board members, method to determine a quorum, and officer’s length of term. (Sole Proprietors are excluded from this item requirement).

Submit a listing of Client Rights Committee members, which includes names, title, and contact information.

Copy of facility license (if applicable) Sandhills Center will schedule an on-site visit for unlicensed sites. Each provider facility/site must be accommodating for members with physical disabilities. If facility is not

accommodating, please provide an explanation of how those members with physical disabilities would be accommodated.

Signed and dated Trading Partner Agreement (included in this application). Copy of Conflict of Interest Policy and Procedure For each of the following written references include the reference person’s name, address, telephone,

and e-mail information. All references must be submitted as originals. No copies will be accepted. Each reference must specifically address: • One from an individual outside the Organization familiar with fiscal operations of the facility. If the

Organization is a new business, the reference must pertain to the fiscal stability of the board/CEO/COO/Owner to support the company fiscally.

• One from an individual familiar with the clinical operations of the Organization. If the Organization is a new business, the reference must be obtained from someone familiar with the clinical director’s qualifications and abilities.

• Two from individuals currently receiving services and /or family members. If the Organization is a new business, the references must be obtained from individuals involved in the field of disabilities either professionally or through life experience.

Please submit the following sample forms and documents that demonstrate compliance with the following regulations.

• Sample Service Notes/Documentation • Sample Treatment Plan/Person Centered Plan • Sample Staff Supervision Plan and Note • Sample Staff Schedule • Sample Job Description

Sandhills Center is interested in a clear understanding of each agency’s organizational qualifications as it related to services or disability group. Please provide a detailed description of the following items:

A. Agency description including: Mission and Philosophy and Vision B. Describe the Agency’s expertise with services provided and priority populations. This should

include how the Agency has developed their overall expertise in the areas of service delivery, access to training and ongoing use of consultation, which will assure adherence to the service definition.

C. Describe how the Agency has developed and maintained the expertise of the Agency in service delivery area requested and priority populations. This answer should be very specific and describe how supervision is done, including the credentials of staff and management. If the service is a nationally recognized best practice, please include what the Agency does to assure fidelity to model.


Instructions for SHC Provider Credentialing Application (continued)

For individuals with 5% or greater ownership in the Organization, original signed and dated SBI Authority for Release of Information form (included in this application).

For individuals with 5% or greater ownership in the Organization, original signed and dated Acknowledgement and Authorization for Social Security Number Check form; must be completed with all personal information (included in this application).

Please describe any local, state, or national recognition that the Agency has received for the service area and all national accreditations.

If national Accreditation is required for the service, please submit your Agency’s Strategic Plan to achieve this within the timelines established.

If peer certification is required for the service, please describe how the Agency will achieve this. Define what steps if any your Agency has taken to achieve cultural competency. Description of how your Agency will operationalize or has operationalized the new service Please submit results of any client satisfaction surveys and if you are a new Agency, a detailed plan and

timeline of how this will be obtained including the types of questions and frequency to be administered. List all services that you are requesting to provide. The services must be listed according to the North

Carolina Department of Health & Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse MH/DD/SA Service Definitions (ex. not group home but (ex.) supervised living moderate). Information to be documented, per service includes: • State Classification of the Service • Consumer capacity • Ages to be served • Disability population to be served • Screening and assessment process • Admission criteria • Discharge criteria • Please include the proposed job descriptions of the staff for the service(s). • Minimum qualifications of staff for the service • Staffing pattern • Sample of the staffing schedule for PSR, Residential, Day Treatment, Day and Night Services that

demonstrates staffing at the ration required by the State Service Definitions • Description of the initial competency training program for staff that is to be offered as required by

the specific service definition. This should include specifics on the training curriculum, who will provide the training, and how competencies will be determined. Cultural Competency Training is required.

• On call support system (clinical) • On call support system (medically) • Are the services within thirty (30) miles of consumers in Sandhills Center catchment area

Include information related to the Agency’s use of person centered and/or recovery models of service. Please include specific examples of how this is demonstrated on a day-to-day basis.


Important Points to Remember: a) If services are being provided at multiple sites, you are required to list each site in this application

and they will be assigned a separate site ID number for each location. Each site must also specify the services that will be rendered at that location.

b) Copies of the applicable accreditation documentation must accompany the application. If these documents are missing, the application will be returned to the provider.

c) Retain a copy of your completed Credentialing Application and all documentation submitted with the Credentialing application for your records. Providers will be notified via email from Sandhills Center upon receipt of their application.

d) Providers are assigned a provider number and are notified by mail once the enrollment and contract process has been completed. Please do not submit claims for dates of services prior to the effective date.

e) Billing information and clinical coverage policies are available on Sandhills Center website at: http://www.sandhillscenter.org

f) Providers are requested to include on their application the name, e-mail address, and fax number of the individual contact person at their site who is responsible for receiving Sandhills Center Health Plan information. We want to thank you in advance for your efforts in completing your Credentialing application

process in the manner stated above. Submitting an organized application will expedite the review process and increase efficiency and accuracy. Please ensure that all applicable information requested

is submitted to avoid delays with processing.


