Addendum to CAQH/North Carolina Uniform Credentialing/Re-Credentialing Application to Participate as a Health Care Practitioner

MANAGING MENTAL HEALTH, INTELLECTUAL/DEVELOPMENTAL DISABILITIES AND SUBSTANCE ABUSE SERVICES 910.67 3.91 11 (FAX) 91 0.67 3.62 02 WWW. S AN D H I L L S C E N T E R. O R G VI C T O RI A WH I T T, CEO Addendum to CAQH/North Carolina Uniform Credentialing/Re-Credentialing Application to Participate as a Health Care Practitioner For IPRS (State Funding) and Medicaid Please submit application to: Sandhills Center for MH, I/DD & SAS Network Operations Dept. Credentialing Specialist PO Box 9 West End, NC 27376 P.O. Box 9, West End, NC 27376 Serving Anson, Guilford, Harnett, Hoke, Lee, Montgomery, Moore, Randolph, & Richmond Counties Available 24 hours a day at 1-800-256-2452

Name of Practitioner: Name of Practice: Licensure: Credentialing & Re-Credentialing Data Form Solo LIP? Yes No Solo LIPs are required to submit a completed original signed and dated W9 Tax Payer Request for Tax ID # form for initial credentialing & re-credentialing. Practice Address: Mailing Address: Email Address (for correspondence): Phone: Are you registered with CAQH? Yes No CAQH #: Date of Birth: NPI #: Required Info Below Social Security Number: Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application Page 2 of 13

Instructions A Licensed Independent Practitioner must apply for and be credentialed/re-credentialed as a practitioner with Sandhills Center to qualify for reimbursement of services provided to Sandhills Center members. Additionally, Practitioners must have a signed contract with Sandhills Center or be employed by an Organization or Group Practice that has a signed contract with Sandhills Center to qualify for reimbursement of services provided to Sandhills Center Members. ****Please Identify Areas of Clinical Expertise and Treatment by completing and signing the Practice Preference Data on the attached Cultural, Racial, Ethnic, Gender, and Linguistic Data Form.**** ***LIPs are required to submit two (2) ea. references see Provider Evaluation Form *** The Credentialing/Re-Credentialing process includes the following steps: 1. Provider completes and signs the Licensed Independent Practitioner Credentialing/Re-Credentialing Application Addendum for Medicaid and IPRS to Participate as a Health Care Practitioner, in addition to the CAQH LIP application and returns it to: Sandhills Center for MH/I/DD/SAS Network Operations Department Attn: Credentialing Specialist PO Box 9 West End, NC 27376 2. A Credentialing/Re-Credentialing Application Addendum to Participate as a Health Care Practitioner is considered to be invalid if: The version date on any of the documents that comprise the provider Credentialing/Re-Credentialing packet is prior to 03/23/2015. All spaces in the application have not been completed. (Please indicate N/A or None, if the question is not applicable) The Signatures, where required, are not original and dated The Signatures are not by the individual applicant. The text has been altered, highlighted, struck through, or obstructed through the use of correction fluids The responses are illegible. Any of the documents or pages that comprise the Credentialing/Re-Credentialing Application to participate as a Heath Care Practitioner are missing. Any of the requested information in any of the documents that comprise the Credentialing/Re- Credentialing Application Addendum to participate as a Health Care Practitioner is missing. Before submitting the Credentialing/Re-Credentialing Application, make sure you have completed the following: Include an answer in all spaces. Indicate N/A or None, if the question is not applicable. 3. For Solo Licensed Independent Practitioners only Solo Licensed Independent Practitioners must furnish a completed original signed and dated W9 Tax Payer Request for Tax ID # Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application Page 3 of 13

Section 3: Professional Information Please check ( ) yes or no for the following questions. Please complete the attached Supplemental Form for any questions to which you answer yes. Also, please sign and date this application. If this application does not have the provider s signature, it cannot be accepted. 1. Has your license to practice in any jurisdiction ever been limited, restricted, reduced, suspended, voluntarily surrendered, revoked, denied or not renewed; have you ever been reprimanded by a state licensing agency; or are any of these actions pending with respect to your license; are you under investigation by any licensing or regulatory agency? (If yes, please complete Supplemental Question #1.) 2. Has your professional employment or membership in a professional organization ever been subject to disciplinary proceedings, denied, limited, restricted, reduced, suspended, revoked, not renewed, or voluntarily relinquished during or under threat of termination for any reason? (If yes, please complete Supplemental Question #2.) 3. Has your Drug Enforcement Agency registration or other controlled substance authorization ever been limited, restricted, reduced, suspended, revoked, denied, not renewed, or have you voluntarily surrendered or limited your registration during or under the threat of an investigation or any such actions pending? (If yes, please complete Supplemental Question #3.) 4. Have you ever been sanctioned or suspended by Medicare or Medicaid? (If yes, please complete Supplemental Question #4.) 5. To your knowledge, have you ever been reported to the National Practitioner Data Bank or the North/South Carolina Board of Medical Examiners? (If yes, please complete Supplemental Question #5.) 6. Have you ever been convicted of a felony or misdemeanor, or are you under investigation with respect to such conduct? (If yes, please complete Supplemental Question #6.) 7. Has a professional liability claim been assessed against you in the past five years, or are there any professional liability cases pending against you? (If yes, please complete Supplemental Question #7.) 8. Has any liability insurance carrier canceled, refused coverage, or rated up because of unusual risk or have any procedures been excluded from your coverage? (If yes, please complete Supplemental Question #8.) 9. Have you ever practiced without liability coverage? (If yes, please complete Supplemental Question #9.) 10. Do you currently have any medical, chemical dependency or psychiatric conditions that might adversely affect your ability to practice medicine or surgery or to perform the essential functions of your position without reasonable accommodation? (If yes, please complete Supplemental Question #10.) 11. Have your Hospital and/or Clinic privileges ever been limited, restricted, reduced, suspended, revoked, denied, not renewed, or have you voluntarily surrendered or limited your privileges during or under the threat of an investigation or are any such actions pending? (If yes, please complete Supplemental Question #11.) Signature Date ***Please provide additional detailed information on the following Supplemental Form. Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application Page 4 of 13

Supplemental Form All spaces in the application must be completed. (Please indicate N/A or None, if the question is not applicable) Provider Name: SHC Provider ID # : 1. License Limited, Reprimanded, etc.: List State(s) where action took place: Date(s) license revoked, suspended, etc.: From To 2. Employment/Membership Suspended, Limited, etc.: List State(s) where action took place: Date(s) license revoked, suspended, etc.: From To 3. Drug Enforcement Agency (DEA) Explanation: List State(s) where action took place: Date(s) license revoked, suspended, etc.: From To Click here to enter text. 4. Medicare/Medicaid Sanction Disciplinary Action(s): Disciplined Action(s): List State(s) where action took place: Date(s) of Action: From To 5. National Practitioner Data Dank Report(s): Please explain the NPDB report (if you have a copy please attach): 6. Felony or Misdemeanor: Did you serve a sentence: If Yes, please check ( ) how many years 1 2 3 4 5 6 Other: Please explain charge and verdict: List State(s): 7. Named in Professional Liability Judgment, Settlement, etc.: Please explain, include dates & amounts: 8. Canceled Refused Coverage, etc.: Please list Insurance Carrier(s): 9. Practiced Without Liability Coverage: 10. Medical, Chemical Dependency, or Psychiatric Conditions: 11. Hospital or Clinic Privileges Revoked, Restricted, etc.: List Hospitals(s): Date privileges revoked, suspended, etc.: From To Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application Page 5 of 13

Attestation Statement Important: Submit Original only No Stamps or Copies Please This Application is to be signed by the individual provider/clinician applying for Credentialing/Re-Credentialing. All information submitted by me in this application, as well as any attachments or supplemental information, is true, current, and complete to my best knowledge and belief as of the date of signature below. I fully understand that any significant misstatement in this application may constitute cause for denial of my application or termination of a resulting participation agreement. By application for membership in the Sandhills Center Network, I signify my willingness to appear for interview in regard to my application. I authorize Sandhills Center to consult with administrators and members of the medical staffs of hospitals or institutions with which I have been associated and with others, including past and present malpractice carriers, who may have information bearing on the questions in this application. Upon request, I will obtain and provide to Sandhills Center materials pertaining to my qualifications and competence, including, materials relating to complaints filed, any disciplinary action, suspension, or action to curtail my medical-surgical privileges. I further consent to the inspection by representatives of Sandhills Center of all documents that may be material to an evaluation of my professional qualifications and competence. I understand and agree that I, as an applicant, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubt about such qualifications. I release from liability all representatives of Sandhills Center for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and I release from any liability, all individuals and organizations that provide information to Sandhills Center in good faith and without malice concerning this application and I hereby consent to the release and verification of information relating to any disciplinary action, suspension, or curtailment of medical-surgical privileges to Sandhills Center. I understand that if my application is rejected for reasons relating to my professional conduct or competence, Sandhills Center, may report the rejection to the appropriate state licensing board and/or National Practitioner Data Bank. In the event I am accepted for participation in Sandhills Center, I hereby consent to Sandhills Center for inspection of my patient records relating to Sandhills Center members as necessary for its peer and utilization review purposed as permitted by state or federal law and regulation I further agree to notify Sandhills Center in a timely manner (not to exceed 30 days) of any changes to the information requested on the initial application. Signature of Applicant Date Printed Name of Applicant Title If this application does not have the provider s signature, it cannot be accepted. (Please sign and date this Attestation Statement). Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application Page 6 of 13

Sandhills Center Network Operations Credentialing Specialist P.O. Box 9, West End, NC 27376 Fax: (910) 673-7013 Provider Evaluation Form Peer (Licensed Practitioner, not partner) Referring Physician or Practitioner Supervisor Chief of Department/Staff where practitioner has admitting privileges (Not partner) Name of the Applicant: Group Name: The above provider is a Sandhills Center network applicant. Please provide us with information concerning his/her professional qualifications. All information submitted will be held in strict confidence. 1. What is your specialty/credentials: 2. What is your relationship to the applicant: 3. How long have you known the applicant: 4. How would you rate the applicant s professional abilities: Excellent Very Good Good Fair Poor 5. How would you rate the applicant s ability to work and communicate with physician and non physician staff: Excellent Very Good Good Fair Poor 6. How would you rate the applicant s rapport with members: Excellent Very Good Good Fair Poor 7. What do you believe to be the applicant s strengths and weaknesses (if any): a). Strengths: b). Weaknesses: 8. To your knowledge, has the applicant had any of the following: Malpractice claim(s): Problems with medical licensure, certification or licensing boards: Revocation, denial or change in hospital privileges: History of/or current impairment due to drugs and/or alcohol: ***If your answer is yes to any of the abgove questions, please provide details.*** 9. Would you recommend this person as a provider for the Sandhills Center network: Without reservation With reservation Would not recommend 10. Please provide any other information that would be helpful to us in evaluating this applicant: Evaluator s Signature Evaluator s Printed Name Date Address: Phone #: Group Name: Address: Street City State Zip Street City State Zip Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application Page 7 of 13

SANDHILLS CENTER Licensed Independent Practitioners Cultural, Racial, Ethnic, Gender, and Linguistic Data Form (This information will reside within Sandhills Center s Provider Directory and the online Provider Search.This section is self-reported information and requires no backup documentation) By providing the information below, you will be assisting Sandhills Center with member/provider matching, as well as providing information necessary for analyzing our Network and its ability to meet our Member s cultural, racial, ethnic and linguistic needs. Name of Practitioner: Name of Practice: Email Address: Counties Served: Anson Guilford Harnett Hoke Lee Montgomery Moore Randolph Richmond Other: Provider Type: APPCNS (Advanced Practice Psychiatric Clinical Nurse Specialist) DO LCAS LCSW LMFT LPA LPC PA PhD PsyD MDNP - Psychiatric Other (please specify): Priority Populations: MH Adult SA Adult I/DD - Adult MH Child SA Child I/DD - Child Your Gender: Female Male Your Race and/or Ethnicity (please check ( ) all appropriate categories): White Black or African American American Indian and Alaska Native Asian, Pacific Islander Hispanic or Latino Other: Populations(s) that you serve (please check ( ) all that apply): Early Childhood (0-4) Child & Adolescent (5-21) Adult (22+) Geriatrics (55+) Women Gay & Lesbian HIV/Aids Hearing Impaired Men Gender Identity Issues Sexually Reactive/Aggressive Youth Visually Impaired Other: Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application Page 8 of 13

Cultural, Racial, Ethnic, Gender, and Linguistic Data Form (continued) (This information will reside within Sandhills Center s Provider Directory and the online Provider Search) Culturally diverse populations that you feel competent to treat (please check ( ) all that apply): White Black or African American American Indian and Alaska Native Asian, Pacific Islander Hispanic or Latino Other Practice Preference Data Language(s) you are able to communicate in fluently (please check ( ) all that apply) American Sign Language English French German Hmong Portuguese Russian Spanish Telugu Other: (The sections below must have backup documentation to be listed with Sandhills Center) Focus of Treatments You Provide (please check ( ) all that apply): Amnestic Disorder Factitious Disorders Anxiety/Phobias Impulse Control Attention Deficit Hyperactivity Disorder Mentally Retarded/Developmentally Disabled Autism Asperger Obsessive-Compulsive Disorder Bipolar Disorder (manic-depressive illness) Personality Disorders Chemical Dependency/Substance Abuse Post Traumatic Stress Disorder Conduct Disorder Schizophrenia and other Psychotic Disorders Co-Occurring/Dual DX-Mental Retardation/Mental Sexual & Gender Identity Disorders Illness, Mental Health/Substance Abuse Dementia Disorder Sleep Disorders Depression Somatoform Disorders Eating Disorders Clinician Expertise/Certified Specialties (please check ( ) all that apply): Psychological Testing Therapy/Service Type Trauma Focused Cognitive/IQ Anger Management Abuse-Physical, Sexual, and/or Emotional Developmental limited/extended Assessment Evaluation Maltreatment Forensic Screening/Evaluation Caree/Vocational Counseling Neglect Neuro Psych Cognitive Behavioral Therapy Rape Personality Crisis/Solution focused Brief Therapy Dialectial Behavior Therapy Faith Based Counseling General Psychiatry General Psychology Gero Psychiatry Grief and Loss Therapy Health Psychology Chronic Medical Conditions Marriage and Family Counseling Play Therapy, Filial Relaxation/ Meditation-Hypnotherapy Self-Direction Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application Page 9 of 13

Practice Preference Data Clinician Expertise/Certified Specialties that Require Verification (please check ( ) all that apply): Verification of specific expertise(s) and/or training(s) selected below must accompany this form for Sandhills Center recognition, i.e. training certificates, certification, supervisor letters verifying training, or proof of experience. If standard training for clinician s licensure does not include area of identified expertise, additional documentation to support expertise will be required, e.g. a Psychiatrist who does psychological testing. Addiction Psychiatry (Fellowship in addiction Psychiatry/Board Certification/ASAM Certification/Experience) Eye Movement Desensitization and Reprocessing Therapy (Training Certificate/Experience) Addiction Treatment (LCAS/CAS/CCS/Experience) Forensic Psychology/Psychiatry (Fellowship in Forensic Psychiatry/Board Certification/Training/Experience) Child Psychiatry (Fellowship in child Psychiatry/Board Certification/Training/Experience) Trauma Focused Cognitive Behavioral Therapy (Course Completion at MUSC, Duke or NCTSN) Dialectical Behavior Therapy (Certification, Supervision, and Experience) Neuro Psych Assessment (Training, Supervision, and Experience) Services Provided in Office: Yes No Services Provided in the Community: Thank you for taking the time to submit this form. If this form is not completed and returned, your provider information will not appear within the Sandhills Center online Provider Search or Provider Handbook. To the best of my knowledge, I am able to meet all requirements necessary to apply for Sandhills Center Credentialing/Re-Credentialing for Licensed Independent Practitioner. I am submitting the attached Sandhills Center Licensed Independent Practitioner Credentialing/Re-Credentialing Application, which, to my knowledge, is a true and complete representation of the required materials. This Licensed Independent Practitioner Credentialing/Re-Credentialing Application is submitted by: Authorized Signature Date Title Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application Page 10 of 13

Outpatient Behavioral Health Service Codes for IPRS & Medicaid Please check ( ) all that apply (only the services you have an existing agreement with Sandhills Center) Procedure Available to Benefit Plan Description Code State (IPRS) Medicaid 90785 Interactive Complexity Add On State Medicaid 90791 Psychiatric Diagnostic Evaluation State Medicaid 90792 Psychiatric Diagnostic Evaluation with Medical Services State Medicaid 90832 Psychotherapy 30 Minutes State Medicaid 90833 Psychotherapy 30 Minutes Add On State Medicaid 90834 Psychotherapy 45 Minutes State Medicaid 90836 Psychotherapy 45 Minutes Add On State Medicaid 90837 Psychotherapy 60 Minutes State Medicaid 90838 Psychotherapy 60 Minutes Add On State Medicaid 90839 Crisis Psychotherapy first 60 Minutes State Medicaid 90840 Crisis Add For Each Additional 30 Minutes State Medicaid 90845 Psychoanalysis N/A Medicaid 90846 Family therapy w/o Patient State Medicaid 90847 Family therapy with Patient State Medicaid 90849 Group Therapy (Multiple Family) State Medicaid 90853 Group Therapy (Non-Multi- Family) State Medicaid 90857 Interactive Group Therapy N/A Medicaid 96101 Psychological Testing F-T-F State Medicaid 96110 Developmental Testing Limited State Medicaid 96111 Developmental Testing Extended State Medicaid 96116 Neurobehavioral Status Exam State Medicaid 96118 Neuropsychological Testing State Medicaid 96372 Therapeutic, Prophylactic, or DX Injection Intra-Muscular State Medicaid H0001 Behavioral Health Assessment State Medicaid H0004 Behavioral Health Counseling/Therapy State Medicaid H0004HQ Outpatient Treatment Group State Medicaid H0004HR Outpatient Tx Family Therapy w/ Client State Medicaid H0004HS Outpatient Tx Family Therapy w/o Client State Medicaid H0005 Alcohol and/or Drug Group Counseling State Medicaid H0031 Mental Health Assessment State Medicaid Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application Page 11 of 13

IPRS (State) Funds Only for Services for Non-Licensed Substance Abuse Professionals Please check ( ) all that applies (only the services you have an existing agreement with Sandhills Center): Check Procedure ( ) Code Description YP830 Behavioral health Assessment YP831 Behavioral health Counseling and Therapy YP832 DMH Outpatient Treatment Group YP833 DMH Outpatient Tx Family Therapy w/ Client YP834 DMH Outpatient Tx Family Therapy w/o Client YP835 Alcohol and/or Drug Services; Group Counseling by Clinician Evaluation & Management Codes Check ( ) ***Evaluation & Management Codes are only provided by Physicians Assistants, Cert. Nurse Practitioners and Physicians (only check ( ) what services you are currently providing). *** Procedure Code Description Check ( ) Procedure Code Description 90865 Narcosynthesis for Psychiatric Diagnostic Hospital Initial Observation Care High 99220 and Therapeutic Purposes Complexity 95970 Neurostimulator 99221 Hospital Initial Care MD (30 min.) 95971 Neurostimulator Simple Spinal Cord 99222 Hospital Initial Care MD (50 min.) 95972 Neurostimulator Complex Spinal Cord (1hr.) 99223 Hospital Initial Care MD (70 min.) 95973 Hospital Subsequent Hospital Care MD Neurostimulator Complex Spinal Cord (30 99231 Low Complexity (15 min.) min.) 95974 Hospital Subsequent Hospital Care MD Neurostimulator Complex Cranial 99232 Moderate Complexity (25 min.) (1 hr.) 95975 Hospital Subsequent Hospital Care MD Neurostimulator Complex Cranial 99233 High Complexity (35 min.) (30 min.) 95978 Hospital Observation/Inpatient Care 99234 Neurostimulator Low Complexity 95979 Hospital Observation/Inpatient Care 99235 Neurostimulator (30 min.) Moderate Complexity 96125 Standardized Cognitive Performance Testing 99236 Observation/Inpatient Care High Complexity 96150 Physical Health and Behavior Assessment F-T-F (15 min.) 99238 Hospital Discharge Services (<30 min.) 95151 Physical Health and Behavior Reassessment 99239 Hospital Discharge Services (>30 min.) 96372 Therapeutic, Prophylactic, or Diagnostic Outpatient Consultation MD Minor Injection 99241 (15 min.) Intra-Muscular 96373 96374 96375 Therapeutic, Prophylactic, or Diagnostic Injection Intra-Arterial Therapeutic, Prophylactic, or Diagnostic Injection Intravenous Push Therapeutic, Prophylactic, or Diagnostic Injection Subsequent Intravenous Push 99242 99243 99244 Outpatient Consultation MD Moderate (30 min.) Outpatient Consultation MD Severe (40 min.) Outpatient Consultation MD Severe (60 min.) Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application Page 12 of 13

Evaluation & Management Codes (continued) Check ( ) ***Evaluation & Management Codes are only provided by Physicians Assistants, Cert. Nurse Practitioners and Physicians (only check ( ) what services you are currently providing). *** Procedure Code Description Check ( ) Procedure Code Description 99201 Outpatient E&M New Patient F-T-F (10 Outpatient Consultation MD Severe 99245 min.) (80 min.) 99202 Outpatient E&M New Patient F-T-F (20 min.) 99251 Inpatient Consultation MD Minor (20 min.) 99203 Outpatient E&M New Patient F-T-F Inpatient Consultation MD Low Severity 99252 (30 min.) (40 min.) 99204 Outpatient E&M New Patient F-T-F (45 min.) 99253 Inpatient Consultation MD Moderate (55 min.) 99205 Outpatient E&M New Patient F-T-F Inpatient Consultation MD Moderate 99254 (60 min.) High Severity (80 min.) 99211 E & M Estab. Patient, w/wo MD Inpatient Consultation MD Moderate 99255 (approx. 5 min.) High Severity (110 min.) 99212 Outpatient Visit Estab. Minor (10 min.) 99281 ER Visit, Minor 99213 Outpatient Visit Estab. Moderate (15 min.) 99282 ER Visit, Low Severity 99214 Outpatient Visit Estab. Severe (25 min.) 99283 ER Visit, Moderate Severity 99215 Outpatient Visit Estab. Severe (40 min.) 99284 ER Visit, High Severity 99217 Hospital Observation Care - Discharge 99285 99218 99219 99306 99307 99308 99309 99310 99315 99316 99318 99324 99325 99326 99327 99328 99334 99335 99336 Hospital Initial Observation Care Low Complexity Hospital initial Observation Care Moderate Complexity Initial Nursing Facility Care E&M high Complexity (45 min.) Subsequent Nursing facility Care E&M Review of Case (10 min.) Subsequent Nursing Facility Care E&M Low Complexity (15 min.) Subsequent Nursing Facility Care E&M Moderate Complexity (25 min.) Subsequent Nursing Facility Care E&M High Complexity (35 min.) Nursing Facility Discharge Management (<30 min.) Nursing Facility Discharge Management (>30 min.) Nursing Facility, E&M Low to Moderate Complexity (30 min.) New Patient Domiciliary/Rest Home E&M Low Severity (20 min.) New Patient Domiciliary/Rest Home E&M Low Complexity (30 min.) New Patient Domiciliary/Rest Home E M Moderate Complexity (45 min.) New Patient Domiciliary/Rest Home E&M High Severity (60 min.) New patient Domiciliary/Rest Home E&M High Complexity (75 min.) Estab. Patient Domiciliary/Rest Home E&M (15 min.) Estab. Patient Domiciliary/Rest Home E&M Low Complexity (25 min.) Estab. Patient Domiciliary/Rest Home E&M Moderate Complexity (40 min.) 99304 99305 99337 99341 99342 99343 99344 99345 ER Visit for the evaluation and management of a patient Initial Nursing Facility Care E&M Low Complexity (25 min.) Initial Nursing Facility Care E&M Moderate Complexity (35 min.) Estab. Patient Domiciliary/Rest Home E&M Moderate to High Severity (60 min.) New Patient Home Visit E&M Low Severity (20 min.) New Patient Home Visit E&M Low Complexity (30 min.) New Patient Home Visit E&M Low Moderate Complexity (45 min.) New Patient Home Visit E&M High Severity (60 min.) New Patient Home Visit E&M High Complexity (75 min.) 99347 Estab. Patient Home Visit E&M (15 min.) 99348 99349 99350 99354 99355 99356 99357 Estab. Patient Home Visit E&M Low Complexity (25 min.) Estab. Patient Home Visit E&M Moderate Complexity (40 min.) Estab. Patient Home Visit E M High Complexity (60 min.) Prolonged MD Service w/f-t-f Patient Contact in Office (60 min.) Prolonged MD Service w/f-t-f Patient Contact in Office (30 min.) Prolonged MD Service w/f-t-f Patient Contact Inpatient (60 min.) Prolonged MD Service w/f-t-f Patient Contact Inpatient (30 min.) Q3014GT TelePsych Site Facility Fee Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application Page 13 of 13