APPLICATION FOR CERTIFICATION. As A Provider in the Community Mental Health for Central Michigan Provider Network

Transcription

1 APPLICATION FOR CERTIFICATION As A Provider in the Community Mental Health for Central Michigan Provider Network Contents: I. Instructions for completing application II. III. IV. Appeals Procedure Application Form Sec. 1 - Identifying Information Sec. 2 - Licensure/Certification/Accreditation Sec. 3 - Provider Profile Sec. 4 - Site Profile Information Verification and Release Form

2 Community Mental Health for Central Michigan Provider Network I. Instructions for completing application: Thank you for your interest in becoming a provider of the Community Mental Health for Central Michigan (CMHCM) Network of services for persons who have serious mental illness, serious emotional disturbance, or developmental disability. CMHCM s determination about your status as a provider in this system will be made based on evaluation of the contents of this application. It is important that you review this application carefully and submit all requested documents with the application. Submit completed application and appended documents to: Contract Management Community Mental Health for Central Michigan 301 South Crapo, Suite 100 Mt. Pleasant, MI Phone (989) Fax (989) II. Appeals Process: In the event a service provider wishes to appeal a denial of certification, the provider must draft a letter to the Provider Network Manager at Community Mental Health For Central Michigan within ten (10) days from the date of the letter of determination. The letter should concisely state the basis for the appeal. Additional documentation which supports the rationale for appeal should be attached. All appeals will be reviewed within thirty (30) days of the Agency s receipt of the letter of appeal. If the appeal is not satisfactorily resolved, the provider may, within ten (10) business days, file an appeal with the Executive Director. The Executive Director will notify the provider within ten (10) business days upon receiving the request for appeal. If the provider is not satisfied with the Executive Director s determination, he/she may further appeal to the Board of Directors. The Board may choose to designate select members of the Board to act as an Appeals Committee. The request for reconsideration of the Executive Director s decision shall be submitted in writing by the grievant to the Board within ten (10) business days of the Executive Director s denial notice. Both the provider and CMHCM may be represented by advocates at a meeting with the Board or Appeals Committee. Both the provider and CMHCM may present a reasonable number of witnesses at this meeting. Both the provider and CMHCM may file written documentation at this meeting. The Board or Appeals Committee shall review the evidence presented and shall be solely responsible for determining the outcome of the appeal. Notice of the Board s determination shall be provided to the provider within ten (10) business days of the review meeting. The decision of the Board of Appeals Committee is final.

3 Community Mental Health for Central Michigan III. Application for Certification as a Provider SECTION 1. IDENTIFYING INFORMATION Name of Organization/Provider: Name & Title of Executive Director: Name & Title of Medical Director: Name & Title of Program Director or Mental Health Administrator of inpatient facilities: Name & Title of Business Manager: Name & Title of MIS Administrator: Name & Title of QI Coordinator: Billing Address Address City State ZIP ( ) Phone Number ( ) Fax Number Mailing Address Address City State ZIP ( ) ( ) Phone Number Fax Number Medicaid Number: Payee Name: (if applicable) Tax ID Number: National Practitioner Identification Number: Also attach a copy of your agency s: W-9 Request for Taxpayer Identification Number and Certification Certificate of Liability Insurance

4 Section I (continued) Type of Organization: Federal State County City Private Non-Profit Private For-Profit Other: (Complete if applicable) Name of Parent Corporation or Owner of Facility: Name & Title of the Corporate Executive Officer: Address of Corporation or Owner of Facility: City, State & ZIP: Phone Number: ( ) Fax Number: ( ) SECTION 2. LICENSURE/CERTIFICATION AND/OR ACCREDITATION PLEASE ATTACH DOCUMENTATION IF APPLICABLE Is the Organization/Provider state licensed/certified? Yes No Type of licensure/certification: Licensing/certifying state agency: State license/certification number: (Please attach a current copy with number & expiration date.) If your organization has more than one applicable state, county or city license/certification, please indicate type, number and expiration date: Has your organization been reviewed and accredited by (if yes, circle relevant organization and attach letter from your accrediting body): TJC CARF COA AOA AC (accreditation after 11/6/97) Please indicate any other accreditation or certification:

5 SECTION 3. 3A Profile PROVIDER PROFILE 1. Has the provider s state license/certification ever been revoked, suspended or restricted? 2. Is there action pending to revoke, suspend or limit the provider's license/certification? 3. Has the provider ever had its accreditation revoked, suspended or restricted? 4. Is there action pending to revoke, suspend or limit the provider's accreditation? 5. Has the provider ever had any sanctions imposed by Medicare and/or Medicaid? 6. Has the provider ever been denied professional liability insurance or had its insurance canceled or renewal denied? 7. Has the provider ever been a defendant in any lawsuit in regard to the practice of health or substance abuse treatment? 8. Has the provider had any malpractice claims in regard to the practice of mental health or substance abuse? Yes No N/A NOTE: If you have answered yes to any of the above questions, please provide the current status and details on a separate sheet of paper. Please include the following: description of incident, including correspondence with state licensing boards, and/or detailed description of any litigation, including settlements, court awards, etc. Please feel free to include a personal summary of the events; however, your application cannot be processed without the requested documentation for each item. 3B Policy & Practice (PLEASE ATTACH ALL POLICIES AND PROCEDURES) Yes No Please indicate page # 1. Does the provider have policy/practice for access to services? (Including timeliness of response to referral, availability of services, access to services, emergency services, etc.) 2. Does the provider have a credentialing and re-credentialing policy/practice? 3. Does the provider conduct primary verification of credentials? 4. Does the provider conduct criminal background checks at time of hire and periodically during employment? 5. Does the provider assess staff competency on an ongoing basis through performance evaluation? 6. Does the provider have a policy/practice regarding ongoing professional development? (Including orientation and ongoing training) 7. Does the provider assess the cultural backgrounds of persons served and provide training to staff on any identified cultural issues? 8. Does the provider's policy on treatment planning describe person-centered planning? 9. Does the provider s policy on treatment planning include consumer involvement in the development of the plan of service? 10. Does the provider have a policy/practice regarding serving persons with Limited English Proficiency? 11. Does the provider have a continuous quality improvement (CQI) policy/practice? 12. Does the provider have a process to assess customer satisfaction? 13. Does the provider have policies and procedures for clinical standards of care? 14. Do the clinical standards of care include defined treatment philosophies and orientations? 15. Does the provider have policy/procedure describing case records, record review, security and case record access? 16. Does the provider have a corporate compliance policy? 17. Does the provider have a safety management plan that includes: a. General Safety b. Security c. Hazardous materials and wastes d. Emergency preparedness e. Fire f. Medical equipment g. Utility systems h. Physical environment i. Infection control

