Uniform Re-Credentialing Application to Participate as a Health Care Practitioner. For IPRS (State Funding) and Medicaid

Transcription

1 MANAGING MENTAL HEALTH, INTELLECTUAL/DEVELOPMENTAL DISABILITIES AND SUBSTANCE ABUSE SERVICES (FAX) WWW. S A N D H I L L S C E N T E R. O R G V I C T O R I A W H I T T, CEO Uniform Re-Credentialing Application to Participate as a Health Care Practitioner For IPRS (State Funding) and Medicaid Please submit application to: Sandhills Center for MH, I/DD & SAS Network Operations Dept. Credentialing Specialist PO Box 9 West End, NC P.O. Box 9, West End, NC Serving Anson, Guilford, Harnett, Hoke, Lee, Montgomery, Moore, Randolph, & Richmond Counties Available 24 hours a day at

2 Instructions A Licensed Independent Practitioner must apply for and be re-credentialed as a practitioner with Sandhills Center to qualify for reimbursement of services provided to Sandhills Center members. Additionally, Practitioners must have a signed contract with Sandhills Center or be employed by an Organization or Group Practice that has a signed contract with Sandhills Center to qualify for reimbursement of services provided to Sandhills Center Members. ****Please Identify Areas of Clinical Expertise and Treatment by completing and signing the Practice Preference Data on the attached Cultural, Racial, Ethnic, Gender, and Linguistic Data Form.**** The Re-credentialing process includes the following steps: 1. Provider completes and signs the Licensed Independent Practitioner Re-Credentialing Application for Medicaid and IPRS to Participate as a Health Care Practitioner and returns it along with the required credentials to: Sandhills Center for MH/I/DD/SAS Network Operations Department Attn: Credentialing Specialist PO Box 9 West End, NC A Re-credentialing Application to Participate as a Health Care Practitioner is considered to be invalid and must 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 Re-Credentialing packet is prior to September, All spaces in the application have not been completed. (Please indicate N/A or None, if the question is not applicable) The Signatures, where required, are not original and dated The Signatures are not by the individual applicant. The text has been altered, highlighted, struck through, or obstructed through the use of correction fluids The responses are illegible. The National Provider Identifier is not a valid number. Any of the documents or pages that comprise the Re-credentialing Application to participate as a Heath Care Practitioner are missing. Any of the requested information in any of the documents that comprise the Re-credentialing Application to participate as a Health Care Practitioner are missing, with the exception of the fax number and address. Before submitting the Re-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 practitioner for whom the Re-credentialing Application is being submitted has signed and dated the last page of the Re-credentialing Application. SHC Uniform LIP Re-Credentialing Application Page 2 of 25

3 Before submitting the Re-credentialing Application, make sure you have enclosed the following, if applicable: Copy of the provider s original state(s) license(s) and current registration. If provisionally licensed, submit a current copy of your supervision contract and complete the clinical supervisor information on page 8 of application. Copy of current Federal DEA certificate (for MD-DOs, Physician Assistants and Psychiatric Nurse Practitioners). The Certificate must have a valid date and refer to current address. Copy of South Carolina Controlled Drug Substance Certificate and DEA information, if applicable 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) covered, coverage amounts, effective date, expiration date, policy number and Sandhills Center should be listed as certificate holder. (Sandhill Center cannot accept Notice of Intent or Declaration as proof of insurance) Proof of professional liability insurance for non-physician providers who care for patients in your practice Coverage amounts $1,000,000 / $3,000,000. Copy of National Provider Identifier (NPI) Certification Letter for Agency and Clinician(s) Copy of certificate from the Specialty Board, if applicable Letter(s) of reference or recommendation, and/or oversight, if required (SHC Provider Evaluation Forms included in this packet). Minimum of two (2) references. Must be dated within the past 180 days. At least one of the references needs to come from a Peer-Licensed Practitioner (not partner), Supervisor, Chief of Department/Staff where practitioner has admitting privileges (not partner) and Referring Physician or Practitioner. SHC reserves the right to contact at least one (1) reference. Note: If provisionally licensed, one of the references must come from your clinical supervisor. Copy of W-9 Form (Please submit an updated W-9 if you had a change in the Federal Tax ID number and/or a name change.) Sandhills Center will schedule an on-site service visit, if applicable Examples of documentation to attach to this application Original N.C. License Medical Board Registration DEA Registration Board Certification Certificate of Insurance SHC Uniform LIP Re-Credentialing Application Page 3 of 25