Section 1: Agency Information Date of Application:

1. Legal Name of Organization: (as used for tax reporting purposes)

2. Federal Tax ID #: 3. NPI #: Please specify the Federal Tax Status:

Not for Profit For Profit 501 C 3 4. Taxonomy #(s): List all applicable to the agency. 5. NC Tracks Requirements:

a. Are you enrolled in NC Tracks? Yes No If “No”, provide Enrollment Registration # and submission date and/or provide the Managed Change Request (MCR) # and submission date below. NC Tracks Registration/MCR#: Submission Date:

b. Do you have an active status in the Medicaid Health Plan? Yes No c. Are all applicable service locations activated in NC Tracks? Yes No d. Do you have a valid taxonomy for each service location? Yes No

6. Organization Legal Entity Type: C-Corporation Sole Proprietorship General Partnership Limited Liability Corporation Limited Liability Partnership 7. Organization

Address:

Street City State Zip+4 (Required) (Must be the physical address – no P.O. Box)

8. Check (√) County of Address :

Anson Guilford Harnett

Hoke Lee Montgomery

Moore Randolph Richmond

Other: 9. Website Address: 10. Number of years doing business under this name: 11. Has this Organization ever been in business under a different name? Yes No

If yes, what name? 12. Primary Contact: 13. Title: 14. Email Address: 15. Phone #: 16. Executive Director: 17. Clinical/Medical Director:

18. Email Address: 19. Phone #: 20. Have background checks been completed on the owners, directors, officers, administrators and

staff? Yes No (If yes, please attach a policy, procedure, and supporting documentation. If no, please provide explanation.)

21. Is this Organization accredited? (If yes, attach verification of accreditation) Yes No JCAHO: Yes No Most recent date accredited: Expiration date: CARF: Yes No Most recent date accredited: Expiration date:

COA: Yes No Most recent date accredited: Expiration date:


Section 1: Agency Information (continued) CQL: Yes No Most recent date accredited: Expiration date:

OTHER: Yes No Most recent date accredited: Expiration date:

If no, please identify, if applicable, the Accrediting body your agency/facility has selected and your current status in the accreditation process as required by the NC Division of MH/IDD/SAS.

Note: Refer to SECTION 10.15A. (c) Article 3A of Chapter 122C of the General Statutes. Sandhills Center “General Credentialing & Re-Credentialing Criteria” stipulates the specific services that require accreditation.

22. Has the Organization ever been sanctioned, placed on probation or lost accreditation or certification status Yes No (If yes, please attach an explanation and any supporting documentation.)

23. Liability Insurance: a) Has there been a claim against you or your organization?

(If yes, please list the name & amounts of the Insurance & disposition.) Yes No

b) Are there any current unsettled claims? (If yes, please attach explanation.)

Yes No

c) Are you aware of any circumstances that may result in a claim or suit? (If yes, please attach explanation.)

Yes No

d) Has your organization ever had a policy cancelled? (If yes, please attach explanation.)

Yes No

24. Has there been any action or investigation against you, your organization, any owner or qualified professional in your Organization relating to: (If yes, please attach explanation.)

License Registration Billing Organization Yes No Yes No Yes No

Certification Privileges Sanctions Yes No Yes No Yes No

25. Have any adverse actions been filed against you, your organization, any owner, or qualified professional by: (If yes, please attach explanation.) Medicaid Medicare Other Insurance

Yes No Yes No Yes No 26. Has the organization ever been sanctioned, placed on probation or lost accreditation or certification status? Yes No (If yes, please attach explanation of the circumstances and how it was resolved.) 27. Has your organization or anyone within your organization who has an ownership, managerial or

clinical role been sanctioned by any professional organization or government organization for violation of ethics, professional misconduct, unprofessional conduct, incompetence, negligence, lost accreditation or certification status in any state or country? Yes No (If yes, please attach explanation of the circumstances and how it was resolved.)

28. Are you aware of any circumstances that may result in such an action? Yes No (If yes, please attach explanation.)

29. Has your organization ever had a contract cancelled by another LME-MCO, Area Authority, County Program in North Carolina or similar entity in another state? Yes No (If yes, please attach explanation.)

30. Has anyone in your company who has an ownership, managerial or clinical role ever been convicted of a felony or misdemeanor, or is under investigation with respect to such conduct?

Yes No (If yes, please attach explanation.)


Section 1: Agency Information (continued) 31. If you are enrolling as a group provider, list all shareholder/partners (including self) who have 5% or

more ownership (or whose spouse, parent, child or sibling has such an interest) and all individual officers, directors, managers, and electronic funds transfer (EFT) authorized individuals and information requested on each. (This page may be duplicated if necessary.)

Name: Date of Birth:

Address:

Street City State Zip+4 (Required) Title: SSN: License #: % Owner: Check business relationship that applies:

Owner Shareholder Partner

Officer/Director Manager EFT Authorized Employee

Check relationship to enrolling provider: (if applicable)

Spouse Parent Child Sibling Name: Date of Birth:

Address:






Address:






Address:





Spouse Parent Child Sibling


Section 1: Agency Information (continued) 32. Identify other providers, if any, which are owned or operated by the applicant under the same

owner name. Provider Name: Address: Street City State Zip+4 (Required) Relationship type:

Nursing Home Home Health Agency

Community Based Residential Facility Hospital 33. Is the applicant a subsidiary company, either wholly or partially owned by another organization or business: Yes No (If yes, please provide the following information.) Legal Business Name: (parent company)

Type of Ownership: 34. Please attach and list all relevant contracts your Organization currently has and/or has had for the

past five (5) years. (Skip to the next question if you have no contracts) Please include for each:

A. Contracting Organization/Area Program LME/MCO • Contact name • Phone number • E-mail address

B. What services are/were provided C. Beginning and ending dates D. Dollar amount of contract


Section 2: Site Specific Credentialing

FACILITY/SITE SPECIFIC INFORMATION – A facility/site is a physical location where supervision and/or management of services occur. Please attach the facility site license if applicable. If your Organization operates more than one facility/site, copy and complete SECTION 2 for each facility/site.

