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University of Massachusetts Medical School

ACQUIRED BRAIN INJURY WAIVER PROVIDER CREDENTIALING SUPPLEMENT

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PROVIDER NAME: _________________________________________________ DATE: ___________________

ADDRESS: ______________________________________________________________________________________

E-MAIL: __________________________________________________________

PHONE : __________________________________________ FAX: ______________________________________

FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN):

SOCIAL SECURITY NUMBER :_________________________________________

UCHECKLIST

All providers (Organizations or Self-Employed Providers) will submit the following documentation and materials:

MassHealth Acquired Brain Injury (ABI) Waivers Provider Application

Massachusetts Medicaid Program Provider Agreement

MassHealth Trading Partner Agreement

Federally Required Disclosures Form

Data Collection Form

Authorization for Electronic Funds Transfer (EFT) of MassHealth Payments

Massachusetts Substitute W-9 Form

ABI Waiver Provider Credentialing Supplement

OrganizationsU only, will also submit:

Proof of Liability Insurance

Proof of Workers Compensation Insurance

Job descriptions of key personnel

Job descriptions for each job title providing ABI Waiver services

Business Certifications by Organization Type, including documentation of 501(c)(3) status for non-profit

organizations

Uniform Financial Report (UFR) or copy of most recent audit

If any EOHHS agency has cancelled their contract with you or your organization in the past three (3) years, please

submit a one-page explanation which identifies the contract that was cancelled and describes: the state agency

involved, why the contract was cancelled and how the situation was rectified, or if it was not resolved.



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For informational purposes only:*

Please indicate geographic region(s) where are you are willing to provide services (Check all that apply – See

Appendix 1 for list of municipalities by region):

Boston/Metro

Central

Southeast/Cape/Islands

Northeast

Western

If applicable, please list the town/s that you do not provide service to within a particular geographic area:

1.__________________________ 3. ____________________________ 5. ____________________________

2. _________________________ 4. ____________________________ 6. ____________________________

In addition to English, please indicate any languages you or your organization service provider staff speak:

Language One: _________________________ Language Two: _________________________

* This information is not for the purpose of credentialing and will not restrict the geographic area you may serve.

SERVICE-SPECIFIC REQUIREMENTS

INSTRUCTIONS: Service-specific requirements begin on page 3 of this supplement. Please check and submit all the

related documentation for each service type which you or your organization are willing to be qualified to provide.

Organizations or self-employed providers submitting an application for multiple service types will be credentialed for

each type.



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SERVICE SPECIFIC REQUIREMENTS – Adult Companion

UAdult Companion- Organization or Self-Employed Provider U Non-medical care, supervision and socialization services provided to a Participant. Companions may assist or supervise

the Participant with such light household tasks as meal preparation, laundry, and shopping.

Requirements

Health or Human Service organization or individual

with experience providing nonmedical care,

supervision, and socialization for persons with ABI or

similar disabilities

All organization staff or self-employed providers

should meet the following qualifications:

o Have a high school diploma, UAND/OR

Have life experience working with

individuals with disabilities

Be able to handle emergency situations

CPR certification for all direct care

staff

o Staff members shall have the ability to

communicate effectively in the language and

communication style of the participant to

whom they provide services and his or her

family

UDocuments to be submitted by Organizations:

Description of experience providing Adult Companion

Services or similar services (not to exceed 1 Page)

Staff Roster which includes: staff name, position, and

# of hours per week that they perform the above listed

service

Resume of Program Director

UDocuments to be submitted by Self-employed Provider

applicants:

Resume

Description of experience providing Adult Companion

or similar services (not to exceed 1 page)

CPR Certificate

Two (2) Letters of professional reference

CORI Request Form

Each participating provider is required to sign a

MassHealth Provider Agreement by which it agrees to

comply with the Federal and State laws, regulations, and

policies governing the ABI Waiver, including the

standards for the specific Medicaid waiver service the

provider will deliver.

For organizational providers, the standards include, but

are not limited to:

For each employee providing Adult Companion

services, maintain the following records:

o CORI

o Reference Checks

o Resume

o Training/in-service certificates

o Copy of Professional License (if

applicable)

o Performance evaluations

o Tuberculosis Screening & Testing

Program Policies and Procedures inclusive of:

o Confidentiality and Release of Information

o Incident Reporting

o Human Rights

o Mandatory Reporting

o Complaint Resolution

o Job Descriptions and Salary Scales

o Universal Precautions

o Policy that prohibits workers from

handling participants money

For self-employed providers, the standards include, but

are not limited to:

o Maintain documentation of completed

trainings

o Maintain a record for each participant

receiving care or services as required in

CMR 630.431

o Maintain a record of Tuberculosis

Screening & Testing

o Work with UMMS Credentialing staff to

establish policies and procedures



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SERVICE SPECIFIC REQUIREMENTS – Chore Services

UChore Services – Organization

An unusual or infrequent household maintenance task that is needed to maintain the Participant's home in a clean, sanitary,

and safe environment. This service includes heavy household chores such as washing floors, windows, and walls; tacking

down loose rugs and tiles; and moving heavy items of furniture in order to provide safe access and egress.

