DHHS91073 Score Sheet.xlsx

Score Sheet

Does the Vendor have a current DHHS OL license for Outpatient Treatment OR for Vendors who have only one licensed professional staff, does the Vendor's professional staff have a DOPL license to prescribe mental health and substance use disorder treatment services according to the Utah Medicaid Manual?

2 Psychological and Neuropsychological Evaluation Services:

Did the Vendor submit the following the name of each licensed professional staff who will be providing this service on its behalf, AND is each staff currently licensed by DOPL as a psychologist?

3 Pharmacologic Evaluation and Management Services:

Did the Vendor submit the name of each licensed professional staff who will be providing this service on its behalf, AND is each staff currently licensed by DOPL to either rendor or prescribe mental health and substance use disorder treatment services according to the Utah Medicaid Manual?

Does the Vendor have a current DHHS OL license for Outpatient Treatment OR for Vendors who have only one licensed professional staff, does the Vendor's professional staff have a DOPL license to prescribe mental health and substance use disorder treatment services according to the Utah Medicaid Manual?

6 Family and Youth Peer Support Services:

Does the Vendor have a current DHHS OL license for Outpatient Treatment OR for Vendors who have only one licensed professional staff, does the Vendor's professional staff have a DOPL license to prescribe mental health and substance use disorder treatment services according to the Utah Medicaid Manual?

7 Evidence-Based Program Models for Prevention of Foster Care Services:

Did the Vendor submit a signed and completed Form 5 - Evidence-Based Program Models Attestation?

8 Mentoring Services:

Did the Vendor submit the following?

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.

9 Day Treatment Services:

Does the Vendor have a current DHHS OL license for Day Treatment?

10 Respite Care Services:

Does the Vendor have a current

1. Day Treatment License issued by DHHS OL;

2. Residential Support License issued by DHHS OL;

3. Residential Site Certification issued by DSPD or DHHS; or

4. Child Placing Agency License issued by DHHS OL?

11 Behavior Consultation and Adaptive Behavior Treatment Services:

Does one of the Vendor's staff meet the following?

1. Has at least one year 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).

12 Clinical Consultation:

Does the Vendor have a current DHHS OL license for Outpatient Treatment OR for Vendors who have only one licensed professional staff, does the Vendor's professional staff have a DOPL license to prescribe mental health and substance use disorder treatment services according to the Utah Medicaid Manual?

13 DSPD Eligibility Evaluation and Specialty Psychological Services:

For each person performing DSPD evaluations, was the following submitted: Experience and Education: A completed Experience and Education form evidencing the person:

1. Meets the professional experience requirements outlined in the Scope of Work; and

2. Has either a Doctorate in Psychology or Psychiatry from an accredited college or university, as required in the Scope of Work?

Experience Exception: If the individual has the required education but does not have the required years of professional experience, the individual may submit a signed and dated statement from a DHHS approved supervisor attesting that the supervisor:

(i) Is currently contracted with DHHS to provide the type(s) of evaluation service(s) the supervised individual is proposing to provide;

(ii) Is approved to provide supervision by the applicable DHHS representative(s) identified in the Scope of Work for the type(s) of evaluation service(s) the supervised individual is proposing to provide; and

(iii) Is willing to co-sign each evaluation report prepared by the individual being supervised until the individual has obtained the required years of experience.

AND

Licensure: A current copy of the person's DOPL license as a Psychologist, or for a Psychiatrist, a license as a physician and surgeon, as required in the Scope of Work?

14a Forensic Evaluation Services (APC, APD):

For each person performing APC or APD, was the following submitted:

Experience and Education: A completed Experience and Education form evidencing the person:

1. Meets the professional experience requirements outlined in the Scope of Work; and

2. Has either a Doctorate in Psychology or Psychiatry from an accredited college or university, as required in the Scope of Work?

Experience Exception: If the individual has the required education but does not have the required years of professional experience, the individual may submit a signed and dated statement from a DHHS approved supervisor attesting that the supervisor:

(i) Is currently contracted with DHHS to provide the type(s) of evaluation service(s) the supervised individual is proposing to provide;

(ii) Is approved to provide supervision by the applicable DHHS representative(s) identified in the Scope of Work for the type(s) of evaluation service(s) the supervised individual is proposing to provide; and

(iii) Is willing to co-sign each evaluation report prepared by the individual being supervised until the individual has obtained the required years of experience.

AND

Licensure: A current copy of a license as a Psychologist, or for a Psychiatrist, a license as a physician and surgeon, issued by DOPL, as required in the Scope of Work?

14b Forensic Evaluation Services (FOR, JFE):

For each person performing APC or APD, was the following submitted:

Experience and Education: A completed Experience and Education form evidencing the person:

1. Meets the professional experience requirements outlined in the Scope of Work; and

2. Meets the education requirements outlined in the Scope of Work.

Experience Exception: If the individual has the required education but does not have the required years of professional experience, the individual may submit a signed and dated statement from a DHHS approved supervisor attesting that the supervisor:

(i) Is currently contracted with DHHS to provide the type(s) of evaluation service(s) the supervised individual is proposing to provide;

(ii) Is approved to provide supervision by the applicable DHHS representative(s) identified in the Scope of Work for the type(s) of evaluation service(s) the supervised individual is proposing to provide; and

(iii) Is willing to co-sign each evaluation report prepared by the individual being supervised until the individual has obtained the required years of experience.

AND

Licensure: DOPL licensure as required in the Scope of Work?

15 Domestic Violence Treatment Services:

Does the Vendor have a current DHHS OL Outpatient Treatment license OR for Vendors who have only one licensed professional staff, does the Vendor's professional staff have a DOPL license to prescribe mental health and substance use disorder treatment services according to the Utah Medicaid Manual?

AND

Did the vendor submit proof of completing at least 24 hours of Domestic Violence Training?

16 PASRR Level II Evaluations:

Did the Vendor submit:

1. The name and job function of each licensed staff who will be providing this service on its behalf, AND Does each of these staff have a current DOPL license as a Psychologist, Licensed Clinical Social Worker or Services Social Worker?

AND

2. A resume for each staff who will be providing this service on its behalf, AND Does each resume demonstrate at lease one year of experience working with facilities such as hospitals, NFs, intermediate care faciliites for people with ID.RCs, geriatric care or local mental health agencies?

17 Mileage:

Does the Vendor have a current contract with DHHS other than a contract under DHHS91073?

18 In-Home Adaptive Parenting Services: Did the Vendor submit the following? 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.