Facility Cred Form PDF Details

In the evolving landscape of behavioral health services, joining a provider network such as Optum/OptumHealth Behavioral Solutions of California requires navigating the complexities of credentialing processes, underscored by the Facility Cred form. This comprehensive document not only serves as a Network Request Form but also as a Credentialing Application, setting the stage for facilities to demonstrate their qualifications and readiness to meet stringent standards. As a linchpin for maintaining a quality network, the form enquires about several facets of a facility, including whether it is already part of Optum's network, its legal and doing-business-as names, locations, levels of care offered, and the demographics it serves. Moreover, the application delves into the essential administrative and clinical details, such as accreditation status, licensure, Medicare, Medicaid, and NPI numbers, general and professional liability insurance, and any legal standing that might affect the organization's eligibility. With the completion of this form and the adherence to a robust preparation checklist—which calls for submission of current state licenses or certificates, accreditation status, program descriptions, professional and general liability insurance certificates, among other documents—a facility can begin its journey towards becoming an integral part of Optum's network. This detailed document underscores Optum's commitment to ensuring that facilities entering their network are well-equipped to provide high-quality, accessible behavioral health services, reinforcing the ongoing contract between the parties to update and verify this credentialing information periodically, approximately every 36 months, to maintain the caliber of care offered to members.

QuestionAnswer
Form NameFacility Cred Form
Form Length10 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 30 sec
Other namesoptum cred network online, optum facility application, california optum facility, california app request online

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Optum/OptumHealth Behavioral Solutions of California Facility Network Request Form / Credentialing Application

Is the facility currently in the Optum network?

Yes

No

Acceptance into the Optum/OptumHealth Behavioral Solutions of California (Optum) provider network is contingent upon the applicant Facility’s meeting our credentialing standards and subject to review and approval by the Optum Credentialing Committee. As a reminder, we consider accurate and up-to-date credentialing documents to be a vital part of maintaining a quality network. The need to keep this information current in our files means that we will approach you to request this documentation throughout the life of the contract between the parties. These requests can be expected approximately every 36 months. We understand that complying with this request can be time consuming, but it is required for your continued participation in our network. The information requested is required in order to comply with Optum’s credentialing standards. Additionally, the information you provide will help ensure the accuracy of claims payment.

ORGANIZATIONAL FACILITY IDENTIFYING INFORMATION

Legal Name of Facility

Parent Company/Health

System Name (if applicable)

DBA (Identifying) Name

 

 

 

 

Administrative Address

 

 

 

 

 

 

 

 

 

 

 

 

 

City, State, Zip

 

 

 

County

 

 

 

 

 

Administrative Phone

 

Fax

Email

Website

 

 

 

 

 

 

 

 

Tax Identification Number

 

 

 

 

 

 

 

 

Billing/Remit Address

 

 

 

 

 

 

 

 

City, State, Zip

 

 

 

 

 

 

 

 

IDENTIFY LEVELS OF CARE FACILITY DESIRES TO CONTRACT

(Optum Participating Providers, only select the Level(s) of Care being added to contract)

 

Substance Abuse/SUD/Chemical Dependency

 

 

Psychiatric/Mental Health

 

 

Geriatric Adult

Adolescent Child

 

 

Geriatric

Adult

Adolescent Child

 

 

 

 

 

 

 

 

 

 

Inpatient Detox

 

 

 

I/P Locked

 

 

 

 

 

 

 

 

 

 

 

 

 

IP Rehab

 

 

 

I/P Open

 

 

 

 

 

 

 

 

 

 

 

 

 

Residential

 

 

 

Residential

 

 

 

 

 

 

 

 

 

 

 

 

 

Partial Day Trmt.

 

 

 

Partial Day Trmt.

 

 

 

 

 

 

 

 

 

 

 

 

 

SA IOP

 

 

 

MH IOP

 

 

 

 

 

 

 

 

 

 

 

 

 

Ambulatory Detox

 

 

 

Crisis Services

 

 

 

 

 

 

 

(i.e. stabilization, 23

 

 

 

(Drug or Alcohol)

 

 

 

 

 

 

 

 

 

hour Ob)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication

 

 

 

 

 

 

 

 

Assisted Trmt.

