This process involved the collection and review of the following items for your organization:

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1 Dear Provider, Highmark Blue Shield is required by federal law and the American Accreditation HealthCare Commission to initially credential providers who participate in Highmark s preferred provider networks and in Highmark s Medicare Advantage network. It has come to our attention that you would like to participate with the plan. This process involved the collection and review of the following items for your organization: 1. A current copy of the state healthcare license, if required, and if licensure is not required, your state business license must be submitted. 2. Documentation of Medicare Welcome Letter and NPI Provider Numbers. A copy of the most recent state agency survey letter for Medicare Certification, if applicable. If there were deficiencies, must include the survey report with plan of correction and documentation that this was approved by the state agency. 3. A copy of a current Professional Liability Insurance Certificate. 4. A copy of applicable accreditation certificates with expiration dates. Thank you for your continued interest in participating with Highmark Blue Shield. Your assistance and cooperation are essential. Please fax all of the documents to your market specific location: Central PA Providers Fax: Counties include: Adams, Berks, Centre, Columbia, Cumberland, Dauphin, Franklin, Fulton, Juniata, Lancaster, Lebanon, Lehigh, Mifflin, Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Union, York Western PA Providers Fax: Counties Include: Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington, Westmoreland Northeastern PA Region Providers Fax: Bradford, Carbon, Clinton, Lackawanna, Luzerne, Lycoming, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne, Wyoming Delaware Providers Fax: West Virginia Providers Fax: Sincerely, Office of Provider Information Management Highmark Blue Shield V12-2/26/18 1

2 A. GENERAL PROVIDER INFORMATION HIGHMARK BLUE SHIELD PA, WV, DE BEHAVIORAL HEALTH APPLICATION *Provider Legal Name: *Provider DBA Name: *Associated with the Tax ID Provider Service Area (circle all those that apply): Pennsylvania West Virginia Delaware Select the application type(s): Commercial Medicaid Both Commercial and Medicaid Medicare Advantage * For WV participation is required in all products. Are you currently a Highmark contracted practice? Yes No If yes, is the NPI the same? Yes No NPI: If no, also complete Request for Assignment Account form and separately fax to Provider Control: (Enter appropriate letter from below) a. Not-For-Profit Corporation b. Sole Proprietorship c. Partnership d. Corporation e. Other Do you bill on a: 1500 UB *Applications must include required supporting documentation for the following: *Provider Federal Tax ID Number Provider Year End: (Fiscal or Calendar) *Medicare Certified Yes No (Circle One) o If Yes, Medicare Number: *Medicaid Certification Number: * Provider State License, Permit or Registration Number Initial Registration Date Current Expiration Date * Provider Accreditation Name & Number Initial Accreditation Date Current Expiration Date * Provider National Provider Identifier Number V12-2/26/18 2

3 B. PROVIDER LOCATION INFORMATION ** Please complete appendix A for any additional service locations. Provider Service Address: Must include zip+4 County: Phone Number ( ) - Credentialing Contact Name Customer Contact Number ( ) - Fax Number ( ) - Web Site PROMISE ID Parking: Free Pay Billing / Check/Remit Address Must include zip+4 Billing Phone Number: ( ) - Billing Fax Number: ( ) - C. PROVIDER CONTACTS Name of Application Contact Person: Application Contact Person Title Application Contact Person Address Phone Number ( ) - Fax Number ( ) - Address Name of Parent Corporation (if applicable) Address of Parent Corporation: Parent Corp. Contact Name Contact Number ( ) - V12-2/26/18 3

4 Name of Chief Executive Officer (if applicable) Title Address: Phone Number ( ) - Fax ( ) - Address Name of Chief Financial Officer (if applicable): Title Address: Phone Number ( ) - Fax ( ) - Address Name of Contract Administrator (if applicable): Address: Title Phone Number ( ) - Fax ( ) - Address D. INSURANCE Name of Facility Liability Insurance Carrier Address of Insurance Carrier Phone Number ( ) - Fax ( ) - Address To what limits is the Facility insured? Each Occurrence Aggregate V12-2/26/18 4

5 *Please provide a copy of the current Professional Liability Insurance documentation. E. ACCREDITATION / CERTIFICATION Please attach a copy of provider s most recent letter of accreditation/certification. Include any commendations, limitations or conditions. F. PROVIDER SERVICES Please indicate the services to be provided by checking the boxes below. Please note the minimum hourly requirements for IOP and PHP. Providers performing inpatient, or both inpatient and outpatient, services will submit claims via UB. Providers performing only outpatient services will submit claims via 1500, with some exception. Alcohol and Drug Counseling Agency DE Medicaid Only Also complete the Alcohol and Drug Counseling Agency Addition form attached as Appendix B Behavioral Health Facilities/Centers Location Name: Location Address: NPI: PA WV DE Inpatient Mental Health Substance Abuse Acute Detox Residential Treatment Center (RTC) N/A Please Check: Adult (18+) Adolescent (13-17) Child (0-12) N/A Please Check: Adult (18+) Adolescent (13-17) Child (0-12) Please Check: Adult (18+) Adolescent (13-17) Child (0-12) Outpatient Mental Health Substance Abuse Intensive Outpatient Program (IOP) Requires greater than or equal to 5 hours per week of face to face client services. This hours should V12-2/26/18 5