4 Section 1: Demographic and Personal Data: Date of Application: 1. Name of Applicant: FOR OFFICE USE ONLY Prior MD Approval Date: SHC ID# : enter text. Last Name First Name Middle Name Maiden 2. List Current Credentials: 3. Date of Birth: 4. Place of Birth: 5. Type of Practice: Primary Care 7. What population(s) do you treat (e.g., geriatric, all ages): 8. Language(s) Spoken, including sign language: 6. Specialty: 9. Are interpreters available: Yes No 10. Name of Practice: 11. Main/Billing Office Address: (If you maintain more than one office, list each office, address, and hours of operation.) Address: enter Street. City State Zip + 4 Street City State Zip+4 (Required) 12. Check ( ) County of Address: Anson Guilford Harnett Hoke Lee Montgomery Moore Randolph Richmond Other: 13. Phone #: 14. Fax #: Accepting New Patients: Yes No Restrictions: 17. Handicapped accessible: Yes No If no, explain how you would accommodate a handicapped member: 18. Days/Hours of Operation Sunday Monday Tuesday Wednesday Thursday Friday Saturday SHC Uniform LIP Re-Credentialing Application Page 4 of 25

5 Section 1: Demographic and Personal Data (continued): 19. IRS requires reimbursement be made payable to name of practice affiliated with Federal Tax ID #: Name: (if different from practice name): Billing Address: (if different from practice name): Street City State Zip+4 (Required) 20. NC Tracks #: 21. Taxonomy #: 22. National Provider Identifier (NPI) #: (Attach copy of NPI Certification Letter to application) 23. DEA #: Exp. Date: (Attach copy to application): 24. Administrative Contact: Name: Title: Address: Street City State Zip+4 (Required) Phone #: Fax #: SHC Uniform LIP Re-Credentialing Application Page 5 of 25

6 Section 1: Demographic and Personal Data (continued) 25. Secondary Office Practice Name: Secondary Office Address: Street City State Zip+4 (Required) 26. Check ( ) County of Address: Anson Guilford Harnett Hoke Lee Montgomery Moore Randolph Richmond Other: 27. Federal Tax ID #: 28. Taxonomy #: 29. National Provider Identifier (NPI) #: 30. Phone #: 31. Fax #: Accepting New Patients: Yes No Restrictions: 34. Handicapped accessible: Yes No If no, explain how you would accommodate a handicapped member: 35. Days/Hours of Operation Sunday Monday Tuesday Wednesday Thursday Friday Saturday 36. Additional Office Address: Practice Name: Address: Street City State Zip+4 (Required) 37. Check ( ) County of Address: Anson Guilford Harnett Hoke Lee Montgomery Moore Randolph Richmond Other: 38. Federal Tax ID #: 39. Taxonomy #: 40. National Provider Identifier (NPI) #: 41. Phone #: 42. Fax #: Accepting New Patients: Yes No Restrictions: 45. Handicapped accessible: Yes No If no, explain how you would accommodate a handicapped member: 46. Day/Hours of Operations: Sunday Monday Tuesday Wednesday Thursday Friday Saturday SHC Uniform LIP Re-Credentialing Application Page 6 of 25

7 Section 1: Demographic and Personal Data (continued): 47. Are you currently providing services at another agency (if so, please list the name of the agency): Agency Name: Start Date: Agency Name: Start Date: Agency Name: Start Date: Agency Name: Start Date: Complete only if Licensed in South Carolina 48. SC Controlled Drug Substance Certificate: (Attach copy to application) Expiration Date: Provide the following information for each state in which you are currently or were previously licensed to practice (if necessary, please attach additional sheet): State Date of License License License Status: Active, Inactive, Expiration Date Number Type Suspended Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text ****PLEASE ATTACH A COPY OF EACH STATE LICENSE CERTIFICATE**** 49. If provisionally licensed, provide a copy of your current supervision contract and the name and contact information for your clinical supervisor: Clinical Supervisor: Address: Street City State Zip+4 (Required) Phone #: Certification of Specialty Boards as applicable: a) If you are certified by a specialty board, indicate name of board and date of certificate. Primary Specialty Board Date Certified Expiration Date Secondary Specialty Board Date Certified Expiration Date b) Are you listed in the American Board of Medical Specialists? Yes No c) If you have applied to a specialty board for examination, give the name of board and the date of the scheduled examination. Specialty Board Name d) If you have not applied to a specialty board, please explain: Date SHC Uniform LIP Re-Credentialing Application Page 7 of 25

