DHHS91073 Form 4 - Service Application.xlsx
XLSX spreadsheet 91 KB Posted
- Solicitation number
- DHHS91073
- Issued by
- Utah
About this file
This document is a Service Application form for a state and local government contract opportunity issued by the Utah Department of Health and Human Services (DHHS). The contract seeks to establish master services agreements with vendors to provide a variety of mental health and substance abuse services, including psychotherapy, psychological and neuropsychological evaluations, pharmacologic management, psychosocial rehabilitation, therapeutic behavioral services, peer support, evidence-based programs, mentoring, day treatment, respite care, behavior consultation, clinical consultation, DSPD eligibility evaluations, forensic evaluations, civil commitment services, and domestic violence treatment. Vendors must meet specific licensure and experience requirements for the services they are applying to provide. There are also mileage and travel reimbursement options available. The contract term is not specified.
The application form outlines the service codes, Medicaid billing codes, service descriptions, and provider requirements for each service category. Vendors must indicate which services they are applying for and submit supporting documentation such as licenses, resumes, and sample evaluations. There are no specific pricing terms, set-asides, or funding source details provided. The contract opportunity is open to new and existing providers in the state of Utah.
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SERVICE APPLICATION
DHHS91073 Form 4 - Service Application
| Vendor's NAME: ____________________________________________________________________________________________ |
| Instructions: Vendors shall place an X in the yellow shaded box beside all the services for which it is applying. |
The Special Incentive for Rural In-Home Evidence-Based Programs & Practices (SIR) service code will be automatically awarded to vendors who are awarded services that may qualify for the rural incentive.
| 1. Psychotherapy Services | |||
| Vendors wishing to provide one or more Psychotherapy Services shall check this category. Vendors will be awarded all of the services in the category as indicated below. However, the Vendor shall only provide those services for which it is qualified. | |||
| Vendors applying for Psychotherapy Services must have a current DHHS OL Outpatient Treatment license; OR For vendors who have only one licensed professional staff, the professional staff must hold a current DOPL license to prescribe mental health and substance use disorder treatment services according to the Utah Medicaid Manual. Vendors must submit the name of the licensed professional staff who will be providing this service. | |||
| Service Name | Medicaid Billing Code | DHHS Service Code | |
| Psychotherapy Services. Vendors will be awarded the following services: | |||
| Psychiatric Diagnostic Interview Examination | 90791 | NCA | |
| Psychotherapy, 30 minutes, with patient and/or family member | 90832 | NT2 | |
| Psychotherapy, 45 minutes, with patient and/or family member | 90834 | NT3 | |
| Psychotherapy, 60 minutes, with patient and/or family member | 90837 | NT4 | |
| Psychotherapy for crisis, first 60 minutes, with patient and/or family member | 90839 | NTC | |
| Psychotherapy for crisis, add-on | 90840 | NTX | |
| Family Psychotherapy - without patient present | 90846 | NFW | |
| Family Psychotherapy - with patient present | 90847 | NFT | |
| Multiple-Family Group Psychotherapy | 90849 | NFG | |
| Group Psychotherapy | 90853 | NGT | |
| Mental Health Assessment By Non Physician | H0031 | NCN | |
| Clinical Consultation | N/A | NCC | |
| Non-Clinical Consultation | N/A | NNC | |
| Mileage & Travel Reimbursement | N/A | MIR |
| 2. Psychological and Neuropsychological Evaluation Services | ||||
| Vendors wishing to provide one or more Psychological and Neuropsychological Evaluation Services shall check this category. Vendors will be awarded all of the services in the category as indicated below. However, the Vendor shall only provide those services for which it is qualified. | ||||