Methadone

Buprenorphine

 

ECT

Inpatient

Outpatient

 

 

(MAT)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

Optum Facility Cred App

Page 1 of 10

United Behavioral Health operating under the brand Optum

Version 6/13/17 v11 (BH808)

U.S. Behavioral Health Plan, California doing business as OptumHealth Behavioral Solutions of California

Optum / OptumHealth Behavioral Solutions of California

Facility Network Request Form / Credentialing Application

IDENTIFY PRACTICE LOCATION(S) ONLY FOR ABOVE CHECKED LEVEL(S) OF CARE

Facility

Location(s)

Location #1

Age Category/ Population

Mental Health

Acute Inpatient

Residential

Partial Hospitalization

Intensive Outpatient

Home Health Svcs.

*Other

 

 

 

 

 

 

Inpatient Detox

Inpatient Rehab

Substance Abuse

Residential

Partial Hospitalization

Intensive Outpatient

Ambulatory Detox (Drug or Alcohol)

 

 

 

 

*Other

Admission

Phone:

Secure Fax:

Location #2

Admission

Phone:

Secure Fax:

Location #3

Admission

Phone:

Secure Fax:

Location #4

Adult

Geri

Adol

Child

# of IP Beds (MH):

 

# of IP Beds (SA):

 

 

 

# of Medicare Acute IP Beds (MH):

 

 

Adult

Geri

Adol

Child

# of IP Beds (MH):

 

# of IP Beds (SA):

 

 

 

# of Medicare Acute IP Beds (MH):

 

 

Adult

Geri

Adol

Child

# of IP Beds (MH):

 

# of IP Beds (SA):

 

 

 

# of Medicare Acute IP Beds (MH):

 

 

 

Adult

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Geri

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Adol

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Admission

Child

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

# of IP Beds (MH):

 

 

 

 

 

# of IP Beds (SA):

 

 

 

 

 

 

 

 

 

 

 

 

Secure Fax:

 

# of Medicare Acute IP Beds (MH):

 

 

 

 

 

 

 

 

 

Location #5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Adult

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Geri

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Adol

 

 

 

 

 

 

 

 

 

 

 

 

 

Admission

Child

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

# of IP Beds (MH):

 

 

 

 

 

# of IP Beds (SA):

Secure Fax:

 

# of Medicare Acute IP Beds (MH):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*If additional space is needed to add “Other” services, please print additional copies of this page and continue to insert services in the “Other” column.

Page 2 of 10

Optum Facility Cred App.

Version 6/13/17.v.11 (BH808)

Optum / OptumHealth Behavioral Solutions of California

Facility Network Request Form / Credentialing Application

ORGANIZATIONAL PROVIDER CONTACT INFORMATION

Name

Phone

E-mail Address

Primary Contact

Signatory Contact

Facility Contracting Contact

Administrator / Roster Contact

Business Office Manager

Director of Clinical Services

Medical Director

Chief Executive Officer

ACCREDITATION

Issue Date

Expiration Date Not Applicable

The Joint Commission

Commission on Accreditation of Rehabilitation Facilities (CARF)

American Osteopathic Association (AOA)

Council on Accreditation (COA)

Community Health Accreditation Program (CHAP)

American Association for Ambulatory Health Care (AAAHC)

Critical Access Hospitals (CAH)

Healthcare Facilities Accreditation Program (HFAP, through AOA)

National Integrated Accreditation for Healthcare Organizations (NIAHO, through DNV Healthcare)

Accreditation Commissions for Healthcare (ACHC)

Please list other Accreditation held by your organization

LICENSURE / CERTIFICATION

[Optum Participating Providers, only include for the Level(s) of Care being added to contract]

1.

2.

3.

4.

Entity Issuing

License or Certification

Type of License or

Certificate

License Number

Expiration Date

 

 

Does the Organizational provider state licensure/certification include a site visit by the State? If “Yes”, please attach a copy of the audit completed by the State with this application.

Page 3 of 10

Optum Facility Cred App.

Version 6/13/17.v.11 (BH808)

Yes

No

Optum / OptumHealth Behavioral Solutions of California

Facility Network Request Form / Credentialing Application

MEDICARE / MEDICAID/ NPI / KePRO

 

 

 

Not

 

Number

Issue Date

Expiration Date Applicable

 

 

 

 

Medicare ID Number (6 digits)

Primary

 

 

 

 

 

Secondary

 

 

(Must include Medicare # validation from CMS)

 

 

 

 

 

 

Medicaid ID Number

Primary

 

 

(Must include Medicaid # validation from

 

 

 

Secondary

 

 

applicable state entity)

 

 

 

 

 

 

National Provider Identifier (NPI)

Primary

 

 

 

 

 

Secondary

 

 

 

 

 

