2-DHHS26149 Attachment G Medicaid Services Attachment.docx
DOCX document 25 KB Posted
- Attached to
- Residential Treatment Services
- Solicitation number
- DHHS26149
- Issued by
- Utah
About this file
This document is Attachment G to DHHS 26149, a Facility Medicaid Assurances and Request to Provide Additional Services form from the Utah Department of Health and Human Services. The attachment establishes Medicaid service requirements and assurances for offerors providing residential treatment services for clients, including diagnostic and rehabilitative mental health services for residents of the facility and for clients in foster/proctor homes or post-adoption settings. Offerors must identify their facility name and any additional locations where non-residential Medicaid services will be provided; additional service locations must match the address on the required DHS/OL Outpatient Treatment License but need not be at the same facility location. The form requires offeror signatures and identification with typed or printed name and title for authorization.
Offerors must commit to enrolling their organization and individual service providers as Utah Medicaid providers, billing Utah Medicaid directly for all diagnostic and rehabilitative mental health services provided, and adhering to rates specified in the DHHS Medicaid Services Rate Table as authorized in the PSA and documented in each client's treatment plan. Offerors agree to comply with relevant sections of the Utah Medicaid Provider Manual, including General Information and Diagnostic and Rehabilitative Mental Health Services by DHHS Contractors sections, plus all General Attachments and subsequent updates. The form allows offerors to indicate provision of additional non-Medicaid wrap services including Mentoring (YIS), Contracted Transportation Payment (CTP), and Contracted High Level Transportation Payment (CTH) for residential clients, with Day Group Skills Support Service (DGS) available only for non-residential clients and only for facilities with a current DHHS/OL Day Treatment License; this option is not available for out-of-state facilities.
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Other files
| File | Type | Posted |
|---|---|---|
| 7-DHHS26149 Attachment D Facility Service Selection.docx | DOCX document | |
| 5-DHHS26149 Attachment E Facility Org Chart.docx | DOCX document | |
| 1-DHHS26149 Attachment F Past Perfomance.docx | DOCX document | |
| 6-DHHS26149 Document Submission Checklist.docx | DOCX document | |
| 4-DHHS26149 Form 4 - Mandatory Minimum Requirements.docx | DOCX document | |
| 13-DHHS26149 Attachment C Established Rates.docx | DOCX document | |
| 3-DHHS26149 RFP Template Residential 9.29.26.docx | DOCX document | |
| 8-DHHS26149 Form 1 - DHHS Data Sheet.pdf | ||
| 12-DHHS26149 Attachment A DHHS Client Service Terms.docx | DOCX document | |
| 14-26089 Form 2 W-9.pdf | ||
| 11-DHHS26149 Attachment B Scope of Work 9.29.26.docx | DOCX document | |
| 9-DHHS26149 Score Sheet.xlsx | XLSX spreadsheet | |
| 10-DHHS26149 Form 3 Conflict of Interest Disclosure Statement.pdf |
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Text version
ATTACHMENT
G
FACILITY
MEDICAID ASSURANCES
REQUEST
TO
PROVIDE
ADDITIONAL
SERVICES
DH
H S
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
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 .