hospital based inpatient psychiatric services ... · 3. retain a copy of your completed...

Managing Mental Health, Intellectual/Developmental Disabilities and Substance Abuse Services 910-673-9111 (FAX) 910-673-6202 www.sandhillscenter.org Victoria Whitt, CEO

P.O. Box 9, West End, NC 27376 24-Hour Access to Care Line: 800-256-2452

TTY: 1-866-518-6778 or 711 Serving Anson, Guilford, Harnett, Hoke, Lee, Montgomery,

Moore, Randolph & Richmond Counties

Hospital Based Inpatient Psychiatric Services

Credentialing Application To the Sandhills Center Network

For IPRS (State Funds) and Medicaid Services

Please email application to:

[email protected]

SHC Hospital Credentialing Application of 27 Qmcappd 06/25/2019

INSTRUCTIONS Hospitals must be enrolled as a provider with Sandhills Center to qualify for reimbursement for Hospital services under the 1915 b/c Medicaid Waiver. Hospitals must also have a signed contract with Sandhills Center to qualify for reimbursement of Hospital services with State (North Carolina) funds.

Credentialing includes the following steps: 1. A provider’s Credentialing packet is considered to be invalid and must be returned to the provider

for corrections and/or for additional information if:2. The version date on any of the documents that comprise the provider’s Credentialing packet is prior

to June 2019. Older versions are not accepted.3. All spaces in the application have not been completed. Please indicate “N/A” or “None” if the

question is not applicable.4. The Contact person’s Name, Title and email address in not completed.5. The Signatures are not original/scanned & are not an authorized agent for the group entity.6. The text has been altered, highlighted, struck through, or obstructed through the use of correction

fluids.7. The responses are illegible.8. The National Provider Identifier is not a valid number.9. Any of the documents or pages that complete the provider Credentialing packet are missing.10. Any of the requested information in any of the documents that comprise the provider Credentialing

packet is missing, with the exception of the fax number and email address.11. Any of the required accreditation documentation is missing, including license, permit, certification,

endorsement, National Plan & Provider Enumeration System (NPPES) letter etc.12. The provider name entered on the Medicaid Participation Agreement (for Out-of-State) does not

match the required accreditation documentation and the NPPES letter (where required).IMPORTANT POINTS TO REMEMBER

1. If services are being provided at multiple sites, you are required to list each site in this application.2. Copies of the applicable accreditation documentation must accompany the application. If these

documents are missing, the application will be returned to the provider.3. Retain a copy of your completed Credentialing application packet and all documentation submitted

with the Credentialing application packet for your records.4. Sandhills Center will notify the provider within ten (10) business days of receipt of the completed

application or if materials are missing.5. Billing information and clinical coverage policies are available on Sandhills Center website at

www.sandhillscenter.org.6. Providers are requested to include on their application the name, email address, phone and fax

numbers of the individual contact person at their site who is responsible for receiving SandhillsCenter Network information.

7. Please review your Credentialing Application packet BEFORE submitting to Sandhills Center forcompleteness, accuracy and that you have signed and dated all pages requiring signature within theapplication. Any illegible or missing items will cause a delay in credentialing your application.

8. If you have any questions regarding the Credentialing process, please contact your CredentialingSpecialist.

9. Providers are assigned a provider number and are notified by mail once the enrollment process hasbeen completed. Please do not submit claims for any services until you have received notification ofyour provider number and effective date.

10. Cultural Competency Training is required.11. Each provider facility must be accommodating for members with physical disabilities. If facility is

not accommodating, please provide an explanation of how those members with physical disabilitieswould be accommodated.

Thank You for submitting your Credentialing application. In order for Sandhills Center to complete the Credentialing process, please submit the following items:


Group Applicant (Required Document Attachments) Sandhills Center Hospital Based Inpatient and Outpatient Psychiatric Services Credentialing Application. A copy of Accreditation Verification Letter. A copy of your National Plan & Provider Enumeration System (NPPES) Letter. A copy of your current license from the N.C. Division of Health Services Regulation. A signed & dated Letter of Attestation for False Claims Act. A copy of your most current Rate Notification for DRG, Rehabilitation, Psychiatric, Inpatient DRG Specific RCC Letter from the North Carolina Department of Health & Human Services Division of Medical Assistance. If an Out-of-State/Border-area Provider – A copy of a current approval letter to participate in your State’s Medicaid Program. A copy of the current approval letter from CMS to participate in the Medicaid Program. A signed & dated Sandhills Center Attestation Statement. A copy of current Certified Articles of Incorporation or Articles of Organization. Documentation required for “Yes” answers under Disciplinary Actions. A signed & dated Trading Partner Agreement (TPA) A copy of current Certificate of Insurance for Commercial General, Professional & Worker’s Compensation Liability indicating by provider’s name coverage amounts, effective dates, expiration dates and policy numbers. (Coverage Minimum Amounts: $1,000,000 / $3,000,000 aggregate.) (SHC does not accept Notice of Intent as proof of insurance). Completed Insurance Attestations form regarding all liability insurance coverages. A copy of current valid DEA Certificate. A copy of current valid W9. Current valid NC Tracks enrollment, active status in Medicaid Health Plan, site affiliations if applicable

NOTE DO NOT submit claims to Sandhills Center until your contract has been executed or you have been notified that you can submit claims as an out –of –state or out-of- network Hospital. CLAIMS MUST BE SUMITTED WITHIN 180 DAYS FROM THE DATE OF RENDERED SERVICE. SANDHILLS CENTER DOES NOT REIMBURSE FOR NON-ANCILLARY SERVICES OR NON-BEHAVIORAL HEALTH RELATED SERVICES. ALL DATES OF SERVICE FOR THE CURRENT SANDHILLS CENTER FISCAL YEAR (7/1-6/30) ARE REQUIRED TO BE SUBMITTED NO LATER THAN 7/31 OF THE FOLLOWING SANDHILLS CENTER FISCAL YEAR. Thank you again for your interest. If you have any questions or need additional information, please feel free to contact the Sandhills Center Provider Help Desk at 1-855-777-4652


Date of Application: Provider is completing application for the purpose of:

Contract Out-of-Network Status Out-of-State

Section 1: Hospital Information 1. Organization Name: (Your organization’s name must match the organization name on you current accreditation

documentation & your current letter of approval from the Centers for Medicare and Medicaid Services).

