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Commonwealth of PennsylvaniaOffice of Mental Health and Substance Abuse ServicesHealthChoices Behavioral Health Supplemental ServicesProvider Enrollment Application InstructionsEffective November 4, 2014, OMHSAS will only accept the current version of the Supplemental ServiceProvider Enrollment Application. If OMHSAS receives an outdated version of any enrollmentapplication, the BH-MCO will be contacted to let them know the enrollment application will not beprocessed and will be shredded.Please Note the following important information: Applications will be scanned – please do not staple;Please return pages 5, 7-as applicable, 9 through 17, 21 through 28, and 30-as applicable. Instructionpages should not be returned.Retroactive enrollment dates will only be considered within 30 days of receipt of application;Applications must be completed in black ink;Handwritten information must be legible;Applications must be completed by the provider representative who has the authority to submitapplications on behalf of the provider;The individual who signs/dates the enrollment application/agreement must be the individual who hasthe authority to assure all information is true and accurate and will be accountable for adhering toDepartment/OMHSAS requirements.No corrections/changes should be made to the data contained in the provider enrollment applicationexcept by the provider representative responsible for completing the application. If a mistake is madeor a change is needed, the provider representative must complete, initial and date the changed page;Modified provider enrollment applications will not be accepted;An enrollment application must be completed for each service location being enrolled;Out-of-State providers must submit proof of participation in their State’s Medicaid ProgramThe BH-MCO Attestation form must be completed in its entirety.1. Supplemental Services:Check the type of supplemental service(s) for which you are applying. As noted, attach a copy of yourLicense/Certificate of Compliance/Certificate of Licensure or your tailored Supplemental ServiceDescription (SSD) and the OMHSAS SSRC approval letter, as applicable2. Population to be Served:Check the appropriate box(es) to denote the age group(s) of the consumers you will be serving.3. Action Requested:Check “Initial Enrollment” if you are:a.requesting enrollment as a new provider;b.expanding your enrollment to include a new or additional specialty type for a supplemental service;c.requesting to open a new service location (including a satellite location)Check “Revalidation” if this is to revalidate your enrollment. Please complete the entire application.Page 1 of 30Updated 09/24/2014
Check “Service Location Change” if:a. you have an existing PROMISe service location and you have moved to a new physical locationCheck “Fee Assignment” if you are:a.Adding this provider to an existing provider group. Fee Assignment may only be made between“like provider types”. If enrollee is a Group, attach a copy of your Corporation Papers4. Enrollee’s Name:List the applicant’s name (individual practitioner, facility or group) and date of birth and gender (if applicantis an individual). If operating under a fictitious business/doing-business-as (dba) name, attach copy ofrecorded/stamped fictitious business name statement/permit.5. Tax Identification Information (TIN):Enter your Social Security Number. A copy of your Social Security card, W-2, or document generated by the FederalIRS containing your Social Security Number must accompany your application.Enter your Federal Tax ID Number (FEIN). A copy of the FEIN (TIN) label or document generated by the FederalIRS containing the name, and IRS number of the entity applying for enrollment must accompany this application. A W-9form will not be accepted.Enter the legal name as shown on the FEIN, and the corresponding current address, telephone and faxnumbers and contact information. (Note: Do not list tax information of entity to which payment will be made if saidentity is not the enrollee.)*Individual practitioners enrolling with a FEIN, must still provide their SSN and SSN documentation.6. National Provider Identifier (NPI) #:List your 10 digit NPI # and taxonomy(s). Include a copy of your NPPES confirmation letter verifying yourNPI #. dex.htm7. Business Type:Check the appropriate box for your business type (check one box only). Include corporation papers fromthe Department of State Corporation Bureau or a copy of your business partnership agreement, asapplicable.8. License:Enter the license number, issuing state, issue date, and expiration date, as applicable. A copy of yourlicense is required for your application to be processed.9. BH-MCO:Identify the BH-MCO with the network in which participation will occur.10. Counties You Are Approved to Serve:List each county you are approved to serve.11. Language:Indicate if any staff member can communicate with patients in another language in addition to English12. Building Accessibility:Answer the questions relating to the Americans with Disabilities Act (ADA)Page 2 of 30Updated 09/24/2014
