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CMH/SAS-SJC

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Community Mental Health & Substance Abuse Services of St. Joseph County

PRACTITIONER APPLICATION

~NETWORK ENROLLMENT & CREDENTIALING FORM~

Section I-III:Is to be completed by the Practitioner making application for enrollment and credentialing (or re-credentialing) into the provider network. For new staff hires, the Supervisor should ensure that Parts I, IIIII of this application are completed and sent to the designated Credentialing Committee prior to the start date, to ensure the person is credentialed, and receives a Provider ID for billing purposes. For initial credentialing or re-credentialing, Parts I, II, III, IV, VI & VII of this application should be completed prior to enrollment/credentialing expiration.

Section II of this application should also be completed when there is any change in an applicant's credentials that results in a request for additional privileges.

Section V:Is completed only for new enrollees and is to be completed by the applicable Credentialing Committee of the, CSSN or sub delegated entity.

Section VI:Is to be completed by the enrollees’ supervisor.

Section VII:Is completed by the CSSN (or delegated entity) Privileging and Credentialing Committee for all new professional practitioners prior to the granting of provisional privileges, for everyone during the re-credentialing process.

Section VIII:Completed by the Privileging and Credentialing Committee

1. PROVIDER PROFILEDate of Hire:

Provider Name:National Provider Identifier (NPI):

Organizational Provider (Employer): Community Mental Health & Substance Abuse Services of St. Joseph County Supervisor:

Employer Address: Employee Phone:

Area Code

E-Mail Address:Job Title:

Employment Type: Full Time Part Time Contractual

Credentialing Type: Provisional Re-credential Additional

Credentials:N/A(Non-credentialed staff)

(Only list the license(s)/certification(s) you are seeking credentialing for within the provider network)

Degree(s):

Licensure: License #: Exp. Date:

Certification(s): Exp. Date(s):

The above licensing credentials permits the applicant to provide designated specialty services, as contained in the PIHP’s Clinical Protocol Manuals.

Target Populations: (Check all that apply)

What target populations are you seeking “privileges” to serve within the CSSN provider network?

DD Children (up to 17 years) Substance Abuse: Children

SED Children (up to 17 years) Substance Abuse: Adults

DD Adults Other: ______

MI Adults

1. PRIVILEGES REQUESTED

= LLMSW and LLBSW providers may only provide these services under the supervision of a LMSW

= SA Development Plan may only provide these services under the supervision of a fully credentialed supervisor.

Substance Abuse Credentials:(check all that apply)

CPS

CPC-R

CADCDate Completed:

CAADC

CADC-M

CCJP-R

CCDP

CCDP-D

CCS

CPRM-M

SA Development Plan

Staff Training: (check all applicable areas or trainings since your last re-credentialing, indicating the most recent date

for any annually required training. This list of training requirements is not all inclusive. Certain types of staff will have other “required” training which must be documented in the personnel files and attached to this application - e.g., behavior management, 24 child training hours for children’s staff (Exhibit D), grievance & appeals for case holders, etc. Include SA credentials, pertinent expertise/training here also).

Scheduled Training Date Completed?

Recipient Rights*Date(s): Yes No

Person-centered Planning**Date(s): Yes No

Limited English Proficiency*Date(s): Yes No

Cultural Competency*Date(s): Yes No

HIV Minimum Knowledge Standards***Date(s): Yes No

HIPAA Privacy Training***Date(s): Yes No

Accessibility Training ** Date (s): ______Yes No

*Required for providers in the SA and MH system

**Required for providers in the MH system

***Required for providers doing SA treatment in an SA licensed organization

Other Pertinent Training:

III. STAFF SKILL SPECIALIZATION

Cultural Competencies:(Skill Specializations; check all that apply)

Afro-American Populations Spanish/Hispanic Populations

Arabic/Middle Eastern Populations None

Amish Other:

Language Expertise:(Indicate below any areas of specialization for which the agency has staff that posses language specialization and communication skills)

Spanish (& Creoles) Arabic Indic Scandinavian

French (& Creoles) Chinese Italian Sign-Language

German (& Western) Japanese Yiddish None

Portuguese (& Creoles) Polish Greek Other:

Best and Evidenced Based Practices: (Indicate below those areas for which you desire to be recognized as

providing best and/or evidenced based practices for future PIHP or CSSN referrals. Include a brief rationale

that supports any consideration (attach additional pages if necessary).

Please place an “X” for best and/or evidence based practices and in box to the left of all those applicable.

Rationale:

IV. PROVIDER ATTESTATION

I understand that I am making application to be appointed to provide specialty services within CMH/SAS-SJC, and that my clinical work may be subject to federal, State, PIHP, and/or CSSN performance and compliance reviews.

Yes No

I have reviewed the CMH/SAS-SJCMission and Values statements, and agree to comply with all stated values and guiding principles.

Yes No.

I have reviewed the CMH/SAS-SJC Code of Ethics as contained in the PIHP Compliance Programand agree to adhere to these ethical standards of practice.