KePRO certification

 

 

 

(TRICARE providers only)

 

 

 

GENERAL / PROFESSIONAL LIABILITY

Please attach current certificates for two types of liability insurance information. Optum insurance requirements are as follows:

For facilities/programs with an acute inpatient component:

 

Professional/general liability

$5,000,000/$5,000,000 minimum coverage

For facilities/programs without an acute inpatient component:

 

Professional liability

$1,000,000/$3,000,000 minimum coverage

Comprehensive general liability

$1,000,000/$3,000,000 minimum coverage

Professional Liability Limits:

 

General Liability Limits:

 

 

 

If you are self-insured, we require the portion of the facility’s independently audited financial statement which shows retention of the required amounts stated above.

LEGAL STATUS

Has the Organizational Provider or any party owning or controlling 5% or more of your company have knowledge of or been subject to disciplinary action, criminal/ethical investigations or convictions, such as but not limited to revocation, suspension or restriction of its license; Medicare/Medicaid provider status; certification or accreditation status (i.e., The Joint Commission, P.R.O., CARF, COA, AOA, etc…); bankruptcy, insolvency or assignment of creditor proceedings?

Yes *

No

*If yes to the above, please attach a brief explanation for each incident.

LOCATION ACCESSIBILITIES (please complete all conditions that apply)

Days

Hours

Not Applicable

Standard business operating hours

Evening Hours (any hours after 5pm)

Page 4 of 10

Optum Facility Cred App.

Version 6/13/17.v.11 (BH808)

Optum / OptumHealth Behavioral Solutions of California

Facility Network Request Form / Credentialing Application

Weekend Hours (Saturday or Sunday)

TDD Capability

Public Transportation Access

Wheelchair Accessibility

SIGNATURE

I hereby certify that all of the responses and information provided pursuant in this application are complete, true and correct to the best of my knowledge and belief. I further warrant that facility’s applicable licensure(s) is current and free of sanction or limitation. I understand that facility is responsible for adherence to Optum’s credentialing plan, clinical guidelines, and other processes and procedures as outlined at providerexpress.com. I warrant that I have the authority to sign this application on behalf of the entity for which I am signing in representative capacity. I warrant that I (or my designee) have reviewed and will consistently review the level of care guidelines associated with services being credentialed. The level of care guidelines can be found at providerexpress.com.

Signature

 

Date

 

 

 

Name (please type or print)

 

Title (please type or print)

PREPARATION CHECKLIST

Please provide the following documents:

Current State License(s)/ Certificate(s) for all behavioral health services you provide, i.e. psychiatric, substance abuse,

residential, intensive outpatient, etc. A18 – include all documentation for multiple facility locations.

Accreditation status (i.e. The Joint Commission, CARF, COA, etc.)

Medicare or Medicaid certification letter with Medicare number (REQUIRED if applying for participation in Medicaid or Medicare networks)

Program Description-including any specialty program descriptions and hours per day/ days per week

Copy of completed Ownership & Disclosure Form (REQUIRED if applying for participation in Medicaid networks)

Professional and General liability insurance certificates showing limits, policy number(s) and expiration date(s). If self -insured, attach a copy of an independently audited financial statement which shows retention of the required amounts.

Other Documents (ONLY NEEDED FOR NEW FACILITY APPLICANTS):

W9 form: If multiple tax ID numbers used, one W9 must be submitted for each

Signed Malpractice Questionnaire

Staff Roster for all behavioral health staff involved with your programs. Please list their degrees, licenses and/or certificates. We do not need an actual copy of their licenses or certifications.

Daily Program Schedule(s) – include an hour-by-hour schedule showing a patient’s daily treatment for each level of care you provide. Include weekend scheduling, where appropriate,

Policies and Procedures (ONLY NEEDED FOR NEW FACILITY APPLICANTS):

Policy and Procedure on Intake/Access Process to Behavioral Medicine

Policy and Procedure on Intake/Access Process if done through E.R.

Policy and Procedure on Holds/Restraints

Policy and Procedure for Discharge Planning

Page 5 of 10

Optum Facility Cred App.

Version 6/13/17.v.11 (BH808)

Optum / OptumHealth Behavioral Solutions of California

Facility Network Request Form / Credentialing Application

MANAGED CARE PARTICIPATION

List the names of any managed care companies with whom you currently contract (including Optum):

1.

 

How long?

2.

 

How long?

 

3.

 

How long?