1. Facility/Site Name: 2. Facility/Site Address:

Street City State Zip+4 (Required) 3. Check (√) County of Address:

Anson Guilford Harnett Hoke Lee Montgomery

Moore Randolph Richmond

Other: 4. Facility/Site Days/Hours of Operation:

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

5. Phone #: 6. Fax #: 7. Email: 8. Please List all National Provider Identifier (NPI) and Taxonomy Numbers that pertain to this site:

NPI Numbers Taxonomy Numbers 9. Please list services to be provided at this site

Service Code(s) Service Description


Section 2: Site Specific Credentialing (continued) 10. Information about the Facility/Site Director/Supervisor Facility/Site Director’s Name & Credentials: Facility/Site Director’s Education: (If necessary add additional page(s) Facility/Site Director’s Credentials: Facility/Site Director’s Phone #: Facility/Site Director’s Email:

11. Is this facility/site staffed and equipped to serve: (If no, please explain how you plan to accommodate below.)

Physically Disabled: Yes No Deaf & Hearing Impaired: Yes No Blind/Visually Impaired: Yes No Behaviorally Disruptive: Yes No Sexually Aggressive: Yes No Foreign Languages: Yes No Foreign Languages please specify:

Plan to accommodate those members with physical disabilities:

12. Is this facility/site licensed by: (if yes, attach a copy of the license)

DHSR: Yes No License #: State: DSS: Yes No License #: State: Other: Yes No Type: 13. Coverage: Indicate what arrangements you have made to cover member emergency situations

during nights, weekends, and holidays:

14. Physician Coverage: Indicate what arrangements you have made to cover your Organization for members who need psychiatric evaluation or psychiatric medication.

List psychiatrist/physician who will see your members:

Name: Phone: Name: Phone: Name: Phone: 15. Do you have a manmade, natural disaster, or act of God crisis/disaster plan? Yes No (if yes, please attach) NOTE: SHC will schedule Health and Safety Review to review personnel, training, medication, facility and

medical records, if applicable.


Section 2: Site Specific Credentialing (continued)

SANDHILLS CENTER Site Specific

Cultural, Gender, and Linguistic Data Form By providing the information below, you will be assisting Sandhills Center with member/provider matching as well as providing information necessary for analyzing the Network and its ability to meet our members’

cultural, racial, ethnic and linguistic needs. This information will reside within Sandhills Center Provider Directory and the online Provider Search.

Name of Agency Site:

Focus of Treatments the Agency Provides:

Chemical Dependency/Substance Abuse Co-Occurring/Dual DX – MI, MH, SA Eating Disorder Intellectual Developmental Disabilities Mental Health

Agency Expertise/Certified Specialties: (please check (√) ONLY those that apply) Co-Location with/Primary Care Physician

Community Based Services Crisis Services

Detoxification Services Faith Based Services Inpatient Services Intensive In-Home Therapy Marriage & Family Counseling MST (Multi-systemic

Therapy) Outpatient Therapy Psychiatry Psychological Testing Residential Services Self-Direction Telemedicine Therapeutic Foster Care Trauma Focused

Services Language(s) the Agency are able to communicate in fluently: (please check (√) ONLY those that apply)

The agency must explain or attach their organizational plan for sustaining their ability for the interpretation services checked below – direct language services through hiring staff or other translation entities.

NOTE: Do not consider licensed practitioners as part of your agency languages. Sandhills Center has already collected the clinicians’ languages spoken that will be credited toward your agency.

American Sign Language Chinese/Korean English

French German Hmong

Porteguese Spanish Telugu Other: Translator on site? Yes No

Population(s) that you serve: (please check (√) ONLY those that apply)

All Populations Gay & Lesbian Gender Identity Issues Geriatric Hearing Impaired HIV/Aids Men Sexually Reactive/Aggressive Youth Visually Impaired Women

MH SA IDD

Adult

18-21

22-54

55 & Up

18-21

22-54

55 & Up

18-21

22-54

55 & Up

Child 3-11 12-17 12-17 18-21 3-11 12-17 Culturally diverse populations the agency feels competent to treat: (please check (√) ONLY those that apply)

All Races/Ethnicities American Indian & Alaska Native Asian, Pacific Islander Black or African American Hispanic or Latino White Other:

Completed Cultural Competency Training? Yes No


Thank you for taking the time to submit this form. If this form is not completed and returned, your agency will not appear within the Sandhills Center online Provider Directory.

Section 3: SIGNATURE AUTHORIZATION PAGE

Authorization to File Credentialing Application

To the best of my knowledge, my agency is able to meet all requirements necessary to apply for Sandhills Center credentialing. I am submitting the attached Sandhills Center Provider Credentialing Application, which, to my knowledge, is a true and complete representation of the requested materials.

Printed Name

Authorized Signature Date

Title


Please List Licensed Practitioners:

If the Agency/Facility has Licensed Practitioners (LP’s) or Provisional Licensed Practitioners (PLP’s) it is the responsibility of the Agency/Facility to ensure that each Practitioner completes and submits the “Uniform Application to Participate as a Health Care Practitioner” (if new with the Agency/Facility) or the “Uniform Credentialing Application to Participate as a Health Care Practitioner”.