Yes No

I attest that I have no present illegal drug use. Yes No

I attest that I have no history of loss of license and/or felony convictions. Yes No

I attest that I have no history of loss or limitation of privileges due to disciplinary action. Yes No

I attest that I have had no professional liability claims resulting in a judgment or settlement, Yes No

within the past five (5) years

My signature below attests that the above statements are true and accurate:

______

Applicant SignatureDate

______

Applicant Name (Print)

This section is completed for new enrollees only and is done before enrollment

V. PROVISIONAL CREDENTIALS GRANTED

The Credentialing Committee Chairperson has reviewed this application enrollment form for credentialing and recommends Provisional Credentials for the position of for days [not to exceed 90 days] from this effective date .

Chairman SignatureDate

VI. SUPERVISORY RECOMMENDATIONS

(To be completed by the supervisor 30-45 daysafter the employee’s provisional privileges are in effect, at the time of re-credentialing, or at the time of any change in credentialing)

A. The employee:(Rate the following; Conditional or Unsatisfactory ratings require explanation)

1. Adherence to Agency Policies, Rules and Regulations, Code Of Ethics:

Satisfactory

ConditionalExplain:

UnsatisfactoryExplain:

1. Performance Appraisal:

1. URC/IPR

Satisfactory

Conditional Explain:

UnsatisfactoryExplain:

NA

1. Employee Performance to Date:

Satisfactory

Conditional Explain:

UnsatisfactoryExplain:

NA

1. Fulfillment of Continuing Education requirements:

Satisfactory N/A

Conditional Explain:

UnsatisfactoryExplain:

PIHP Clinical Protocols****Date(s):

PIHP Utilization Management Policy****Date(s):

PIHP Procedure Codes and Definitions Policy****Date(s):

****Required for providers in the SA and MH system. These items may be covered via supervisory orientation and oversight as opposed to via formal training. All three boxes must be checked prior to any employee requesting privileges to perform Level I authorizations initially and at renewal.

1. Has adequate liability insurance:

Part-time and full-time staff covered by CMH/SAS-SJC policy.

Part-time/Contractual: Company: Coverage:

D. Supervisor Recommendation: Approve Disapprove

SUPERVISOR SIGNATURE: DATE:

STAFF SIGNATURE: DATE:

VII. PRIMARY SOURCE VERIFICATION

Must complete:

Work history review of at least previous five years (or review of full history for those with less than

five years experience) with satisfactory outcome, and either

National Practitioner Databank/Healthcare Integrity and Protection Data Bank [NPDB/HIPDB] query –

verified at , or the following three items,

Minimum five year history of professional liability claims resulting in a judgment or settlement, and

Disciplinary status with regulatory board or agency - verified at and,

Verified on: by:

Medicare/Medicaid sanctions – verified at

Verified on: by:

N/A (Non-credentialed Staff)

Results of NPDB/HIPDB or alternate query:

Verified on: by:

VIII. COMMITTEE DETERMINATION

This section of the form is to be completed by either the PIHP, CSSN or sub-delegated entity Credentialing Committee, as applicable and qualified in the delegation agreement.

The Credentialing Committee has reviewed this application enrollment form for credentialing or

re-credentialing and recommends:

Credentialing of the practitioner into the CMH/SAS-SJC network.

Provisional credentialing of the practitioner into the CMH/SAS-SJC network, until:

Does not recommend credentialing of the practitioner into the CMH/SAS-SJCnetwork

Start Date:End Date:

* = LLMSW and LLBSW providers may only provide these services under the supervision of a LMSW

= SA Development Plan may only provide these services under the supervision of a fully credentialed supervisor.

Target Populations (check all that are granted):

DD Children (up to 17 years) Substance Abuse: Children

SED Children (up to 17 years) Substance Abuse: Adults

DD Adults Other:______

MI Adults

Provide Rationale for Denial:

Committee Signatures below verify credentialing and privileging of the above named staff.

______

Committee Chairperson Signature DateChairperson (Print Name) Date

______

Medical Director Signature Date Medical Director (Print Name) Date

______

Committee MemberDateCommittee Member (Print Name) Date

______

Committee MemberDateCommittee Member (Print Name) Date

______

Committee MemberDateCommittee Member (Print Name) Date

Committee Member DateCommittee Member(Print Name) Date

______

Committee MemberDateCommittee Member (Print Name) Date

PIHP/CSSN/Delegated Entity: Upon completion or updating of this form, please ensure all data is loaded into the designated PIHP software/data base. As an outcome of the credentialing process, the provider must be enrolled or re-enrolled into the data base prior to any future service provision and subsequent encounter data submission/billing. Additionally, upon completion please submit a copy of this form to the PIHP Provider Network Management Department for entry into the PIHP Provider Registry Database.

cc:CMH Program Supervisor (if applicable); or

Contract Agency Director (if applicable)

CSSN (or PIHP) Data Enrollment Staff

PIHP Provider Network Management Department

CMH/SAS-SJC P&C Administration File

Personnel File