LETTER OF INTENT TO CONTRACT WITH AMERIHEALTH CARITAS VIRGINIA FOR THE PROVISION OF SERVICES TO VIRGINIA MEDICAID RECIPIENTS AmeriHealth Caritas Virginia, Inc., a member of the AmeriHealth Caritas Family of Companies, is currently developing a network of hospital, physician and ancillary healthcare providers in order to qualify as a Virginia health maintenance organization, with the ultimate goal of entering into a contract with the Virginia Department of Services ( DMAS ). The goal of partnering with DMAS is to arrange for the delivery of health care services to individuals under DMAS proposed Managed Long Term Services and Supports ( MLTSS ) initiatives. Please sign below to indicate your intent to enter into contract negotiations with AmeriHealth Caritas Virginia for the provision of health care services to recipients who will be enrolled with AmeriHealth Caritas Virginia if we enter into a contract with DMAS. Please also complete the Provider Information Attachment. Providing specific information regarding your practice(s) and/or facility will help AmeriHealth Caritas Virginia demonstrate provider network adequacy as well as provide you with the appropriate provider contracts in the near future. This Letter of Intent is non-binding; signing this Letter of Intent does not obligate you to sign a contract with AmeriHealth Caritas Virginia. Either you or AmeriHealth Caritas Virginia can terminate this Letter of Intent at any time by notifying the other party in writing. By signing this Letter of Intent, you agree to allow AmeriHealth Caritas Virginia to identify you to DMAS and to the Virginia Bureau of Insurance ( BOI ) as a potential provider in the AmeriHealth Caritas Virginia provider network. AmeriHealth Caritas Virginia will not otherwise identify you as being affiliated in any manner with AmeriHealth Caritas Virginia until you have signed a definitive provider agreement with AmeriHealth Caritas Virginia. DMAS and BOI may use this Letter of Intent to evaluate AmeriHealth Caritas Virginia s qualification as a health maintenance organization. Please check all boxes that apply: Provider Identified below is a Virginia Provider Provider is not currently a Virginia Provider but intends to apply This Letter of Intent may be subject to review or approval by DMAS and may be amended by AmeriHealth Caritas Virginia to comply with the requirements of DMAS. Please fax the signed Letter of Intent and completed provider information attachment to 1-888-498-8751 or mail/email it to AmeriHealth Caritas Virginia, PO Box 406, Essington, PA 19029-9903 ProviderEnrollment@AmeriHealthCaritas.com no later than June 6 th, 2016 Contact Provider Network Management at 844-399-0474 or AmerihealthCaritasIntake@amerihealthcaritas.com for questions. 1
Group/Entity Information: Contract entity name: Entity taxonomy number: Entity tax ID number Entity NPI number: NPI not applicable Yes No Waiting for NPI: Yes No Virginia number: Entity mailing address: Primary contact email: Phone number: Authorized signature: Printed name: Title: Date: By providing your email address above, you grant AmeriHealth Caritas Virginia permission to contact you via email regarding participation in our provider network. Please let us know, at any time, if you wish to stop receiving communications from AmeriHealth Caritas Virginia via email. 2
Main Provider Name (as written on W9): Entity type: Individual Group Facility Provider TIN/EIN # (9 characters): 24 Hour Access: Yes No 24 Hour Answering Service: Yes No Primary Contact Name: Primary Contact Email: Primary Contact Phone: Primary Language Spoken: Other Languages Spoken: Location Main Location 1 Name (as it will appear in Provider Directory) Street Address Bldg # and/or Ste # City State Zip + 4 Digits Facility Type (ex., SNF, Case Mgmt., Hospice) Taxonomy Code Site/Group NPI Telephone w/ Area Code *Waiver Type (1,2,3,4,5,6,7,8) Location 2 Location 3 Location 4 Location 5 Location 6 Location 7 Please feel free to attach an additional document if more space is required. *HCBS Providers Only (Please add which waivers you serve at each location above.) Day Support (1) DD (2) EDCD (3) ID (4) Tech (5) AAL (6) HIV/AIDS (7) Other: (8) Page 1 of 3