8 Section 1: Demographic and Personal Data (continued): 51. List the dates of all current professional memberships in societies, including state and county societies: Professional Membership From (Month/Year) To (Month/Year) 52. List all hospitals where you currently have privileges and indicate the type and status of those privileges: a) Hospital: Estimated % of Admissions: Privilege and Status of Privilege: b) Type: Active Admitting Associate Consulting Courtesy c) Status: Pending Provisional Suspended Temporary Visiting d) Primary Admitting Facility: Estimated % of Admissions: e) Type: Active Admitting Associate Consulting Courtesy f) Status: Pending Provisional Suspended Temporary Visiting 53. If you do not have admitting privileges, who admits for you: Name of Admitting: Address: Street City NC Zip+4 (Required) Phone #: SHC Uniform LIP Re-Credentialing Application Page 8 of 25

9 Section 2: Practice History 1. List work history since beginning of medical, dental or other professional school (last 5 years) and explain any employment gaps longer than 6 months; please be specific. See Resume is not acceptable. (If not enough space, please attach additional sheet). Practice Name: From Month/Year To Month/Year Current Practice: Current Practice: Current Practice: Previous Practice: Previous Practice: Previous Practice: Previous Practice: 2. List other training and/or education (including CME) within the last three years: 3. Have you involuntarily or voluntarily withdrawn, or been suspended from any internship, residency or fellowship training program (Please explain): 4. Please explain any incident(s) in which you have involuntarily or voluntarily withdrawn your application for appointment, clinical privileges or reappointment before a decision was made by a hospital or healthcare facility s governing board: SHC Uniform LIP Re-Credentialing Application Page 9 of 25

10 Section 3: Professional Information Please check ( ) yes or no for the following questions. Please complete the attached Supplemental Form for any questions to which you answer yes. Also, please sign and date this application. If this application does not have the provider s signature, it cannot be accepted. 1. Has your license to practice in any jurisdiction ever been limited, restricted, reduced, suspended, voluntarily surrendered, revoked, denied or not renewed; have you ever been reprimanded by a state licensing agency; or are any of these actions pending with respect to your license; are you under Yes No investigation by any licensing or regulatory agency? (If yes, please complete Supplemental Question #1.) 2. Has your professional employment or membership in a professional organization ever been subject to disciplinary proceedings, denied, limited, restricted, reduced, suspended, revoked, not renewed, or voluntarily relinquished during or under threat of termination for any reason? Yes No (If yes, please complete Supplemental Question #2.) 3. Has your Drug Enforcement Agency registration or other controlled substance authorization ever been limited, restricted, reduced, suspended, revoked, denied, not renewed, or have you voluntarily surrendered or limited your registration during or under the threat of an investigation or any such Yes No actions pending? (If yes, please complete Supplemental Question #3.) 4. Have you ever been sanctioned or suspended by Medicare or Medicaid? (If yes, please complete Supplemental Question #4.) Yes No 5. To your knowledge, have you ever been reported to the National Practitioner Data Bank or the North/South Carolina Board of Medical Examiners? Yes No (If yes, please complete Supplemental Question #5.) 6. Have you ever been convicted of a felony or misdemeanor, or are you under investigation with respect to such conduct? Yes No (If yes, please complete Supplemental Question #6.) 7. Has a professional liability claim been assessed against you in the past five years, or are there any professional liability cases pending against you? Yes No (If yes, please complete Supplemental Question #7.) 8. Has any liability insurance carrier canceled, refused coverage, or rated up because of unusual risk or have any procedures been excluded from your coverage? Yes No (If yes, please complete Supplemental Question #8.) 9. Have you ever practiced without liability coverage? (If yes, please complete Supplemental Question #9.) Yes No 10. Do you currently have any medical, chemical dependency or psychiatric conditions that might adversely affect your ability to practice medicine or surgery or to perform the essential functions of your position without reasonable accommodation? Yes No (If yes, please complete Supplemental Question #10.) 11. Have your Hospital and/or Clinic privileges ever been limited, restricted, reduced, suspended, revoked, denied, not renewed, or have you voluntarily surrendered or limited your privileges during or under the threat of an investigation or are any such actions pending? (If yes, please complete Supplemental Question #11.) Yes No Signature Date ***Please provide additional detailed information on the following Supplemental Form. SHC Uniform LIP Re-Credentialing Application Page 10 of 25

