10/23/2015 Consolidated Community Reporting Initiative (CCRI) Provider Enrollment Frequently Asked Questions What is the CCRI enrollment process? To ensure continuity, the CCRI county representative will be required to assist providers in the completion of the CCRI Base Enrollment Application with applicable addenda, complete the County CCRI Attestation Form and submit the completed enrollment application(s), documentation and Attestation Form(s) in one complete package. Providers do not have access to the OMHSAS Intranet site; therefore each county mental health program is responsible for providing a CCRI enrollment application and working with their base-funded mental health providers in completing the application. Related Attachments: CCRI Provider Enrollment Tool, CCRI Provider Change/Closure Form, CCRI Provider Enrollment Application Short Form, CCRI Provider Enrollment Base Application (Long Form) What requires a CCRI Provider Enrollment Base Application (Long Form) and what requires the CCRI Provider Enrollment Application Short Form? The CCRI short form is exclusive to CCRI and is used for a provider who is currently enrolled, has a valid PROMISe Provider Identification Number and is requesting to have the EPOMS PEP added to this location for service(s) contracted and paid with county base funds. The CCRI Base Enrollment Form is used for a provider who is not otherwise enrolled in PA Medicaid and who does not have a current PROMISe Provider Identification Number for the service(s) contracted through and paid with county base funds. Related Attachments: CCRI Provider Enrollment Tool, CCRI Provider Change/Closure Form, CCRI Provider Enrollment Application Short Form, CCRI Provider Enrollment Base Application (Long Form) For all other questions, issues or concerns with CCRI Provider Enrollment please contact CCRI_Data_Support@pa.gov 1
10/23/2015 How do I find out whether provider applications were added for our county and the application as successful? Once the enrollment occurs for the CCRI provider, a letter is generated and mailed to the CCRI provider and a copy of the letter is generated to the county that submitted the CCRI Provider Enrollment Application. The provider enrollments would then appear on the latest PRV416 file (i.e., the statewide file of PROMISe - enrolled CCRI providers). Related Attachments: PRV416 File What is the difference between the PRV414 and the PRV416? The PRV414 is a weekly file that contains a statewide listing of all PROMISe -enrolled providers in Pennsylvania and the adjoining states of New Jersey, Delaware, Maryland, Ohio, West Virginia, and New York. This file is utilized by HealthChoices managed care organizations, as well as CCRI counties. It is sent to CCRI Counties as a resource to identify potential mental health providers with which to contract, and to research PROMISe IDs for enrolled providers. The PRV416 is a CCRI-specific monthly file that contains all active and closed provider service locations with a PROMISe EPOMS PEP. For CCRI encounter reporting, the provider must have an open EPOMS PEP on the date of service in the PROMISe system. Related Attachments: PRV416 File, PRV 414 File Does the PRV416 file sent to us from the Department verify that a provider is enrolled correctly with an EPOMS PEP in PROMISe? In other words, if a provider is listed on the 416 file with the correct provider type and specialty code, can we then assume that they are correctly enrolled for provider billing and county CCRI encounter data reporting? Yes, the monthly PRV416 file is your source for CCRI provider information. The county can use the file to verify the accuracy of enrollment of the county s providers. The information contained in that file should reflect all providers enrolled into PROMISe. Related Attachments: PRV416 File Who receives notice of successful enrollment with CCRI from OMHSAS? When a provider is enrolled with the CCRI initiative, the provider receives the original letter identifying the PROMISe provider ID and specific information relevant to the enrollment and the county receives a copy of the letter. For all other questions, issues or concerns with CCRI Provider Enrollment please contact CCRI_Data_Support@pa.gov 2
10/23/2015 We have a few providers which we use on an occasional, as-needed basis (e.g., respite care). Should they be enrolled for the CCRI Initiative? We have contracts with them and pay on a per diem cost basis. Yes. In order for CCRI encounters to be accepted, the providers must be appropriately enrolled in PROMISe with an EPOMS PEP. How are Purchased Drugs handled? Does every pharmacy need to be enrolled? You do not need to enroll pharmacies. Medication payments are not to be reported in EPOMS. They will continue to be reported in the Income & Expense Report. What cost centers are used for each individual service? This question can be answered by reviewing OMHSAS Bulletin 12-02. Related Attachment: OMHSAS Bulletin 12-02 Who is responsible to submit CCRI revalidation information for continued enrollment in PROMISe? The provider is responsible for submitting the re-validation information necessary for continued enrollment in PROMISe. In addition, revalidation dates have been added to correspondence that informs providers/counties of their revalidation enrollment date. Related Attachments: OMHSAS Bulletin 14-03 If a provider is enrolled recently do they have to be CCRI revalidated again? Providers that initially enrolled with an effective date on or before March 25, 2011 will have to complete the re-enrollment process by March 24, 2016, and subsequent re-enrollments every five (5) years thereafter. Providers that initially enrolled after March 25, 2011 will not have to re-enroll until five (5) years from the date they were initially enrolled. They will also complete subsequent reenrollments every five (5) years thereafter. For all other questions, issues or concerns with CCRI Provider Enrollment please contact CCRI_Data_Support@pa.gov 3
10/23/2015 How does a provider know their CCRI revalidation date? Providers can determine their next re-enrollment deadline by logging in to the provider portal for each service location. The re-enrollment/revalidation date will be displayed in the masthead of the provider portal for each service location. The date identified is the expiration date for that specific service location based on the most recent application on file with DHS/OMHSAS. When OMHSAS mails the confirmation letter out, we also include the revalidation date specific to the service location that was enrolled. What forms does the provider need to complete for the CCRI re-validation? Providers of CCRI, enrolled through the County MH Office will need to meet the requirements set forth by the County. When the provider has met the County requirements, the County will provide the current CCRI Base Provider Enrollment Application/required documentation and will coordinate and submit the Provider Enrollment Application/documentation along with the County Attestation Form to OMHSAS at the address below, for processing. OMHSAS requires original hardcopy enrollment documents/supporting documentation, which includes original provider signature/dates. DHS/OMHSAS Business Partner Support Unit 112 East Azalea Drive 2nd Floor Harrisburg PA 17110 Related Attachments: OMHSAS Bulletin 14-03, CCRI Provider Enrollment Application Short Form, CCRI Provider Enrollment Base Application (Long Form) What effective date should be used on the CCRI revalidation? The date of when the provider is completing the application for revalidation. What specific services have to be CCRI revalidated for 2015? Is there a list of the services that require revalidation? The Department must revalidate the enrollment of all providers, regardless of provider type/service at least every five (5) years. For all other questions, issues or concerns with CCRI Provider Enrollment please contact CCRI_Data_Support@pa.gov 4
10/23/2015 Is an attestation form required with the CCRI Encounter Submitters Provider Enrollment/Revalidation Application? The County is the only entity that has a Provider Enrollment Submitter ID. The County does not need an attestation to approve the County Submitter ID. Related Attachment: CCRI Encounter Submitters Provider Enrollment/Revalidation Application With the upcoming electronic enrollment process is the only county responsibility in completing the attestation form? OMHSAS will be establishing a webinar that explains how the electronic enrollment process will work and confirm the role of the County. If I have questions about Provider Enrollment for CCRI who can I contact? All questions, issues or concerns about Provider Enrollment can be sent to CCRI_Data_Support@pa.gov. We will be able to provide prompt and accurate answers to questions and inquiries received. Attachments: CCRI Provider Enrollment Application Short Form CCRI Provider Enrollment Base Application (Long Form) CCRI Provider Enrollment Tool CCRI Provider Change/Closure Form CCRI Encounter Submitters Provider Enrollment/Revalidation Application OMHSAS Bulletin 12-02 OMHSAS Bulletin 14-03 PRV 414 File PRV416 File For all other questions, issues or concerns with CCRI Provider Enrollment please contact CCRI_Data_Support@pa.gov 5
Commonwealth of Pennsylvania Office of Mental Health and Substance Abuse Services Consolidated Community Reporting Initiative Provider Enrollment Application Short Form Instructions for Completing the Consolidated Community Reporting Initiative (CCRI) Provider Enrollment Application Short Form This application is for providers already enrolled in either Medical Assistance Fee-for-Service or HealthChoices and requesting enrollment as a CCRI provider. 1. Action Requested: Enter the effective date of enrollment and your 13 digit PROMISe provider ID number. 2. Enrollee s Name: List the applicant s name (individual practitioner or facility) and date of birth (if applicant is an individual). If operating under a fictitious business/doing-business-as (dba) name, attach copy of recorded/stamped fictitious business name statement/permit. 3. Provider Type Number and Description: Enter the provider type number and the description of the provider type you are requesting enrollment for. 4. Provider Specialty Number and Description: Enter the provider specialty and the description of the provider specialty you are requesting enrollment for. 5. License number: Enter the professional or state license number, if applicable 6. Physical Service Location: List the physical address where services will be provided. A Post Office Box is not a valid service location. 6a. Mail to Information: Indicate the address where you want correspondence to be mailed. (e.g. notification of enrollment) 7. Sign and date the application, print your name and list your telephone number. The signature should be that of the individual applying for enrollment, or someone able to represent the facility applying for enrollment. Use black ink. Forward completed application to the county in which the CCRI contract is associated with. The County MH/MR representative will be required to complete and submit the CCRI Attestation Form to support the enrollment of this service provider along with the completed application. Page 1 of 3 Updated 02/01/2013