2. Legal Name of Organization: (as used for tax reporting purposes if different from Organization Name)

3. Doing Business As (DBA): (if applicable)

4. Federal Tax ID #: 5. Federal Tax Status: For Profit Non-Profit

6. Taxonomy #(s): (Please provide a list of Taxonomy #s for each site you are applying for on this application.)

7. National Provider Identifier #:(Please provide a copy of the NPI Certification Letter with this application. Please provide a list of NPI #s for each siteyou are applying for on this application.)

8. NC Tracks Requirements:a. Is your organization enrolled in NC Tracks? Yes No

b. Does your organization have an active status in the Medicaid Health Plan? Yes No c. Are all applicable service locations activated in NC Tracks? Yes No d. Does your organization have a valid taxonomy for each location? Yes No 9. Is your Hospital/Program an approved North Carolina Medicaid Service

Provider?Yes No

If yes, please attach the most recent copy of your “Rate Notification for DR, Rehabilitation, Psychiatric, Inpatient DRG Specific RCC Letter” from the North Carolina Division of Medical Assistance. 10. Organization Address:

Street City State Zip+4 (Required) (Must be a physical address – P.O. Box is not acceptable)

11. Check (√)County of Address :Anson Guilford Harnett Hoke Lee Montgomery Moore Randolph Richmond Other:

12. Accepting new patients? Yes No 13. Website Address:14. Number of years doing business under this name:15. Has this Organization ever been in business under a different name? Yes No

If yes, what name:16. PRIMARY CONTACT INFORMATIONPrimary Contact Name: Primary Contact Title: Primary Contact Phone: Primary Contact E-mail Address: 17. DIRECTORS’ INFORMATION

Director’s Name Director’s Phone & Email Address Executive Director / CEO: Financial Director/CFO: Assistant Director: Clinical/Medical Director: Behavioral Health Director:

If "No", provide Enrollment Registration # and submission date and/or or provide the Managed Change Request (MCR) # and submission date.NC Tracks Registration /MCR #:Submission Date:


Section 1: Hospital Information continued Emergency Dept. Director: Chairman of the Board: 18. PERSONS AUTHORIZED TO SIGN CONTRACTS & OTHER LEGAL DOCUMENTSName: Title: Name: Title: Name: Title:

19. Is the Organization incorporated? Yes No(If yes, please attach a copy of the Certified Articles of Incorporation and any subsequent changes to the Articles ofIncorporation)

20. Organization Legal Entity Type: Corporation General Partnership Cooperative S-Corporation Sole Proprietorship Not for Profit

Limited Liability Corporation Limited Liability Partnership Government Public Authority (LME, Hospital or Healthcare Authority)

21. Is the Organization State owned? Yes No 22. Has your organization ever had a contract cancelled by another LME-MCO / Area Authority /

County Program in North Carolina or similar entity in another state? Yes No(If yes, please attach explanation) 23. Identify other providers, if any, which are owned or operated by the applicant under the same

owner name.Name of Provider: Address w/ Zip+4: Relationship (Nursing Home, Home Health Agency, Community Based Residential Facility Hospital)

24. Have background checks been completed on the owner(s), board members, director(s), officers,administrators and staff; is documentation of background checks maintained by the hospital?

Yes No (If yes, please attach the policy/procedure and any supporting documentation. If no, please provide explanation.)

25. Is the applicant a subsidiary company, either wholly or partially owned by another organization orbusiness?

Yes No (If yes, please provide the following information) Legal Business Name – Parent Company: _____________________________________________________________ Type of Ownership: 26. Admission/Discharge Criteria for Inpatient Psychiatric Services, PRTF, IOP, PH, or Outpatient

Services: (May attach facility policy)

27. FINANCIAL & BILLING INFORMATION (The following capacity will be needed)a) An operational computer system to include Digital Subscriber Line (DSL) or higher speed connection to

the internet and hardware and/or software fire wall.Is this currently available? Yes No

b) Current Anti-virus Protection on all devices that will store or display member identifiable information.Is this currently available? Yes No

c) Please provide the name, number and email address of your facility’s billing staff:Name:Phone:Email Address

d) Please indicate the method you will use to perform electronic billing:Sandhills Center Provider Direct System (web based system that you will access through high speed internet.) HIPAA Compliant Transaction Sets (837P and/or 8371 electronic files)

If you plan to use HIPAA Compliant Transaction Sets (837P and/or 8371), please list the name of your software & software vendor.

e) Do you currently have members insured by third party payers? Yes No f) Are you contracted with any third party payer? Yes No g) Are you interested in electronic funds transfer of payments from Sandhills Center? Yes No

If yes, you must complete an Authorization Agreement for Automatic Deposits.