Please list all Licensed Practitioners (LP) their Taxonomy #, NPI #, and License Type who are currently

seeing Sandhills Center members. (You may make copies of this page if more space is needed/ please print)

LP Name License Type NPI Taxonomy

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44


Outpatient Behavioral Health Service Codes for IPRS & Medicaid

Please check (√) all that apply (only the services you have an existing agreement with Sandhills Center)

Procedure

Code Description

Available to Benefit Plan State (IPRS) Medicaid

90785 Interactive Complexity Add On State Medicaid

90791 Psychiatric Diagnostic Evaluation State Medicaid

90792 Psychiatric Diagnostic Evaluation with Medical Services

State Medicaid

90832 Psychotherapy 30 Minutes State Medicaid

90833 Psychotherapy 30 Minutes Add On State Medicaid





90839 Crisis Psychotherapy first 60 Minutes State Medicaid

90840 Crisis Add For Each Additional 30 Minutes State Medicaid

90845 Psychoanalysis N/A Medicaid

90846 Family therapy w/o Patient State Medicaid

90847 Family therapy with Patient State Medicaid

90849 Group Therapy (Multiple Family) State Medicaid

90853 Group Therapy (Non-Multi Family) State Medicaid

96110 Developmental Testing Limited State Medicaid

96112 Developmental Test Administration State Medicaid

96113 Dev Test Admin Addtl 30 State Medicaid

96116 Neurobehavioral Status Exam State Medicaid

96121 Neuro Exam Addtl hour State Medicaid

96130 Psych Test Eval 1st hour State Medicaid

96131 Psych Test Add on State Medicaid

96132 Neuropsych Test Eval State Medicaid

96133 Neuropsych Test add on State Medicaid

96136 Psych or Neuro tests two or more State Medicaid

96137 Psych test two or more add on State Medicaid

96138 Psych test Tech two or more NA Medicaid

96139 Psych test Tech two or more add on NA Medicaid

96146 Psych test Automated NA Medicaid


Evaluation & Management Codes

***Evaluation & Management Codes are only provided by Physician Assistants, Certified Nurse Practitioners and Physicians (only check (√) what services you are currently providing). ***

Check (√)

Procedure Code

Description

Check (√)

Procedure Code

Description

90865 Narcosynthesis for Psychiatric Diagnostic and Therapeutic Purposes

99222 Hospital Initial Care MD (50 min.)

95970 Electronic Analysis of Implanted Neuro stimulator


95971 Electronic Analyses of Implanted Neuro stimulator Simple Spinal Cord

99231

Hospital Subsequent Hospital Care MD Low Complexity (15 min.)

95972 Electronic Analysis of Implanted Neuro stimulator Complex Spinal Cord (1hr.)

99232

Hospital Subsequent Hospital Care MD Moderate Complexity (25 min.)

95973 Electronic Analysis of Implanted Neuro stimulator Complex Spinal Cord (30 min.)

99233

Hospital Subsequent Hospital Care MD High Complexity (35 min.)

95974 Electronic Analysis of Implanted Neuro stimulator Complex Cranial (1 hr.)

99234

Hospital Observation/Inpatient Care Low Complexity

95975 Electronic Analysis of Implanted Neuro stimulator Complex Cranial (30 min.)

99235

Hospital Observation/Inpatient Care Moderate Complexity

95978 Electronic Analysis of Implanted Neuro stimulator

99236 Observation/Inpatient Care High Complexity

95979 Electronic Analysis of Implanted Neuro stimulator (30 min.)

99238 Hospital Discharge Services (<30 min.)

96125 Standardized Cognitive Performance Testing

99239 Hospital Discharge Services (>30 min.)

96150 Physical Health and Behavior Assessment F-T-F (15 min.)

99241 Outpatient Consultation MD Minor (15 min.)

96151 Physical Health and Behavior Reassessment 99242 Outpatient Consultation MD Moderate (30 min.)

96372 Therapeutic, Prophylactic, or Diagnostic Injection Intra-Muscular

99243 Outpatient Consultation MD Severe (40 min.)

96373 Therapeutic, Prophylactic, or Diagnostic Injection Intra-Arterial


96374 Therapeutic, Prophylactic, or Diagnostic Injection Intravenous Push


96375 Therapeutic, Prophylactic, or Diagnostic Injection Subsequent Intravenous Push

99251 Inpatient Consultation MD Minor (20 min.)

99201 Outpatient E&M New Patient F-T-F (10 min.)

99252 Inpatient Consultation MD Low Severity (40 min.)

99202 Outpatient E&M New Patient F-T-F (20 min.) 99253 Inpatient Consultation MD Moderate (55 min.)


99254 Inpatient Consultation MD Moderate – High Severity (80 min.)


99255 Inpatient Consultation MD Moderate – High Severity (110 min.)

99205 Outpatient E&M New Patient F-T-F (60 min.) 99281 ER Visit, Minor

99211 E & M Estab Patient, w/wo MD (approx. 5 min.)

99282 ER Visit, Low Severity

99212 Outpatient Visit Estab. Minor (10 min.) 99283 ER Visit, Moderate Severity

99213 Outpatient Visit Estab. Moderate (15 min.) 99284 ER Visit, High Severity

99214 Outpatient Visit Estab. Severe (25 min.)

99285 ER Visit for the evaluation and management of a patient

99215 Outpatient Visit Estab. Severe (40 min.) 99291 Critical Care 30-74 minutes

99217 Hospital Observation Care – Discharge

99304 Initial Nursing Facility Care E&M Low Complexity (25 min.)

99218 Hospital Initial Observation Care Low Complexity

99305

Initial Nursing Facility Care E&M Moderate Complexity (35 min.)

99219 Hospital initial Observation Care Moderate Complexity

99306

Initial Nursing Facility Care E & M High Complexity (45 min.)

99220 Hospital Initial Observation Care High Complexity

99307

Subsequent Nursing Facility Care E & M Review of Case (10 min.)