6 PA WV DE include: Psychiatric evaluation completed within the first week, to include medication review. (If length of stay exceeds 4 weeks, follow up psychiatric evaluation should occur at least once per month thereafter.) 2. Comprehensive psychosocial evaluation should be completed within first program day and include mental health and substance abuse assessment. 3. Other required services include individual, group, family, and psychoeducation services as indicated by the patient s treatment plan. ** The applicant must meet this criteria for the specialty type. Partial Hospitalization (PHP) Requires greater than or equal to 4 hours per day at least 3 days per week of face to face client services per week. Those hours should include: 1. Psychiatric evaluation completed within the first week, to include medication review and mental status review at least once per week. 2. Comprehensive psychosocial evaluation should be completed within first program day and include mental health and substance abuse assessment. 3. Other required services include individual, group, family, and psychoeducation services as indicated by the patient s treatment plan. ** The applicant must meet this criteria for the specialty type. Methadone Clinic Separately Billed Outpatient Services Autism in PA and DE Only Clinical Director Information Name of Clinical Director: V12-2/26/18 6

7 Please indicate the specialty of the Clinical Director: Psychiatrist Psychologist LCSW LPC Family Practice MD/DO Internal Med MD/DO Addiction Medicine MD/DO CRNP Behavioral Health Other: Is the Clinical Director a Highmark Participating Provider? Yes No Clinical Director Specialty: Date of Birth: CAQH ID: Practitioner NPI: Certified in Addiction Medicine by the American Osteopathic Association (AOA) or the American Society of Addiction Medicine (ABMS) or American Society of Addiction Medicine (ASAM)? Yes No Address: Phone Number ( ) - Fax ( ) - Address 1. Can the Facility provide 24 hour, 7 days a week coverage? If no, please specify hours available. M T W T F Sat. Sun. 2. Will the Facility provide a Customer Service/Technical Support telephone number or dedicated phone line? Yes No If Yes, please attach a listing of the addresses and phone numbers of the Call Centers. 3. Does the Facility have the capability for EFT and NaviNet to facilitate communications and electronic billing between Highmark and you? If yes, please provide the name, phone number, Address and address of person using Navinet: Name: V12-2/26/18 7

8 Address: Phone number: Address: 4. If no, please give timeframe for the Facility to have the capability? **Electronic connectivity is a requirement. 5. Please check the counties where provider expects to provide services. PA Counties - All If not, all, select the applicable counties from the chart below. WV Counties- All If not, all, select the applicable counties from the chart below. PA and WV Counties- All If not, all, select the applicable counties from the chart below. DE Counties All - If not, all, select the applicable counties from the chart below. Pennsylvania Counties Adams Fayette Philadelphia Allegheny Forest Pike Armstrong Franklin Potter Beaver Fulton Schuylkill Bedford Greene Snyder Berks Huntingdon Somerset Blair Indiana Sullivan Bradford Jefferson Susquehanna Bucks Juniata Tioga Butler Lackawanna Union Cambria Lancaster Venango Cameron Lawrence Warren Carbon Lebanon Washington Centre Lehigh Wayne Chester Luzerne Westmoreland Clarion Lycoming Wyoming Clearfield McKean York Clinton Mercer Columbia Mifflin Crawford Monroe Cumberland Montgomery Dauphin Montour Delaware Northampton Elk Northumberland Erie Perry West Virginia Counties Barbour Hardy Pleasants Berkeley Jackson Pocahontas Boone Jefferson Preston Braxton Kanawha Putnam V12-2/26/18 8