| Individuals applying for these services must have a current DOPL license as a psychologist. Vendors must submit the name of each staff who will be providing this service on its behalf. | ||||
| Service Name | Medicaid Billing Code | DHHS Service Code | ||
| Psychological and Neuropsychological Evaluation Services. Vendors will be awarded the following services: | ||||
| Psychological testing with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to face | 96102 | NX2 | ||
| Psychological testing administered by a computer, with qualified health care professional interpretation and report. | 96103 | NX3 | ||
| Assessment of Aphasia | 96105 | NXA | ||
| Developmental Testing (Limited) | 96110 | NDL | ||
| Developmental Testing (Extended) | 96111 | NDE | ||
| Developmental Test Administration - 1st Hour | 96112 | NDT | ||
| Developmental Test Administration – Each Additional Hour | 96113 | ND2 | ||
| Neurobehavioral Status Examination – by Physician or Qualified Health Care Professional – 1st Hour | 96116 | NXB | ||
| Neurobehavioral Status Examination – by Physician or Qualified Health Care Professional – Each Additional Hour | 96121 | NB2 | ||
| Neuropsychological Testing with qualified health care professional interpretation | ||||
| and report, administered by technician, per hour of technician time, face-to-face | 96119 | NXQ | ||
| Neuropsychological Testing, administered by computer, with qualified health care professional interpretation and report. | 96120 | NXC | ||
| Standardized Cognitive Performance Testing by a Health Care Professional - per hour | 96125 | NST | ||
| Psychological Testing Evaluation by Physician or Qualified Health Care Professional - 1st Hour | 96130 | NP1 | ||
| Psychological Testing Evaluation by Physician or Qualified Health Care Professional – Each Additional Hour | 96131 | NP2 | ||
| Neuropsychological Testing Evaluation by Physician or Health Care Professional - 1st Hour | 96132 | NP3 | ||
| Neuropsychological Testing Evaluation by Physician or Health Care Professional – Each Additional Hour | 96133 | NP4 | ||
| Psychological or Neuropsychological Testing by Physician or Health Care Professional - 1st Half Hour | 96136 | NP5 | ||
| Psychological or Neuropsychological Testing by Physician or Health Care Professional – Each Additional Half Hour | 96137 | NP6 | ||
| Psychological or Neuropsychological Testing by Technician - 1st Half Hour | 96138 | NP7 | ||
| Psychological or Neuropsychological Testing by Technician - Each Additional Half Hour | 96139 | NP8 | ||
| Psychological or Neuropsychological Testing by Electronic Platform – Auto Result | 96146 | NP9 | ||
| Clinical Consultation | N/A | NCC | ||
| Mileage & Travel Reimbursement (over 75 miles) | N/A | MIR |
| 3. Pharmacologic Evaluation and Management Services | |||
| Vendors wishing to provide one or more Pharmacologic Evaluation and Management Services shall check this category. Vendors will be awarded all of the services in the category as indicated below. However, the Vendor shall only provide those services for which it is qualified. | |||
| Individuals providing these services must have a current DOPL license to either render or prescribe mental health and substance use disorder treatment services according to the Utah Medicaid Manual. Vendors must submit the name of each licensed professional staff who will be providing this service on its behalf. | |||
| Service Name | Medicaid Billing Code | DHHS Service Code | |
| Pharmacologic Evaluation and Management Services. Vendors will be awarded the following services: | |||
| Pharmacologic Management, Prescriber (MD/APRN) (based on complexity and time, 5 Minutes typical) | 99211 with CG modifier | NM1 | |
| Pharmacologic Management, Prescriber (MD/APRN) (based on complexity and time, 10 Minutes typical) | 99212 with CG modifier | NM2 | |
| Pharmacologic Management, Prescriber (MD/APRN) (based on complexity and time, 15 Minutes typical) | 99213 with CG modifier | NM3 | |
| Pharmacologic Management, Prescriber (MD/APRN) (based on complexity and time, 25 Minutes typical) | 99214 with CG modifier | NM5 | |
| Pharmacologic Management, Prescriber (MD/APRN) (based on complexity and time, 40 Minutes typical) | 99215 with CG modifier | NM8 | |
