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2519 Scripture Street PO Box 2346 Denton, Texas 76201 Denton, Texas 76202

OPEN ENROLLEMENT

REQUEST FOR APPLICATION (RFA)

Substance Use Disorder Services – Provider Application

October 2025

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TABLE OF CONTENT: SUBSTANCE USE DISORDER SERVICES RFA – PROVIDER

APPLICATION

Checklist

Attach a copy of Certificate of Occupancy

Attach a copy of General Liability Insurance

Attach proof of current accreditation by the Joint Commission on Accreditation of Health Care Organizations

Attach proof of health facility licensure

Attach Form W-9

Attach Signed Copy of Attestation

Attach Signed Copy of General Authorization for Release of Information

Attach Signed Copy of Assurances

Attach Signed Copy of Certification Regarding Lobbying, Grants, Loans & Cooperative Agreements

Attach Criminal Background Check Form

Attachments Attachment A – DENTON COUNTY MHMR CENTER RATES

Attachment B - APPLICATION

Attachment C – ATTESTATION

Attachment D – GENERAL AUTHORIZATION FOR RELEASE OF INFORMATION

Attachment E – ASSURANCES DOCUMENT

Attachment F – CERTIFICATION REGARDING LOBBYING, GRANTS, LOANS, & COOPERATIVE AGREEMENTS

Attachment G – EXECUTIVE LEADERSHIP TEAM

Attachment H – LOCAL AUTHORITY

Attachment I – CRIMINAL BACKGROUND CHECK FORM

Attachment J – BACKGROUND AND REGISTRIES CHECK CONTRACTOR REQUIREMENTS

Attachment K – Form W-9

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INTRODUCTION

The Denton County MHMR Center (hereinafter referred to as “The Center”), a community MHMR Center and governmental unit of the State of Texas, is seeking to contract with eligible providers to expand access to substance use disorder (SUD) treatment and behavioral health services in Denton County. This effort supports Denton County MHMR Center’s mission to reduce emergency room visits, overdose deaths, and hospital admissions by promoting recovery through accessible and evidence-based care.

The Center is committed to supporting the health and well-being of adults throughout Denton County. Network providers are key to the overall success of the individuals who depend on our agency for their healthcare needs.

Open enrollment documents are posted on The Center’s website at https://www.dentonmhmr.org/volunteers/contract-opportunities/. Notice is hereby given that The Center will receive applications for providers beginning October 2025. An original of the application and (1) copy of the attachments is due to:

ATTENTION:

Denton County MHMR Center contractsubmission@dentonmhmr.org

Center Background Denton County MHMR Center or “Local Authority” (Local Mental Health Authority “LMHA and Local Intellectual and Developmental Disability Authority “LIDDA”) is the Texas Health and Humas Services “HHS” designated authority established to plan, coordinate, develop policy, develop, and allocate resources, supervise, and ensure the provision of community based for the residents of Denton County, Texas. The Center receives funding from many diverse sources that enable it to provide a variety of services for people who have needs related to behavioral health and/or intellectual/developmental disabilities. A board of Directors appointed by the Denton County Commissioners court governs The Center.

2519 Scripture Street Denton, Texas 76201 1614 Scripture Street Denton, Texas 76201 3835 Morse Street, Denton, Texas 76208

3827 Morse Suite 101, Denton, Texas 76208 and 1001 Cross Timbers Suites 1250 and 1040, Flower Mound, Texas 75028

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(The Center is exempt from State and local sales tax and federal excise tax)

Pursuant to 25 Texas Administrative Code $ 412.5 and 40 Texas Administrative Code $2.55, the LMHA and LIDDA have the authority to acquire services to address needs of mental health and/or intellectual/developmental disabilities needs by certain procurement methods. This Request for Applications (RFA)/Open Enrollment invites and encourages the submission of applications (each, an “Application” and collectively, the “Applications,” and any party applying, and “Applicant”) from those interested in entering one or more contracts (each a “Contract” and collectively the “Contracts”) with The Center. Each qualified Applicant(s) under this RFA/Open Enrollment (each a “Successful Applicant” and collectively, the “Successful Applicants”) will be eligible to enter a Contract with The Center to provide one or more of the community-based services.

