5-HealthChoices Service Description Template.docx
DOCX document 34 KB Posted
- Attached to
- Drug & Alcohol Treatment Services
- Solicitation number
- 25-47
- Issued by
- Montgomery County, Pennsylvania
About this file
The document is a HealthChoices Behavioral Health Program Service Description Template from Pennsylvania, specifically focused on developing new in-lieu-of or additional behavioral health services. The template provides a structured framework for proposing new service offerings within the state's behavioral health system, requiring detailed documentation of service characteristics including billing codes (such as H0039 for Assertive Community Treatment and H0047 for Substance Abuse Services), anticipated service units, targeted population demographics, and clinical staffing patterns.
The template is designed to support comprehensive service development by requiring providers to outline population characteristics, program philosophy, expected outcomes, and a cost-benefit analysis. While directly linked to a Montgomery County Drug & Alcohol Treatment Services request for proposal, the document serves as a standardized mechanism for behavioral health providers to propose new services across different treatment modalities. The template mandates providers submit detailed information about staff qualifications, anticipated service volumes, and potential cost offsets, ensuring a structured approach to expanding or modifying behavioral health service offerings within the Pennsylvania HealthChoices program.
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Text version
HEALTHCHOICES BEHAVIORAL HEALTH PROGRAM
SERVICE DESCRIPTION TEMPLATE
For NEWLY PROPOSED IN LIEU OF OR IN ADDITION TO SERVICES
Date of Submission:
Provider’s Name:
Service Name:
County Contractor/ BH-MCO Name:
Description of Service:
Coding for Billing and/or Reporting of Services Rendered: (Check One)
Check One Prov.
Type Spec.
Code Proc.
Code Info Modifier Service Description
| Units |
| Place of |
Service
| 11 |
| 111 |
| H0039 |
| HB |
| Assertive community treatment, face to face (Community Treatment Teams) |
| 15 |
Min.
(Other)
| 11 |
| 119 |
| H0046 |
| HW |
| Mental health services, not otherwise specified (Community MH Svc. Other requires Service Description approved by OMHSAS) |
| 15 |
Min.
(Other)
| 11 |
| 184 |
| H0047 |
| HW |
| Alcohol and/or other drug abuse svc., not other specified (D&A Other requires Service Description approved by OMHSAS) |
| 15 Min. |
| 99 |
(other)
Anticipated Units of Service per Person:
Targeted Length of Service:
Information About Population to be Served: Submit this information in the table format below
| Population |
| Age Ranges |
| # of Persons to be Served Annually |
| Characteristic of Population to be Served |
| Children/Adolescents |
| 0-17 |
| Adults |
| 18-64 |
| Elderly |
| 65 and over |
Program Philosophy, Goals and Objectives:
Expected Outcomes:
Clinical Staffing Pattern: Submit this information in the table format below
| Staff Position |
| Qualifications |
| # of Staff |
| Total FTEs |
Cost Benefit Analysis: Submit this information in the table format below:
Cost Benefit Analysis
Service(s) Being Offset
Anticipated Unit Rate of New Service
Forward the completed service description to the OMHSAS Regional Field Office
| pg. 2 | |
| Newly Proposed HealthChoices Service Description | October 2018 |
File details come from the government source that posted it. Updated .