Facility Cred Form PDF Details

Facility crediting is a process by which one company credits another company for the use of its Facility. The credited company, sometimes called the tenant, receives financial and other benefits in return for the credit. This arrangement allows companies to reduce costs and conserve resources without reducing productivity. In order to participate in facility crediting, both companies must have a signed agreement that outlines the terms and conditions of the credit arrangement. The credited company typically provides at least 10,000 square feet of manufacturing or office space, or invest $1 million in capital improvements. Benefits that may be gained from facility crediting include: lower rent expenses, usage of shared equipment or services, improved marketing exposure, and tax advantages. If you are interested in learning more about facility crediting or want to explore becoming a credited company , please contact us . We would be happy to discuss this process with you further. Tha

Question	Answer
Form Name	Facility Cred Form
Form Length	10 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 30 sec
Other names	optum 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

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
Administrative Address

City, State, Zip		County

Administrative Phone	Fax	Email
Website
Website
Tax Identification Number
Tax Identification Number
Billing/Remit Address
Billing/Remit Address
City, State, Zip
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
Ambulatory Detox			(i.e. stabilization, 23
(Drug or Alcohol)			(i.e. stabilization, 23
(Drug or Alcohol)			hour Ob)
			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]

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

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)	Secondary

Medicaid ID Number	Primary
(Must include Medicaid # validation from
(Must include Medicaid # validation from	Secondary
applicable state entity)	Secondary

National Provider Identifier (NPI)	Primary

	Secondary
	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 *

*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?
2.		How long?
3.		How long?
3.		How long?

FACILITY TYPE INFORMATION

Identify what best describes your organization:

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:

		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

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)				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 /
4. Identify specialty services offered:				Available	Available		Location(s)	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 /
Identify specialty services offered (cont):		Available	Available	Location(s)	Descriptions
					Descriptions
ASAM Residential Services
3.1	– Clinically Managed Low Intensity Res.				3.1	3.3
3.3	– Clinically Managed Population –				3.1	3.3
3.3	– Clinically Managed Population –				3.5
	Specific High Intensity Res.				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

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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