 

 

 

 

FACILITY TYPE INFORMATION

Identify what best describes your organization:

MH SA

MH SA

MH SA

Freestanding Day Treatment Freestanding IOP General Acute Care Hospital

Free standing Psychiatric Hospital Residential Treatment Center Ambulatory Detox (Drug) Ambulatory Detox (Alcohol)

General Acute Hospital with Detox Psychiatric Residential Facility Community Mental Health Center Home Health Care Agency Facility Opioid Treatment Center IHS Facility/Agency

Rural Health Clinic

Outpatient Detox Center

SA Recovery Home

SA Rehabilitation Facility

SA Residential Facility

Skilled Nursing Facility

Tribal 638 Facility/Agency

Other

STAFFING

Please answer the following questions relating to your professional psychiatry staff:

1. Are services by psychiatrists restricted to staff / faculty psychiatrists?

Yes

2.Number of board certified psychiatrists on staff:

3.Indicate the number of psychiatrist visits per week by level of care:

No

 

 

SA

 

 

 

 

 

Inpatient

 

 

 

IP Acute

IP Detox

Rehab

Residential

Partial

IOP

Number of visits by MD

Number required in Facility bylaws or policy

COMPENSATION

Indicate your current retail rates and approximate discounted contracted rates for each level of care on a per diem basis, exclusive or inclusive of professional fees:

Mental Health

Level of Care

Retail

Discount

IP Locked

IP Acute

Residential

Full day Partial

Intensive OP

ECT – Outpatient

ECT – Inpatient

Substance Abuse/Chemical Dependency

Level of Care

Retail

Discount

IP Detox

Inpatient Rehab

Residential

Full day Partial

Intensive OP

Please identify any other services that are provided by the facility with rate information:

Service Type

Retail Rate

Discount Rate

Comments

Page 6 of 10

Optum Facility Cred App.

Version 6/13/17.v.11 (BH808)

Optum / OptumHealth Behavioral Solutions of California

Facility Network Request Form / Credentialing Application

DELIVERY OF CARE

Please answer the following questions relating to your policy and procedures as identified:

1.How often is individual therapy provided?

2.How often is family therapy provided?

3.What is the patient staff ratio?

4.What is the staff position responsible for discharge planning?

5.Describe your discharge planning procedures:

6.What percentage of patients are referred for follow up care?

7.What are your protocols for psych testing?

8.For the partial hospital and IOP services, does the program serve as a step down or are patients directly admitted?

8.1Does your Partial Hospital or IOP program meet the level of care guidelines

as outlined at Provider Express – providerexpress.com?

Yes

No

9.What percentage of patients are directly admitted to the partial and IOP programs?

10.What components are present in your Substance Abuse programs?

No SA services offered

Education is directed to drug of choice

Relapse prevention is part of program

Program meets Department of Transportation requirements

There are criteria for drug/alcohol urine screens

11.Please identify your Average Length of Stay (ALOS) for each program

ALOS

Mental Health Services

ALOS

Substance Abuse Services

 

Locked

 

Detox

 

Acute

 

Inpatient

 

Residential

 

Residential

 

Partial Day Hospitalization

 

Day Treatment

 

Intensive Outpatient

 

Intensive Outpatient

12.

Are there any programs/departments within the facility managed by external organizations?

Yes

No

 

(i.e. emergency room, specialty programs)

 

 

 

 

 

 

 

 

If “Yes”, please provide the following:

 

 

 

 

 

 

 

 

 

 

 

Facility Dept or Program

Organization Name

Address

Contact Name

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 7 of 10

Optum Facility Cred App.

Version 6/13/17.v.11 (BH808)

Optum / OptumHealth Behavioral Solutions of California

Facility Network Request Form / Credentialing Application

SERVICE DELIVERY / SPECIALTY SERVICES

1.If detoxification is offered at Facility, please identify, with a check mark, the physical location of detoxification beds:

Bed located on a medical floor/unit

Bed located on a behavioral health unit

2.If Facility offers partial hospitalization programs, please indicate number of hours of treatment her day and how many days per week (please review UBH Clinical requirements at www.providerexpress.com):

Full Day Partial

 

Intensive Outpatient

3.Please indicate if Facility is able to accommodate the following membership needs in your service area:

 

 

 

Not

 

 

 

 

 

 

Available

Available

 

Accommodation Method

 

 

Member language needs

 

 

 

 

 

 

 

Member handicap needs

 

 

 

 

 

 

 

a. Are all locations handicapped accessible?