13. Managing Employees or Agents:Indicate whether you retain any managing employees or agents.*If “yes” complete Attachment I14. Confidential Information:The individual applying for enrollment OR the representative of the facility applying for enrollment mustcomplete ALL confidential information questions. If “Yes” is answered to any of the questions, provide allapplicable documentation as requested. Sign and date the form.15. Physical Service Location:List the physical address where services will be provided. A Post Office Box is not a valid service location.16. Mail To Information:Indicate the address of where you want correspondence to be mailed. (e.g. notification of enrollment)17. Pay To Information:Indicate address of where payments will be sent. Payments will be initiated via the BH-MCO.18. Home Office Information:Indicate the entity’s headquarters address.19. Sign and date the application, print your name and list your telephone number. The signature should bethat of the individual applying for enrollment, or someone able to represent the facility applying forenrollment. Use black ink.Additional Required Forms: - Forward completed application to the Behavioral Health Managed CareOrganization (BH-MCO) with which you are affiliated. Also include as applicable: One DPW Outpatient Provider Agreement with original signature and current date.Copy of Department of Drug and Alcohol Program (DDAP) Certificate of Licensure, Department ofPublic Welfare (DPW) Certificate of Compliance, Department of State (DOS) Licensure or a tailoredservice description, as applicableCopy of OMHSAS Field Office letter denoting SSRC approval of the tailored service description, asapplicable.Verification of Tax ID name and number using the Department issued requirements.Individual practitioners enrolling with a FEIN, must still provide their SSN and SSN documentationCompleted Ownership or Control Interest Forms, as applicable to the business type identified inquestion 7 on page 11 of the Behavioral Health Supplemental Services Provider EnrollmentApplication.Page 3 of 30Updated 09/24/2014
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Commonwealth Of PennsylvaniaOffice of Mental Health and Substance Abuse ServicesHealthChoices Behavioral Health Supplemental ServicesBehavioral Health Managed Care Organization Attestation Form**This form must be completed in its entirety**BH-MCO Name:Provider Name:Check one of the boxes below: has successfully completed the credentialing process as aType of Supplemental Serviceprovider. The population to be served is consistent with the requirements for this supplemental service. The County Contractor(s), where applicable, has/have approved the enrollment of this provider for theHealthChoices Supplemental Service listed above. List the applicable county(ies): is a (LPC, LMFT, etc) Group serving only as payee for services rendered, is the entity to whichpayment will be made, and is not a rendering provider. (Note: A group can be a provider type/providerspecialty code combination 11/112 [MH Outpatient Practitioner] or 11/127 [D&A Outpatient Practitioner], andcan serve as payee only for providers of a like provider type/provider specialty code combination)The requested effective date of enrollment into PROMISe is ,BH-MCO SignaturePrinted NameDateSubmittal InformationForward the completed BH-MCO Attestation Form, enrollment packet and all supporting documentation to:DPW/OMHSASBusiness Partner Support UnitHealthChoices Enrollmentnd112 East Azalea Drive; 2 FloorHarrisburg, Pennsylvania 17110-3594 If the credentialed provider’s enrollment application requires a Field Office Attestation Form, forward the completed BH-MCOAttestation Form, enrollment packet and all supporting documentation to the appropriate OMHSAS Field Office denoted below:OMHSASScranton Field Office100 Lackawanna AveRoom 321Scranton, PA 18503OMHSASPittsburgh Field Office301 Fifth AveSuite 480Pittsburgh, PA 15222OMHSASSoutheast Field Office1001 Sterigere StBldg 57; Room 105Norristown, PA 19401Page 5 of 30OMHSASHarrisburg Field OfficeDGS Complex - Logan Bldgnd120 E Azalea Dr – 2 FloorHarrisburg, PA 17105Updated 09/24/2014