28. QUALITY MANAGEMENTa) Please indicate your hospital’s contact name, phone number & email address for follow-up on incident

reports or investigations:Name: Phone Number: Email Address: b) Do you have a Clients’ Rights Committee? Yes No Clients’ Rights Contact Name: Phone Number: Email Address: c) Quality Management Contact:Phone Number: Email Address:


Section 2: Facility Programs Information Facility/Program Name: Address w/ Zip+4: NPI #: Rate Billing Code: Number of Beds: Child/Adolescent or Adult: Is this facility/site staffed and equipped to serve members with physical disabilities? Yes No If no, please explain how you plan to accommodate those members with physical disabilities.

Supporting Psychiatrist(s) Name & Address: Hospital Employee or Other Practice? If Hospital Employee please list their NPI #:

Accreditation: Date of last JCAHO Review: Years Accredited Expiration Date

Licensure: DHSR License #: Expiration Date:


Supporting Psychiatrist(s) Name & Address: Hospital Employee or Other Practice? If Hospital Employee please list their NPI #:




Supporting Psychiatrist(s) Name & Address: Hospital Employee or Other Practice? If Hospital Employee, please list their NPI #:




Section 3: Provider Disclosure 1. Providers must disclose the following information to Sandhills Center. List all information requested for

each person, including yourself, who has direct or indirect ownership or control interest of 5% ormore in the organization/entity. If any of the persons named are related to each other as parent, spouse,child or sibling, indicate the relationship. Failure to provide sufficient information, including completeSocial Security Numbers, to allow for the verification of the disclosed information may result in a denialfor participation with the NC Medicaid Program.

Name: Address:

Title: SSN: License # Date of birth: % Ownership: Check business relationship that applies:

Owner Shareholder Partner Officer Managing Employee

Director Board Member Other Electronic Funds Transfer (EFT) authorized individual

Check relationship to other persons named: Spouse Parent Child Sibling None Other

Name: Address:





Name: Address:






Section 3: Provider Disclosure (continued) Providers must disclose the following information to Sandhills Center. List all information requested for each agent of the organization/entity including individual officers, directors, managing employees (general manager, business manager, administrator), and Electronic Funds Transfer (EFT) authorized individuals. If any of the persons named are related to each other as parent, spouse, child or sibling, indicate the relationship. Failure to provide sufficient information, including complete Social Security Numbers, to allow for the verification of the disclosed information may result in a denial for participation with Sandhills Center and the 1915 bc waiver. Name: Address:





Name: Address:





Name: Address:






Section 4: DISCIPLINARY ACTIONS You must answer all section of this question.

Yes No 1. Have you, any of the individuals or entities listed in sections above or any individual

employed in a clinical role ever:a) Been convicted of a felony, had adjudication withheld on a felony, pled no contest to a

felony or enter into a pre-trial agreement for a felony?If yes, list the name(s) of the individual(s) and you must attach a complete copy of thecriminal complaint and final disposition. Submitting only a written explanation inresponse to this question is not sufficient. You must attach the applicabledocumentation.

Names of Individual(s):b) Had any disciplinary action taken against any business or professional license held in

this or any other state?c) Had your license to practice restricted, reduced or revoked in this or any other state?d) Been previously found by a licensing, certifying or professional standards board or

agency to have violated the standards or conditions relating to licensure or certificationor the quality of services provided?

e) Entered into a Consent Order issued by a licensing, certifying or professional standardsboard or agency?

If any of the questions above were answered “Yes”, please provide the following information:

Against Whom? Action Taken? Who Took Action? Date of Action?

If yes, you must attach a complete copy of the Consent Order and/or Final Disposition. You must also attach documentation from the proper authorities approving the re-instatement of the license. f) Had any action or investigation against you or any owner or qualified professional in

your organization relating to:License: Certification: Registration: Privileges: Billing Organizations: Sanctions:

g) Have any adverse actions been filed against you by : (If yes, please attach anexplanation)

Medicaid: Medicare: Other Insurance:

h) Been denied enrollment, suspended, excluded, terminated or involuntarily withdrawn fromMedicare, Medicaid or any other government or private health care or health insuranceprogram in any state, or been employed by a corporation, business, or professionalassociation that has ever been suspended, excluded, terminated or involuntarilywithdrawn from Medicare, Medicaid or any other government or private health care orhealth insurance program in any state?

If yes, you must list the name(s) & provider number(s) of the individual(s) or entity(ies) & attach a complete copy of the applicable documentation.

Name Provider Number

i) Has your organization been excluded from participation in Federal Health Care Programsunder either Sections 1128 or 1128A of the Social Security Act?


Section 4: DISCIPLINARY ACTIONS continued Yes No

j) Had suspended payments from Medicare or Medicaid in any state, or been employed by acorporation, business, or professional association that ever had suspended payments fromMedicare or Medicaid in any state?

If yes, you must list the name(s) and provider number(s) of the individual(s) or entity(ies) & attach a complete copy of the applicable documents.

Name Provider Number

k) Had any civil monetary penalties levied against this organization / entity or anyindividuals or entities listed above in h), i), j) or k) above by Medicare, Medicaid or otherState or Federal Agency Program, including the Division of Health Service Regulation(DHSR), even if the fine(s) have been paid in full?

If yes, you must attach an explanation & supporting documentation from the agency or program which levied the penalties as to the reason. l) Owe money to Medicare or Medicaid that has not been paid?m) Been convicted under Federal or State Law of a criminal offense related to the neglect or

abuse of a patient in connection with the delivery of any health care goods or services?

If yes, list the name(s) of the individual(s) & you must attach a complete copy of the criminal complaint & final disposition. Submitting only a written explanation in response to this question is not sufficient. You must attach the applicable documentation.

Name(s)

n) Been convicted under Federal or State Law of a criminal offense related to the unlawfulmanufacture, distribution, prescription or dispensing of a controlled substance?