Requirements

Health or Human Service organization with

experience providing services needed to maintain the

home in a clean, sanitary, and safe condition

Staff members shall have the ability to communicate

effectively in the language and communication style

of the participant to whom they provide services and

his or her family

The provider must accept or reject an ABI Waiver

service request by the end of the next business day

following receipt of the request

UDocuments to be submitted:

Description of experience providing Chore Services

or similar services (not to exceed 1 Page)

Staff Roster which includes: staff name, and position









are not limited to:

For each employee providing Chore Services,

maintain the following records

o CORI

o Reference Checks

o Resume


o Copy of Professional License (if applicable)


o Tuberculosis Screening &Testing




o Human Rights





o Policy that prohibits workers from handling

participants money



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SERVICE SPECIFIC REQUIREMENTS – Community-Based Substance Abuse Treatment

UCommunity-Based Substance Abuse Treatment - Organization

Individually designed strategies and approaches provided via 24-hour support and supervision in a residential rehabilitation

substance abuse treatment and education program for adults, that promote independence and integration to decrease the

Participant's substance abuse and/or alcohol abuse behaviors that interfere with his or her ability to remain in the community.

Requirements

Licensed as a residential rehabilitation substance

abuse treatment and education program for adults;

UAND

Private organization operating as a free standing

residential rehabilitation substance abuse treatment

program for adults, NOT provided in a hospital,

nursing facility or similar medical facility

UDocuments to be submitted:

Copy of DPH License;

Letter stating that the organization meets free standing

residential rehab requirements

Description of experience providing Community-

Based Substance Abuse services (not to exceed 1

Page)








are not limited to:

For each employee providing Community-Based

Substance Abuse Treatment Services, maintain the

following records:

o CORI

o Reference Checks

o Resume








o Human Rights






participants money



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SERVICE SPECIFIC REQUIREMENTS – Day Services (2 pages)

UDay Services - OrganizationU A structured, site-based, group program for participants that offers assistance with the acquisition, retention, or improvement

in self-help, socialization, and adaptive skills, and that takes place in a nonresidential setting separate from the Participant's

private residence or other residential living arrangement. Services often include assistance to learn activities of daily living and

functional skills; language and communication training; compensatory, cognitive and other strategies; interpersonal skills,

prevocational skills; and recreational and socialization skills.

Requirements

Health or Human Service Organization engaged in the

business of providing Day Services to persons with

acquired brain injuries or similar disabilities

Programs must employ a designated Program Director

who must have a Master’s degree in health and human

services related field or a Bachelors degree with five

years experiencing working with individuals with ABI

or similar disability

Senior Staff must have a Bachelor’s in rehabilitation

or related field; and two years experience working

with the ABI population



of the individual to whom they provide services and

his or her family

Fire Drills must be conducted at least quarterly

At a minimum, maintain 1:6 staff to Participant ratio

Must meet site requirements established by the Mass

Rehabilitation Commission for the provision of day

services to persons with a acquired brain injuries

UDocuments to be submitted by existing Day Service

providers who are either MassHealth enrolled or State

Agency certified/ licensed:

Documentation indicating current Day Service

Provider approval:

Adult Day Health Certificate; UOR

Documentation that indicates the organization

has met the requirements of 130 CMR 419.000

as a Day Habilitation Program; UOR

State Agency Day Program License/Certificate,

i.e. DDS/DMH/MRC


# of hours per week that they perform the above

listed service

Resume of Program Director and applicable

professional licensure

Occupancy permit which includes capacity and

current census

(continued on next page)








are not limited to:

For each employee providing Day Services, maintain

the following records:

o CORI

o Reference Checks

o Resume





For each consultant (i.e. of therapies such as Speech

Therapy, Occupational Therapy, etc.) maintain the

following records:

o Contracts

o Resumes

o Professional licenses




o Human Rights






participants money

o Policy for Fire Safety and Fire Drills

o Policy which illustrates Evacuation Plan

inclusive of Emergency protocol



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DAY SERVICES REQUIREMENTS (cont’d)

Documents to be submitted by new Day Service

Providers:

Description of experience providing day services or

similar service (not to exceed 1 Page)

Day Program organization chart

Proposed Staff Roster which includes: staff name,

position and # of hours per week that they perform

the above listed service

Copy of CARF Accreditation (if applicable)



Occupancy permit which includes capacity and

current census

Local fire department inspection report

Current local Board of Health inspection or

certificate (e.g. Food Establishment permit). If the

town or city where the program will be sited does not

require a Board of Health inspection, the provider

must submit supporting documentation.

