10-DHHS26105 Attachment G Medicaid Services Attachment.docx
DOCX document 25 KB Posted
- Attached to
- Residential Treatment Services
- Solicitation number
- DHHS26105
- Issued by
- Utah
About this file
This is a Medicaid Services Attachment form for a Residential Treatment Services contract issued by the Utah Department of Health and Human Services (DHHS). The document outlines assurances and service requirements for offerors providing diagnostic and rehabilitative mental health services to clients in residential treatment facilities. Offerors must provide required Medicaid services for all clients residing in the residential treatment facility and may offer additional Medicaid services for clients not residing in the residential program, including those in foster or proctor homes or in post-adoption placements. Additional services that offerors may provide include mentoring (Youth In Strive/YIS), contracted transportation payment (CTP), contracted high level transportation payment (CTH), and day group skills support services (DGS) for facilities holding a current DHHS/OL Day Treatment License. Additional Medicaid service locations must be documented with matching addresses to the required DHS/OL Outpatient Treatment License.
Offerors are required to enroll as Medicaid providers for diagnostic and rehabilitative mental health services, bill Utah Medicaid directly for all services provided pursuant to the request for proposal, and provide services at rates specified in the DHHS Medicaid Services Rate Table as documented in each client's treatment plan. All offerors must demonstrate compliance with the Utah Medicaid Provider Manual, including Section 1 (General Information), Section 2 (Diagnostic and Rehabilitative Mental Health Services by DHHS Contractors), and General Attachments, as well as any subsequent updates to the manual or Medicaid Information Bulletins. Offerors must complete the required signature section, providing name, title, and date of authorization.
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Other files
| File | Type | Posted |
|---|---|---|
| 5-DHHS26105 Attachment A DHHS Client Service Terms.docx | DOCX document | |
| 6-DHHS26105 Attachment B Scope of Work.docx | DOCX document | |
| 9-DHHS26105 Attachment D Facility Service Selection Template 6.26.docx | DOCX document | |
| 11-DHHS26105 Document Submission Checklist.pdf | ||
| 7-DHHS26105 Attachment E Facility Org Chart.docx | DOCX document | |
| 12-DHHS26105 RFP Template Residential 6 2026.docx | DOCX document | |
| 2-DHHS26105 Form 3 Conflict of Interest Disclosure Statement.pdf | ||
| 4-DHHS26105 Form 1 - DHHS Data Sheet.pdf | ||
| 13-DHHS26105 Score Sheet.xlsx | XLSX spreadsheet | |
| 1-DHHS26105 Attachment C Established Rates for Residential Treatment Services 2026.docx | DOCX document | |
| 3-DHHS26105 Form 2 W-9 Form.pdf | ||
| 8-DHHS26105 Attachment F Past Perfomance.docx | DOCX document |
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Text version
ATTACHMENT
G
FACILITY
MEDICAID ASSURANCES
REQUEST
TO
PROVIDE
ADDITIONAL
SERVICES
DH
H S 26105
OF
OFFEROR NAME:
FACILITY NAME:
REQUIRED MEDICAID SERVICES for all Clients residing in the Residential Treatment Facility
Diagnostic and Rehabilitative Mental Health Services (Medicaid Services)
REQUIRED ADDITIONAL MEDICAID SERVICES for Clients NOT residing in the Residential Treatment Program / Clients in Foster/Proctor Homes or Post Adopt
Diagnostic and Rehabilitative Mental Health Services (Medicaid Services) Additional Medicaid Services Location (The location listed in this section MUST match the address on the REQUIRED DHS/OL Outpatient Treatment License, but is not required to be at the same location as the Residential Treatment Facility) This requirement does not apply to facilities located outside of Utah:
Location Name: _ _ Address City, State, Zip:
· Check box if there are multiple locations for the additional Medicaid services, and list additional locations at the bottom of this form.
MEDICAID ASSURANCES
The Offeror agrees to do each of the following in connection with any Medicaid services it provides for Clients pursuant to this RFP:
| ► |
| To enroll the organization and each individual provider of services as a Medicaid provider for diagnostic and rehabilitative mental health services |
| ► |
| To provide services at the rates specified in the DHHS Medicaid Services Rate Table, as authorized in the PSA, and as documented in each Client's treatment plan. |
| ► |
| To bill Utah Medicaid directly for all diagnostic and rehabilitative mental health services provided to Clients pursuant to this RFP. |
The Offeror has read the following sections of the Utah Medicaid Provider Manual and agrees to comply with Utah Medicaid Provider Manual requirements, including any subsequent updates in the Manual or Medicaid Information Bulletins:
| ► |
| Section 1, “General Information” |
| ► |
| Section 2, “Diagnostic and Rehabilitative Mental Health Services by DHHS Contractors” and |
| ► |
| “General Attachments” |
ATTACHMENT
G
FACILITY
MEDICAID ASSURANCES
REQUEST
TO
PROVIDE
ADDITIONAL
SERVICES
DH
H S 26105
OF
ADDITIONAL NON-MEDICAID SERVICES (for Clients in the Residential Treatment Program)
Offeror agrees to provide the following additional services:
· Mentoring (YIS)(Wrap Service/ Non-Medicaid/ Mental Health)
· Contracted Transportation Payment (CTP)
· Contracted High Level Transportation Payment (CTH)
Offerors desiring to provide the following additional service MUST check the box below:
· Day Group Skills Support Service for Clients NOT residing in the Residential Treatment Program, DGS (Wrap Services/ Non-Medicaid/ Mental Health) (only if Offeror has a current DHHS/OL Day Treatment License) This option is not available for facilities located outside of Utah.
REQUIRED SIGNATURE
| Signature: |
| Date: |
Name/Title (typed or printed):
File details come from the government source that posted it. Updated .