Evaluation & Management Codes (continued)

***Evaluation & Management Codes are only provided by Physician Assistants,

Certified Nurse Practitioners and Physicians (only check (√) what services you are currently providing). ***

Check (√)

Procedure Code

Description Check

(√) Procedure

Code Description


99308 Subsequent Nursing Facility Care E & M Low Complexity (15 in.)

99309 Subsequent Nursing Facility Care E&M Moderate Complexity (25 min.)

99341

New Patient Home Visit E & M Low Severity (20 min.)

99310 Subsequent Nursing Facility Care E&M High Complexity (35 min.)

99342

New Patient Home Visit E&M Low Complexity (30 min.)

99315 Nursing Facility Discharge Management; (<30 min.)

99343

New Patient Home Visit E&M Low Moderate Complexity (45 min.)

99316 Nursing Facility Discharge Management; (>30 min.)

99344

New Patient Home Visit E&M High Severity (60 min.)

99318 Nursing Facility, E&M Low to Moderate Complexity (30 min.)

99345

New Patient Home Visit E&M High Complexity (75 min.)

99324 New Patient Domiciliary/Rest Home E&M Low Severity (20 min.)

99347 Estab. Patient Home Visit E&M (15 min.)

99325 New Patient Domiciliary/Rest Home E&M Low Complexity (30 min.)

99348

Estab. Patient Home Visit E&M Low Complexity (25 min.)

99326 New Patient Domiciliary/Rest Home E M Moderate Complexity (45 min.)

99349

Estab. Patient Home Visit E&M Moderate Complexity (40 min.)

99327 New Patient Domiciliary/Rest Home E&M High Severity (60 min.)

99350

Estab. Patient Home Visit E M High Complexity (60 min.)

99328 New patient Domiciliary/Rest Home E&M High Complexity (75 min.)

99354

Prolonged MD Service w/F-T-F Patient Contact in Office (60 min.)

99334 Estab. Patient Domiciliary/Rest Home E&M (15 min.)

99355

Prolonged MD Service w/F-T-F Patient Contact in Office (30 min.)

99335 Estab. Patient Domiciliary/Rest Home E&M Low Complexity (25 min.)

99356

Prolonged MD Service w/F-T-F Patient Contact Inpatient (60 min.)

99336 Estab. Patient Domiciliary/Rest Home E&M Moderate Complexity (40 min.)

99357

Prolonged MD Service w/F-T-F Patient Contact Inpatient (30 min.)

99337 Estab. Patient Domiciliary/Rest Home E & M Moderate to High Severity (60 min.)

Q3014GT TelePsyc Site Facility Fee

IPRS (State) Funds Only for Non-Licensed Substance Abuse Professionals

Please check (√) all that apply (only the services you have an existing agreement with Sandhills Center)

Check (√)

Procedure Code

Description

YP830 Behavioral health Assessment

YP831 Behavioral health Counseling and Therapy

YP832 DMH Outpatient Treatment Group

YP833 DMH Outpatient Tx Family Therapy w/ Client

YP834 DMH Outpatient Tx Family Therapy w/o Client

YP835 Alcohol and/or Drug Services; Group Counseling by Clinician


IPRS (State) Funds Only

Please check (√) all that apply. (Only the services you have an existing agreement with Sandhills Center.)

Check (√)

Procedure Code Description Check

(√) Procedure

Code Description

H0038 State funded Peer Support – Ind. YP010 Hourly Respite - Individual

H0038HQ State funded Peer Support – Grp. YP011 Hourly Respite – Group

H2014 Developmental Therapy – Prof- Ind. YP020 Personal Assistance – Individual

H2014HM Developmental Therapy – Para Prof – Ind. YP021 Personal Assistance – Group

H2014HQ Developmental Therapy – Prof- Group YP230 Assertive Outreach

H2014U1 Developmental Therapy – Para Prof – Group YP450 Deaf Interpretation

H2034 SA Halfway House YP485 Facility Based Crisis

YA125 Hourly Respite YP610 Developmental Day

YA213 Community Respite YP620 Adult Developmental Vocational Program (ADVP)

YA230 Psychiatric Residential Treatment Facility YP630 Supported Employment – Individual – MH

YA345 Jail Diversion YP640 Supported Employment – Group - MH

YA352 Assertive Engagement Qualified Prof YP650 Community Rehab Prg (Shelter Work)

YA353 Assertive Engagement Assoc./Para Prof YP660 Day Activity

YA389 Supported Employment Long Term Vocational – IDD

YP710 Supervised Living – Low

YA390 Supported Employment – Individual - IDD YP720 Supervised Living – Mod

YM050 Personal Care YP730 Community Respite

YM645 Long Term Support - MH YP740 Family Living – Low

YM700 Independent Living – MR/MI YP750 Family Living – Mod

YM755 Family Living – High YP760 Group Living – Low

YM811 Supervised Living – 1 Residential YP770 Group Living – Moderate

YM812 Supervised Living – 2 Residential YP780 Group Living – High

YM813 Supervised Living – 3 Residential YP790 Detox – Social Setting

YM814 Supervised Living – 4 Residential YP820 Inpatient Hospital

YM815 Supervised Living – 5 Residential YP821 3-Way Hospital Contract

YM816 Supervised living – 6 Residential YP851 Public Psychiatry – Administrative Functions

YP852 Public Psychiatry – Consultative Services


Enhanced Mental Health & Substance Abuse Service Codes for IPRS & Medicaid Please check (√) all that apply. (Only the services you have an existing agreement with Sandhills Center.)