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Commonwealth of PennsylvaniaOffice of Mental Health and Substance Abuse ServicesHealthChoices Behavioral Health Supplemental ServicesOMHSAS Field Office Attestation FormThis form should only be completed for the provider types/provider specialties listed below.If the provider types/provider specialties are not listed below, do not complete this form.Provider Name:Check the appropriate box(es) below:I have reviewed and approved the attached tailored service description for this provider. The type of service is: BSU Diagnostic Assessment(Provider Type/Provider Specialty 11/110) Drug and Alcohol Intervention(Provider Type/Provider Specialty 11/184) Drug and Alcohol Level of Care Assessment(Provider Type/Provider Specialty 11/184) Drug and Alcohol Intensive Case Management(Provider Type/Provider Specialty 21/138) Drug and Alcohol Resource Coordination(Provider Type/Provider Specialty 21/138)Field Office SignaturePrinted NameDateForward the completed enrollment packet,including the tailored service description and attestation forms to:DPW/OMHSASBusiness Partner Support UnitHealthChoices Enrollmentnd112 East Azalea Drive; 2 FloorHarrisburg, Pennsylvania 17110-3594Page 7 of 30Updated 09/24/2014
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COMMONWEALTH OF PENNSYLVANIAOFFICE OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICESHealthChoices Behavioral Health Supplemental ServicesProvider Enrollment ApplicationFor OMHSAS Internal Use OnlyPROMISe ID /1. Supplemental Services: Check the service(s) below for which you are applying. Attach a copy of therequired document(s) as identified below.Residential and Housing Support Services – DPW Certificate of ComplianceAdult Residential Treatment FacilityAdult Outpatient Treatment in an Alternative SettingLong Term Structured ResidencePT/PS 11/110PT/PS 11/110PT/PS 11/110Rehabilitative & Day Treatment Program Services – DPW Certificate of CompliancePsychiatric RehabilitationSite BasedMobileClubhousePT/PS 11/123Outpatient - Drug & Alcohol – DDAP Certificate of LicensureD&A Intensive Outpatient (IOP)D&A Outpatient in an Alternative SettingPT/PS 11/128PT/PS 11/184Drug & Alcohol Inpatient Non-Hospital – DDAP Certificate of LicensureDrug-Free HalfwayDetoxificationDrug-Free Residential, Short TermDrug Free Residential, Long TermPT/PS 11/131PT/PS 11/132PT/PS 11/133PT/PS 11/134Drug & Alcohol Partial Hospitalization – DDAP Certificate of LicensureMethadone MaintenanceDrug-FreePT/PS 11/129PT/PS 11/129Drug and Alcohol Behavioral HealthD&A Outpatient PractitionerD&A Services – OtherD&A InterventionD&A Level of Care AssessmentD&A Intensive Case ManagementD&A Resource CoordinationDDAP Certificate of Licensure & DOS LicensureSSD and FO SSRC approval letterSSD & Field Office AttestationSSD & Field Office AttestationSSD & Field Office AttestationSSD & Field Office AttestationPT/PS 11/127PT/PS 11/184PT/PS 11/184PT/PS 11/184PT/PS 21/138PT/PS 21/138Mental Health GeneralBSU Diagnostic AssessmentCommunity Treatment TeamsAssertive Community Treatment (ACT)MH Outpatient PractitionerCommunity MH Services, OtherSSD & Field Office AttestationSSD and FO SSRC approval letterDPW Certificate of ComplianceDOS LicensureSSD and FO SSRC approval letterPT/PS 11/110PT/PS 11/111PT/PS 11/111PT/PS 11/112PT/PS 11/1192. Population to be Served:Children (ages 0-12)Adolescents (13-17)Page 9 of 30Adults (18-64)Elderly (65 and up)Updated 09/24/2014
3. Action Requested - Check Boxes That Apply:Initial Enrollment cilityGroupService Location Change (include Service Location Change Form to close old location)Fee Assignment – Add this provider to an existing provider group. You must complete theHealthChoices Behavioral Health Supplemental Services Fee Assignment Form.4. Enter Name of Enrollee:Facility Name:OrLast Name: First: Middle:Date of Birth: / /Ex: (yyyy/mm/dd)Gender:MaleFemale5. Tax Identification InformationSocial Security Number: - -*A copy of the document generated by the IRS that includes your name and SSN must accompany thisapplication.ORFederal Tax ID Number: -*A copy of the document generated by the Federal IRS with the name and IRS number must accompanythis application.**Individual practitioners enrolling with a FEIN, must still provide their SSN and SSN documentation**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:6. National Provider Identifier (NPI) #:*A copy of the NPPES confirmation letter must be attachedTaxonomy(s): (10 tion/index.htmPage 10 of 30Updated 09/24/2014