Commonwealth of Pennsylvania Office of Mental Health and Substance Abuse Services Consolidated Community Reporting Initiative Provider Enrollment Application Short Form This application is for providers already enrolled in either Medical Assistance fee-for-service or HealthChoices and requesting enrollment as a CCRI provider. 1. Action Requested: Add the EPOMS PEP to an existing service location. Effective date of enrollment: PROMISe Provider ID & Service Location: / 2. Enter Name of Enrollee: Facility Name: Or Last Name: First: Middle: Date of Birth: / / Ex: (2012/xx/xx) Gender: Male Female 3. Provider Type Number and Description: / 4. Provider Specialty Number and Description: / 5. License Number: (Professional or State License, if applicable) 6. Physical Service Location: 6a. Mail to Information: Street City State Zip (9 digit) County ( ) - Phone Email Street City State Zip (9 digit) County ( ) - Phone Email 7. I certify that the information provided in this enrollment package is true to the best of my knowledge. _( ) Provider s Signature Printed Name Telephone Date Page 2 of 3 Updated 02/01/2013
Commonwealth Of Pennsylvania Office of Mental Health and Substance Abuse Services Consolidated Community Reporting Initiative Attestation Form County Name: CCRI County Contact Name: Print Name has successfully completed the Name of Provider credentialing process as a provider. Type of CCRI Service The population to be served is consistent with the requirements for this service. The County or County Contractor(s), where applicable, has/have approved the enrollment of this provider for the CCRI program. Provider Type Number and Description: / Provider Specialty Number and Description: / The requested effective date of the CCRI enrollment into PROMISe is, CCRI County Contact Signature Printed Name Date Submittal Information The county will submit the CCRI enrollment packet along with this CCRI Attestation Form to the following address: DPW/OMHSAS Business Partner Support Unit CCRI Enrollment 112 East Azalea Drive Harrisburg, Pennsylvania 17110-3594 Applications that are received directly from the provider will be returned unprocessed. Page 3 of 3 Updated 02/01/2013
Commonwealth of Pennsylvania Office of Mental Health and Substance Abuse Services Consolidated Community Reporting Initiative Provider Enrollment Base Application Instructions for Completing the Consolidated Community Reporting Initiative (CCRI) Provider Enrollment Base Application To the County: Refer to the County Funded Services document and/or the CCR POMS Reporting Tool when assisting the provider in identifying the correct provider type/specialty combination specific to the service being paid for through the County contract. 1. Action Requested: Check Initial Enrollment, check whether you are an individual or facility and enter the effective date of enrollment. 2. Enrollee s Name: List the applicant s name (individual practitioner or facility) and date of birth (if applicant is an individual). If operating under a fictitious business/doing-business-as (dba) name, attach copy of recorded/stamped fictitious business name statement/permit. 3. Tax Identification Information (TIN): List the enrollee s Social Security Number (SSN) or Federal Employer Identification Number (FEIN). Enclose verification of the TIN with your application (e.g., a copy of Social Security card, W-2 or a copy of an IRS-generated document containing the IRS number and name. Note: A W-9 is not acceptable proof of tax ID.) Enter the legal name as shown on the tax ID, and the corresponding current address, telephone and fax numbers and contact information. (Note: Do not list tax information of entity to which payment will be made if said entity is not the enrollee.) 4. National Provider Identifier (NPI) #: List your 10 digit NPI # and taxonomy(s). Include a copy of your NPPES confirmation letter verifying your NPI #. 5. Business Type: Check the appropriate box for your business type (check one box only). Include corporation papers from the Department of State Corporation Bureau or a copy of your business partnership agreement, if applicable. 6. Provider Type Number and Description: Enter the provider type number and the description of the provider type you are requesting enrollment for. Please contact the County MH/MR representative who will be assisting you in identifying the correct provider type specific to the service being paid for through the County contract. 7. Provider Specialty Number and Description: Enter the provider specialty and the description of the provider specialty you are requesting enrollment for. Please contact the County MH/MR representative who will be assisting you in identifying the correct provider specialty specific to the service being paid for through the County contract. 1 of 3 Updated February 1, 2013
7a. Procedure code and modifier: This section applies to providers who are enrolling as one of the following provider types with provider Specialty: 11-110 11-111 11-112 11-119 11-123 11-126 21-215 26-267 51-512 51-513 51-515 52-456 52-520 52-521 53-531 08-110 (only if enrolling for H2013) Enter the procedure code and modifier, if applicable, of the service you will be providing. 8. Program Eligibility Maintenance: This block is already completed. 9. License number: Enter the professional or state license number, if applicable 10. Managing Employee or Agent Disclosure: Indicate whether you retain any managing employees or agents. If yes please complete Attachment I Managing Employee or Agent Disclosure Form 11. Confidential Information: The individual applying for enrollment OR the representative of the facility applying for enrollment must complete ALL confidential information questions. If Yes is answered to any of the questions, provide a detailed explanation and include it with your completed enrollment application. 12. Physical Service Location: List the physical address where services will be provided. A Post Office Box is not a valid service location. Complete a separate Page 4 of the application for each intended physical service location. 13. Mail To Information: Indicate the address where you want correspondence to be mailed. (e.g. notification of enrollment) 14. Pay To Information: Indicate address where payments will be sent. Payments will be initiated via the county. 15. Home Office Information: Indicate the entity s headquarters address. 16. Sign and date the application, print your name and list your telephone number. The signature should be that of the individual applying for enrollment, or someone able to represent the facility applying for enrollment. Use black ink. 2 of 3 Updated February 1, 2013
Additional Required Forms: Also include as applicable: One DPW Outpatient Provider Agreement with original signature. Completed Ownership or Control Interest Forms Copy of DPW Certificate of Compliance, Department of State Licensure, or an appropriate license or a tailored service description that supports the provider type/specialty being requested for enrollment. Verification of Tax ID name and number. Forward the completed application to the county in which the CCRI contract is associated with. The County MH/MR representative will be required to complete and submit the CCRI Attestation Form to support the enrollment of this service provider along with the completed application. Applications that are received directly from the provider will be returned unprocessed. 3 of 3 Updated February 1, 2013
Commonwealth of Pennsylvania Office of Mental Health and Substance Abuse Services Consolidated Community Reporting Initiative Provider Enrollment Base Application Page 1 of 4 For OMHSAS Internal Use Only PROMISe ID / 1. Action Requested: Initial Consolidate Community Reporting Initiative Enrollment (New) Individual Facility Effective date of enrollment: 2. Enter Name of Enrollee: Facility Name: Or Last Name: First: Middle: Date of Birth: / / Ex: (2012/xx/xx) Gender: Male Female 3. Tax Identification Information Social Security Number: - - *A copy of the document generated by the IRS that includes your name and SSN must accompany this application. ************************************************************************************************************************* Federal Tax ID Number: - *A copy of the document generated by the Federal IRS with the name and IRS number must accompany this application. Legal Name (must be same as denoted on tax ID): Address: City: County: State: Zip Code (9 digit) Telephone: ( ) - Fax: ( ) - Contact Name/Title: Contact e-mail: Updated February 1, 2013
4. National Provider Identifier (NPI) #: Page 2 of 4 *A copy of the NPPES confirmation letter must be attached Taxonomy(s): (10 digits) 5. Business Type: Corporation Not-for-Profit Government Owned Partnership Estate/Trust Sole Proprietorship (Include corporation papers or business partnership agreement, if applicable) 6. Provider Type Number and Description: / 7. Provider Specialty Number and Description: / 7a. Procedure code Modifier if applicable 8. Program Eligibility Maintenance: EPOMS 9. License Number: (must include a copy of the license with the application) Professional or State License, if applicable PLEASE NOTE: Services that fall under a provider type/provider specialty that is unlicensed, must submit a service description along with the application. 10. Does the provider retain any managing employees or agents? Yes No If yes please complete Attachment I Managing Employee or Agent Disclosure Form Updated February 1, 2013