| Home Services E/M Codes – established patient | 99347 | NH1 | |
| Home Services E/M Codes – established patient | 99348 | NH2 | |
| Home Services E/M Codes – established patient | 99349 | NH3 | |
| Home Services E/M Codes – established patient | 99350 | NH4 | |
| Psychiatric Diagnostic Evaluation with Medical Services, by physician or APRN | 90792 | NPE | |
| Psychotherapy add-on code, witha patient and/or family member - 30 mins (added to applicable E/M service code) | 90833 | NMT | |
| Psychotherapy add-on code, with a patient and/or family member - 45 mins (added to applicable E/M code) | 90836 | NMI | |
| Psychotherapy add-on code, with a patient and/or family member - 60 mins (added to applicable E/M code) | 90838 | NMC | |
| Nurse Assessment/Evaluation | T1001 | NAE | |
| Therapeutic, prophylactic, or Diagnostic Injection, Subcutaneous/Intramuscular | 96372 | NDI | |
| Mental Health Assessment | H0031 | NCN | |
| Clinical Consultation | N/A | NCC | |
| Mileage & Travel Reimbursement (over 75 miles) | N/A | MIR |
| 4. Psychosocial Rehabilitative Services | |||
| Vendors wishing to provide one or more Psychosocial Rehabilitative Services shall check this category. Vendors will be awarded all of the services in the category as indicated below. However, the Vendor shall only provide those services for which it is qualified. | |||
| Vendors applying for Psychosocial Rehabilitative Services must have a current DHHS OL Outpatient Treatment license; OR For vendors who have only one licensed professional staff, the professional staff must hold a current DOPL license to prescribe mental health and substance use disorder treatment services according to the Utah Medicaid Manual. Vendors must submit the name of the licensed professional staff who will be providing this service. | |||
| Service Name | Medicaid Billing Code | DHHS Service Code | |
| Psychosocial Rehabilitative Services. Vendors will be awarded the following services: | |||
| Individual Skills Training and Development (Psychosocial rehabilitative services with an individual) | H2014 | NRI | |
| Group Psychosocial Rehabilitative Services | H2017 | NRG | |
| Group Psychosocial Rehabilitative Services - Intensive | H2017 U1 | NRX | |
| Non-Clinical Consultation | N/A | NNC | |
| Mileage & Travel Reimbursement (over 75 miles) | N/A | MIR |
| 5. Therapeutic Behavioral Services | |||
| Vendors wishing to provide one or more Therapeutic Behavioral Services shall check this category. Vendors will be awarded all of the services in the category as indicated below. However, the Vendor shall only provide those services for which it is qualified. | |||
| Vendors applying for Therapeutic Behavioral Services must have a current DHHS OL Outpatient Treatment license; OR For vendors who have only one licensed professional staff, the professional staff must hold a current DOPL license to prescribe mental health and substance use disorder treatment services according to the Utah Medicaid Manual. Vendors must submit the name of the licensed professional staff who will be providing this service. | |||
| Service Name | Medicaid Billing Code | DHHS Service Code | |
| Therapeutic Behavioral Services. Vendors will be awarded the following services: | |||
| Individual/Family Therapeutic Behavioral Services | H2019 | NBT | |
| Group Therapeutic Behavioral Services | H2019 HQ | NBG | |
| Non-Clinical Consultation | N/A | NNC | |
| Mileage & Travel Reimbursement (over 75 miles) | N/A | MIR |
| 6. Family and Youth Peer Support Services | |||
| Vendors wishing to provide Family and Youth Peer Support Services shall check this category. | |||
| Vendors applying for Family and Youth Peer Support Services must have a current DHHS OL Outpatient Treatment license; OR For vendors who have only one licensed professional staff, the professional staff must hold a current DOPL license to prescribe mental health and substance use disorder treatment services according to the Utah Medicaid Manual. Vendors must submit the name of the licensed professional staff who will be providing this service. | |||
| Service Name | Medicaid Billing Code | DHHS Service Code | |
