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Facility or Hospital-Based Providers

Our facility or hospital-based organizations

Facility or Hospital-Based Providers

  • Do you offer licensed/certified Mental Health and/or Substance Use Disorder (SUD) inpatient and/or lower level of care services (i.e., Inpatient, Detox, Residential, Partial Hospitalization (PHP), and Intensive Outpatient (IOP) programs?
  • Do you have minimum professional liability coverage of $5 million/$5 million for acute inpatient services, and minimum professional and comprehensive liability coverage of $1 million/$3 million for non-acute inpatient services (unless state requirements vary)?

If meet above requirements, please click on the Facility Application link below to complete and select all applicable Level(s) of Care you provide.

IMPORTANT:  For covered facility-based services billed with Revenue Code or Revenue Code + HCPC or CPT code on a UB-O4 form, please complete the Facility Application. For covered facility-based services billed with single HCPC code or HCPC code + CPT code on a CMS 1500 form, please confirm the appropriate application to complete before completing the Facility Application.

Facility Application

For questions or help – contact Network Management at (877) 614-0484

Please note following documents will be required (As Applicable):

  • 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.)
  • ASAM CARF Level of Care Certification, if applicable
  • 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)
  • Copy of completed Ownership & Disclosure Form (REQUIRED if applying for participation in Medicaid networks)
  • Current 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.
  • W9 form: If multiple tax ID numbers used, one W9 must be submitted for each (NOTE: required if adding or changing tax ID or entity name)
  • 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,
  • 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

Improve the Speed of Processing - Tips for Applying to the Network

  • It is important to attach all correct and required documents as applicable.
  • Levels of Care will require appropriate state licensure and/or certification to be provided as part of the application process.
  • If not accredited, a site audit will need to be scheduled and conducted
  • Please include a signed completed W-9 form
  • Current Liability Insurance Certificate is not expired.

For help with this process, you can go to Network Management then click on "Network Management Contact Information" in the Network Management section.