11. CONFIDENTIAL INFORMATION Page 3 of 4 Have you or any director, officer, manager, consultant, agent, employee, or volunteer of your Organization/facility: Been terminated, excluded, precluded, suspended, debarred from or had their participation in any federal or state health care program limited in any way, including voluntary withdrawal from a program for an agreed to definite or indefinite period of time? Yes No Been the subject of a disciplinary proceeding by any licensing or certifying agency, had his/her license limited in any way, or surrendered a license in anticipation of or after the commencement of a formal disciplinary proceeding before a licensing or certifying authority (e.g., license revocations, suspensions, or other loss of license or any limitation on the right to apply for or renew license or surrender of a license related to a formal disciplinary proceeding)? Yes No Had a controlled drug license withdrawn? Yes No Been convicted of a criminal offense related to Medicare or Medicaid; practice of the provider s profession; unlawful manufacture, distribution, prescription or dispensing of a controlled substance; or interference with or obstruction of any investigation? Yes No In connection with the delivery of a health care item or service, been convicted of a criminal offense relating to neglect or abuse of patients or fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct? Yes No If you answered Yes to any of the questions above, provide a detailed explanation (on a separate piece of paper) and submit three (3) statements from professional associates or peer review bodies giving factual evidence of why they believe the violation(s) will not be repeated, and attach it to your application. Include the following information as applicable to the situation: 1. Name and title of individual 8. Disposition/State 2. Name of federal or state health care program 9. Date license was surrendered 3. Name of licensing/certifying agency taking the action 10. Name of court 4. Date of action 11. Date of conviction 5. Type of action taken 12. Offense(s) convicted of 6. Length of action 13. Sentence(s) 7. Basis for action 14. Categorization of offense (e.g., felony, misdemeanor) Updated February 1, 2013
12. Physical Service Location: Page 4 of 4 Street (Note: List physical street address. A PO Box is not acceptable.) City State Zip (9 digit) County ( ) - Phone E-mail 13. Mail To Information: Same as Service Location Street City State Zip (9 digit) County ( ) - Phone E-mail 14. Pay To Information: Same as Service Location Same as Mail To Street City State Zip (9 digit) County ( ) - Phone E-mail 15. Home Office Information: Same as Service Location Same as Mail To Same as Pay To Street City State Zip (9 digit) County ( ) - Phone E-mail 16. I certify that the information provided in this enrollment package is true to the best of my knowledge. _( ) Provider s Signature Printed Name Telephone Date Updated February 1, 2013
Commonwealth of Pennsylvania Office of Mental Health and Substance Abuse Services Consolidated Community Reporting Initiative PROVIDER AGREEMENT 1. This is to certify that agrees to participate in the Pennsylvania Medical Assistance Program on the following terms: 2. The provider shall comply with all applicable State and Federal laws, regulations, and policies which pertain to participation in the Pennsylvania Medical Assistance Program. 3. Specifically, and without limitations, the provider shall: a. Keep any records necessary to disclose the extent of services the provider furnishes to recipients; b. Upon request, furnish to the Department of Public Welfare, the United States Department of Health and Human Services, the Medicaid Fraud Control Unit, any other authorized governmental agencies and the designee of any of the foregoing, any information maintained under paragraph (a) above and any information regarding payments claimed by the provider for furnishing services under the Pennsylvania Medical Assistance Program; and c. Comply with the disclosure requirements specified in 42 CFR, Part 455, Subpart B (relating to Disclosure of Information by Providers and Fiscal Agents), or any amendments thereto. 4. This agreement shall continue in effect unless and until it is terminated by either the provider or the Department. Either the provider or the Department may terminate this agreement, without cause, upon thirty days prior written notice to the other. The provider s participation in the Pennsylvania Medical Assistance Program may also be terminated by the Department, with cause, as set forth in applicable Federal and State laws and regulations. Outpatient providers sign in this block By: Original Signature of Provider (No Stamp) Printed Name of Provider Date Inpatient providers sign in this block By: Signature of Chief Executive Officer/Chief Financial Officer/Administrator (No Stamp) Printed Name Date 1 of 1 Updated February 1, 2013
Commonwealth of Pennsylvania Office of Mental Health and Substance Abuse Services Provider Disclosure Statement Definitions The definitions below are designed to clarify certain questions on the following forms. If you cannot report all of the necessary information in a designated section of the form because of space limitations, please print and attach additional sheets. Definitions Agent means any person who has been delegated the authority to obligate or act on behalf of a provider. Disclosing entity means a Medicaid provider (other than an individual practitioner), or a fiscal agent. Any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of participation in any of the programs established under title V, XVIII, or XX of the Act means: a. Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization that participates in Medicare (title XVIII); b. Any Medicare intermediary or carrier; and c. Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, health-related services for which it claims payment under any plan or program established under title V or title XX of the Act. Fiscal agent means a contractor that processes or pays vendor claims on behalf of the Medicaid agency. Group of practitioners means two or more health care practitioners who practice their profession at a common location (whether or not they share common facilities, common supporting staff, or common equipment). Indirect ownership interest means an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity. Individual practitioner means a physician or other person licensed or certified under State Law to practice his or her profession. Managing employee means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day to day operation of an institution, organization, or agency. Ownership interest means the possession of equity in the capital, the stock, or the profits of the disclosing entity. Person with an ownership or control interest means a person or corporation that: a. Has an ownership interest totaling 5 percent or more in a disclosing entity; b. Has an indirect ownership interest equal to 5 percent or more in a disclosing entity; c. Has a combination of direct and indirect ownership interest equal to 5 percent or more in a disclosing entity; 1 0f 9 Updated February 1, 2013
d. Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5 percent of the value of the property or assets of the disclosing entity; e. An officer or director of a disclosing entity that is organized as a corporation; or f. Is a partner in the disclosing entity that is organized as a partnership Significant business transaction means any business transaction or series of transactions that, during any one fiscal year, exceed the lesser of $25,000 and 5 percent of a provider s total operating expenses. Subcontractor means: a. An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or b. An individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the Medicaid agreement. Supplier means an individual, agency, or organization from which a provider purchases goods and services used in carrying out its responsibilities under Medicaid (e.g., a commercial laundry, a manufacturer or hospital beds, or a pharmaceutical firm). Wholly owned supplier means a supplier whose total ownership interest is held by a provider or by a person, persons, or other entity with an ownership or control interest in a provider. 2 of 9 Updated February 1, 2013
If you are a non-profit organization, please skip this section and complete Attachment II. Ownership or Control Interest Note: Ownership information is required in accordance with Federal Regulation 42 CFR, Part 455, published July 17, 1979. Please enter the full name and address of partners, stockholders, corporate owners, or officers that have at least 5% direct or indirect ownership interest. Attach additional sheets, if necessary. Complete below for Individuals: - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code 3 of 9 Updated February 1, 2013
Complete the below for Corporate Entities: Ownership or Control Interest (continued) The address for each corporate entity must include: primary business address, every business location, and P.O. Box address Attach additional sheets, if necessary. - Name of Corporation FEIN/Tax ID Number Street Address PO Box City State Zip Code - Name of Corporation FEIN/Tax ID Number Street Address PO Box City State Zip Code - Name of Corporation FEIN/Tax ID Number Street Address PO Box City State Zip Code - Name of Corporation FEIN/Tax ID Number Street Address PO Box City State Zip Code 4 of 9 Updated February 1, 2013
Ownership or Control Interest (continued) Please enter the full name and address of each person with an ownership or controlling interest in any subcontractor in which the disclosing entity has a direct or indirect ownership interest of 5% or more. Attach additional sheets, if necessary. - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code Has this individual been convicted of a criminal offense related to Medicare or Medicaid, or a state health care program? Yes* No * If Yes, please attach details. - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code Has this individual been convicted of a criminal offense related to Medicare or Medicaid, or a state health care program? Yes* No * If Yes, please attach details. Are any of the aforementioned persons related to each other as a spouse, parent, child, or sibling? If so, please list the names of the individuals and how they are related. Names: Relationship: Names: Relationship: Names: Relationship: 5 of 9 Updated February 1, 2013
Ownership or Control Interest (continued) Do you or any of the aforementioned individuals have a controlling interest in, or own other providers of services? Yes* No *If Yes, list the name and address of each provider. Name: (First) (Middle) (Last) Street Address City State Zip Code Name of individual with ownership or control interest Name: (First) (Middle) (Last) Street Address City State Zip Code Name of individual with ownership or control interest Has the provider had any significant business transactions with any wholly owned supplier or with any subcontractor during the preceding five year period? Yes* No *If Yes, give the information below for each wholly owned supplier or subcontractor. Attach additional sheets, if necessary - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code 6 of 9 Updated February 1, 2013