Check

(√) Procedure

Code Description

0183 Therapeutic Leave H0010 Non-Hosp Medical Detox H0012HB Comm Residential Tx-Adult H0013 Medical Comm Residential Tx H0014 Ambulatory Detox H0015 Alcohol and Drug Services Intensive Outpatient H0019UQ Residential Level III 1-4 beds (Former Y2348) H0019US Residential Level III 5+ beds (Former Y2349) H0019US Residential Level IV (Former Y2360) H0020 Methadone Administration H0035 Partial Hospital H0040 Assertive Community Treatment Program (ACTT) H0046 High Risk Intervention Level I H2011 Mobil Crisis Management H2012HA Day Treatment – Child H2015HT Community Support Team H2017 Psychosocial Rehabilitation H2020 Residential Level 2 Group Home-High Risk H2022 Intensive In-Home H2033 Multi-Systemic Therapy H2035 SA Comprehensive Outpatient Treatment H2036 Medically Supervised Detox/Crisis Facility S5145 Child Foster Care, Therapeutic, Level II S9484 Crisis Intervention (Facility Based Crisis) S9484A Facility Based Crisis Program-Children and Adolescents T1023 Diagnostic Assessment

B-3 Medicaid Services Only Please check (√) all that apply. (Only the services you have an existing agreement with Sandhills Center.)

Check (√)

Procedure Code Description

H2023U4 Supported Employment – IDD H2023U4HE Supported Employment-MH H2023HQU4 Supported Employment Group H2026U4 Long Term Supported Employment - IDD H2026U4HE Long Term supported employment—MH H0038U4 Peer Support H0038HQU4 Peer Support Group H0045HAU4 Individual Respite – Child H0045HBU4 Individual Respite - Adult H0045HAHQU4 Respite Group - Child H0045HBHQU4 Respite Group – Adult T2041U4 Community Guide


Innovations Medicaid Services Codes Only

Please check (√) all that applies (Only the services you have an existing agreement with Sandhills Center.) Check

(√) Procedure

Code Description Check

(√) Procedure

Code Description

H2011HI Primary Crisis Response T2013TFER Community Living and Supports-Enhanced Rate

H2015 Community Networking T2013TFHQ Community Living and Supports-Group

H2015HQ Community Networking Group T2014 Residential Supports Level 2 H2015U1 Community Networking Class/Conf. T2020 Residential Supports Level 3 H2016 Residential Supports Level 1 T2021 Day Supports – Ind. H2016HI Residential Supports Level 4 T2021HQ Day Supports – Grp. H2025 Supported Employment-Individual T2025 Specialized Consultative Service H2025HQ Supported Employment – Group T2025U1 Financial Supports

H2025TS Supported Employment-Long Term Follow Up

T2025U2 FM Supplies

H2025TSHQ Supported Employment – Long Term Follow Up Group

T2025U3 Crisis Behavioral Consultation

S5110 Natural Supports Education T2027 Day Supports – Developmental Day S5111 Natural Supports Educ. – Conf. T2029 Assistive Technology: Equip. Supplies S5150 Respite Care – Community Individual T2033 Supported Living-Level 1 S5150HQ Respite Care –Community Group T2033HI Supported Living-Level 2 S5150US Respite Care –Community Facility T2033TF Supported Living-Level 3 S5165 Home Modifications T2034 Out of Home Crisis T1005TD Respite Care Nursing-RN T2038 Community Transition Supports T1005TE Respite Care Nursing-LPN T2039 Vehicle Adaptions T1999 Individual Goods & Services T2041 Community Guide/Navigator

T2013TF Community Living and Supports T2041U1 Community Guide/Navigator Training – Employer


ICF – IID Medicaid Service Only

Please check (√) all that apply.

Check

(√) Procedure

Code Description

0183 Therapeutic Leave ICF - MR 0100 ICF-MR

PRTF Medicaid Only Service Code

Please check (√) all that apply.

Check

(√) Procedure

Code Description

0183 Therapeutic Leave PRTF 0911 PRTF

If you are currently providing a service that is NOT listed above, please type the service code and description below.

Procedure Code Description



P.O. Box 9, West End, NC 27376 24-Hour Access to Care Line: 800-256-2452

TTY: 1-866-518-6778 or 711 Serving Anson, Guilford, Harnett, Hoke, Lee, Montgomery,

Moore, Randolph & Richmond Counties

Attestation Statement

No Stamps or Copies Please (Original Only) This Application is to be signed by the individual who has authorization to submit an application on behalf of this

agency/facility.

All information submitted by me in this application, as well as any attachments or supplemental information, is true, current, and complete to my best knowledge and belief as of the date of signature below. I fully understand that any significant misstatement in this application may constitute cause for denial of my application or termination of a resulting participation agreement. By application for membership in Sandhills Center Network, I signify my willingness to appear for an interview in regards to my application. I authorize Sandhills Center to consult with administrators and members of the medical staffs of hospitals or institutions with which I have been associated and with other, including past and present malpractice carriers, who may have information bearing on the questions in this application. Upon request, I will obtain and provide to Sandhills Center materials pertaining to my qualifications and competence, including, materials relating to complaints filed, any disciplinary actions, suspensions, or actions to curtail my medical - surgical privileges. I further consent to the inspection by representatives of Sandhills Center of all documents that may be material to an evaluation of my professional qualifications and competence. I understand and agree that I, as an applicant, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubt about such qualifications. I release from liability all representatives of Sandhills Center for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and I release from any liability, all individuals and organizations that provide information to Sandhills Center in good faith and without malice concerning this application and I hereby consent to the release and verification of information relating to any disciplinary actions, suspensions, or curtailment of medical - surgical privileges to Sandhills Center. I understand that if my application is rejected for reasons relating to my professional conduct or competence, Sandhills Center may report the rejection to the appropriate state licensing board and/or National Practitioner Data Bank. In the event I am accepted for participation in Sandhills Center Network, I hereby consent to Sandhills Center for inspection of my patient records relating to Sandhills Center members as necessary for its peer and utilization review purposes as permitted by state or federal laws and regulations. I further agree to notify Sandhills Center in a timely manner (not to exceed 30 days) of any changes to the information requested on the application.