A floor plan (or drawing) of the proposed program

site which identifies:

Label all rooms for use, be specific as to length

and width of each space

Provide square footage for each room or space

Closet, storage areas, hallways, lobbies and

similar spaces should be clearly labeled with the

dimensions indicated

Copy of the evacuation plan for meeting the special

needs of members, under circumstances requiring

emergency evacuation



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SERVICE SPECIFIC REQUIREMENTS – Homemaker

Homemaker (HM) - Organization

A person who performs light housekeeping duties (for example, cooking, cleaning, laundry, and shopping) for the purpose

of maintaining a household.

Requirements


business of providing Homemaker services whose

employees have at least one of the following

qualifications:

o Certificate of 40-hour homemaker

training; OR

o Certificate of 60-hour personal care

training; OR

o Certificate of home health aide training;

OR o Certificate of nurse’s aide training



of the Participant to whom they provide services and

his or her family

CPR certification for all direct care staff

Providers must ensure that supervision is provided by

Social Workers, Registered Nurses, and/or

professionals with relevant expertise with availability

offered during regular business hours, and on

weekends, holidays, and evenings

Supervision must be carried out at least once every

three months by a qualified supervisor. In-home

supervision must be done with a representative sample

of participants

A sufficient number of HM staff must be available to

meet the needs of participants accepted for service




Documents to be submitted:

Description of experience providing HM services or

similar services (not to exceed 1 page)

Resumes of staff providing supervision to HM


# of hours per week that they provide the above listed

service








are not limited to:

For each employee providing HM services, maintain

the following records:

o CORI

o Reference Checks

o Resume








o Human Rights






participants money



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SERVICE SPECIFIC REQUIREMENTS – Individual Support and Community Habilitation

Individual Support and Community Habilitation – Organization or Self-Employed Providers

Regular or intermittent services designed to develop, maintain, and/or maximize the participant’s independent functioning

in self-care, physical and emotional growth, socialization, communication, and vocational skills, to achieve objectives of

improved health and welfare and to the support the ability of the participant to establish and maintain a residence and live

in the community.

Requirements

All organization staff or self-employed providers

should meet the following qualifications:

o Have a College degree (preferably in a human

service field) plus experience in providing

community-based services to individuals with

disabilities or at least 2 years comparable,

community-based, life or work experience

providing services to individuals with disabilities

o Have the ability to communicate effectively in the

language and communication style of the

Participant to whom they provide services and his

or her family

o CPR certification for all direct care staff

Documents to be submitted by organizations:

Description of experience providing Individual Support

and Habilitation services or similar services (not to

exceed 1 Page)

Resume of Program Director and applicable licenses


# of hours per that they provide the above listed service

Documents to be submitted by self-employed providers :

Resume

Description of experience providing Individual Support

and Community Habilitation or similar services (not to

exceed 1 page)

CPR Certificate

Two (2) Letters of professional reference

CORI Request Form








are not limited to:

For each employee providing Individual Support and

Community Habilitation services, maintain the

following records:

o CORI

o Reference Checks

o Resume


o Copy of Professional License (if

applicable)






o Human Rights





o Policy that prohibits workers from

handling participants money

For self-employed providers, the standards include, but

are not limited to:


trainings



CMR 630.431

o Maintain a record of Tuberculosis

Screening & Testing





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SERVICE SPECIFIC REQUIREMENTS – Personal Care

Personal Care – Organization

A range of assistance that is appropriate and necessary for the participant’s health and well-being to enable the participant

to accomplish fundamental activities of daily living, including, but not limited to, eating, toileting, dressing, bathing,

transferring, and ambulation.