Attachment I Managing Employee or Agent Disclosure Form A. Please provide the name, address, social security number, and date of birth of any person who is an agent or managing employee of the provider - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code B. Please provide the name and description of offense of any person who is an agent or managing employee and has been convicted of a criminal offense related to Medicare or Medicaid, or a state health care program. Name: (First) (Middle) (Last) Description of offense Name: (First) (Middle) (Last) Description of offense Name: (First) (Middle) (Last) Description of offense 7 of 9 Updated February 1, 2013
Non-Profit Disclosure Attachment II Please add anyone who has a controlling interest or is a board member President: - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code Vice President: - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code Secretary: - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code Treasurer: - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code 8 of 9 Updated February 1, 2013
Attachment II continued Other: - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code - - Name: (First) (Middle) (Last) Social Security Number / / Date of Birth Street Address City State Zip Code 9 of 9 Updated February 1, 2013
Commonwealth Of Pennsylvania Office of Mental Health and Substance Abuse Services Consolidated Community Reporting Initiative Attestation Form County Name: CCRI County Contact Name: Print Name has successfully completed the Name of Provider credentialing process as a provider. Type of CCRI Service For providers who are enrolling as one of the following provider type and provider specialty, the procedure code and modifier combination (if applicable) must be listed below: 11-110 11-111 11-112 11-119 11-123 11-126 21-215 26-267 51-512 51-513 51-515 52-456 52-520 52-521 53-531 08-110 (only if enrolling for H2013) Procedure code Modifier The population to be served is consistent with the requirements for this service. The County or County Contractor(s), where applicable, has/have approved the enrollment of this provider for the CCRI program. The requested effective date of the CCRI enrollment into PROMISe is, CCRI County Contact Signature Printed Name Date PLEASE NOTE: Services that fall under a provider type/provider specialty that is unlicensed, must submit a service description along with the application. Submittal Information The county will submit the CCRI enrollment packet along with this CCRI Attestation Form to the following address: DPW/OMHSAS Business Partner Support Unit CCRI Enrollment 112 East Azalea Drive Harrisburg, Pennsylvania 17110-3594 Applications that are received directly from the provider will be returned unprocessed. 1 of 1 Updated February 1, 2013
PT PS Service Name Outpatient Clinical Services, Psychiatric HealthCare Facility Services 08 110 Payments to clinics for services to clients, not categorized elsewhere 11 110 Example: monthly membership management fee Alternative Outpatient Program (AOP) in an Alternative Setting Highly structured therapeutic intervention Serves persons 18 years and older who do not need hospitalization Mental health treatment and supervision on a 24 hour per day basis Cannot be a permanent dwelling Proc Code Mod (I/A) Unit of Svc 11 11 112 119 Certificate of Compliance under Regulation 5320 Behavioral Health Counseling Individual,group,or family therapy provided by a licensed MH Practitioners MH licensed practitioners no existing PT/Spec are available School based counseling and mobile services can be reported here Community Mental Health Services Other (Adults) not otherwise specified. Services include, but are not limited to: Diversion and stabilization programs Outreach and engagement H0004 H0046 HE HW 15 min 15 min Services with emergency capacity to the homeless 11 119 Service Description required Community Mental Health Services Other (Children) not otherwise specified. Services include, but are not limited to: Assessment, counseling, consultation or referrals related to the Student Assistance Programs that are not reportable elsewhere H0046 HK 15 min Service Description required Adult Developmental Training (ADT) - Adult Day Care Skills Training and Development Community based programs designed to facilitate the acquisition of 51 515 prevocational behavioral activities of daily living & independent living skills H2014 HK 15 min Adult Development Training programs are provided in licensed facilities Certificate of Compliance under 2380 Regulations (Adult Care Care Ctrs) Community Employment and Employment Related Services Community Employment and Employment Related Services Employment in a community setting or employment related program which may combine vocational evaluation & vocational training in a setting such as a business,industry, or in other work sites within the community. 53 531 H2023 HX 15 min (Includes transitional employment & industry-integrated vocational 53 531 rehabilitation programs such as work stations in industry, transitional training, mobile work forces, etc) Service Description required Supported Employment Evidence based service to promote employment for persons with serious mental illness Programs provide jobs that are competitive,permanent in nature and uses a team approach with integrated treatment Programs must meet the guidelines on evidence based practices that are a part of the county plan guidelines Service Description required Facility Based Vocational Rehabilitation Services Facility Based Vocational Rehabilitation Services Designed to provide vocational training within a community-based 53 531 specialized facility (sheltered workshop) Certificate of Compliance under 2390 Regulations (Voc Rehab Facilities) H2013 H0037 H2023 per diem per diem H2023 HW 15 min 15 min 1
PT PS Service Name Social Rehabilitation Services Social Rehabilitation Services (Mental Health-Not Otherwise Specified) Includes a variety of programs designed to connect persons to others and to the community. Services included, but are not limited to: Therapeutic Recreation Proc Code Mod (I/A) Unit of Svc Socialization 11 126 H0046 15 min Training activities such as outreach services Representative payee programs Volunteer programs Drop-in centers Guardianship Service Description required Family Support Services Comprehensive Community Support Services Designed to enable persons with mental illness and their families to continue living with the family unit or provide supports which enable the person to live 11 126 independently in the community. Services include but are not limited to: Payments for clients or family members to attend special events H2015 HX 15 min Payments for homemakers, family aids, art classes,sign language interpreting services, equipments such as TTY, etc. Service Description required Comprehensive Community Support Services Designed to enable persons with mental illness and their families to continue living with the family unit or provide supports which enable the person to live independently in the community. Services include but are not limited to: 11 126 H2016 HW per diem Payments for clients or family members to attend special events Payments for homemakers, family aids, art classes,sign language interpreting services, equipments such as TTY, etc. 26 267 Service Description required Non-Emergency Transportation Enables consumers to get to necessary mental health locations for services when no alternative is available T2003 HX per trip 51 512 Provided by a county contracted transportation company for specific consumers Respite Care Services for Children, Unskilled Respite Care Provided in a non-facility setting such as a home 51 512 Providers may be non-professional Respite Care Services for Children, Unskilled Respite Care Provided in a non-facility setting such as a home Providers may be non-professional S5151 per diem Service is provided pursuant to the funding and guidelines provided by OMHSAS Children s Bureau Respite Care Services, Not in the Home 51 513 Used to provide families of children & adults with mental illness the opport- H0045 per diem unity for periodic relief from caring for their family member at home. Respite Care Services, In the Home 51 513 Used for adult consumers with mental illness treatment needs, to allow the S9125 per diem opportunity for periodic relief from caring for their family member at home S5150 15 min 2
PT PS Service Name Proc Code Mod (I/A) Unit of Svc Community Residential Services Mental Health Residential (Non-Hospital Residential & Community Support Program) including Room & Board - Adult CRR Offer care, treatment,rehabilitation,social, & personal development services 52 456 T2048 per diem For adults capable of benefiting from social and personal development services away from their own homes and families Mental Health Long Term Highly Structured Care in a Residential Program 52 456 Licensed as a Long Term Structured Residence Chapter 5320 Persons 18 years or older who require a highly structured therapeutic T2048 HX per diem program Certificate of Compliance under 5320 Regulations Enhanced Support in a Community Residence with Room & Board Includes any room and board payment by the county that helps an individual to remain in the community. Services provided in: A personal care home or an enhanced personal care home; 52 456 Private residence, apartment, host home, foster home, supported living T2048 HW program, or a specialized community residence where the individual does not hold a lease Personal Care Boarding Home License or 52 456 Service Description required Mental Health Program with Room and Board Highly structured therapeutic residential mental health treatment facility Serves persons 18 and older who do not need hospitalization T2048 HK per diem Typically provides a step down from inpatient care 52 456 Certificate of Compliance as an Residential Treatment Facility for Adults Mental Health Program with Room and Board Associated with Adult Outpatient Services Room and board costs associated with adult outpatient services provided in an alternative setting that is an AOP T2048 HE per diem Certificate of Compliance under 5320 Regulations Behavioral Health Short Term Residential (Non-Hospital Residential Treatment Program) without room and board Department approved community residential agency or home 52 456 Offers care, treatment, rehabilitation, habilitation, social and personal H0018 HB per diem development services For adults capable of benefiting from social and personal development services away from their own homes and families RTF Non-JCAHO Room & Board Children under the age of 21 In a RTF Non-JCAHO, CRR Host Home or CRR Group Home setting 52 520 Costs include food, clothing, shelter, child care, etc T2048 SC per diem Authorized for MH only children when the Standard Room and Board Contract is submitted per MH Bulletin 4000-95-01 52 521 Certificate of Compliance under 5310 or 3800 regulations Community Home for Individuals with Mental Retardation A building or separate dwelling unit in which residential care is provided to one or more individuals with MR T2048 per diem Individuals with MR or dual diagnosis Certificate of Compliance under 6400 Regulations per diem 3