Print Name of Agency / Facility above

Print Name of Authorized Agent to sign the application on behalf of the Agency / Facility above

Signature of Authorized Agent above Date



P.O. Box 9, West End, NC 27376 24-Hour Access to Care Line: 800-256-2452

TTY: 1-866-518-6778 or 711 Serving Anson, Guilford, Harnett, Hoke, Lee, Montgomery,

Moore, Randolph & Richmond Counties

Trading Partner Agreement

TRADING PARTNER AGREEMENT– Electronic Data Interchange (EDI) This document constitutes an agreement to the following provisions for exchanging Electronic Data Interchange (EDI) between the Trading Partner and Sandhills Center (SHC). The Trading Partner agrees: 1. To conform to the requirements for Administrative Simplifications as defined in the provisions of the Health

Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L. 104-91), and regulations promulgated there under and to take no action which adversely affects SHC’s HIPAA compliance.

2. That it will promptly notify SHC of any and all unlawful or unauthorized disclosures of confidential information or

protected health information (PHI) that comes to its attention and will cooperate with SHC in the event any litigation arises concerning the unauthorized use, transfer, or disclosure of either confidential or protected health information.

3. That it will use sufficient security procedures to ensure that all transmissions of documents are authorized and

protect all participant-specific data from improper access. 4. That it will ensure that all files transmitted comply with the appropriate national Electronic Data Interchange (EDI)

Transaction Set Implementation Guide, in effect on the date of transmission, as provided by the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

5. That it will establish and maintain procedures and controls so that information concerning SHC health plan

participants or any information obtained from SHC, shall not be used by agents, officers, or employees of the trading partner other than for its sole intended purpose.

6. That the information stated in any EDI Trading Partner Profile(s) submitted with this Agreement, or subsequently is

correct and complete. 7. That it will allow SHC 30 days after receipt of written notice from the Trading Partner if there is any change in the

trading partner representative or location where electronic transactions are sent. 8. That it is bound by this written agreement to comply with state and federal law, if the trading partner is an

intermediary for the billing provider. SHC agrees:

1. To conform to the requirements for Administrative Simplifications as defined in the provisions of the Health

Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L. 104-91), and regulations promulgated there under and to take no action which adversely affects the trading partner’s HIPAA compliance.

2. That it will use sufficient security procedures to ensure that all transmissions of documents are authorized and protect all participant-specific data from improper access.

3. That it will ensure that all files transmitted comply with the appropriate national Electronic Data Interchange (EDI)

Transaction Set Implementation Guide, in effect on the date of transmission, as provided by the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

Both parties agree:

1. That documents will not be considered as received and no responsibility assigned until accessible at the receiving party’s computer.

2. That upon receiving any documents, to prepare and transmit a timely response or an acknowledgement of transaction

receipt. If acceptance of a document is required, a document is not considered received until an acceptance acknowledgement is returned.

3. To notify the other party within a reasonable time frame if any transmitted data are received in an unintelligible or

garbled form. 4. That each party will provide and maintain the equipment, software, services, and testing necessary to transmit and

receive documents. 5. To conduct business and perform as required by this agreement and any applicable rules or regulations. 6. That this agreement will remain in effect until terminated by either party with at least 30 days prior written notice.

The notice will specify the effective date of termination, but will not affect the obligations or rights of either party prior to the effective date of termination. This agreement is automatically terminated in the event the trading partner is disqualified through a federal administrative action or state action. That any document transmitted according to this agreement will be considered an original and signed when received.

Effect of Termination

1. Except as provided in paragraph (2) of this section or in the contract or by other applicable law or agreements, upon

termination of this agreement and services provided by the Trading Partner, for any reason, the Trading Partner shall return or destroy all Protected Health Information received from SHC, or created or received by Trading Partner on behalf of SHC. This provision shall apply to Protected Health Information that is in the possession of subcontractors or agents of the Trading Partner. Trading Partner shall retain no copies of the Protected Health Information.

2. In the event that Trading Partner determines that returning or destroying the electronic protected health information

is not feasible, Trading Partner shall provide to SHC notification of the conditions that make return or destruction not feasible. Trading Partner shall extend the protections of this agreement to such Protected Health Information and limit further uses and disclosures of such Protected Health Information to those purposes that make the return or destruction infeasible, for so long as Trading Partner maintains such Protected Health Information.

Trading Partner Name Street Address Line 1 (Site/Physical Address, not a P.O. Box)

Street Address Line 2

City, State, Zip Code

Contact Information (Phone Number, email address) ____________________________________________________________________________________ Signature of Applicant or Authorized Individual Date Printed Name and Title

___________________________________________________________________________________ For Sandhills Center for MH, DD & SAS use only

Trading Partner’s EDI Submitter ID: Sandhills Center for MH, DD & SAS Receiver ID: SHC303 Please return completed form to: Sandhills Center for MH, DD & SAS P.O. Box 9 West End, NC 27376 Attn: EDI Coordinator, Information Technology Department

AUTHORITY FOR RELEASE OF INFORMATION State Access Only

Name Check Access I authorize the North Carolina Department of Justice through the State Bureau of Investigation to perform a North Carolina name-based criminal history record information check in connection with my application for employment, my employment or volunteer services with SANDHILLS CENTER FOR MENTAL HEALTH pursuant to DHHS-LONG TERM – STATE AND FED – NCGS 122C-80B/131 D-40A A1/131D-40A A1.