Names(s)

o) Been convicted of any criminal offense related to fraud, theft, embezzlement, breach offiduciary responsibility, financial misconduct or moral turpitude?


Name(s)

p) Been found to have violated Federal or State Laws, rules or regulations governing NorthCarolina’s Medicaid Program or any other State Medicaid Program or any other publiclyfunded Federal or State Health Care or Health Insurance Program and been sanctionedaccordingly?

If yes, you must list the name(s) and provider number(s) of the individual(s) or entity(ies) & attach a complete copy of the applicable documentation.

Name(s) Provider Number(s)


Section 4: DISCIPLINARY ACTIONS continued Yes No

q) Been convicted of an offense against the law other than a minor traffic violation?

If yes, list the name(s) of the individual(s) & you must attach a complete copy of the criminal complaint & final disposition. Submitting only a written explanation in response to this question is not sufficient. You must attach the applicable documentation. r) Has anyone in your company who has an ownership, managerial or clinical role ever

been sanctioned by any professional organization or government organization forviolation of ethics, professional misconduct, unprofessional conduct, incompetence ornegligence in any state or country?


Section 4: SIGNAUTRE AUTHORIZATION & RELATED INFORMATION REQUIRED ***ALL INFORMATION MUST BE ENTERED FOR THE APPLICATION TO BE PROCESSED***

I certify that the above information is true and correct. I further understand that any false or misleading information may be cause for denial or termination of participation as a PCHP Medicaid Provider.

Printed Name of Authorized Agent:

Title:

Authorized Agent’s Signature Date


SANDHILLS CENTER

Hospital Specifics

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 Members’ cultural, racial, ethnic and linguistic needs.

Hospital Name:

Counties Served: Anson Guilford Harnett Hoke Lee Montgomery Moore Randolph Richmond Other(s): Populations your organization serves:

MH – Adult SA – Adult IDD - Adult 18-21 22-54 55 & up 18-21 22-54 55 & up 18-21 22-54 55 & up

MH – Child SA – Child IDD - Child 3-11 12-17 12-17 18-21 3-11 12-17

Race/Ethnicities: All Races/Ethnicities American Indian & Alaska

Native Asian, Pacific Islander

Black or African American Hispanic or Latino White Languages Spoken Fluently: American Sign Language Chinese/Korean English French German Hmong Spanish Other:

Completed Cultural Competency Training? Yes No

Sandhills Center


Hospital Specialties

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 members’ needs.

Please check all that apply.

Abuse and Neglect Grief and Loss Therapy

Abuse-Physical, Sexual, and/or Emotional Health Psychology-Chronic Medical Conditions

Addiction Psychiatry Impulse Control

Addiction Treatment Inpatient Services

Amnestic Disorder Intellectual /Developmental Disabilities

Anger Management Intensive In-Home Therapy

Anxiety/Phobias Maltreatment

Assessment Evaluation Marriage and Family Counseling

Attention Deficit Hyperactivity Disorder Matrix Model (SA)

Autism - Asperger Mental Health

Behavior Plans Motivational Interviewing

Bipolar Disorder (Manic - Depressive Illness) MST (Multi Systemic Therapy)

Career/Vocational Counseling Neglect

Chemical Dependency / Substance Abuse Neuro Psych

Child Psychiatry Obsessive-Compulsive Disorder

Cognitive / IQ Outpatient Therapy

Cognitive Behavioral Therapy Personality

Co-Location with/Primary Care Physician Personality Disorders

Community-Based Services Play Therapy, Filial Relaxation / Meditation-Hypnotherapy

Conduct Disorders Post-Traumatic Stress Disorder (PTSD)

Co-Occurring / Dual DX-Mental Illness, Mental Health, Substance Abuse

Psychiatry

Crisis Services Psychological Testing

Crisis/Solution focused Brief Therapy Rape

Dementia Disorder Residential Services

Depression Schizophrenia and other Psychotic Disorders

Detoxification Services Self-Direction

Developmental limited/extended Seven Challenges (SA)

Dialectical Behavior Therapy Sex Offender Treatment

Dual Disability Sexual & Gender Identity Issues Illness, Mental Health / Substance Abuse

Eating Disorders Sleep Disorders

Eye Movement Desensitization and Reprocessing Therapy

Somatoform Disorders

Factitious Disorders Telemedicine

Faith Based Counseling/Services Therapeutic Foster Care

Forensic Psychology/Psychiatry Trauma Focused Cognitive Behavioral Therapy (TF-CBT)

Forensic Screening/Evaluation Trauma Focused Services

General Psychiatry Traumatic Brain Injury

General Psychology Wellness Recovery Action Plan

Gero Psychiatry


Please List Practitioners:

If the Hospital has LPs (including provisional) that are billing for services under the Hospital’s Tax ID #, then please list all LPs with their credentials, license type, NPI # and Taxonomy # for those who are currently serving SHC members.