PT PS Service Name Administrative Management Administrative Management Activities and administrative functions undertaken by staff in order to ensure Proc Code Mod (I/A) Unit of Svc intake into the county mental health system; addresses appropriate and 21 215 T1016 HX 15 min timely use of available resources & specialized services to meet the consumer's needs Refer to OMHSAS-12-92 Bulletin for specific descriptions Emergency Services Emergency Services Emergency related activities & administrative functions undertaken to 11 119 proceed after a petition for voluntary or involuntary commitment has been H0046 ET 15 min done. Refer to OMHSAS Bulletin 12-02 for specifics Service Description required Housing Support Services Supported Living Services provided to consumers living in housing which they do not hold a 11 126 lease and receive services to maintain the housing Includes life skills or a treatment component Provided in an enhanced personal care home, private residence, apartment host home, foster home, a supported living program or specialized community residence Includes licensed or unlicensed residences Service Description required Supported Living Services provided to consumers living in housing which they do not hold a lease and have to receive services to maintain the housing Includes life skills or a treatment component 11 126 Provided in an enhanced personal care home, private residence, apartment H2016 host home, foster home, a supported living program or specialized community residence Includes licensed or unlicensed residences Service Description required Supported Housing Services provided to consumers with a lease or master lease Assists consumer in obtaining and retaining permanent housing Includes assistance in finding adequate housing, moving and household 11 126 H2015 HE 15 min establishment, acting in a tenant/landlord liaison role, counseling and/or advocacy in tenant rights and responsibilities, life skills and money management, services/supports coordination Service Description required Supported Housing Contingency funding supports individuals with a lease or master lease agreement in obtaining and retaining permanent housing 11 126 May include payment of utilities, taxes, rent, repairs, furnishings, security H0043 deposits; Giving financial assistance on behalf of a consumer Service Description required H2015 HW 15 min per diem per diem or occurrence 4
Proc Mod PT PS Service Name Code (I/A) Assertive Community Treatment (ACT) Teams and Community Treatment Teams (CTT) Assertive Community Treatment (ACT) Direct care service which merges clinical, rehabilitation and support staff Unit of Svc expertise within one service delivery team 11 111 H0039 HE 15 min Requirements in the ACT Bulletin OMHSAS 08-03 Service Description required Certificate of Compliance as Assertive Treatment Team (as applicable) 11 111 Community Treatment Team Direct care service which merges clinical, rehabilitation and support staff expertise within one service delivery team Does not meet the requirements of the ACT Bulletin OMHSAS 08-03 Service Description required Psychiatric Rehabilitation Community Psychiatric Rehabilitation - Facility Based (Community Psychiatric Supportive Treatment - Face to Face) Persons 18 years & older with functional disabilities resulting from mental 11 123 illness H0036 HK 15 min To enhance/retain psychiatric stability, social competencies, personal adjustment and/or independent living Certificate of Compliance as a Psychiatric Rehabilitation Provider Community Psychiatric Rehabilitation - Community Based Persons 18 years & older with functional disabilities resulting from mental illness 11 123 H0036 15 min To enhance/retain psychiatric stability, social competencies, personal adjustment and/or independent living Certificate of Compliance as a Psychiatric Rehabilitation Provider Mental Health Psychiatric Rehabilitation Clubhouse Services Persons 18 years & older with functional disabilities resulting from mental illness 11 123 To enhance/retain psychiatric stability, social competencies, personal H2030 15 min adjustment and/or independent living Certified by the International Center for Clubhouse Development (ICCD) Certificate of Compliance as a Psychiatric Rehabilitation Provider Children's Evidence Based Practices Children s Evidence Based Practices - Multi-Systemic Therapy Persons under 21 years Family therapy and parent counseling are the primary treatment modes 11 119 H2033 15 min Treatment involves consultation and collaboration with other systems such as school, probation, child welfare 11 119 Service Description required Children s Evidence Based Practices Trauma Focused Cognitive Behavioral Therapy Persons under 21 years Weekly sessions for trauma such as sexual abuse, traumatic grief, H2019 HK 15 min domestic violence, disasters, terrorism, etc 11 119 Service Description required Children s Evidence Based Practices Functional Family Therapy (FFT) Persons under 21 years Focus is on at risk youth and their families H2019 HA 15 min Service Description required H0039 15 min 5
PT PS Consumer Driven Services Service Name Proc Code Mod (I/A) Unit of Svc 11 126 Consumer Driven Services (Comprehensive Community Support Services) Psychiatric rehabilitation services serving county funded consumers operate without a license (i.e. Fairweather Lodges, clubhouses that H2015 HK 15 min are not ICCD certified, peer programs that do not meet the guidelines established in the Peer Support Bulletin, volunteer programs Service Description required Transitional and Community Integration Services Transitional and Community Integration Forensic Services Includes mental health court activities not otherwise characterized and 11 119 services that are provided in jail settings H2017 H9 15 min Used to capture activities not reported in case management 11 119 Service Description required Transitional and Community Integration Services to Adults Includes assessments and service plan development May occur in a nursing home, personal care home, or consumers home H2017 HW 15 min Used to capture activities not reported in case management 11 119 Service Description required Transitional and Community Integration Continuity of Care Teams Include monitoring of admissions to and discharges from state mental hospitals and community hospitals H2017 HE 15 min Used to capture activities not reported in case management Service Description required County Only CCRI Provider Enrollment Resource Tool Revised - May 2013 6
Commonwealth of Pennsylvania Office of Mental Health and Substance Abuse Services Consolidated Community Reporting Initiative Provider Change/Closure Form Instructions for PROMISe Provider Service Location Change Request for Consolidated Community Reporting Initiative Providers This form can be used for the following purposes only: 1. To close an existing service location 2. To change the Mail-To address for an existing service location 3. To change the Pay-To address for an existing service location 4. To change the Home Office address for an existing service location 5. To change the e-mail address for an existing service location This form cannot be used to add a service location To add a service location, complete a Consolidated Community Reporting Initiative Provider Enrollment Application, as applicable, and any required related forms. Please return form to: DPW/OMHSAS Business Partner Support Unit CCRI Enrollment 112 East Azalea Drive Harrisburg, Pennsylvania 17110-3594 Page 1 of 2 Updated 03/01/2012
PROMISe Provider Service Location Change Request for Consolidated Community Reporting Initiative Providers Provider Change/Closure Form This form cannot be used to add a new service location address Please close the following service location on my provider file: Provider Name: PROMISe Provider Number: (13 digits) Provider Type and Description: / Provider Specialty and Description: / Effective Close Date: / / Service location address: City: State: Zip: County: Phone Number: ( ) - Please change the following address for a previously established service location: (Mail-To, Pay-To, Home Office, or e-mail address only. You cannot add or change a service location address using this form) Provider Name: PROMISe Provider Number: (13 digits) Change the Current: Mail-To Pay-To Home Office Effective change date: : / / Provider Type and Description: / Provider Specialty and Description: / E-mail Address: Street address: City: State: Zip: County: Phone Number: ( ) - Print or Type Provider Name / / Date Original Provider Signature (Signature stamps not accepted) Page 2 of 2 Updated 03/01/2012
OFFICE OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES BULLETIN ISSUE DATE: March 26, 2012 EFFECTIVE DATE: July 01, 2012 NUMBER: OMHSAS-12-02 SUBJECT: BY: Cost Centers for County Based Mental Health Services Blaine L. Smith Deputy Secretary Office of Mental Health and Substance Abuse Services SCOPE: This bulletin applies to County Mental Health Programs. PURPOSE: The purpose of this bulletin is to accommodate data reporting for the changing and growing array of services provided by the counties that use state and county funding. This bulletin establishes new cost centers, expands some existing cost centers and combines others. It allows for appropriate reporting and monitoring of expenditure and service information for a number of new community mental health services. The reporting of county mental health (MH) program costs must conform to the cost centers as presented on the Income and Expenditures Report for Fiscal Year 2012/2013. DISCUSSION: Increasingly, the Pennsylvania Office of Mental Health and Substance Abuse Services (OMHSAS) and other state mental health authorities across the country are being required to provide service utilization, performance measure and consumer outcome indicator information to the federal Substance Abuse and Mental Health Services Administration (SAMHSA) on mental health service recipients. To capture this information in a format that will inform the federal government, while simultaneously demonstrating County government accountability of public funds, OMHSAS worked closely with county mental Health programs and other stakeholders to update the community mental health cost centers that had been established in 1994. This Bulletin is the result of those efforts. COMMENTS AND QUESTIONS REGARDING THIS BULLETIN SHOULD BE DIRECTED TO: Office of Mental Health and Substance Abuse Services, Bureau of Policy, Planning & Program Development, P.O. Box 2675, Harrisburg, PA 17105. General Office Number (717) 772-7900.