11 Supplemental Form All spaces in the application must be completed. (Please indicate N/A or None, if the question is not applicable) Provider Name: SHC Provider ID # : 1. License Limited, Reprimanded, etc.: List State(s) where action took place: Date(s) license revoked, suspended, etc.: From To Please explain: 2. Employment/Membership Suspended, Limited, etc.: List State(s) where action took place: Date(s) license revoked, suspended, etc.: From To Please explain: 3. Drug Enforcement Agency (DEA) Explanation List State(s) where action took place: Date(s) license revoked, suspended, etc.: From To Please explain: 4. Medicare/Medicaid Sanction Disciplinary Action(s) Disciplined Action(s): List State(s) where action took place: Date(s) of Action: From To Please explain: 5. National Practitioner Data Dank Report(s) Please explain the NPDB report (if you have a copy please attach): 6. Felony or Misdemeanor Did you serve a sentence: Yes No If Yes, please check ( ) how many years Other: Please explain charge and verdict: List State(s): 7. Named in Professional Liability Judgment, Settlement, etc. Please explain, include dates & amounts: 8. Canceled Refused Coverage, etc. Please list Insurance Carrier(s): Please explain: 9. Practiced Without Liability Coverage Please explain: 10. Medical, Chemical Dependency, or Psychiatric Conditions Please explain: 11. Hospital or Clinic Privileges Revoked, Restricted, etc. List Hospitals(s): Date privileges revoked, suspended, etc.: From To Please explain: SHC Uniform LIP Re-Credentialing Application Page 11 of 25

12 Section 4: Ownership Information 1. Do you ownership or control interest of 5% or more in other organizations that bills Medicaid for services? If yes, please fill in the following for each organization: Organization Legal Business Name: Employer ID #: National Provider Identifier (NPI) #: Organization Legal Business Name: Employer ID #: National Provider Identifier (NPI) #: Organization Legal Business Name: Employer ID #: National Provider Identifier (NPI) #: Organization Legal Business Name: Employer ID #: National Provider Identifier (NPI) #: Organization Legal Business Name: Employer ID #: National Provider Identifier (NPI) #: Yes No SHC Uniform LIP Re-Credentialing Application Page 12 of 25

13 Attestation Statement Important: Submit Original only No Stamps or Copies Please This Application is to be signed by the individual provider/clinician applying for Re-Credentialing. 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 the Sandhills Center Network, I signify my willingness to appear for interview in regard 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 others, 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 action, suspension, or action 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 action, suspension, 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, 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 purposed as permitted by state or federal law and regulation 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 initial application. Signature of Applicant Printed Name of Applicant Date Title If this application does not have the provider s signature, it cannot be accepted. (Please sign and date this Attestation Statement). SHC Uniform LIP Re-Credentialing Application Page 13 of 25

14 Sandhill Center Network Operations Credentialing Specialist P.O. Box 9, West End, NC Fax: (910) Sandhills Center Provider Evaluation Form Peer (Licensed Practitioner, not partner) Referring Physician or Practitioner Supervisor Chief of Department/Staff where practitioner has admitting privileges (Not partner) Name of the Applicant: Group Name: The above provider is a Sandhill Center network applicant. Please provide us with information concerning His/her professional qualifications. All information submitted will be held in strict confidence. 1. What is your specialty/credentials: 2. What is your relationship to the applicant: 3. How long have you know the applicant: 4. How would you rate the applicant s professional abilities: Excellent Very Good Good Fair Poor 5. How would you rate the applicant s ability to work and communicate with physician and non physician staff: Excellent Very Good Good Fair Poor 6. How would you rate the applicant s rapport with members: Excellent Very Good Good Fair Poor 7. What do you believe to be the applicant s strenghts and weaknesses (if any): a). Strenghts: b). Weaknesses: 8. To your knowledge, has the applicant had any of the following: Malpractice claim(s): Yes No Problems with medical licensure, certification or licensing boards: Yes No Revocation, denial or change in hospital privileges: Yes No History of/or current impairment due to drugs and/or alcohol: Yes No ***If your answer is yes to any of the abgove questions, please provide details.*** SHC Uniform LIP Re-Credentialing Application Page 14 of 25