Requirements


business of providing personal care services that

employs personal care staff with at least one of the

following qualifications:

o Certificate of 60-hour personal care training;

OR o Certificate of home health aide training; OR

o Certificate of nurse’s aide training


Have the ability to communicate effectively in the

language and communication style of the Participant

to whom they provide services and his or her family

Providers must ensure that supervision is provided by

Social Workers, Registered Nurses; and/or

professionals with relevant expertise with availability

offered during regular business hours, and on

weekends, holidays, and evenings

PC Supervision: An RN must provide in-home

supervision of PC staff at least once every 3 months

with a representative sample of participants. A written

performance of PC skills must be completed after

each home visit. LPNs may provide in-home

supervision if the LPN has a valid license in

Massachusetts, and works under the direction of an

RN who is engaged in field supervision a minimum of

20-hours per week and is responsible for the field

supervision carried out by LPN

A sufficient number of PC staff must be available to

meet the needs of participants accepted for service.





Description of experience providing Personal Care

Services (not to exceed 1 Page)




# of hours per week that they provide the above listed

service








are not limited to:

For each employee providing Personal Care services,

maintain the following records:

o CORI

o Reference Checks

o Resume








o Human Rights






participants money



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SERVICE SPECIFIC REQUIREMENTS – Respite

Respite - Organization Services provided to individuals unable to care for themselves; furnished on a short-term basis because of the absence or

need for relief of those persons normally providing the care.

Requirements

Agencies applying to be Respite providers must:

o Be licensed as a hospital by MA Department of

Public Health under 105 CMR 130.00; OR

o Be certified as an assisted living residence by the

Executive Office of Elder Affairs under 651 CMR

12.00; OR

o Be licensed as a nursing facility by the MA

Department of Public Health under 105 CMR

153.00; OR

o Meet site based requirements established by the

MA Department of Developmental Services under

115 CMR 7.00; OR

o Be enrolled as a participating adult foster care

provider in the MassHealth Program under 130

CMR 408.000


Description of experience providing Respite Services

(not to exceed 1 Page)

Copy of appropriate license or certificate indicating

respite provider type








are not limited to:

For each employee providing Respite services,


o CORI

o Reference Checks

o Resume








o Human Rights






participants money



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SERVICE SPECIFIC REQUIREMENTS – Specialized Medical Equipment

Specialized Medical Equipment - Organization

Devices controls or appliances to increase abilities in activities of daily living, or to control or communicate with the

environment.

Requirements

A provider must be an individual or entity engaged in

the business of furnishing durable medical equipment,

medical/surgical supplies, or customized equipment,

or a provider participating in MassHealth under 130

CMR 409.000 or a pharmacy participating in

MassHealth under 130 CMR 406.000; OR

An entity engaged in the business of furnishing

durable medical equipment, medical/surgical supplies,

or customized equipment




his or her family


Description of experience being a Specialized Medical

Provider or similar service provider (not to exceed 1

Page)

DME providers must have documentation that they

meet requirements set forth in 130 CMR 409

If not a DME provider, a list of contracted

manufacturers used for purchased products

Copy of current accreditation letters

For PERS providers only, a copy of documentation

demonstrating compliance with UL Standards 1637 in

accordance with 130 CMR 409.429(C)

Copy of Massachusetts Board of Registration in

Pharmacy license (Pharmacy only)








are not limited to:

For each employee working with ABI participants,


o CORI

o Reference Checks

o Resume



o Performance evaluation

o For mobility providers only, a copy of current

Rehabilitation Engineering and Assistive

Technology Society of North America

Assistive Technology Professional (RESNA

ATP) certificate for each certified staff person.




o Human Rights





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SERVICE SPECIFIC REQUIREMENTS – Supported Employment

Supported Employment - Organization

Regularly scheduled services that enable Participants, through training and support, to work in integrated work settings in

which individuals are working toward compensated work, consistent with the strengths, resources, priorities, concerns,

abilities, capabilities, interests, and informed choice of the individuals.

Requirements

Human Service organization with experience

providing supported employment or similar services

Employ staff that have a college degree and

experience in providing community-based services or

at least 2 years experience providing services to

individuals with disabilities


Have direct experience working one-to one with

individuals with an ABI or similar disabilities




his or her family


Description of experience providing Supported

Employment services or similar services (not to

exceed 1 Page)

Staff Roster which includes: staff name, and position









are not limited to:

For each employee providing Supported Employment

services, maintain the following records:

o CORI

o Reference Checks

o Resume








o Human Rights






participants money



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SERVICE SPECIFIC REQUIREMENTS – Therapy Services (2 pages)

Therapy Services (Occupational, Physical and Speech Therapy) - Organizations or Self-Employed Providers Therapy services, including diagnostic evaluation and therapeutic intervention, designed to improve, develop, correct,

rehabilitate, or prevent the worsening of physical or speech/language communication and swallowing disorders functions

that affect the activities of daily living that have been lost, impaired, or reduced as a result of acute or chronic medical

conditions, congenital anomalies, or injuries.