(You may make copies of this page if more space is needed/ please print)

LP Name License Type NPI Taxonomy 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30


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 Code

Description Available to Benefit Plan 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 96110 Developmental Testing Limited State Medicaid 96112 Developmental Test Administration State Medicaid 96113 Dev Test Admin Addtl 30 State Medicaid 96116 Neurobehavioral Status Exam State Medicaid 96121 Neuro Exam Addtl hour State Medicaid 96130 Psych Test Eval 1st hour State Medicaid 96131 Psych Test Add on State Medicaid 96132 Neuropsych Test Eval State Medicaid 96133 Neuropsych Test add on State Medicaid 96136 Psych or Neuro tests two or more State Medicaid 96137 Psych test two or more add on State Medicaid 96138 Psych test Tech two or more NA Medicaid 96139 Psych test Tech two or more add on NA Medicaid 96146 Psych test Automated NA Medicaid


Evaluation & Management Codes

***Evaluation & Management Codes are only provided by Physician Assistants, Certified Nurse Practitioners and Physicians (only check (√) what services you are currently providing). ***

Check (√)

Procedure Code

Description Check

(√) Procedure

Code Description

90865 Narcosynthesis for Psychiatric Diagnostic and Therapeutic Purposes

99222 Hospital Initial Care MD (50 min.)

95970 Electronic Analysis of Implanted Neuro stimulator

99223 Hospital Initial Care MD (70 min.)

95971 Electronic Analyses of Implanted Neuro stimulator Simple Spinal Cord

99231 Hospital Subsequent Hospital Care MD Low Complexity (15 min.)

95972 Electronic Analysis of Implanted Neuro stimulator Complex Spinal Cord (1hr.)

99232 Hospital Subsequent Hospital Care MD Moderate Complexity (25 min.)

95973 Electronic Analysis of Implanted Neuro stimulator Complex Spinal Cord (30 min.)

99233 Hospital Subsequent Hospital Care MD High Complexity (35 min.)

95974 Electronic Analysis of Implanted Neuro stimulator Complex Cranial (1 hr.)

99234 Hospital Observation/Inpatient Care Low Complexity

95975 Electronic Analysis of Implanted Neuro stimulator Complex Cranial (30 min.)

99235 Hospital Observation/Inpatient Care Moderate Complexity

95978 Electronic Analysis of Implanted Neuro stimulator

99236 Observation/Inpatient Care High Complexity

95979 Electronic Analysis of Implanted Neuro stimulator (30 min.)

99238 Hospital Discharge Services (<30 min.)

96125 Standardized Cognitive Performance Testing

99239 Hospital Discharge Services (>30 min.)

96150 Physical Health and Behavior Assessment F-T-F (15 min.)

99241 Outpatient Consultation MD Minor (15 min.)

96151 Physical Health and Behavior Reassessment 99242 Outpatient Consultation MD Moderate (30 min.)

96372 Therapeutic, Prophylactic, or Diagnostic Injection Intra-Muscular

99243 Outpatient Consultation MD Severe (40 min.)

96373 Therapeutic, Prophylactic, or Diagnostic Injection Intra-Arterial


96374 Therapeutic, Prophylactic, or Diagnostic Injection Intravenous Push


96375 Therapeutic, Prophylactic, or Diagnostic Injection Subsequent Intravenous Push

99251 Inpatient Consultation MD Minor (20 min.)

99201 Outpatient E&M New Patient F-T-F (10 min.) 99252 Inpatient Consultation MD Low Severity (40 min.)

99202 Outpatient E&M New Patient F-T-F (20 min.) 99253 Inpatient Consultation MD Moderate (55 min.)

99203 Outpatient E&M New Patient F-T-F (30 min.) 99254 Inpatient Consultation MD Moderate – High Severity (80 min.)

99204 Outpatient E&M New Patient F-T-F (45 min.) 99255 Inpatient Consultation MD Moderate – High Severity (110 min.)

99205 Outpatient E&M New Patient F-T-F (60 min.) 99281 ER Visit, Minor

99211 E & M Estab Patient, w/wo MD (approx. 5 min.)

99282 ER Visit, Low Severity

99212 Outpatient Visit Estab. Minor (10 min.) 99283 ER Visit, Moderate Severity 99213 Outpatient Visit Estab. Moderate (15 min.) 99284 ER Visit, High Severity

99214 Outpatient Visit Estab. Severe (25 min.) 99285 ER Visit for the evaluation and management of a patient

99215 Outpatient Visit Estab. Severe (40 min.) 99291 Critical Care 30-74 minutes

99217 Hospital Observation Care – Discharge 99304 Initial Nursing Facility Care E&M Low Complexity (25 min.)

99218 Hospital Initial Observation Care Low Complexity

99305 Initial Nursing Facility Care E&M Moderate Complexity (35 min.)

99219 Hospital initial Observation Care Moderate Complexity

99306 Initial Nursing Facility Care E & M High Complexity (45 min.)

99220 Hospital Initial Observation Care High Complexity

99307 Subsequent Nursing Facility Care E & M Review of Case (10 min.)


Evaluation & Management Codes (continued)

***Evaluation & Management Codes are only provided by Physician Assistants, Certified Nurse Practitioners and Physicians (only check (√) what services you are currently providing). ***

Check (√)