15 Sandhills Provider Evaluation Form (continued) 9. Would you recommend this person as a provider for the Sandhills Center network: Without reservation With reservation Would not recommend 10. Please provide any other information that would be helpful to us in evaluating this applicant: Evaluator s Signature Date Evaluator s Printed Name Address: Street City State Zip Phone #: Group Name: Address: Street City State Zip SHC Uniform LIP Re-Credentialing Application Page 15 of 25

16 SANDHILLS CENTER Licensed Independent Practitioners Cultural, Racial, Ethnic, Gender, and Linguistic Data Form (This information will reside within Sandhill Cener s Provider Directory and the online Provider Search.This section is self-reported information and requires no backup documentation) By providing the information below, you will be assisting Sandhills Center with member/provider matching as well as providing information necessary for analyzing our Network and its ability to meet our Members cultural, racial, ethnic and linguistic needs. Name of Practitioner: Name of Practice: Address: Counties Served: Anson Guilford Harnett Hoke Lee Montgomery Moore Randolph Richmond Other: Provider Type: APPCNS (Advanced Practice Psychiatric Clinical Nurse Specialist) DO LCAS LCSW LMFT LPA LPC PA PhD PsyD MDNP - Psychiatric Other (please specify): Priority Populations: MH Adult SA Adult I/DD - Adult MH Child SA Child I/DD - Adult Your Gender: Female Male Your Race and/or Ethnicity (please check ( ) all appropriate categories): White Black or African American American Indian and Alaska Native Asian, Pacific Islander Hispanic or Latino Other: Populations(s) that you serve (please check ( ) all that apply): Early Childhood (0-4) Child & Adolescent (5-21) Adult (22+) Geriatrics (55+) Women Gay & Lesbian HIV/Aids Hearing Impaired Men Gender Identity Issues Sexually Reactive/Aggressive Youth Visually Impaired Other: SHC Uniform LIP Re-Credentialing Application Page 16 of 25

17 Cultural, Racial, Ethnic, Gender, and Linguistic Data Form (continued) (This information will reside within Sandhill Center s Provider Directory and the online Provider Search) Culturally diverse populations that you feel competent to treat (please check ( ) all that apply): White Black or African American American Indian and Alaska Native Asian, Pacific Islander Hispanic or Latino Other Practice Preference Data Language(s) you are able to communicate in fluently (please check ( ) all that apply) American Sign Language English French German Hmong Portuguese Russian Spanish Telugu Other: (The sections below must have backup documentation to be listed with Sandhills Center) Focus of Treatments You Provide (please check ( ) all that apply): Amnestic Disorder Factitious Disorders Anxiety/Phobias Impulse Control Attention Deficit Hyperactivity Disorder Mentally Retarded/Developmentally Disabled Autism Asperger Obsessive-Compulsive Disorder Bipolar Disorder (manic-depressive illness) Personality Disorders Chemical Dependency/Substance Abuse Post Traumatic Stress Disorder Conduct Disorder Schizophrenia and other Psychotic Disorders Co-Occurring/Dual DX-Mental Retardation/Mental Sexual & Gender Identity Disorders Illness, Mental Health/Substance Abuse Dementia Disorder Sleep Disorders Depression Somatoform Disorders Eating Disorders Clinician Expertise/Certified Specialties (please check ( ) all that apply): Psychological Testing Therapy/Service Type Trauma Focused Cognitive/IQ Anger Management Abuse-Physical, Sexual, and/or Emotional Developmental limited/extended Assessment Evaluation Maltreatment Forensic Screening/Evaluation Caree/Vocational Counseling Neglect Neuro Psych Cognitive Behavioral Therapy Rape Personality Crisis/Solution focused Brief Therapy Dialectial Behavior Therapy Faith Based Counseling General Psychiatry General Psychology Gero Psychiatry Grief and Loss Therapy Health Psychology Chronic Medical Conditions Marriage and Family Counseling Play Therapy, Filial Relaxation/ Meditation-Hypnotherapy Self-Direction SHC Uniform LIP Re-Credentialing Application Page 17 of 25