7. Business Type:CorporationNot-for-ProfitGovernment OwnedEstate/TrustSole ProprietorshipPartnership(Include corporation papers or business partnership agreement, as applicable)8. License #: Issuing State: Issue Date: / / Expiration Date: / /*A copy of your license is required for your application to be processed.9. Behavioral Health Managed Care Organization (BH-MCO):Identify the BH-MCO with the network in which participation will occur.10. Counties You Are Approved to Serve:11. In addition to English, do you or your staff communicate with patients in another language: YesIf yes, list language(s):No12. a) Does the office have exterior or interior steps leading to the main entrance doorway?YesNoExteriorInteriorb) If the answer to (a) is yes, does the office have a permanent or portable wheelchair ramp?YesNoPermanentPortablec) If the answer to (a) is yes, is there an alternate entrance that has no exterior or interior steps or has awheelchair ramp? YesNoNo exterior stepsNo interior stepsPermanent rampPortable rampd) Does the office have an official exemption from the U.S. Department of Justice excusing compliancewith Title III of the Americans with Disabilities ACT (ADA)? YesNo*If yes, attach a copy of the exemption to your application.13. Does the provider retain any managing employees or agents? Yes*NoIf yes, please complete Attachment I (Managing Employee or Agent Disclosure Form) on the next page.Page 11 of 30Updated 09/24/2014
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Attachment IManaging Employee or Agent Disclosure FormA. Please provide the name, home address, social security number, and date of birth of any person who isan agent or managing employee of the provider.Is the following individual a: Managing employeeor an Agent- -Name: (First)/ /Date of Birth(Middle)(Last)Social Security NumberHome Street AddressCityStateIs the following individual a: Managing employeeZip Codeor an Agent- -Name: (First)/ /Date of Birth(Middle)(Last)Social Security NumberHome Street AddressCityStateZip CodeB. Please provide the name and description of offense of any person who is an agent or managingemployee and has been convicted of a criminal offense related to Medicare or Medicaid, or a statehealth care program.Name: (First)(Middle)(Last)Description of offenseName: (First)(Middle)(Last)Description of offenseName: (First)(Middle)(Last)Description of offensePage 13 of 30Updated 09/24/2014
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14. CONFIDENTIAL INFORMATIONHave you, any agent, or managing employee ever:Been terminated, excluded, precluded, suspended, debarred from or had their participation in anyfederal or state health care program limited in any way, including voluntary withdrawal from a programfor an agreed to definite or indefinite period of time?YesNoBeen the subject of a disciplinary proceeding by any licensing or certifying agency, had his/her licenselimited in any way, or surrendered a license in anticipation of or after the commencement of a formaldisciplinary 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 alicense related to a formal disciplinary proceeding)?YesNoHad a controlled drug license withdrawn?YesNoBeen convicted of a criminal offense related to Medicare or Medicaid; practice of the provider’sprofession; unlawful manufacture, distribution, prescription or dispensing of a controlled substance; orinterference with or obstruction of any investigation?YesNoIn connection with the delivery of a health care item or service, been convicted of a criminal offenserelating to neglect or abuse of patients or fraud, theft, embezzlement, breach of fiduciary responsibility,or other financial misconduct?YesNoIf you answered “Yes” to any of the questions above, you must provide a detailed explanation (on aseparate piece of paper) and submit three (3) statements from professional associates or peer reviewbodies giving factual evidence of why they believe the violation(s) will not be repeated, and attach it toyour application. Include the following information as applicable to the situation:1.2.3.4.5.6.7.Name and title of individualName of federal or state health care programName of licensing/certifying agency taking the actionDate of actionType of action takenLength of actionBasis for action8.9.10.11.12.13.14.Disposition/StateDate license was surrenderedName of courtDate of convictionOffense(s) convicted ofSentence(s)Categorization of offense(e.g., felony, misdemeanor)This section requires the original signature of the individual applying for enrollment.TitlePrinted NameOriginal SignatureDatePage 15 of 30Updated 09/24/2014
15. Physical Service Location:Street(Note: List physical street address. A PO Box is not acceptable.)CityStateZip (9 digit)County( ) -PhoneE-mailIs this address an active Rural Health Clinic or FQHC?Yes orNo16. Mail To Information:StreetCityStateZip (9 digit)CountyContact Name/Title( ) -PhoneE-mail17. Pay To Information:StreetCityStateZip (9 digit)CountyContact Name/Title( ) -PhoneE-mail18. Home Office Information:StreetCityStateZip (9 digit)CountyContact Name/Title( )
Provider Enrollment Application Instructions Effective November 4, 2014, OMHSAS will only accept the current version of the Supplemental Service Provider Enrollment Application. If OMHSAS receives an outdated version of any enrollment . The requested effective date of