| Family and Youth Peer Support Services. Vendors will be awarded the following services: | |||
| Peer Support Services, Individual - per 15 mins | H0038 | NPS | |
| Mileage at Standard Rate of Reimbursement (over 60 miles) | N/A | MSR |
| 7. Evidence-Based Program Models for Prevention of Foster Care Services | |||
| Vendors wishing to provide Evidence-Based Program Models for Prevention of Foster Care Services shall check the box next to each Program the Vendor wants to provide. Vendors applying for any of the Evidence-Based Program Models for Prevention of Foster Care Services will also receive Mileage Reimbursement (MIR). | |||
| Vendors applying for Evidence-Based Program Models for Prevention of Foster Care Services must submit a signed and completed Form #5: Attestation - Evidence-Based Program Models for Prevention of Foster Care Services. | |||
| Service Name | Medicaid Billing Code | DHHS Service Code | |
| Functional Family Therapy | N/A | FFT | |
| Trauma Focused Cognitive Behavior Therapy | N/A | TFT | |
| Parent-Child Interaction Therapy - Provided by a therapist who is certified or trained and working toward certification by PCIT International | N/A | PCE | |
| DHHS | N/A | MIT | |
| Mileage & Travel Reimbursement (over 75 miles round trip) | N/A | MIR |
| 8. Mentoring Services | |||
| Vendors wishing to provide one or more Mentoring Services shall check this category. Vendors will be awarded all of the services in the category as indicated below. However, the Vendor shall only provide those services for which it is qualified. | |||
| Vendors applying for Mentoring Services must submit: 1. A Resume or written statement demonstrating at least one year of mentoring experience; and 2. A mission statement or business plan that is related to mentoring. | |||
| Service Name | Medicaid Billing Code | DHHS Service Code | |
| Mentoring Services. Vendors will be awarded the following services: | |||
| Mentoring (1:1) | N/A | MT1 | |
| Mentoring (1:2) | N/A | MT2 | |
| Mentoring (1:3) | N/A | MT3 | |
| Mileage at Standard Rate of Reimbursement (over 60 miles) | N/A | MSR | |
| Staff Assistance Added | N/A | SAA |
| 9. Day Treatment Services | |||
| Vendors wishing to provide Day Treatment Services shall check the box before each Day Treatment Service the Vendor wants to provide. Vendors applying for Day Treatment Services will also receive Mileage Reimbursement (MIR). | |||
| Vendors applying for Day Treatment Services must havea current DHHS OL Day Treatment License. | |||
| Service Name | Medicaid Billing Code | DHHS Service Code | |
| Day Group Skills | N/A | DGR | |
| Day Group Skills - Intensive | N/A | DGX | |
| Community Group Supports | N/A | CGS | |
| Mileage & Travel Reimbursement | N/A | MIR |
| 10. Respite Care Services |
| Vendors wishing to provide Respite Care Services shall check the box before each Respite Care Service the Vendor wants to provide. |
| Vendors applying for Respite Care Services must have at least one of the following: |
1. A current Day Treatment License issued by DHHS OL;
2. A current Residential Support License issued by DHHS OL;
3. A current Residential Site Certification issued by DSPD or DHHS; or
4. A current Child Placing Agency License issued by DHHS OL.
| Service Name | Medicaid Billing Code | DHHS Service Code | |
| Overnight Respite | N/A | OVR | |
| Overnight Respite - High Needs | N/A | OVH | |
| Day Respite | N/A | DAR | |
| Day Respite - High Needs | N/A | DAH |
| 11. Behavior Consultation and Adaptive Behavior Treatment Services |
| Vendors wishing to provide one or more Behavior Consultation and Adaptive Behavior Treatment Services shall check this category. Vendors will be awarded all of the services in the category as indicated below. However, the Vendor shall only provide those services for which it is qualified. |
| Vendors applying for Behavior Consultation and Adaptive Behavior Treatment Services must submit proof that it has at least one staff person who meets the following: |
1. Has at least one year of experience working with individuals with intellectual disabilities, related conditions, acquired brain injury, and severe emotional or behavioral disorders;