18 Practice Preference Data Clinician Expertise/Certified Specialties that Require Verification (please check ( ) all that apply): Verification of specific expertise(s) and/or training(s) selected below must accompany this form for Sandhills Center recognition, i.e. training certificates, certification, supervisor letters verifying training, or proof of experience. If standard training for clinician s licensure does not include area of identified expertise, additional documentation to support expertise will be required, e.g. a Psychiatrist who does psychological testing. Addiction Psychiatry (Fellowship in addiction Psychiatry/Board Certification/ASAM Certification/Experience) Eye Movement Desensitization and Reprocessing Therapy (Training Certificate/Experience) Addiction Treatment (LCAS/CAS/CCS/Experience) Forensic Psychology/Psychiatry (Fellowship in Forensic Psychiatry/Board Certification/Training/Experience) Child Psychiatry (Fellowship in child Psychiatry/Board Certification/Training/Experience) Trauma Focused Cognitive Behavioral (Course Completion at MUSC, Duke or NCTSN) Dialectical Behavior Therapy (Certification, Supervision, and Experience) Neuro Psych Assessment (Training, Supervision, and Experience) Services Provided in Office: Yes No Services Provided in the Community: Yes No Thank you for taking the time to submit this form. If this form is not completed and returned, your provider information will not appear within the Sandhills Center online Provider Search or Provider Handbook. To the best of my knowledge, I am able to meet all requirements necessary to apply for Sandhills Center Re-Credentialing for Licensed Independent Practitioner. I am submitting the attached Sandhills Center Licensed Independent Practitioner Re-Credentialing Application, which, to my knowledge, is a true and complete representation of the required materials. This Licensed Independent Practitioner Re-Credentialing Application is submitted by: Authorized Signature Date Title SHC Uniform LIP Re-Credentialing Application Page 18 of 25

19 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 Available to Benefit Plan Description Code State (IPRS) Medicaid Interactive Complexity Add On State Medicaid Psychiatric Diagnostic Evaluation State Medicaid Psychiatric Diagnostic Evaluation with Medical Services State Medicaid Psychotherapy 30 Minutes State Medicaid Psychotherapy 30 Minutes Add On State Medicaid Psychotherapy 45 Minutes State Medicaid Psychotherapy 45 Minutes Add On State Medicaid Psychotherapy 60 Minutes State Medicaid Psychotherapy 60 Minutes Add On State Medicaid Crisis Psychotherapy first 60 Minutes State Medicaid Crisis Add For Each Additional 30 Minutes State Medicaid Psychoanalysis N/A Medicaid Family therapy w/o Patient State Medicaid Family therapy with Patient State Medicaid Group Therapy (Multiple Family) State Medicaid Group Therapy (Non-Multi- Family) State Medicaid Interactive Group Therapy N/A Medicaid Psychological Testing F-T-F State Medicaid Developmental Testing Limited State Medicaid Developmental Testing Extended State Medicaid Neurobehavioral Status Exam State Medicaid Neuropsychological Testing State Medicaid Therapeutic, Prophylactic, or DX Injection Intra-Muscular State Medicaid H0001 Behavioral Health Assessment State Medicaid H0004 Behavioral Health Counseling/Therapy State Medicaid H0004HQ Outpatient Treatment Group State Medicaid H0004HR Outpatient Tx Family Therapy w/ Client State Medicaid H0004HS Outpatient Tx Family Therapy w/o Client State Medicaid H0005 Alcohol and/or Drug Group Counseling State Medicaid H0031 Mental Health Assessment State Medicaid SHC Uniform LIP Re-Credentialing Application Page 19 of 25