Practitioner Roster If you will be credentialed as an organization/facility and will not credential your clinicians/practitioners separately you do not need to complete this page. Initial here if leaving this page blank Location (From # listed above) First Name Last Name MI Degree Specialty CAQH Reg. # Individual NPI Number and Primary Taxonomy Code (10 characters) ID and ID Numbers PCP Yes Page 2 of 3
Long Term Services & Supports, Substance Use Disorder and Community Based Mental Health Providers only. Please mark procedures you offer, and indicate the location (# from page 1) where the service is provided. Please use more than one form if there are multiple locations with differing services. Location where these procedures are offered (from page #1, example: Main, 1, 2, 3, etc.) Billed Procedure and Revenue Codes By Location Substance Use Disorder (SUD) Proc/Rev Code Description 0906 Intensive OP Svcs Chemical Dependency 0913 Partial Hospitalization - Intensive 1002 Residential Treat Chemical Dependency 90785 SA Out Patient, Interactive Complexity 90791HO Psychiatric diag eval, no Medical, Masters 90791HP Psychiatric diag eval, no Medic, Doctorate 90792 Psychiatric Eval, w/ Medical MD/DO 90832 Psychotherapy, 30 min 90834 Psychotherapy, 45 min 90837 Psychotherapy, 60 min 90847 Family Psychotherapy 90853 Group Psychotherapy 99201 Office/OP Visit New Pt: L1 99202 Office/OP Visit New Pt: L2 99203 Office/OP Visit New Pt: L3 99204 Office/OP Visit New Pt: L4 99205 Office/OP Visit New Pt: L5 99211 Office/OP Visit Established: L1 99212 Office/OP Visit Established: L2 99213 Office/OP Visit Established: L3 99214 Office/OP Visit Established: L4 99215 Office/OP Visit Established: L5 G9012 Other specified case management H0006 SUD Case Management H0007 SUD Crisis Intervention H0010 Alcohol and/or drug services H0011 Alcohol and/or drug services; sub- acute detox (residential addiction program IP) H0014 Alcohol and/or drug services; ambulatory detoxification H0015 H0020 H0035 H0038 H2034 Intensive Outpatient (IOP) Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed program) Partial Hospitalization Self- help/peer services, per 15 minutes Alcohol/drug abuse halfway house services, per diem H2036 Q3014 S9445 S9446 T1012 Alcohol and/or other drug treatment program, per diem SUD TeleHealth Patient education, not otherwise classified, non- physician provider, individual, per session Patient education, not otherwise classified, non- physician provider, group, per session Alcohol and/or substance abuse services, skills development Long Term Services & Supports Providers Proc/Rev Code Description S5102 Adult Day Health Care T1999 T1000 T1031 T1030 Assistive Technology Only Congregate Nursing/RN or LPN Congregate Respite Nursing/LPN Congregate Respite Nursing/RN 99199 Environmental Modification, Maintenance Costs Only S5165 Environmental Modifications Only S5160 PERS Installation S5185 S5161 H2021 T1019 T1005 S9125 S5109 H2000 S5116 T1028 PERS Medication Monitoring PERS Monitoring PERS Nursing Services/LPN or RN Personal Care Respite Care Respite Care LPN Service Facilitation Consumer Training Visit Service Facilitation Initial Comprehensive Visit Svc Facilitation Mgmt Training Hours Svc Facilitation Reassessment Visit 99509 Service Facilitation Routine Visit T1003 T1002 H2015 Skilled Nursing Services/LPN Skilled Nursing Services/RN Transition Coordination Non-Traditional Mental Health Services Proc/Rev Code Description H0023 Mental Health Case Management H0035 HA Therapeutic Day Treatment (TDT) for Children H0035 HB Day Treatment/ Partial Hospitalization for Adults H0036 Crisis Intervention H0039 H0046 H2012 H2017 H2019 H2020 H2022 T1016 H2033 H0038 T1012 S9445 S9446 Intensive Community Treatment Mental Health Skill- building Services (MHSS) Intensive In- Home Psychosocial Rehab Crisis Stabilization Level B Group Home Level A Group Home Treatment Foster Care Case Management Multi- systemic Therapy (ABA) Self- help/peer services, per 15 min Alcohol and/or substance abuse services, skills development Patient education, not otherwise classified, non- physician provider, individual, per session Patient education, not otherwise classified, non- physician provider, group, per session Page 3 of 3