The individual who will be served under this arrangement each, a “Client” and collectively, “Clients” must always (a) meet the then current requirements of the funder of the services, and

(b) reside in Denton County, Texas. An individual’s designation as a client may only be made by the Local Authority and must be documented in their record. This RFA/Open Enrollment invites the submission of Applications from those interested in being considered for a Contract with The Center for the purpose of offering services for Clients.

Mission Statement, Agency Principles, Vision, & Values

Mission Statement Denton County MHMR Center enhances the quality of the individuals served and their family members.

Our Guiding Principles Denton County MHMR Center we believe these principles should guide our interactions with our clients and with interactions between our staff.

Assumes Good Intentions Create a Safe Space

Understanding You is Important Good Ideas Can Come from Anywhere at Any Time

Share Knowledge and Resources Strive for Continual Improvement

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The Center’s Values are:

We respect each individual’s unique and special concerns by providing assistance to best fit their needs, that enhances their ability to live a full and dignified life, and that celebrates the contributions all individuals make to our community. Our core values are:

Individual Worth Compassion

Integrity Dignity

Community Inclusion Choice

Opportunity

The Center’s Vision Statement is:

We envision a DCMHMR Center

That provides effective, comprehensive, and timely services to any and all people in need.

Where a qualified, motivated, and caring staff strive to make a difference in the lives of those they serve.

That offers state-of-the-art, high-quality facilities to assist individuals in living full and productive lives.

General Information The Center reserves the right to modify the general description and scope of services contained in the RFA/Open Enrollment by notifying potential applicants of any modifications. If any of the provisions of the RFA/Open Enrollment conflict with applicable laws, rules, regulations, and/or other codes of professional ethics, the latter shall prevail over the provisions of the RFA/Open Enrollment.

The Center shall not reimburse potential contractors for any expenses incurred preparing applications in response to this request. Any information that the respondent deems to be proprietary or otherwise confidential in the text of the application should be marked with red brackets or clearly designated as such. However, respondents are advised that the Center may disclose such proprietary information to appropriate parties if required to do so by applicable Texas open meetings and public record statues. All questions and communications concerning

P a g e 6 | 35 the RFA/Open Enrollment, and process must be made in writing to the Director of Procurement only, at the following email address:

contractsubmission@dentonmhmr.org.

Note: Subject line of the email must read RFA/Open enrollment – Substance Use Disorders Services RFA – Provider Application

Note: It is the Centers intent to respond to all appropriate questions or convers received.

Purpose of the RFA/Open Enrollment The purpose of this RFA/Open Enrollment is to offer contracts to eligible providers to expand access to substance use disorder (SUD) treatment and behavioral health services in Denton County. This effort supports Denton County MHMR Center’s mission to reduce emergency room visits, overdose deaths, and hospital admissions by promoting recovery through accessible and evidence-based care.

This RFA seeks to increase the availability of comprehensive, community-based services – such as outpatient treatment, medication-assisted treatment (MAT), intensive outpatient programming (IOP), recovery peer support, and case management – particularly for vulnerable populations including individuals below 200% of the federal poverty level, those experiencing homelessness, individuals at high risk of overdose, and pregnant women with

SUD.

By contracting with qualified providers, the Center aims to strengthen the local behavioral health systems, increase treatment capacity, ensure timely service access, and deliver cost-effective, high-quality care to individuals who otherwise may not have the means or stability to engage in recovery services.

Target Population The target population for this RFA/Open Enrollment consists of individuals residing in Denton County who have been identified by Denton County MHMR Center as eligible for substance use disorder (SUD) services, with a focus on individuals under 200% of the federal poverty level.

These individuals must meet Texas Health and Human Services Commission (HHSC) Client Eligibility requirements for SUD services, as determined and documented by the Center.

Priority populations include:

Individuals at high risk for overdose

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Individuals referred by the Department of Family and Protective Services (DFPS)

Individuals experiencing housing instability or homelessness

Individuals who inject drugs

Pregnant individuals who use substances or inject drugs

Youth 13-17 with SUD

Women who are pregnant or responsible for the care of dependent child

The Center also prioritizes individuals with co-occurring psychiatric, and substance use disorders (COPSD), those who are uninsured or underinsured, individuals involved in the justice systems, and those without financial means to access treatment independently. All designations of eligibility and priority will be made by the Center and documented in the individual’s record.