Procedure Code

Description Check

(√) Procedure

Code Description

99221 Hospital Initial Care MD (30 min.) 99308 Subsequent Nursing Facility Care E & M Low Complexity (15 in.)

99309 Subsequent Nursing Facility Care E&M Moderate Complexity (25 min.)

99341 New Patient Home Visit E & M Low Severity (20 min.)

99310 Subsequent Nursing Facility Care E&M High Complexity (35 min.)

99342 New Patient Home Visit E&M Low Complexity (30 min.)

99315 Nursing Facility Discharge Management; (<30 min.)

99343 New Patient Home Visit E&M Low Moderate Complexity (45 min.)

99316 Nursing Facility Discharge Management; (>30 min.)

99344 New Patient Home Visit E&M High Severity (60 min.)

99318 Nursing Facility, E&M Low to Moderate Complexity (30 min.)

99345 New Patient Home Visit E&M High Complexity (75 min.)

99324 New Patient Domiciliary/Rest Home E&M Low Severity (20 min.)

99347 Estab. Patient Home Visit E&M (15 min.)

99325 New Patient Domiciliary/Rest Home E&M Low Complexity (30 min.)

99348 Estab. Patient Home Visit E&M Low Complexity (25 min.)

99326 New Patient Domiciliary/Rest Home E M Moderate Complexity (45 min.)

99349 Estab. Patient Home Visit E&M Moderate Complexity (40 min.)

99327 New Patient Domiciliary/Rest Home E&M High Severity (60 min.)

99350 Estab. Patient Home Visit E M High Complexity (60 min.)

99328 New patient Domiciliary/Rest Home E&M High Complexity (75 min.)

99354 Prolonged MD Service w/F-T-F Patient Contact in Office (60 min.)

99334 Estab. Patient Domiciliary/Rest Home E&M (15 min.)

99355 Prolonged MD Service w/F-T-F Patient Contact in Office (30 min.)

99335 Estab. Patient Domiciliary/Rest Home E&M Low Complexity (25 min.)

99356 Prolonged MD Service w/F-T-F Patient Contact Inpatient (60 min.)

99336 Estab. Patient Domiciliary/Rest Home E&M Moderate Complexity (40 min.)

99357 Prolonged MD Service w/F-T-F Patient Contact Inpatient (30 min.)

99337 Estab. Patient Domiciliary/Rest Home E & M Moderate to High Severity (60 min.)

Q3014GT TelePsyc Site Facility Fee

PRTF Medicaid Only Service Code

Please check (√): (only check (√) what services you are currently providing)

Check (√)

Procedure Code

Description

0183 Therapeutic Leave 0911 PRTF

Hospital Inpatient Service Code

Please check (√): (only check (√) what services you are currently providing)

Check (√)

Procedure Code

Description

0101 Hospital Inpatient


IPRS (State) Funds Only


Check (√)

Procedure Code Description

YP820 Inpatient Hospital YP821 3 Way Hospital Contract YP851 Public Psychiatry – Administrative Functions YP852 Public Psychiatry – Consultative Services

IPRS (State) Funds Only for Non-Licensed Substance Abuse Professionals


If you have a service that you are currently providing and it is NOT listed above, please use this sheet

Please list services to be provided at this site: Service Code(s) Service Description

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


Attestation Statement No Stamps or Copies Please (Original Only)

This Application is to be signed by the individual who has authorization to submit an application on behalf of this hospital.

I certify that I am authorized to sign this application and the information I have provided is complete and accurate to my knowledge. I understand that any misstatement in this application may constitute grounds for denial of the application or termination of a resulting participating agreement.

In making this application for membership or reappointment in the Sandhills Center Provider Network, I acknowledge that I have read and agree to comply with the Sandhills Center contract requirements, Trading Partner Agreement, and credentialing criteria and I am familiar with the standards and ethics of the national, state, and local associations that apply to and govern the hospital and the clinical professions within. I agree to be bound by the terms thereof if the hospital is granted provider status, and I further agree to be bound by the terms thereof in all matters relating to the consideration of this application for membership in the provider network.

By application for membership or reappointment in the Sandhills Center Provider Network, I signify my willingness to appear for an interview in regard to my application. I authorize Sandhills Center to consult with administrators and members of the agencies, corporations 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 actions, suspensions, or actions to curtail my clinical practice, I further authorize Sandhills Center to collect any information necessary to verify the information in the credentialing application.

I understand and agree that I, as representative of this Hospital, 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. I also hereby release from liability any and all individuals and organizations that provide information to Sandhills Center or its staff in good faith and without malicious intent concerning my competence, ethics, character, and other qualifications for membership in the Provider Network, and I hereby consent to the release of such information.

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.

In the event that I am accepted for participation in the Sandhills Center provider network, I consent to Sandhills Center for inspection of member records relating to Sandhills Center members as necessary for its peer and utilization review purposes as permitted by state or federal laws and regulations. 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 application.

Name of Hospital

Name of Authorized Representative (please print)

Signature of Authorized Representative above Date

North Carolina Department of Health & Human Services

MEDICAID LETTER OF ATTESTATION

The Deficit Reduction Act (DRA) of 2005, which went into effect January 1, 2007, required specific changes to states’ Medicaid programs. One of the changes is the requirement for employee education about false claims recovery. Section 6032 of the DRA amended the Social Security Act, Title 42, United States Code, Section 1396(a) by inserting an additional relevant paragraph (68). This paragraph is cited below; in summary it requires any entities that receive or make annual payment under the Medicaid State Plan of at least five million dollars to have detailed, specific written policies established about the Federal and State False Claims Act for their employees, agents and contractors.

Specifically, 1396(a) (68) of the Social Security Act requires that any entity that receives or makes annual payments under the State plan of at least $5,000,000 as a condition of receiving such payments, shall –

(A) Establish written policies for all employees of the entity (including management), and of any contractor or agent of theentity, that provide detailed information about the False Claims Act established under section 3729 through 3733 oftitle 31, United States Code [31 USCS 3729-3733], administrative remedies for false claims and statements establishedunder chapter 38 of title 31, United States Code [31 USCS 3801 et. seq.], an State laws pertaining to civil penalties forfalse claims and statements, and whistleblower protections under such laws, with respect to the role of such laws inpreventing and detecting fraud, waste and abuse in Federal health care programs (as defined in section1128B(f)[42USCS 1320-7b(f)];

(B) Include as part of such written policies, detailed provisions regarding the entity’s policies and procedures for detectingand preventing fraud, waste and abuse; and

(C) Include in any employee handbook for the entity, a specific discussion of the laws described in subparagraph (A), therights of the employees to be protected as whistleblowers, and the entity’s policies and procedures for detecting andpreventing fraud, waste and abuse;

Effective January 1, 2007, all providers who meet the above conditions are required to certify that they are in compliance with 1396(a)(68) of the Social Security Act as a condition of enrollment in the North Carolina Medicaid Program.