 

Yes

No

 

 

 

If “No”, please indicate which location(s) would not meet the criteria for handicapped accessibility:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Identify specialty services offered:

 

Available

 

Not

Location(s)

Comments /

 

Available

Descriptions

 

Eating Disorder Treatment – Inpatient

 

 

 

 

 

 

Electro-convulsive Therapy (ECT) - Inpatient

Electro-convulsive Therapy (ECT) – Outpatient

Dual Diagnosis Services

Continuing Day Treatment

LGBT services

Domiciliary Services in an IOP or PHP setting (program must be formally approved by UBH)

Chronically Mentally Ill Services (CMI)/Severely

Mentally Ill Services (SMI)

Respite Care Services

Emergency Room Services (assessment only)

Twenty-three (23) Hour Crisis Observation

Mobile Crisis Stabilization

MHSA Outpatient Clinics in a hospital

Ambulatory Detox - Drug

Ambulatory Detox - Alcohol

Medication Assisted Treatment (MAT) - in an

Detox, IOP or PHP setting

Methadone Suboxone

Buprenorphine Naltrexone (i.e. vivitrol)

Sober Living/Supervised Living

Halfway House

Group Home

Therapeutic Foster Care

ASAM Intensive Inpatient Services

 

 

3.7

– Medically Monitored Intensive IP

3.7

4.0

4.0

– Medically Managed Intensive IP

 

 

Optum Facility Cred App

Page 8 of 10

Version 6/13/17 v11 (BH808)

 

Optum / OptumHealth Behavioral Solutions of California

Facility Network Request Form / Credentialing Application

Identify specialty services offered (cont):

Available

Not

Location(s)

Comments /

Available

Descriptions

 

 

 

 

 

ASAM Residential Services

 

 

 

 

 

3.1

– Clinically Managed Low Intensity Res.

 

 

 

3.1

3.3

3.3

– Clinically Managed Population –

 

 

 

 

 

 

3.5

 

 

Specific High Intensity Res.

 

 

 

 

 

 

 

 

 

 

3.5

– Clinically Managed High Intensity Res.

 

 

 

 

 

ASAM Partial Hospitalization Services (PHP)

 

 

 

 

 

2.5

– Partial Hospitalization

 

 

 

 

 

ASAM Intensive Outpatient Services (IOP)

 

 

 

 

 

2.1

– Intensive Outpatient

 

 

 

 

 

Optum Facility Cred App

Page 9 of 10

Version 6/13/17 v11 (BH808)

 

Optum / OptumHealth Behavioral Solutions of California

Facility Network Request Form / Credentialing Application

OPTUM INTERNAL USE ONLY

FACILITY:TIN:Facets # (if applicable):

NETWORK MANAGER/ASSOCIATE

Name:

 

 

 

Date Received:

 

 

Date Reviewed:

Networks (check all that apply):

UBH Commercial

Medicare

Medicaid

TriCare

Other

# of Covered Lives:

 

 

Current Network (# of PAR facilities offering same level(s) of care:

Network Needs (based on GeoAccess Standards):

If network need is determined, Network Manager verified levels of care with facility (including Optum’s Level of Care Guidelines).

Date:

 

 

Confirmed facility has reviewed Provider Express, particularly manual, claims and clinical guidelines:

Yes

No

PROVIDER SERVICES GOVERNANCE COMMITTEE OUTCOME

Reviewed by Provider Services Governance Committee :

Date:

 

 

 

 

 

 

APPROVED (Rationale):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DENIED (Rationale):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Clinical Operation Representative Signature / Title:

 

 

 

 

 

 

Date:

 

Network Manager Signature:

 

 

 

 

 

 

Date:

 

Outcome Communicated to Facility by Network Manager (if approved, NM educated facility on next steps in process): Date:

 

 

 

 

 

 

 

CREDENTIALING CHECKLIST

 

 

 

 

 

 

 

 

 

 

 

(Only if approved)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sent to Facility Credentialing Team: Date:

 

 

Application Sent Via:

ePUF

Email

FORCE

CMS Disclosure Form Attached (required for all State Medicaid providers):

Yes

No/Not Applicable

 

Site audit request form completed (if applicable):

 

 

 

Yes

No/Not Applicable

 

Exception Form needed:

 

 

 

Yes

No/Not Applicable

 

If Yes, Reason for Exception:

 

 

 

 

 

 

 

 

Additional Comments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Optum Facility Cred App

Page 10 of 10

 

 

 

 

Version 6/13/17 v11 (BH808)

 

 

 

 

 

 

 

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