2. Has a current Board Certified Behavior Analyst (BCBA) certification; and
3. Has a current Utah DOPL Behavior Analyst License (LBA).
| Service Name | Medicaid Billing Code | DHHS Service Code | |
| Behavior Consultation and Adaptive Behavior Treatment Services. Vendors will be awarded the following services: | |||
| Behavior Analysis Consultation - Level 2 (Licensed Behavior Analyst) | N/A | BHX | |
| Behavior Analysis Consultation - Level 1 | N/A | BHA | |
| Adaptive Behavior Treatment | N/A | BHT | |
| Mileage & Travel Reimbursement (over 75 miles) | N/A | MIR |
| 12. Clinical Consultation | |||
| Vendors wishing to provide Clinical Consultation Services shall check this category. | |||
| Vendors applying for Clinical Consultation must have a current DHHS OL Outpatient Treatment license; OR For vendors who have only one licensed professional staff, the professional staff must hold a current DOPL license to prescribe mental health and substance use disorder treatment services according to the Utah Medicaid Manual. Vendors must submit the name of the licensed professional staff who will be providing this service. | |||
| Service Name | Medicaid Billing Code | DHHS Service Code | |
| Clinical Consultation | N/A | NCC | |
| Mileage & Travel Reimbursement (over 75 miles) | N/A | MIR |
| 13. DSPD Eligibility Evaluation and Specialty Psychological Services |
| Vendors wishing to provide one or more DSPD Eligibility Evaluation and Specialty Psychological Services shall check each service for which the Vendor is applying. |
| Vendors applying for DSPD Eligibility Evaluation and Specialty Psychological Services must submit the the following for each person who will be performing evaluations on behalf of the Vendor: |
1. Experience and Education: A completed Experience and Education form.
2. Licensure: A current copy of the person's DOPL license as a Psychologist, or for a Psychiatrist, as a physician and surgeon, as required in the Scope of Work;
3. For persons who do not meet the experience requirements for the type(s) of evaluations to be performed, a signed supervisor statement as required in the Scope of Work; and
4. A sample evaluation prepared by the person that meets the specifications set forth in the RFSQ.
| Service Name | Medicaid Billing Code | DHHS Service Code | |
| Psychological Evaluations for DHHS/DSPD Eligibility Determination | N/A | APL | |
| Special Need Evaluation - Neuropsychological | N/A | APN | |
| Special Need Evaluation - Psychosexual | N/A | APS | |
| If any of the above DSPD Eligibility Evaluation and Specialty Psychological Services are selected, Vendors will also be awarded the following services: | |||
| DSPD Consultation and/or Atypical Evaluation | N/A | APX | |
| Defendant No-Show | N/A | DNS | |
| Psychological Evaluation Court Appearances and Testimony | N/A | APQ | |
| Mileage & Travel Reimbursement (over 75 miles) | N/A | MIR |
| 14. Forensic Evaluation Services |
| Vendors wishing to provide one or more Forensic Evaluation Services shall check each service for which the Vendor is applying. |
Vendors applying for Forensic Evaluation Services must submit the following for each person who will be performing evaluations on behalf of the Vendor:
1. Experience and Education: A completed Experience and Education form.
2. Licensure: A current copy of the person's DOPL license as a Psychologist, or for a Psychiatrist as a physician and surgeon, or as a Licensed Clinical Social Worker (if applying for FOR) as required in the Scope of Work;
3. For persons who do not meet the experience requirements for the type(s) of evaluations to be performed, a signed supervisor statement as required in the Scope of Work; and
4. A sample evaluation prepared by the person that meets the specifications set forth in the RFSQ.
| Service Name | Medicaid Billing Code | DHHS Service Code | |
| Psychological Evaluation for, or Restoration Evaluation of, Competency to Stand Trial | N/A | APC | |
| Psychological Evaluation to Determination Exception to Death Penalty | N/A | APD | |
| Forensic Evaluation Services - For A Person Without Intellectual Disabilities - Juvenile | N/A | JFE | |
| Forensic Evaluation Services - For A Person Without Intellectual Disabilities - Adult | N/A | FOR | |
| If any of the above Forensic Evaluation Services are selected, Vendors will also be awarded the following services: | |||
| DSPD Consultation and/or Atypical Evaluation | N/A | APX | |
| Defendant No-Show | N/A | DNS | |
| Psychological Evaluation Court Appearances and Testimony | N/A | APQ | |
| Mileage & Travel Reimbursement (over 75 miles) | N/A | MIR |
| 15. Civil Commitment Services | |||
| Vendors wishing to provide Civil Commitment Services shall check this category. | |||