2 COST CENTER DEFINITIONS: 3.1 Administrator s Office This cost center is defined for purposes of the account structure as referring to activities and services provided by the Administrator s Office of the County MH Program. The Administrator s Office activities include: a. The general administrative, programmatic, and fiscal responsibility for the county MH program. b. Development of planning documents addressing the county program needs, local planning efforts, and other information pertinent to planning for and providing a more adequate service delivery system. c. Research projects, the evaluation of program effectiveness, the analysis of programmatic needs of specific target groups, and the determination of the availability of services to the general public. d. Continuing relationships with the county MH board, the OMHSAS regional field office and OMHSAS central office, contracted service providers, and family/consumer groups. e. The initiation of guardianship proceedings; and f. The activities of the County MH Board. For more details please refer to Commonwealth of Pennsylvania Code Title 55, Chapter 4200: County Board and Program Administration. 3.2 Community Services The cost of programs and activities made available to community human service agencies, professional personnel, and the general public concerning the mental health service delivery system and mental health disorders, in order to increase general awareness or knowledge of same. Prevention, consultation and education services are also included in this cost center. The Community Services activities include: a. Advice and expertise given to professionals or other human service agencies concerning mental health disorders and services in order to expand knowledge concerning same. b. Educational information given and disseminated to the general public or community agencies concerning the services available from the county program. c. Activities and programs developed to reduce the incidence of mental health disorders, such as community awareness and prevention programs designed to promote mental health, resiliency and recovery. d. Activities designed to build community awareness and acceptance. e. Activities designed to develop community resources. 3.4 Targeted Case Management Targeted Case Management (TCM) services provide assistance to persons with serious mental illness (SMI) and children diagnosed with or at risk of serious emotional disturbance (SED) in gaining access to needed medical, social, educational, and other services through
3 natural supports, generic community resources and specialized mental health treatment, rehabilitation and support services. TCM staff operates in identifiable: Intensive Case Management (ICM), Blended Case Management (BCM), or Resource Coordination (RC) units, with limited case loads. Only those services that are part of an approved rebudget/county plan may be reported under this cost center. Targeted Case Management services are expected to help consumers achieve specific outcomes of independence of living, vocational/educational participation, adequate social supports and reduced hospitalization. The Targeted Case Management activities include: a. Assessment and understanding of the consumer s history and present life situation. b. Service planning based on the consumer s strengths and desires, to include any activities necessary to enable the consumer to live as an integral part of the community. c. Assertive and creative attempts to help the consumer gain access to resources and required services identified in the treatment or service plan. d. Monitoring of service delivery. e. Problem resolution, to include active efforts in advocacy to assist the consumer in gaining access to needed services and entitlements. f. Assistance to persons in identifying, accessing and learning to use community resources. g. Informal support network building. h. Linking with services. For more details please refer to Commonwealth of Pennsylvania Code Title 55, Chapter 5221: Mental Health Intensive Case Management; and OMHSAS Bulletin 09-02, Blended Case Management (BCM). 3.6 Outpatient This cost center applies to treatment-oriented services provided to a consumer who is not admitted to a hospital, institution, or community mental health facility for twenty-four hour a day service. These services may be provided to an individual or his/her family and may include services prior to or after inpatient or institutional care has been provided, outpatient treatment would be specified on a consumer s treatment plan. The outpatient activities include: a. Psychiatric or psychological, or therapy. b. Supportive counseling for the consumer s family members or other involved persons. c. Individual or group therapy. d. Treatment plan development, review and re-evaluation of a client s progress. e. Psychiatric services, including evaluation, medication clinic visit, and medical treatment required as part of the treatment of the psychiatric service. f. Psychological testing and assessment. g. Mobile mental health treatment and mobile medication management h. Telepsychiatry. i. Alternative Outpatient Therapy (AOP). For more details please refer to Commonwealth of Pennsylvania Code Title 55, Chapter 5200: Psychiatric Outpatient Clinics.
4 3.7 Psychiatric Inpatient Hospitalization This cost center applies to treatment or services provided an individual in need of twenty-four hours of continuous psychiatric hospitalization. The activities involve care in a licensed psychiatric inpatient facility. The Psychiatric Inpatient Hospitalization activities include: a. Diagnostic study or evaluation. b. Intensive psychiatric inpatient treatment at the onset of an illness, or under periods of stress. c. Close supervision necessitated by the inability of a person to function independently. d. Treating medical needs associated with the psychiatric inpatient treatment, medication stabilization, and intensive services required as part of the psychiatric inpatient treatment program. e. Extended acute care. 3.8 Partial Hospitalization This cost center is to be used for non-residential treatment services licensed by the Office of Mental Health & Substance Abuse Services (OMHSAS) for persons with moderate to severe mental illness and children and adolescents with serious emotional disturbance (SED) who require less than twenty-four hour continuous care but require more intensive and comprehensive services than are offered in outpatient treatment. Partial hospitalization services may be: 1) a day service designed for persons able to return to their home in the evening, 2) an evening service designed for persons working and/or in residential care, 3) a weekend program and /or 4) a day or evening program in conjunction with school. The Partial Hospitalization activities include: a. Medical, psychiatric, psychological and psychosocial treatment services, including individual, family, and group psychotherapy. b. Health education, to include basic physical and mental health information; nutrition information and assistance in purchasing and preparing food, personal hygiene instruction; basic health care information, child care information and family planning information and referral; information on prescribed medications. c. Instruction in the basic care of the home or residence for daily living, and in age appropriate developmental skills. d. Instruction in basic personal financial management for daily living. e. Medication administration and evaluation. f. Social interaction and pre-vocational service instruction. g. Crisis counseling. h. Acute partial programs that are generally three (3) weeks or less in duration. For more details please refer to Commonwealth of Pennsylvania Code Title 55, Chapter 5210: Partial Hospitalization. 3.10 Mental Health Crisis Intervention Services Mental Health Crisis Intervention Services are immediate, crisis-oriented services designed to ameliorate or resolve precipitating stress, which are provided to adults or children and their
5 families who exhibit an acute problem of disturbed thought, behavior, mood or social relationships. The services provide rapid response to crisis situations, which threaten the wellbeing of the individual or others. The Mental Health Crisis Intervention Services activities include: intervention, assessment, counseling, screening and disposition services in the following categories: a. Telephone crisis services, b. Walk-in crisis services, c. Mobile Crisis services (Individual-Delivered), d. Mobile Crisis services (Team-Delivered), e. Medical Mobile Crisis services (Team-Delivered), f. Crisis Residential services, and g. Crisis In-Home Support services. Only those services delivered by facilities licensed as Mental Health Crisis Intervention Services by OMHSAS may be reported under this cost center. 3.11 Adult Developmental Training (ADT) - Adult Day Care ADT services are categorized as those community-based programs designed to facilitate the acquisition of prevocational, behavioral activities of daily living, and independent living skills. As a prerequisite for work-oriented programming, ADT programs concentrate on cognitive development, affective development, communication development, physical development, and working skills development. ADT programs are provided in facilities licensed under Commonwealth of Pennsylvania Code Title 55, Chapter 2380: Adult Training Facilities. 3.12 Community Employment and Employment Related Services This cost center includes: employment in a community setting or employment-related programs, which may combine vocational evaluation, vocational training and employment in a non-specialized setting such as a business or industry. There are two different types of employment services included in this cost center. One is employment in a community or employment setting which combines vocational training in a business or industry setting. That includes transitional employment, industry-integrated vocational programs, mobile work forces, enclaves, and affirmative industries or businesses. The other type is Supported Employment, which is an Evidence Based Practice (EBP) recognized by the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services administration (SAMHSA). This involves community based job placements other than sheltered workshops. Employment specialists work as a team with consumers from intake through follow-up. The staff-consumer ratio is small. Team-delivered contacts occur at the consumer s home, at the job site or in the community. This employment is competitive. Eligibility is based on consumer choice and readiness, and involves rapid job search and follow-along supports.