20 IPRS (State) Funds Only for Services for Non-Licensed Substance Abuse Professionals Please check ( ) all that applies (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 Evaluation & Management Codes Check ( ) ***Evaluation & Management Codes are only provided by Physicians Assistants, Cert. Nurse Practitioners and Physicians (only check ( ) what services you are currently providing). *** Procedure Code Description Check ( ) Procedure Code Description Narcosynthesis for Psychiatric Diagnostic Hospital Initial Observation Care High and Therapeutic Purposes Complexity Electronic Analysis of Implanted Neurostimulator Hospital Initial Care MD (30 min.) Electronic Analysis of Implanted Neurostimulator Simple Spinal Cord Hospital Initial Care MD (50 min.) Electronic Analysis of Implanted Neurostimulator Complex Spinal Cord (1hr.) Hospital Initial Care MD (70 min.) Electronic Analysis of Implanted Hospital Subsequent Hospital Care MD Neurostimulator Complex Spinal Cord ( Low Complexity (15 min.) min.) Electronic Analysis of Implanted Hospital Subsequent Hospital Care MD Neurostimulator Complex Cranial Moderate Complexity (25 min.) (1 hr.) Electronic Analysis of Implanted Hospital Subsequent Hospital Care MD Neurostimulator Complex Cranial High Complexity (35 min.) (30 min.) Electronic Analysis of Implanted Hospital Observation/Inpatient Care Neurostimulator Low Complexity Electronic Analysis of Implanted Hospital Observation/Inpatient Care Neurostimulator (30 min.) Moderate Complexity Standardized Cognitive Performance Testing Observation/Inpatient Care High Complexity Physical Health and Behavior Assessment F-T-F (15 min.) Hospital Discharge Services (<30 min.) Physical Health and Behavior Reassessment Hospital Discharge Services (>30 min.) Therapeutic, Prophylactic, or Diagnostic Outpatient Consultation MD Minor Injection (15 min.) Intra-Muscular Therapeutic, Prophylactic, or Diagnostic Injection Intra-Arterial Therapeutic, Prophylactic, or Diagnostic Injection Intravenous Push Therapeutic, Prophylactic, or Diagnostic Injection Subsequent Intravenous Push Outpatient Consultation MD Moderate (30 min.) Outpatient Consultation MD Severe (40 min.) Outpatient Consultation MD Severe (60 min.) SHC Uniform LIP Re-Credentialing Application Page 20 of 25

21 Evaluation & Management Codes (continued) Check ( ) ***Evaluation & Management Codes are only provided by Physicians Assistants, Cert. Nurse Practitioners and Physicians (only check ( ) what services you are currently providing). *** Procedure Code Description Check ( ) Procedure Code Description Outpatient E&M New Patient F-T-F (10 Outpatient Consultation MD Severe min.) (80 min.) Outpatient E&M New Patient F-T-F (20 min.) Inpatient Consultation MD Minor (20 min.) Outpatient E&M New Patient F-T-F Inpatient Consultation MD Low Severity (30 min.) (40 min.) Outpatient E&M New Patient F-T-F (45 min.) Inpatient Consultation MD Moderate (55 min.) Outpatient E&M New Patient F-T-F Inpatient Consultation MD Moderate (60 min.) High Severity (80 min.) E & M Estab. Patient, w/wo MD Inpatient Consultation MD Moderate (approx. 5 min.) High Severity (110 min.) Outpatient Visit Estab. Minor (10 min.) ER Visit, Minor Outpatient Visit Estab. Moderate (15 min.) ER Visit, Low Severity Outpatient Visit Estab. Severe (25 min.) ER Visit, Moderate Severity Outpatient Visit Estab. Severe (40 min.) ER Visit, High Severity Hospital Observation Care - Discharge Hospital Initial Observation Care Low Complexity Hospital initial Observation Care Moderate Complexity Initial Nursing Facility Care E&M high Complexity (45 min.) Subsequent Nursing facility Care E&M Review of Case (10 min.) Subsequent Nursing Facility Care E&M Low Complexity (15 min.) Subsequent Nursing Facility Care E&M Moderate Complexity (25 min.) Subsequent Nursing Facility Care E&M High Complexity (35 min.) Nursing Facility Discharge Management (<30 min.) Nursing Facility Discharge Management (>30 min.) Nursing Facility, E&M Low to Moderate Complexity (30 min.) New Patient Domiciliary/Rest Home E&M Low Severity (20 min.) New Patient Domiciliary/Rest Home E&M Low Complexity (30 min.) New Patient Domiciliary/Rest Home E M Moderate Complexity (45 min.) New Patient Domiciliary/Rest Home E&M High Severity (60 min.) New patient Domiciliary/Rest Home E&M High Complexity (75 min.) Estab. Patient Domiciliary/Rest Home E&M (15 min.) Estab. Patient Domiciliary/Rest Home E&M Low Complexity (25 min.) Estab. Patient Domiciliary/Rest Home E&M Moderate Complexity (40 min.) ER Visit for the evaluation and management of a patient Initial Nursing Facility Care E&M Low Complexity (25 min.) Initial Nursing Facility Care E&M Moderate Complexity (35 min.) Estab. Patient Domiciliary/Rest Home E&M Moderate to High Severity (60 min.) New Patient Home Visit E&M Low Severity (20 min.) New Patient Home Visit E&M Low Complexity (30 min.) New Patient Home Visit E&M Low Moderate Complexity (45 min.) New Patient Home Visit E&M High Severity (60 min.) New Patient Home Visit E&M High Complexity (75 min.) Estab. Patient Home Visit E&M (15 min.) Estab. Patient Home Visit E&M Low Complexity (25 min.) Estab. Patient Home Visit E&M Moderate Complexity (40 min.) Estab. Patient Home Visit E M High Complexity (60 min.) Prolonged MD Service w/f-t-f Patient Contact in Office (60 min.) Prolonged MD Service w/f-t-f Patient Contact in Office (30 min.) Prolonged MD Service w/f-t-f Patient Contact Inpatient (60 min.) Prolonged MD Service w/f-t-f Patient Contact Inpatient (30 min.) Q3014GT TelePsych Site Facility Fee SHC Uniform LIP Re-Credentialing Application Page 21 of 25