9 Brooke Lewis Raleigh Cabell Lincoln Randolph Calhoun Logan Ritchie Clay Marion Roane Doddridge Marshall Summers Fayette Mason Taylor Gilmer McDowell Tucker Grant Mercer Tyler Greenbrier Morgan Wirt Hampshire Nicholas Wood Hancock Ohio Wyoming Harrison Pendleton Mineral Upshur Mingo Wayne Monongalia Webster Monroe Wetzel Delaware Counties Kent New Castle Sussex G. FINANCIAL PERFORMANCE Please enclose the Facility s most recent CPA audit report and management letter (if available) or budgeted financial statements (if a new facility and no audited statements are available). H. ADDITIONAL INFORMATION Please provide any additional information that will assist in determining the need for the Facility or Ancillary and rationale for Highmark Blue Shield to contract with the Facility or Ancillary provider to be a participating provider. I. CONDITIONS OF APPLICATION By applying for participation status with Highmark Blue Shield, the Facility hereby represents warrants and agrees that: Any material misstatements in or omissions from this application constitute cause for denial, at Highmark s discretion, of the application and that Highmark may terminate an Agreement that is or will be entered into between the Provider and Highmark Blue Shield; The submission of this application in no way constitutes an assurance of acceptance for participation with Highmark Blue Shield and nor does it constitute a contractual arrangement with Highmark Blue Shield. Highmark maintains various business reasons and protocols applicable to its network management; therefore, non-acceptance is not necessarily a reflection of the quality of the Facility; and V12-2/26/18 9

10 Facility s signatory has full binding legal authority and is authorized by the Facility, on its own behalf and on behalf of each of its participating providers, to submit this application and to provide additional information to Highmark Blue Shield in connection with this application. All information submitted in this application is true and complete to the best of my knowledge and belief. A copy of this statement constitutes written authorization and requires facility to release any and all documentation relevant to this application. Such copy shall have the same force and effect as the signed original. Date Authorized Signature & Title V12-2/26/18 10

11 H. PLEASE REVIEW THE SUBMISSION INFORMATION BELOW BASED ON YOUR LOCATION Central PA Providers Fax: Counties include: Adams, Berks, Centre, Columbia, Cumberland, Dauphin, Franklin, Fulton, Juniata, Lancaster, Lebanon, Lehigh, Mifflin, Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Union, York Western PA Providers Fax: Counties Include: Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington, Westmoreland Northeastern PA Region Providers Fax: Bradford, Carbon, Clinton, Lackawanna, Luzerne, Lycoming, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne, Wyoming Delaware Providers Fax: West Virginia Providers Fax: V12-2/26/18 11

12 MATERIALS CHECKLIST Copy of license/registration/certification (if applicable) Copy of Medicare certification, (if applicable) Copy of most recent letter of accreditation (if applicable) Copy of CPA audit report and management letter and/or budgeted financial statements (if available) Copy of National Provider Identifier documentation from CMS and/or the appropriate CMS-contracted entity Copy of W-9 Form Copy of the current insurance verification (Professional Liability Insurance or Certificate of Insurance) Copy of CMS or State Site Survey V12-2/26/18 12

13 APPENDIX A For multiple locations, please complete the following, as applicable. PA WV DE Alcohol and Drug Counseling Agency DE Medicaid Only Also complete the Alcohol and Drug Counseling Agency Addition form attached as N/A N/A Appendix B Behavioral Health Facilities/Centers Location Name: Location Address: NPI: Inpatient Mental Health Substance Abuse Acute Please Check: Adult (18+) Adolescent (13-17) Child (0-12) Please Check: Adult (18+) Adolescent (13-17) Child (0-12) Detox Please Check: Adult (18+) Adolescent (13-17) Child (0-12) Residential Treatment Center (RTC) Outpatient Mental Health Substance Abuse Intensive Outpatient Program (IOP) Requires > 2.5 hours per day at least 2 per week Partial Hospitalization (PHP) Requires > 4 hours per day at least 3 times per week Separately Billed Outpatient Services Autism in PA and DE Only Medical Director Information Name of Medical Director: Medical Director Specialty: V12-2/26/18 13

14 Certified in Addiction Medicine by the American Osteopathic Association (AOA) or the American Society of Addiction Medicine (ABMS) or American Society of Addiction Medicine (ASAM)? Yes No Address: Phone Number ( ) - Fax ( ) - Address 6. Can the Facility provide 24 hour, 7 days a week coverage? If no, please specify hours available. M T W T F Sat. Sun. 7. Will the Facility provide a Customer Service/Technical Support telephone number or dedicated phone line? Yes No If Yes, please attach a listing of the addresses and phone numbers of the Call Centers. 8. Does the Facility have the capability for EFT and NaviNet to facilitate communications and electronic billing between Highmark and you? If yes, please provide the name, phone number, Address and address of person using Navinet: Name: Address: Phone number: Address: If no, please give timeframe for the Facility to have the capability? **Electronic connectivity is a requirement. 9. Please check the counties where provider expects to provide services. PA Counties - All If not, all, select the applicable counties from the chart below. WV Counties- All If not, all, select the applicable counties from the chart below. PA and WV Counties- All If not, all, select the applicable counties from the chart below. DE Counties All - If not, all, select the applicable counties from the chart below. Pennsylvania Counties Adams Fayette Philadelphia Allegheny Forest Pike Armstrong Franklin Potter Beaver Fulton Schuylkill V12-2/26/18 14