3.13 Facility Based Vocational Rehabilitation Services 6 This cost center includes programs designed to provide paid development and vocational training within a community-based, specialized facility (sheltered workshop) using work as the primary modality. Sheltered workshop programs include vocational evaluation, personal work adjustment training, work activity training, and regular work training and are provided in facilities licensed under the Commonwealth of Pennsylvania Code Title 55, Chapter 2390: Vocational Facilities. 3.14 Social Rehabilitation Services This cost center refers to programs or activities designed to teach or improve self-care, personal behavior and social adjustment for adults with mental illness. Social rehabilitative activities are intended to make community or independent living possible by increasing the person s level of social competency and by decreasing the need for structured supervision. The Social Rehabilitation activities include: a. Social skills development to enhance habits, attitudes, and social skills. b. Cognitive development, affective development, communication development, physical skills development services. c. Activities of daily living skills development. d. Educational services and general skill levels to enhance employability. e. Drop-In Centers. Note: Services for children and adolescents may not be reported in this cost center (see Section 3.23; Children s Psychosocial Rehabilitation Services). 3.15 Family Support Services This cost center refers to supportive services designed to enable persons with serious mental illness (SMI), children and adolescents with or at risk of serious emotional disturbance (SED), and their families, to be maintained at home with minimal disruption to the family unit. The following list, which is not exhaustive, outlines the variety of activities that may be reported in the Family Support Services cost center: a. Homemakers, family aides, b. Art classes, c. Sign Language interpreting services, TTY equipment, d. Furnishing of apartment for individuals released from an institution, e. Visits by family members to visit loved ones placed in a remote facility, f. Bus passes, YMCA/YWCA memberships, g. Specialized summer camps, h. Attendance at conferences or meetings, i. Legal advocacy, j. Resource materials and training for family members to care for consumer, and k. Non-emergency transportation. NOTE: This cost center does not include Family-Based Mental Health Services.
7 3.16 Community Residential Services The Community Residential Services cost center applies to care, treatment, rehabilitation, habilitation, and social and personal development services provided to persons in a community based residential program which is a Department-licensed or approved community residential agency or home. Community residential services are intended for persons capable of benefiting from social and personal development services away from their own homes or family, or for children and adolescents with serious emotional disturbance (SED) who cannot be maintained in his/her own home. Included in this category are the room and board costs associated with the residence. Those costs include food, clothing, shelter, child care, personal incidentals for children, liability insurance with respect to the child, and reasonable travel for the child to visit family and school supplies. The settings include, but are not limited to: a. Community Residential Rehabilitation Services (CRRS), b. Personal Care Homes, c. Family living homes and host homes, d. Long Term Structured Residence (LTSR) facilities, e. Residential Treatment Facilities, f. Enhanced/Specialized Personal Care Homes, and g. Non-hospital acute care. NOTE: This cost center does not include MH Housing Support Services or Crisis Residential Services. 3.17 Family-Based Mental Health Services Comprehensive services designed to assist families in caring for their children or adolescents with emotional disturbances at home. This is an OMHSAS-licensed program which offers mental health treatment, casework services, and family support. Services are available twenty-four (24) hours a day, seven (7) days a weeks, for up to thirty-two (32) weeks or longer, if deemed medically necessary. Family-Based Mental Health Services (FBMHS) are team-delivered by mental health professionals and mental health workers, primarily in the family home. The cost of all services provided with Family-Based Mental Health Services funds, and to families enrolled in the Family-Based program, should be reported in this cost center. 3.20 Administrative Management The Administrative Management cost center applies to those activities and administrative functions undertaken by staff in order to ensure intake into the county mental health system and the appropriate and timely use of available resources and specialized services to best address the needs of individuals seeking assistance. Services are available for all persons who have a mental health diagnosis, as identified within the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) or a subsequent revision; or within the International Classification of Diseases, Ninth Edition (ICD-9) or a subsequent revision. Services are delivered for the purposes of facilitating and monitoring a person s access to mental health services and community resources. The activities include, but are not limited to:
8 a. Processing of intake into the Base Service Unit, which includes assessments, development of a care plan and referrals to services, b. Verification of disability, c. Liability determination, d. Authorization for services, e. Monitoring of service delivery through review of evaluations, progress notes, treatment/service plans, and other written documentation of services, f. Maintenance of records and case files, and g. On an occasional and situational basis, administrative case managers may provide some direct service to individuals as described below: 1. Coordination of service planning with state mental hospitals and other out-ofhome placement facilities with other systems, 2. Provision of supportive listening and guidance in problem-solving to consumers, their families and significant others, 3. Contact with family, friends, school personnel and significant others to develop or enhance the consumer s natural support network, and 4. Advocacy efforts to improve consumer s life situations, promote consumer choice, improve services, eliminate stigma, etc. 3.21 Emergency Services This cost center applies to those emergency related activities and administrative functions undertaken to proceed after a petition for voluntary or involuntary commitment has been completed, including any involvement by staff of the County Administrator s Office in this process. Activities include, but are not limited to: a. Mental Health Delegate services, b. Emergency psychiatric evaluations provided to a consumer to determine the need for psychiatric inpatient care, c. Searches for placement in an inpatient facility (bed searches), d. Emergency transportation, and e. Legal fees associated with the commitment process. 3.22 Housing Support Services Housing Support Services are services provided to mental health consumers which enable the recipient to access and retain permanent, decent, affordable housing, acceptable to them. They are provided by county MH program housing specialists or other staff designated by the county program. There are two (2) unique services that should be reported in this cost center. The first is Supported Living, which is provided to an individual in a setting in which they do not hold a lease and as a condition of retaining the housing, the individual must receive community-based behavioral health services. The setting may be a private residence, apartment, host home or foster home, and the services may include life skills or treatment.