| Vendors applying for Civil Commitment Services must submit the following for at least three staff members who will be providing services: 1. A current copy of the person's DOPL license as a Psychologist, AND a resume indicating at least one year of: (1) training in a field of study specifically related to Persons with ID/RC, or (2) clinical experience working with Persons with ID/RC; OR 2. A current copy of the person's DOPL license as a Clinical Social Worker, Certified Social Worker, Marriage and Family Therapist, or Clinical Mental Health Counselor, AND a resume indicating at least two years clinical experience working with Persons with ID/RC. | |||
| Service Name | Medicaid Billing Code | DHHS Service Code | |
| Civil Commitment Services. Vendors will be awarded the following services: | |||
| Civil Commitment Examination | N/A | CCE | |
| Civil Commitment Court Appearance | N/A | CCC | |
| Mileage & Travel Reimbursement (over 75 miles round trip) | N/A | MIR | |
| Defendant No-Show | N/A | DNS |
| 16. Domestic Violence Treatment Services |
| Vendors wishing to provide one or more Domestic Violence Treatment Services shall check this category. Vendors will be awarded all of the services in the category as indicated below. However, the Vendor shall only provide those services for which it is qualified. |
| Vendors applying for Domestic Violence Treatment Services must have: |
1. A current DHHS OL Outpatient Treatment license; OR, for vendors who have only one licensed professional staff, the professional staff must hold a current DOPL license to prescribe mental health and substance use disorder treatment services according to the Utah Medicaid Manual. Vendors must submit the name of the licensed professional staff who will be providing this service;
AND
2. Completed at least 24 hours of Domestic Violenc Training (UADVT Offender Preservice Training). Vendors must submit proof of completed training.
| Service Name | Medicaid Billing Code | DHHS Service Code | |
| Domestic Violence Services. Vendors will be awarded the following services: | |||
| DV Child/Youth Survivors Behavioral Health Assessment | 90791 | VCA | |
| DV Adult Survivors Behavioral Health Assessment | 90791 | VNA | |
| DV Offender Evaluation | 90791 | VOE | |
| DV Adult Survivors Individual Therapy | 90832, 90834, 90837 | VNI | |
| DV Offender Individual Intervention Services | 90832, 90834, 90837 | VOI | |
| DV Child/Youth Survivors Individual Therapy | 90832, 90834, 90837 | VCI | |
| DV Adult Survivors Group Therapy | 90853 | VNG | |
| DV Child/Youth Survivors Group Therapy | 90853 | VCG | |
| DV Offender Group Intervention Services | 90853 | VOG | |
| DV Adult Survivors Medication Management (MD/APRN) - 15 Minutes | 99213 with CG modifier | VNM | |
| DV Child/Youth Survivors Medication Management (MD/APRN) - 15 Minutes | 99213 with CG modifier | VCM |
| 17. Pre-Admission Screenings and Resident Review (PASRR) Level II Evaluations |
| Vendors wishing to provide PASRR Level II Evaluations shall check this category. |
| Individuals providing these services must have a current DOPL license as a Psychologist, Licensed Clinical Social Worker or Certified Social Worker. For each licensed professional staff who will be providing evaluations on its behalf, Vendors must submit: 1. The name of each individual, along with their job function related to this contract; AND |
2. A resume of each individual demonstrating at least one year of experience working with people with ID.RC's, geriatric care, or local mental health agencies.
| Service Name | Medicaid Billing Code | DHHS Service Code | |
| PASRR Level II Evaluations | N/A | PAS |
| 18. Mileage | |||
| Vendors wishing to provide Mileage shall check this category. | |||
| Vendors applying for Mileage must have a current contract with DHHS other than a contract under DHHS91073. | |||
| Service Name | Medicaid Billing Code | DHHS Service Code | |
| Mileage at Standard Rate of Reimbursement (over 60 miles round trip) | N/A | MSR |
| 19. In-Home Adaptive Parenting Services |
| Vendors wishing to provide In-Home Adaptive Parenting Services shall check this category. |
| Vendors applying for In-Home Adaptive Parenting Services must submit: 1. Proof of a Bachelor's degree in social or behavioral sciences; and |
2. A Resume or written statement demonstrating at least one year of work experience, within the past five years, working with Persons with ID.RC.
| Service Name | Medicaid Billing Code | DHHS Service Code | |
| In-Home Adaptive Parenting Services | N/A | IAP | |
| Mileage & Travel Reimbursement (over 75 miles round trip) | N/A | MIR |
Service Code Application Page &P of &N
Service Code Application Page &P of &N
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