6 SECTION 4. SITE PROFILE 4A Site Information (if applicable) Please complete Section 4 for each of your Program Sites. Make additional copies of this section as needed. Please indicate professional staff for each program on the enclosed form for Licensed Qualified Professionals (exclude residential direct care staff). Name of Site: Program Director: Address City State ZIP ( ) Phone Number ( ) Fax Number ( ) TTY Number, if applicable Hours of Operation: Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday: Yes No Does this service address comply with ADA (Americans with Disabilities Act) regulations? Is this service address accessible by bus? 4B Special Accommodations Please indicate if you have made any accommodations at this site for these populations (check all that apply): Hearing Impaired Visually Impaired Speech Impaired Other Disabled (Please specify)

7 4C Programs and Services for Adults and Children with Mental Illness or Developmental Disabilities Please check the programs offered at this site. Programs/Services MI Child/ Adolescent Less Than 18 MI Adult 18 + MI Older Adult 65 + All Ages DD Assertive Community Treatment Assessments Behavior Management Review Child Therapy Clubhouse Psychosocial Rehabilitation Community Living Support Community Living in Licensed Residential Settings Crisis Interventions Crisis Residential Services Family Therapy Family Support and Training Fiscal Intermediary Services Health Services Home-Based Services Individual Therapy Inpatient Psychiatric Hospitalization Intensive Crisis Stabilization Medication Administration Medication Review Occupational Therapy Personal Care in Licensed Residential Settings Physical Therapy Skill Building Assistance Speech, Hearing and Language Substance Abuse

8 Supports Coordination Supported/Integrated Employment Services Programs/Services MI Child/ Adolescent Less Than 18 MI Adult 18 + MI Older Adult 65 + All Ages DD Targeted Case Management Transportation Treatment Planning Wraparound Services

9 Section 4D Note: Add pages as necessary. Licensed Qualified Professionals PLEASE ATTACH ALL LICENSURES - Professional and Liability Insurance Name Degree Licensure (Include expiration date) Job Title NPI Number

10 Community Mental Health for Central Michigan PROVIDER APPLICATION VERIFICATION OF INFORMATION AND AUTHORIZATION FOR RELEASE OF INFORMATION For purposes of making this application for participation in the Community Mental Health for Central Michigan (CMHCM) Provider Network, the Organization certifies that all information provided to CMHCM is true and correct to the best of the Organization's knowledge and belief. The Organization agrees to promptly notify CMHCM if there are any material changes in the information provided, whether prior to or after acceptance as a CMHCM participating provider. The Organization understands and agrees that if CMHCM determines that this application contains any significant misstatements, misrepresentations or omissions, CMHCM s acceptance of this application for participation and any subsequent participating provider agreement which CMHCM enters into with the Organization will be voidable at CMHCM's sole discretion. The Organization hereby authorizes the release to CMHCM of any information from any source including but not limited to information from an individual, an entity or governmental agency for purposes of verifying information obtained in the attached application or any preferred provider re-application information. The Organization agrees to hold CMHCM and the informant harmless from any liability to the Organization for providing such information. The Organization hereby further authorizes CMHCM to release any and all information related in any way to the Organization's professional practice to any person, entity or governmental agency which: (a) provides CMHCM with an authorization signed by the Organization; or (b) has a legal right to know under any state or Federal law. The Organization agrees to hold CMHCM harmless from any liability for providing any such information as specified herein. I authorize CMHCM to perform a criminal background check on all parties applying for network membership. The Organization understands and agrees that the certifications, authorizations and other provisions contained herein shall remain in force for so long as this application is pending and, if accepted for participation, for so long as the Organization's participating provider agreement with CMHCM remains in force. The Organization further understands and agrees that: (a) The Organization has the burden of producing all information required or requested by CMHCM in connection with this application; (b) CMHCM is under no obligation to complete the processing of this application until all information requested is provided; (c) CMHCM has the sole discretion to determine whether or not the Organization will be accepted as a participating provider; and (d) in the event that CMHCM decides not to accept the Organization as a participating provider, the Organization may initiate administrative appeal procedures as defined in the instructions for completing the application. Name of Organization: Authorized Representative: Print Name Title Signature: Date: