Prospective Provider Information Form Organizational / Group Behavioral Health and Substance Use Providers Please review our current provider network needs outlined on the Health Share of Oregon website before continuing. If you are an organizational behavioral health or substance use disorder provider who meets our current network needs, and would like to be considered for a contract with Health Share, please complete and submit this form. Incomplete or illegible forms will not be reviewed. **If you are a physical or dental health provider, please contact one or more of Health Share s Physical or Dental Health Plan Partners to pursue a contract.** Contact Name: Email: ORGANIZATIONAL GROUP INFORMATION Group Name: Tax ID Number: NPI: DMAP # Group Email: Typical wait time to see new members? Phone: How many Health Share members could your group serve on a monthly basis? Will unlicensed practitioners (ie, QMHP, QMHA, etc) or registered interns provide services to Health Share members? Yes No Does the group have an active OHA issued Certificate of Approval (COA) for the services offered? Yes No COA in Process How many years of experience does the group have serving Oregon Medicaid Members and billing a CCO and/or MCO for reimbursement? What is your group s plan for addressing members in crisis after business hours? Does your service array align with the Regional Practice Guidelines as described on the Health Share website? Yes No Does your organization serve the Medicare population? Yes No Last Updated: December 2017 Continued on next page
If there are no prescribers affiliated with your group, does your organization have a relationship with a prescriber to handle emergent or ongoing member medication needs? Yes No N/A If your organization does have a relationship with a prescriber, please indicate their name(s), location(s) and the types of prescription services they will offer your members: Is the prescriber with whom you have a relationship willing and able to treat Medicaid members and bill Health Share? Yes No How do you handle member s emergent or ongoing medication needs? PRACTICE LOCATION(S) If you have more than one location, please duplicate this section for each additional location as needed. Location Name: Office Address: Street Address City State Zip County Office Phone: Service area (by zip code): Office Fax: Traveling/In Home Services Offered? Yes No Is this location ADA Accessible? Yes No Office Hours: (Include days & hours) Continued on next page Provider Information Form_Organization Page 2 of 6
Organizational Specialties Please indicate organizational specialties: Mental Health Outpatient DBT Psychological Testing Psychiatric Residential Treatment Mental Health IOP Intellectual and Developmental Disabilities (IDD) Medication Management Eating Disorder Treatment ABA Mental Health Other SUD Outpatient SUD Residential SUD Partial Hospitalization SUD Withdrawal Mmgt SUD MAT SUD Medically Monitored Detox SUD Other Age of Members Served: Please give a brief description of the services and levels of care which your group provides and how they align with Health Share s Regional Practice Guidelines. Please include the name of the Practice Guideline within which your service array aligns. Please use additional sheets if necessary. Continued on next page Provider Information Form_Organization Page 3 of 6
PRACTIONER INFORMATION Please copy and complete this page for all providers who will be providing services to Health Share members. If you have a provider roster which includes this data, you may send them instead of completing this section. Practitioner Name: Licensure Type: License Number: Practitioner NPI: DMAP #: Has provider ever faced a license stipulation/sanction or exclusion? Yes No Foreign Languages in which services are offered: NA Preferred Pronoun: She/Her He/Him They/Them Other: Culturally Specific Focus (if applicable) : Please check only culturally specific foci in which this provider has experience and training for treating members within their specialty: African American Asian American Hispanic/Latinx Native American /Alaskan Native Hawaiian/Pacific Islander LBGTQ+ Other (please specify): If you indicated that you provide culturally specific services, how long have you served this population? If you have any special specific education, training, and/or certifications you have which qualify you to treat this specific population, please include those below (include additional sheets if necessary). Provider Information Form_Organization Page 4 of 6
Prospective Provider Attestation All contracted Health Share Providers are required to follow federal and state laws and regulations related to providing services to OHP beneficiaries. The purpose of those laws and regulations is to ensure Member safety and provision of quality care and include requirements related to credentialing, criminal records checks, fraud, waste, and abuse, privacy, Member rights, abuse reporting, grievance and appeals, record keeping standards, and other applicable criteria. Provider acknowledges and understands that submitting this form to Health Share does not guarantee network participation. Provider acknowledges and understands that if they have been seeing Health Share members and have not obtained a prior authorization, services may not be reimbursed, and per OAR 410 120 1280, the member may not be billed. Provider acknowledges that they have reviewed and understand Health Share s Regional Practice Guidelines, and attests that their service array for which they are requesting a contract aligns with these guidelines. Provider acknowledges and understands that according to CMS 42 CFR 431.52, 42 CFR 447.15, 42 CFR 447.56, and OAR 410 120 1280 members may not be charged a co pay, nor billed for services rendered. Provider acknowledges and understands that members cannot be billed for missed appointments, services provided which were not authorized, or any portion of charges which were not reimbursed by Health Share. Provider acknowledges and understands that they cannot bill Health Share for a missed appointment or services which were not rendered. Provider acknowledges that they have reviewed and understand Health Share s Regional Rate Schedule. Provider understands that all NPIs which appear on a claim must have a Division of Medical Assistance Programs (DMAP) number in order to be reimbursed for services rendered. Provider understands that, should they be approved to provide services to Health Share members, they will be held accountable to the Fraud, Waste, and Abuse regulations set forth by the Centers for Medicare and Medicaid Services. Fraud, Waste, and Abuse overview available on the Health Share website at http://www.healthshareoregon.org/for providers/fraud waste and abuse.html. Provider understands the rules and regulations established by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Provider agrees to comply with all HIPAA laws. Provider will never disclose protected health information (PHI) in a manner that is not in compliance with HIPAA laws. By submitting this form to Health Share, you are attesting that you have read and understand the above statements regarding rules and regulations surrounding network participation, and affirm that you would like to be considered for a contract with Health Share. Provider Information Form_Organization Page 5 of 6
If you have any additional information you would like to supply to Health Share regarding your ability to treat Health Share members, or your specialties, please include it on separate sheets. To submit this form for consideration, please email the entire completed form, any supporting documents, and a signed copy of your organization s current W9 to providers@healthshareoregon.org. You may also FAX the form to 503 459 5749, Attn. Contracts and Network Management. Once your complete Provider Information Form and W9 have been received, your request will be reviewed by our internal staff and committees. You will be contacted only if additional information is needed or if there is a member need. Provider Information Form_Organization Page 6 of 6