22 If you are currently providing a service that is NOT listed above, please type the service code and description below. Procedure Code Description SHC Uniform LIP Re-Credentialing Application Page 22 of 25

23 ( ) Services Member Capacity (total # for all counties served) Accepting New Patients (Y/N) Anson Guilford Harnett Hoke Lee Montgomery Moore Randolph Richmond Miscellaneous Population Information for Solo LIPs Only 1. Member/Age/Disability/Gender Check ( ) all populations served: Age and Disabilities Served Mental Health (MH) Substance Abuse (SA) Intellectual/Developmental Disabilities (I/DD) (Check ( ) all that apply) Child/Adolescent Adult Gender(s) Served Male Female 2. Please indicate with a check ( ) only the services you have an existing agreement with Sandhills Center to deliver or are currently providing to Sandhills Center area eligible members: (Place a ( ) for all counties to be served) 1. Periodic a b c d e f g h i j k l m Assertive Community Treatment Team (ACTT) Community Support - Team Diagnostic Assessment Emergency Services/Assessments (ED Physicians only) Inpatient Psychiatric Physician Services Intensive In-Home Mobile Crisis Management Multi Systemic Therapy (MST) Outpatient Opioid Treatment Peer Support Substance Abuse Comprehensive Outpatient Treatment (SACOT) Substance Abuse Intensive Outpatient (SAIOP) Other (please specify) SHC Uniform LIP Re-Credentialing Application Page 23 of 25

24 ( ) Services Member Capacity (total # for all counties served) Accepting New Patients (Y/N) Anson Guilford Harnett Hoke Lee Montgomery Moore Randolph Richmond ( ) Services Member Capacity (total # for all counties served) Accepting New Patients (Y/N) Anson Guilford Harnett Hoke Lee Montgomery Moore Randolph Richmond Please indicate with a check ( ) only the services you have an existing agreement with Sandhills Center to deliver or are currently providing to Sandhills Center area eligible members: (Place a ( ) for all counties to be served) 2. Day / Night a b c d Child & Adolescent Day Treatment Partial Hospitalization (PH) Psychosocial Rehabilitation (PSR) Other (please specify) 3. Residential 24 Hour a b c d e f g h i j Ambulatory Detoxification Facility Based Crisis Program Residential Level II Program Type Residential Level III Residential Level IV Professional Treatment Services in Facility Based Crisis Program Psychiatric Residential Treatment Facilities (PRTF) Substance Abuse Medically Monitored Community Residential Treatment Substance Abuse Non-Medical Community Residential Treatment Other (please specify) SHC Uniform LIP Re-Credentialing Application Page 24 of 25

25 ( ) Services Member Capacity (total # for all counties served) Accepting New Patients (Y/N) Anson Guilford Harnett Hoke Lee Montgomery Moore Randolph Richmond ( ) Services Member Capacity (total # for all counties served) Accepting New Patients (Y/N) Anson Guilford Harnett Hoke Lee Montgomery Moore Randolph Richmond Please indicate with a check ( ) only the services you have an existing agreement with Sandhills Center to deliver or are currently providing to Sandhills Center area eligible members: (Place a ( ) for all counties to be served) 4. Residential Level II Family Type a Residential Level II Family Type 5. Outpatient Therapy a Outpatient Therapy SHC Uniform LIP Re-Credentialing Application Page 25 of 25