The other service, Supportive Housing is a SAMHSA-recognized Evidence Based Practice (EBP). The services are provided in a setting for which the consumer does hold a lease and has no requirement that behavioral health services must be received to retain housing. Housing Support Services include the following: a. Housing location/re-location assistance, b. Roommate assistance, c. Renter skills training, d. Emergency rent or utility payments, e. Landlord/tenant negotiations, f. Rent guarantees, g. Security deposits for rent or utilities, h. Furniture and household goods, i. Moving assistance, j. Repair guarantees, k. Interim rent assistance, l. Assistance in obtaining housing benefits, m. Life skills training, and n. Tenant rights and responsibilities. 9 3.23 Assertive Community Treatment (ACT) Teams and Community Treatment Teams (CTT) Assertive Community Treatment (ACT) is a SAMHSA-recognized Evidence Based Practice (EBP) delivered to individuals with serious mental illness (SMI) who have a Global Assessment of Functioning (GAF) score of 40 or below and meet at least one other eligibility criteria (psychiatric hospitalizations, co-occurring mental health and substance abuse disorders, being at risk for or having a history of criminal justice involvement, and a risk for or history of homelessness). ACT teams are a self-contained program where individuals receive a comprehensive array of services from a multidisciplinary team. ACT teams must adhere to such requirements as outlined within OMHSAS Bulletin 08-03: Assertive Community Treatment. Pennsylvania s ACT teams are monitored for fidelity to the Dartmouth Assertive Community Treatment Scale. Community Treatment team (CTT) services merge clinical, rehabilitation and support staff expertise within one service delivery team. CTT services are targeted for those persons who have not achieved and maintained health and stability in the community, and who would continue to experience hospitalization, incarceration, psychiatric emergencies and/or homelessness without these services. 3.24 Psychiatric Rehabilitation Psychiatric Rehabilitation Services (PRS) assist persons with long-term psychiatric disabilities in developing, enhancing, and/or retaining: psychiatric stability, social competencies, personal and emotional adjustment and/or independent living competencies so that they may experience more success and satisfaction in the environment of their choice, and can function as independently as possible. Interventions may occur within a program facility or in community settings. This cost center applies to site-based and mobile services specifically
10 licensed by the Office of Mental Health and Substance Abuse Services (OMHSAS) as Psychiatric Rehabilitation. This service is intended primarily for adults. Services delivered by facilities that have earned certification from the International Center for Clubhouse Development (ICCD) and are licensed by OMHSAS as a clubhouse would be included in this category. 3.25 Children s Psychosocial Rehabilitation Services Children s Psychosocial Rehabilitation Services are designed to assist a child or adolescent (i.e., a person aged birth through 17, or through age 21if enrolled in a special education service) to develop stability and improve capacity to function in family, school and community settings. This may occur through training, support or intervention in the areas of problem solving and coping skills; social and interpersonal relationship skills; effective and appropriate communication of emotions, concerns and personal issues; behavior management; and community living. Services may be delivered to the child or adolescent in the home, school, community or a residential care setting. Among these services are after-school programs that include professional mental health staff. 3.26 Children s Evidence Based Practices This cost center refers to the array of practices for children and adolescents that by virtue of strong scientific proof are known to produce favorable outcomes. A hallmark of these practices is that there is sufficient evidence that supports their effectiveness. According to the Institute of Medicine evidence based practice integrates research evidence with clinical expertise and patient values. Some examples of programs currently in practice include: Multi-Systemic Therapy (MST) a SAMHSA-recognized EBP, Functional Family Therapy (FFT) - a SAMHSA-recognized EBP, and Therapeutic Foster Care (TFC) - a SAMHSA-recognized EBP. 3.27 Peer Support Services This cost center refers specifically to the Peer Support Services which meet the qualifications for peer support services as set forth in the Peer Support Services Bulletin (OMHSAS 08-07- 09), effective November 01, 2006. The peer support provider must: Be licensed by OMHSAS, Be enrolled in the Department s Provider Reimbursement an Operations Management Information System in electronic format (PROMISe) as a Medicaid provider of peer support services, Have an approved peer support service description, and Have a letter of approval from OMHSAS to operate a peer support services program.
11 3.28 Consumer-Driven Services This cost center refers to a host of services that do not meet the licensure requirements for psychiatric rehabilitation programs, but which are consumer-driven and extend beyond social rehabilitation services. Examples of services that would fit within this category are as follows: Fairweather Lodge programs, Peer programs that do not meet the guidelines established in the Peer Support Services Bulletin (i.e., are not Medicaid-enrolled and OMHSAS-licensed), Compeer programs, Peer-to-peer programs, Clubhouses that do not have OMHSAS licensure or ICCD credentials, Warmlines, and Peer monitoring services. 3.29 Transitional and Community Integration Services This cost center includes services that are provided to individuals who are residing in a facility or institution as well as individuals who are incarcerated, diversion programs for consumers at risk of incarceration or institutionalization, adult outreach services, and homeless outreach services. Services may have a dual focus such as helping the individuals to reintegrate into the community or services directed to the underserved and or atypical populations. This cost center captures services and activities that cannot be appropriately billed as case management. 3.98 Other Services Forensic services may include mental health court activities not otherwise characterized and services that are provided in jail settings both to the general prison population and to those housed in inpatient/crisis units within the prisons. Geriatric services include assessment, service plan development. Services may be provided in a variety of settings such as a nursing home, Personal Care Home or the individual s home. Continuity of Care team activities include the monitoring of admissions and discharges from state hospitals and community hospitals. The teams work with the consumers to assure that the necessary services are provided to prevent further hospitalizations. They also monitor consumer compliance with agreedupon treatment plans. This cost center refers to those activities or miscellaneous programs which could not be appropriately included in any of the previously cited cost centers. The specific activity or activities reported in this cost center must be described on all reporting forms submitted to the Department of Public Welfare. Use of this cost center requires prior approval from the Department.
12 OBSOLETE BULLETIN: This bulletin obsoletes OMH-94-10, Account Structure Manual- Revised Cost Centers for County Mental Health and Mental Retardation Programs, issued June 24, 1994.
Section Cost Center Title Type of changes made Cost Center Change Services Change 3.1 Administrator's Office No changes 3.2 Community Services No changes Title change (formerly called Intensive Case Management which was collapsed within), Resource Coordination collapsed 3.4 Targeted Case Management (MH Only) Cost center, Services within Added: Blended Case Management. Added: Mobile Mental Health; Mobile Medications; Telepsychiatry; 3.6 Outpatient Services Alternative Outpatient Therapy (AOP). 3.7 Psychiatric Inpatient Hospitalization (MH Only) Services Extended Acute Care added 3.8 Partial Hospitalization (MH Only) Services Added: Acute Partial Programs. 3.1 Mental Health Crisis Intervention Services Services Added: In Home Crisis Aides. 3.11 Adult Developmental Training (ADT) (Adult Daycare) No changes 3.12 Community Employment and Employment Related Services No changes 3.13 Facility Based Vocational Rehabilitation Services No changes 3.14 Social Rehabilitation Services No changes 3.15 Family Support Services No changes 3.16 Community Residential Services Services 3.17 Family Based Mental Health Services No changes 3.19 Resource Coordination Cost center 3.2 Administrative Management No changes 3.21 Emergency Services No changes 3.22 Housing Support Services Services Dissolved & collapsed within Section 3.4 Added: Enhanced/Specialized Personal Care Homes; Non hospital Acute Care. Added: Life Skills Training; ng; Tenant Rights and Responsibilities. 3.23 Assertive Community Treatment (ACT) Teams and Community Treatment Teams (CTT) Cost center Title change (ACT added) 3.24 Psychiatric Rehabilitation No changes 3.25 Children's Psychosocial Rehabilitation Services No changes 3.26 Children's Evidence Based Practices Cost center Newly created 3.27 Peer Support Services Cost center Newly created 3.28 Consumer Driven Services Cost center Newly created 3.29 Transitional and Community Integration Services Cost center Newly created 3.98 Other Services No changes
ISSUE DATE August 1, 2014 EFFECTIVE DATE: March 25, 2011 OFFICE OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES BULLETIN NUMBER: OMHSAS-14-03 SUBJECT: BY: Affordable Care Act (ACA) Re-enrollment Guidance for Behavioral Health Providers Dennis Marion Deputy Secretary Office of Mental Health and Substance Abuse Services SCOPE: Select Behavioral Health Providers in the Medical Assistance (MA) Fee-for-Service Program Select Providers in HealthChoices Behavioral Health Managed Care Providers in Consolidated Community Reporting Initiative (CCRI) Delivery System PURPOSE: The Office of Mental Health and Substance Abuse Services (OMHSAS) is issuing this bulletin to provide additional guidance to OMHSAS enrolled providers of behavioral health services, specifically, Community Support Service (CSS) providers. CSS include Intensive Case Management, Resource Coordination, Blended Case Management, Family Based Mental Health Services, Mental Health Crisis Intervention Services, and Peer Support Services. In addition to these providers, this guidance also applies to providers of HealthChoices Supplemental Services and providers of base-funded (CCRI) Mental Health services. BACKGROUND: On March 7, 2014, Department of Public Welfare s (DPW) Office of Medical Assistance Programs (OMAP) issued Bulletin 99-14-06 to outline the requirements associated with the reenrollment (revalidation) requirements for continued participation in the MA Program for currently enrolled providers. As outlined in Bulletin 99-14-01, Section 6401(b) of the Patient Protection and Affordable Care Act (Pub. L. 111 148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111 152) (collectively known as the Affordable Care Act or ACA), amended Section 1902 of the Social Security Act (Act) to add paragraphs (a) (77) and (kk), requiring States to comply with provider screening requirements. The federal Department of Health and Human Services promulgated regulations implementing these provisions of the statute on COMMENTS AND QUESTIONS REGARDING THIS BULLETIN SHOULD BE DIRECTED TO: Office of Mental Health and Substance Abuse Services, Bureau of Policy, Planning & Program Development, P.O. Box 2675, Harrisburg, PA 17105. General Office Number 717-772-7900.