As a North Carolina Medicaid provider, or the owner / operator / manager of a North Carolina Medicaid provider entity, I certify that our entity has read and understands the above requirements. I also certify that if our entity receives or makes annual payments under the State plan of at least $5,000,000 we have complied with and established written policies and procedures that provide detailed information concerning the Federal False Claims Act, 31 USC 3729 et. seq., administrative remedies for false claims and statements established under 31USCS 3801 et. seq., and any North Carolina State Laws pertaining to civil or criminal penalties for false claims and statements, and whistleblower protections under such laws, with respect to the role of such laws in preventing and detecting fraud, waste and abuse in Federal health care programs.

I further certify, when the above conditions apply, that our entity’s written policies include detailed provisions regarding our policies and procedures for detecting and preventing fraud, waste and abuse; and that our employee handbook contains a specific discussion of the Federal and State False Claims Act, the rights of the employees to be protected as whistleblowers, and our policies and procedures for detecting, preventing fraud, waste and abuse.

Copies of any and all training manuals, written policies and procedures for detecting and preventing fraud, waste, and abuse, and employee handbooks will be maintained on site for a minimum of five (5) years for inspection and auditing by the Division of Medical Assistance.

*Medicaid Provider Name (must match name on Medicaid Participation Agreement or Provider Administrative ParticipationAgreement)

*Street Address (Physical Site – not P.O. Box)

*City, State and Zip + 4 (required)

I certify that the above information is true and correct. I further understand that any false or misleading information may be cause for denial or termination of participation as a Medicaid Provider. Individual applications must have the provider’s original signature. Authorized agents can only sign for a group application.

*Signature of Applicant or Authorized Agent Date

*Printed Name and Title

Required fields are marked with an asterisk (*).


Trading Partner Agreement TRADING PARTNER AGREEMENT– Electronic Data Interchange (EDI)

This document constitutes an agreement to the following provisions for exchanging Electronic Data Interchange (EDI) between the Trading Partner and Sandhills Center (SHC).

The Trading Partner agrees:

1. To conform to the requirements for Administrative Simplifications as defined in the provisions of the HealthInsurance Portability and Accountability Act (HIPAA) of 1996 (P.L. 104-91), and regulations promulgated there underand to take no action which adversely affects SHC’s HIPAA compliance.

2. That it will promptly notify SHC of any and all unlawful or unauthorized disclosures of confidential information orprotected health information (PHI) that comes to its attention and will cooperate with SHC in the event any litigationarises concerning the unauthorized use, transfer, or disclosure of either confidential or protected health information.

3. That it will use sufficient security procedures to ensure that all transmissions of documents are authorized andprotect all participant-specific data from improper access.

4. That it will ensure that all files transmitted comply with the appropriate national Electronic Data Interchange (EDI)Transaction Set Implementation Guide, in effect on the date of transmission, as provided by the Health InsurancePortability and Accountability Act (HIPAA) of 1996.

5. That it will establish and maintain procedures and controls so that information concerning SHC health planparticipants or any information obtained from SHC, shall not be used by agents, officers, or employees of the tradingpartner other than for its sole intended purpose.

6. That the information stated in any EDI Trading Partner Profile(s) submitted with this Agreement, or subsequently iscorrect and complete.

7. That it will allow SHC 30 days after receipt of written notice from the Trading Partner if there is any change in thetrading partner representative or location where electronic transactions are sent.

8. That it is bound by this written agreement to comply with state and federal law, if the trading partner is anintermediary for the billing provider.

SHC agrees:

1. To conform to the requirements for Administrative Simplifications as defined in the provisions of the HealthInsurance Portability and Accountability Act (HIPAA) of 1996 (P.L. 104-91), and regulations promulgated there underand to take no action which adversely affects the trading partner’s HIPAA compliance.

2. That it will use sufficient security procedures to ensure that all transmissions of documents are authorized andprotect all participant-specific data from improper access.

3. That it will ensure that all files transmitted comply with the appropriate national Electronic DataInterchange (EDI) Transaction Set Implementation Guide, in effect on the date of transmission, asprovided by the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

Both parties agree:

1. That documents will not be considered as received and no responsibility assigned until accessible at thereceiving party’s computer.

2. That upon receiving any documents, to prepare and transmit a timely response or an acknowledgement oftransaction receipt. If acceptance of a document is required, a document is not considered received until anacceptance acknowledgement is returned.

3. To notify the other party within a reasonable time frame if any transmitted data are received in anunintelligible or garbled form.

4. That each party will provide and maintain the equipment, software, services, and testing necessary totransmit and receive documents.

5. To conduct business and perform as required by this agreement and any applicable rules or regulations.

6. That this agreement will remain in effect until terminated by either party with at least 30 days prior writtennotice. The notice will specify the effective date of termination, but will not affect the obligations or rightsof either party prior to the effective date of termination. This agreement is automatically terminated in theevent the trading partner is disqualified through a federal administrative action or state action. That anydocument transmitted according to this agreement will be considered an original and signed when received.

Effect of Termination

1. Except as provided in paragraph (2) of this section or in the contract or by other applicable law oragreements, upon termination of this agreement and services provided by the Trading Partner, for anyreason, the Trading Partner shall return or destroy all Protected Health Information received from SHC, orcreated or received by Trading Partner on behalf of SHC. This provision shall apply to Protected HealthInformation that is in the possession of subcontractors or agents of the Trading Partner. Trading Partner shallretain no copies of the Protected Health Information.

