5-REFERENCE DOCUMENT WholeYouNYC Social Care Network - HRSN Service Provider Application.pdf

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WholeYouNYC Social Care Network - HRSN Service Provider Application

Health-Related Social Need (HRSN) Service Provider Application

Notice for Previous Applicants Organizations who have applied to the previous WholeYouNYC Social Care Network Community-Based Organization (CBO) Application or WholeYouNYC Social Care Network Healthcare Providers Application, need not apply to this application. This is a re-release of those applications for new applicants only.

Instructions Organizations must choose to join the network as a Community-Based Organization (CBO) or a Healthcare Provider. Please refer to the solicitation for requirements for CBOs and Healthcare Providers.

Community-Based Organization (CBO) [Definition of a CBO - 501(c)(3) or 501(c)(4) non-profit community focused organization that provides HRSN services directly to Members. CBOs may or may not bill Medicaid within their organization. CBOs may contract with SCN Lead Entities to become part of a Social Care Network (SCN).]

Healthcare Provider [Definition of a Healthcare Provider - Provide physical and/or behavioral health care to individuals, including Medicaid members. Healthcare providers may include, but are not limited to, hospitals, health systems, primary care practices, health centers, behavioral health providers, and other licensed practitioners.]

Please select the provider type under which your organization will join the WholeYouNYC SCN: * 1.

CBO Verification

Yes

No

Will your organization provide at least one HRSN Service for the SCN? (including screening, navigation/care management and/or enhanced services?)

See the supporting document “Public Health Solutions SCN HRSN Fee Schedule” in the PHS Procurement Portal for a list of HRSN services *

2.

Yes

No

Is your organization a non-for-profit charitable organization? * 3.

Yes

No

Does your organization work at the local level to meet community needs? * 4.

Healthcare Provider Verification

No

Will your organization provide at least one HRSN Service for the SCN (including screening, navigation/care management and/or enhanced services?)

See the supporting document “Public Health Solutions SCN HRSN Fee Schedule” in the PHS Procurement Portal for a list of HRSN services *

5.

Yes

No

Is your organization a healthcare provider?

Definition of a Healthcare Provider - Provide physical and/or behavioral health care to individuals, including Medicaid members. Healthcare providers may include, but are not limited to, hospitals, health systems, primary care practices, health centers, behavioral health providers, and other licensed practitioners.

6.

A Provider group, practice, hospital, or facility

A single provider, physician, or practioner

Select the choice below for the provider type that best applies to the organization you represent.

7.

Please provide the associated Type 2 NPI. If you have multiple, please list all. * 8.

Please provide the associated Type 1 NPI. * 9.

Organization Information

Enter your full name * 10.

Enter your email address * 11.

Enter your contact phone number * 12.

What is the legal name of your organization? * 13.

What is your organizations legal address?

(Street address, City, State, Zip) *

14.

What is your organization's Employee Identification Number (EIN)?

15.

Yes

No

Is your organization a registered 501(c)(3) or 501(c)(4)? * 16.

Yes

No

Does your organization classify as a Faith-Based Organization? * 17.

Enter your answer

Full Name:

Email Address:

Phone Number:

Enter the contact information of your organization's primary authorized signatory * 18.

Full Name:

Email Address:

Phone Number:

Enter the contact information of your organization's secondary authorized signatory (if applicable)

19.

Service Area Information

No

Does your organization’s service area include at least one zip code in Brooklyn, Manhattan and/or Queens? *

20.

Brooklyn

Manhattan

Queens

Which borough(s) does your organization serve residents of? * 21.

What is/are your service location address(es) in Brooklyn?

(Street Address, City, State, Zip Code)

[Enter N/A if you do not have a service location address(es) in Brooklyn] *

22.

What is/are your service location address(es) in Manhattan?

(Street Address, City, State, Zip Code)

[Enter N/A if you do not have a service location address(es) in Manhattan]

23.

What is/are your service location address(es) in Queens?

(Street Address, City, State, Zip Code)

[Enter N/A if you do not have a service location address(es) in Queens] *

24.

SCN Services Information Select the HRSN service(s) your organization will provide. Please refer to the Public Health Solutions SCN HRSN Fee Schedule in Bonfire for additional information on each service type.

Health-Related Social Needs (HRSN) Screening

Health-Related Social Needs (HRSN) Screening (0)25.

Navigation (1.1)

Enhanced HRSN Care Management (1.2)

Care Management26.

Home Accessibility and Safety Modifications (2.1)

Home Remediation Service: Mold and Pest Remediation (2.2a)

Home Remediation Service: Ventilation Improving Systems (2.2b)

Home Remediation: Equipment Provision (2.2c)

Asthma Remediation: Self-Management Education (2.3a)

Asthma Remediation and Supportive Products (2.3b)

Medical Respite (2.4)

Rent / Temporary Housing (2.5)

Utility Setup - Activation Expenses (2.6a)

Utility Setup – Back Payment (2.6b)

Utility Assistance (2.6c)

Pre-tenancy Services (2.7)

Community Transitional Supports (CTS) (2.8a)

CTS Broker’s Fee (2.8b)

Tenancy Sustaining Services (2.9)

Housing Transition and Navigation Service (2.10)

Housing 27.

Nutrition Counseling and Education (3.1)

Medically Tailored Meals (3.2a)

Clinically Appropriate Home Delivered Meals (3.2b)

Medically Tailed or Nutritionally Appropriate Food Prescriptions (3.3)

Fresh Produce and Non-perishable Groceries (Pantry Stocking) (3.4)

Cooking Supplies: Kitchenware, Microwave, and Refrigerator (3.5)

Nutrition28.

Transportation

Transportation (4.1)29.

Medicaid High Utilizer (defined by Emergency Department, Inpatient or Medicaid spend or transitioning from an institutional setting)

Individuals enrolled in a designated Health Home

Pregnant Persons / up to 12 months Postpartum

Post-Release Criminal Justice-Involved Population

Juvenile Justice-Involved, Foster Care Youth, and those under Kinship Case

Children Under the Age of 6

Children Under the Age of 18 with One or More Chronic Conditions

Substance Use Disorder (SUD)

Intellectual or Developmental Disability (I/DD)

Serious Mental Illness (SMI)

None of the above

Will your organization provide services to the following populations?

Check all that apply

30.

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Bonfire Confirmation Submission

Yes

No

A complete submission of the Health-Related Social Need (HRSN) Service Provider Application includes uploading the following documents into your organization's vendor record in Bonfire :

New York State Certificate of Incorporation/Authority/Formation (full copy, including any amendments)

Internal Revenue Service 501(c)3 or 501(c)4 Determination Letter, if applicable IRS form 990 or equivalent Completed Attachment B: HRSN Services Completed Attachment I: Languages, Formats and Service Availability

Finally, you must confirm the submission of the Health-Related Social Need (HRSN) Service Provider Application in Bonfire and receive a Bonfire Submission Confirmation

Did you complete your submission in Bonfire? * 31.