(type or print clearly)

Last Name First Middle Maiden

Social Security # Date of Birth Sex Race

I understand that the North Carolina State Bureau of Investigation, officials and employees shall not be held legally accountable in any way for providing this information to the above named agency, and I hereby release said agency and persons from any and all liability which may be incurred as a result of furnishing such information. I further understand that the above named agency cannot provide a HARD COPY of the results of this criminal history record check to me. *Disclosure of social security number is entirely voluntary and not required. If disclosed, the social security number will be utilized to assist with accurate identification/exclusion of possible criminal history records. Applicant’s/Employee’s/Volunteer’s Signature _______________________________________ Date _______________________________________ This form must be maintained on file with the above named agency for one year. UPON COMPLETION OF THIS FORM, MAIL A PHOTOCOPY TO THE ADDRESS INDICATED BELOW:

State Bureau of Investigation Criminal Information and Identification Section Attn: Applicant Unit Post Office Box 29500 Raleigh, North Carolina 27626-0500 ORI # HCP000008 – SANDHILLS CENTER FOR MENTAL HEALTH

HCP000008



Provider Insurance Coverage – Attestations Directions: These attestations are required as proof that the signatory agency/practice (CONTRACTOR) (1) does not transport Sandhills Center’s members and therefore does not maintain Automobile Liability Insurance; and/or (2) is not required by law to acquire and maintain Workers’ Compensation/Employer Liability Insurance; and (3) holds coverage under its Comprehensive General Liability, Professional Liability and Automobile insurance, if applicable, for the CONTRACTOR’s employees and agents. The third and fourth attestations, regarding the scope of the CONTRACTOR’s insurance coverage, and notice of changes to CONTRACTOR’s insurance coverages, are required by the State of North Carolina and cannot be waived.

Provider (CONTRACTOR) Name:

Attestation No. 1 -- Automobile Liability Insurance Select one (1) of the following in this section:

(Initials)

CONTRACTOR uses and maintains insurance coverage for all vehicles owned, non-owned, and hired that are used by CONTRACTOR “for the provision of services under the Contract.” If not already submitted, CONTRACTOR will provide Sandhills Center with a Certificate of Insurance reflecting the requirements of the contract.

(Initials)

CONTRACTOR attests that it does not use any automobile or other vehicle for the provision of services under its Contract with Sandhills Center.

Attestation No. 2 – Workers’ Compensation and Employer Liability Insurance Select one (1) of the following in this section:

(Initials)

CONTRACTOR maintains Worker’s Compensation and Employer Liability Insurance to the extent required by North Carolina Law.” If not already submitted, CONTRACTOR will provide Sandhills Center with a Certificate of Insurance reflecting the requirements of the contract.

(Initials) CONTRACTOR attests that it is not required under North Carolina law to secure and maintain Workers’ Compensation and Employer Liability Insurance.

Attestation No. 3 – Scope of CGL and PL coverage, and Automobile coverage (if applicable)

(Initials)

The scope of the CONTRACTOR’s CGL and PL insurance, as well as its Automobile insurance (if applicable), must cover all of the CONTRACTOR’s employees and agents.

Attestation No. 4 – Notice of Change in Insurance Policy Status

(Initials)

CONTRACTOR attests that CONTRACTOR’s insurance coverages cannot be suspended, voided, canceled or reduced unless the agency/practice gives thirty (30) calendar days prior written notice to Sandhills Center.

By signature and date below, CONTRACTOR attests that each of the initialed statements accurately reflect the agency/practice’s insurance coverages and requirements as set out by the contract with Sandhills Center.

Printed Name Signature

Printed Title Date

Indemnification Agreement: By signing this waiver, I hereby agree to indemnify and hold harmless Sandhills Center from all losses, costs, damages, claims, liabilities and expenses (including attorneys’ fees and court costs) whatsoever, which may arise or be claimed against Sandhills Center, for any loss, injuries or damages, consequent upon or arising from any acts, omissions, neglect or fault in connection with Sandhills Center’s reliance upon this waiver.

22 W

aive

r A

uto

& W

C Insu

rance

Cove

rage

ACKNOWLEDGEMENT AND AUTHORIZATION FOR SOCIAL SECURITY NUMBER CHECK

I, , hereby authorize Sandhills Center to verify my

(Print Name)

Social Security Number through a third party consumer reporting agency for credentialing/re- credentialing purposes. This verification will be conducted by American DataBank, 110 Sixteenth St., 8th

Fl., Denver, CO 80202, 1-800-200-0853, www.americandatabank.com. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

All of the information requested below is mandatory and must be provided. Please type or print clearly.

Last Name: First Name: Middle:

Social Security Number*: Date of Birth*:

Present Address:

City/State/Zip:

Email Address: Signature: Date:

*This information is limited to verification of the individual’s Social Security Number and will not be used for employment/hiring purposes. American DataBank’s privacy policy can be found at http://www.americandatabank.com/consumer-information/privacy-policy/.

qmcappd 10/12/2017

Provider Agency/Facility Application For IPRS (State Funds ...

Documents

Transcript of Provider Agency/Facility Application For IPRS (State Funds ...