2. In the event that Trading Partner determines that returning or destroying the electronic protected healthinformation is not feasible, Trading Partner shall provide to SHC notification of the conditions that makereturn or destruction not feasible. Trading Partner shall extend the protections of this agreement to suchProtected Health Information and limit further uses and disclosures of such Protected Health Information tothose purposes that make the return or destruction infeasible, for so long as Trading Partner maintains suchProtected Health Information.

Trading Partner Name

Street Address Line 1 (Site/Physical Address, not a P.O. Box)

Street Address Line 2

City, State, Zip Code

Contact Information (Phone Number, email address)

____________________________________________________________________________________ Signature of Applicant or Authorized Individual Date

Printed Name and Title ___________________________________________________________________________________

For Sandhills Center for MH, DD & SAS use only

Trading Partner’s EDI Submitter ID: Sandhills Center for MH, DD & SAS Receiver ID: SHC303

Please return completed form to: Sandhills Center for MH, DD & SAS P.O. Box 9 West End, NC 27376 Attn: EDI Coordinator, Information Technology Department

Managing Mental Health, Intellectual/Developmental Disabilities and Substance Abuse Services

910-673-9111 (FAX) 910-673-6202 www.sandhillscenter.org Victoria Whitt, CEO

P.O. Box 9, West End, NC 27376 24-Hour Access to Care Line: 800-256-2452

TTY: 1-866-518-6778 or 711 Serving Anson, Guilford, Harnett, Hoke, Lee, Montgomery,

Moore, Randolph & Richmond Counties

Insurance Requirements and Attestations

CONTRACTOR shall purchase and maintain insurance as listed below from an agency which is licensed and authorized to do business with the State of North Carolina by the NC Department of Insurance as specified below. A. Professional Liability: The CONTRACTOR shall purchase and maintain Professional Liability

Insurance protecting the CONTRACTOR and any employee performing work under the Contract for an amount of not less than $1,000,000.00 per occurrence/$3,000,000.00 annual aggregate. Please initial one:

I have provided my Certificate of Insurance showing that I meet this requirement.

I am covered by my employer’s insurance and I have enclosed my employer’s certificate of insurance with a statement that affirms I am covered.

All of my Practitioners associated with my practice are independent contractors carrying their own professional liability insurance; therefore, I do not maintain this coverage.

B. Comprehensive General Liability: If CONTRACTOR owns or leases the building or facility where services are provided under this agreement, the CONTRACTOR shall purchase and maintain Bodily Injury and Property Damage Liability Insurance protecting the CONTRACTOR and any employee performing work under the contract from claims of bodily Injury or Property Damage arising from operations under the Contract for an amount of not less than $1,000,000.00 per occurrence/$3,000,000.00 annual aggregate. Please initial all that apply:

I do not own or lease the building or facility where I provide services, however I have included a statement from the owner/ leasing management of insurance coverage.

I have provided my Certificate of Insurance showing that I meet this requirement. I am a practitioner within this agency or Hospital and have enclosed my employer’s

certificate of insurance. C. Automobile Liability: If the CONTRACTOR transports members, the CONTRACTOR shall purchase

and maintain Automobile Bodily Injury and Property Damage Liability Insurance covering all owned, non-owned, and hired automobiles for an amount of not less than $500,000.00 each person and $500,000.00 each occurrence. Policies written on a combined single limit basis shall have a minimum limit of $1,000,000.00.

Please initial one:

Not applicable; I do not transport members.

I have provided my Certificate of Insurance showing that I meet this requirement.

I am covered by my employer’s insurance and I have enclosed my employer’s certificate of insurance with a statement that affirms I am covered.

Qmcappd 11-01-2019

Insurance Requirements and Attestations continued

D. Worker’s Compensation and Occupational Disease Insurance, Employer’s Liability Insurance: the CONTRACTOR shall purchase and maintain Worker’s Compensation and Occupational Disease Insurance as required by the statutes of the State of North Carolina. The CONTRACTOR shall purchase and maintain Employer’s Liability Insurance for an amount of not less than Bodily Injury by Accident $100,000.00 each Accident/Bodily Injury by Disease $100,000.00 each Employee/Bodily Injury by Disease $500,000.00 Policy Unit. Please initial one:

Clinicians associated with my practice are independent contractors and I do not have the minimum number of employees that would require me to maintain this coverage.

I have provided the Certificate of Insurance and verification the practitioners are covered under the plan.

I am covered by my employer’s insurance; • I have enclosed my employer’s certificate of insurance and • I have enclosed a statement that affirms I am covered.

Not applicable, I am a Solo practitioner and I do not have the minimum number of employees that would require me to maintain this coverage.

CONTRACTOR shall:

i. Submit new COI’s no later than ten (10) calendar days after the expiration of any listed policy to ensure documentation of continual coverage;

ii. Notify LME/MCO in writing within two (2) business days of any cancellation or material change in coverage;

iii. Provide evidence to the LME/MCO of continual coverage at the levels stated above within seven (7) calendar days if CONTRACTOR changes insurance carriers during the performance period of the Contract including tail coverage for continual coverage; and

iv. Notify the LME/MCO in writing within two (2) business days of knowledge or notice of a claim, suit, criminal, or administrative proceeding against CONTRACTOR and/or Practitioner relating to the quality of services provided under this Contract.

Applicant’s Printed Name Applicant’s Signature

Agency/Facility Name

Date

Indemnification Agreement: By signing this waiver, I hereby agree to indemnify and hold harmless Sandhills Center from all losses, costs, damages, claims, liabilities and expenses (including attorneys’ fees and court costs) whatsoever, which may arise or be claimed against Sandhills Center, for any loss, injuries or damages, consequent upon or arising from any acts, omissions, neglect or fault in connection with Sandhills Center’s reliance upon this waiver.

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