Requirements

Homecare Agency or Individual licensed in

Massachusetts to provide Occupational, Physical, or

Speech Therapy

Occupational Therapy

o An individual Occupational Therapist under

MassHealth 130 CMR 432.000; OR

o A home health agency operating under 130 CMR

403.000

Physical Therapy

o An individual Physical Therapist under

MassHealth 130 CMR 432.000; OR

o A home health Agency participating in

MassHealth under 130 CMR 403.000

Speech Therapy

o An individual Speech Therapist under MassHealth

130 CMR 432.000; OR

o A speech/hearing center under MassHealth 130

CMR 413.000; OR

o A home health agency under MassHealth 130

CMR 403.000

All occupation therapy services must be provided by

a licensed occupational therapist or by a licensed

occupational therapy assistant under the supervision

of a licensed occupational therapist

All physical therapy services must be provided by a

licensed physical therapist or by a licensed physical

therapy assistant under the supervision of a licensed

physical therapist

All speech therapy services must be provided by a

licensed speech therapist

Documents to be submitted by Organizations:

Description of experience providing therapy services

(not to exceed 1 Page)

Staff Roster which includes staff name, position, and

# hours per week that they perform the above listed

service

Certificate as a provider of home health services; OR

DPH Speech and Hearing Center License; OR

American Speech-Language-Hearing Association

(ASHA) Certificate

(Continued to next page)








are not limited to:

For each employee providing Therapy services,


o CORI

o Reference Checks

o Resume


o Copy of Professional License






o Human Rights






participants money

For self-employed providers, the standards include, but are

not limited to:


trainings



CMR 630.431

o Maintain a record of Tuberculosis Screening

& Testing





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THERAPY SERVICES (cont’d)

Documents to be submitted by Self-employed

providers :

Description of experience providing either

Occupational, Physical or Speech Therapy services

(not to exceed 1 page)

Two (2) letters of professional reference

Copy of state license, i.e. OT, PT, SL/P

CORI Request Form



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SERVICE SPECIFIC REQUIREMENTS – Transportation

Transportation - Organization

Conveyance of participants by vehicle from their residence to and from the site of ABI Waiver services and other

community services, activities and resources, including physical assistance to participants while entering and exiting the

vehicle.

Requirements

An organization engaged in the business of

transporting persons with disabilities, which must:

o Ensure that vehicles are leased or controlled by

the provider

o Maintain workers compensation insurance for

drivers and monitors

o Employ drivers that are at least 19, have a valid

driver’s license and 3 years driving experience

o Ensure vehicles are insured and liability insurance

documentation is provided

o Ensure vehicles are registered with the MA RMV

o Ensure that accessible vehicles are equipped with

safety equipment to secure wheelchairs


Description of experience providing transportation to

individuals with disabilities (not to exceed 1 Page)

Organization policy on driver safety training

Company Hiring Policy

Roster of Drivers

Each participating provider is required to sign a MassHealth

Provider Agreement by which it agrees to comply with the

Federal and State laws, regulations, and policies governing

the ABI Waiver, including the standards for the specific

Medicaid waiver service the provider will deliver.

For organizational providers, the standards include, but are

not limited to:

For each employee providing Transportation services,


o CORI

o Reference Checks

o Resume




o Tuberculosis Screening & Testing

o Copy of Valid Massachusetts Driver’s License




o Human Rights






participants money

Certification of vehicle maintenance (including age

of vehicle, capacity, seatbelts, list of safety

equipment, air conditioning/heating) for each vehicle

RMV inspection for each vehicle

Completed log indicating that for vehicles with lifts,

the lifts are cycled daily

Inspection of vehicles’ that demonstrates:

o First Aid kits

o Snow Tires in the winter

o 2-Way communication



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CERTIFICATION

I certify under the pains and penalties of perjury that the information on this form and any attached statement that I have

provided has been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge. I also

certify that I am the provider or, in the case of a legal entity, duly authorized to act on behalf of the provider. I understand

that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any

material fact contained herein.

Provider’s signature (signature and date stamps, or the signature of anyone other than the provider or a person legally

authorized to sign on behalf of a legal entity, are not acceptable)

Printed legal name of provider:

Printed legal name of individual signing:

(if the provider is a legal entity)

Date:

MAIL TO:

ABI WAIVER UNIT

UMASS Medical School

ABI Waiver Unit

Attn: Provider Network Manager

333 South Street

Shrewsbury, MA 01545