15 Bedford Greene Snyder Berks Huntingdon Somerset Blair Indiana Sullivan Bradford Jefferson Susquehanna Bucks Juniata Tioga Butler Lackawanna Union Cambria Lancaster Venango Cameron Lawrence Warren Carbon Lebanon Washington Centre Lehigh Wayne Chester Luzerne Westmoreland Clarion Lycoming Wyoming Clearfield McKean York Clinton Mercer Columbia Mifflin Crawford Monroe Cumberland Montgomery Dauphin Montour Delaware Northampton Elk Northumberland Erie Perry West Virginia Counties Barbour Hardy Pleasants Berkeley Jackson Pocahontas Boone Jefferson Preston Braxton Kanawha Putnam Brooke Lewis Raleigh Cabell Lincoln Randolph Calhoun Logan Ritchie Clay Marion Roane Doddridge Marshall Summers Fayette Mason Taylor Gilmer McDowell Tucker Grant Mercer Tyler Greenbrier Morgan Wirt Hampshire Nicholas Wood Hancock Ohio Wyoming Harrison Pendleton Mineral Upshur Mingo Wayne Monongalia Webster Monroe Wetzel Delaware Counties Kent New Castle Sussex V12-2/26/18 15

16 APPENDIX B Alcohol and Drug Counseling Agency Addition Form Please note that this form may be used for providers of Highmark Inc. ( Highmark ) and certain of its affiliates: Highmark West Virginia Inc. ( Highmark WV ), Highmark Health Insurance Company ( HHIC ) and Highmark BCBSD Inc. ( Highmark DE ). Highmark, Highmark WVA, HHIC and Highmark DE may each be referred to herein as the Plan. When the term Plan is used, it will mean each Plan that the Provider contracts with as a network provider. This form covers specific products of the Plan, as offered in a Plan s service area and for which the Provider is credentialed. Name of Account (DBA name) Tax ID Group specialty Type 2 (Group) National Provider Identifier Highmark Group Number Main Practice Address Primary physical practice location (PO Box numbers are NOT acceptable) Telephone number: ( ) Fax number: ( ) Member Access Number Patients can call this number to make an appointment for this location ( ) Note: If a practitioner needs to be credentialed, visit the Provider Resource Center via NaviNet or the public website and complete the Initial Credentialing Request Form located under Credentialing Request Process. Practitioner Name Date of Birth License Number Type I NPI (Individual) Social Security Number Specialty Type: LADC CADC Effective Date of Change Deletions Please provide the following information for providers being deleted from the assignment account: Practitioner Name Practitioner Number Effective Date of Change V12-2/26/18 16

17 Assignment Account Agreement of Provider 1. We hereby agree to only bill those services performed by individual providers in the group account. 2. We certify that each individual provider in our account agrees to assign his/her fee to the group account ( our account or account ). 3. We agree that every 1500 claim form submitted will include the provider number of the individual provider who actually performed the service (place in Block 24K of the claim or in any other location as determined in the future). 4. We agree that the group and each individual provider in our account will be jointly and severally liable for any overpayment that the group receives. 5. We agree to notify each applicable plan in writing of any subsequent changes in the composition of the group prior to the effective date of each change. 6. We agree to inform each applicable plan of any change in the group s contractual arrangements that directly or indirectly impact this Assignment Account (PA or DE) or Pay-To Account (WV) or that would necessitate the Plan s payments to be made to some entity other than that designated in this Assignment Account (PA or DE) or Pay-To Account (WV) application. 7. [For PA providers only] We certify that we will not bill for any professional services that are reimbursed through another Pennsylvania Blue Cross Plan. All claims for these services will be submitted on the 1500 claim form for all appropriate Blue lines of business patients. 8. We understand that for certain networks all individual providers in our account must be fully credentialed in order for the group to be able to bill directly for that network and before rendering services to members. 9. We have carefully reviewed the forms and applications associated with the establishment of this agreement and each individual provider in our account has verified the accuracy and completeness of all information provided. 10. We have carefully reviewed the Request for Assignment Account and each individual provider in our account certifies and represents that the requested account will satisfy the requirements, and when established, that the account will not represent an ineligible arrangement as described in Part III of the Assignment Account Regulations, available at the Provider Resource Center at On behalf of the group, I certify that all individual providers in the group account have reviewed and agree to be bound by the Assignment Account Regulations. I represent and warrant I have the authority to bind the individual providers and sign on their behalf. By signing this Provider Form, we are agreeing to the Assignment Account Regulations (version 1.0) found on the Provider Resource Center. You'll find the link to the Provider Resource Center on our NaviNet Plan Central page. If you don't have access to NaviNet, you'll find the link to the Provider Resource Center on our public website in your region. Signature of Authorized Representative of Group Title Date ( ) Telephone Number V12-2/26/18 17