Eligible Applicants Applicants must be registered with the Secretary of State in Texas and have a Tax Identification Number. Individuals providing professional services must hold valid Texas licenses and/or certifications as required by state law. In any situation where a consortium of providers is applying, a single entity responsible for services delivered must be identified and the financial agent must be an organization with a demonstrated ability to manage funds.

Applicants may not subcontract responsibilities for these services. All service providers must be eighteen (18) years of age or older. Applicants may not have been convicted of a crime relevant to a person's duties including any sexual offense, drug-related offense, homicide, theft, assault, battery, or any other crime involving personal injury or threat to another person.

INSTRUCTIONS FOR SUBMISSION FOR APPLICATIONS

To facilitate and ensure an objective review, Applicants must follow these instructions for submission. Denton County MHMR Center (The Center) expressly reserves the right to reject any application that is not submitted according to the instructions below.

Applicants must email (1) original of the completed application and one (1) copy of all applicable attachments to:

Email: contractsubmission@dentonmhmr.org Subject: SUD Services RFA – Provider Application Submission

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Applicants must follow the attached outline for submissions to facilitate objective review. Please be sure to answer every question. If the question does not apply to your or your organization, simply and clearly document “N/A.”

False statements or false information provided by an Applicant may result in disqualification from or termination of enrollment into the network. In accepting applications, The Center reserves the right to reject any and all Applications, to waive formalities and reasonable irregularities in submitted documents, and to waive any requirements in order to take the action which it deems to be in the best interest of the Local Authority. The Center will not pay for any costs incurred by Applicants in the preparation and submission of a response to this RFA.

Each Applicant is responsible for ensuring that documents for potential enrollment are submitted completely and on time. The Local Authority expressly reserves the right not to evaluate any enrollment documents that are incomplete or late. Any attached form(s) must be completed by each Applicant to be considered for possible enrollment in the network.

Each Applicant shall be subject to disclosure under the Texas Public Information Act, Chapter 552 of the Texas Government Code, except for trade secrets and confidential information contained in the Application and clearly identified by the Applicant as such with blue ink.

Such information may still be subject to disclosure under the Public Information Act and other applicable law.

Specialized Services Provided The services provided are person-centered, family-centered, trauma-informed, and recovery oriented, being respectful of the needs of each person receiving services, their preferences, and values, and ensuring both individual involvement and self-direction of services received.

Applicants will endeavor to identify any individuals who are in need of mental health or substance use treatment and provide a referral to MHMR. If the individual identified appears to be in an immediate crisis, they will be connected to MHMR's 24/7 Crisis Hotline, 1-800-762- 0157.

Type, Frequency, Quantity, and Duration of Services

1. Confidentiality Compliance,

a. The Contractor agrees to institute procedures for safeguarding the PHI of individuals.

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b. The Contractor agrees to maintain individual’s records in compliance with Federal/State/Local/Center Guidelines relating to the security and retention of medical/mental health/substance use disorder treatment records, including but not limited to,

i. Omnibus Rule,

ii. 42 Code of Fed. Reg. (I)(A) § 2,

iii. Tex. Health and Safety Code §§ 181, 182, 576, 595, and 611, and

iv. Tex. Occ. Code § 159.

2. Definition Of Services,

a. “Substance Use Disorder (SUD) Detoxification and/or Rehabilitation Services” provide individuals with Licensed Professionals/Providers available twenty-four (24) hours per day, delivering medical detoxification, withdrawal management, and/or residential rehabilitation in environment designated to promote recovery, safety, and stabilization from substance use disorders.

b. The Contractor must ensure that all Contractor staff, Licensed Professionals/Providers, and facilities serving individuals under this Agreement adhere to all applicable provisions of Tex. Health and Safety Code, including §§ 464, 466, and 448 relating to substance use treatment facility operations.

c. The Contractor’s staff will provide intensive interventions designed to relieve acute withdrawal symptoms, stabilize the individual medically and behaviorally, and restore the individual’s ability to engage in rehabilitation and ongoing recovery supports in the least restive setting.

d. Treatment at the Contractor’s facility will be effective, responsive, individualized, and focused on maintaining the least restrictive environment.

e. Treatment and care are delivered through a comprehensive treatment plan that promotes recovery of independence and self-sufficiency, establishes relapse prevention or recovery management plans, and utilizes culturally competent treatment.

f. Treatment and care must be delivered in a way that does not violate client rights, and the Omnibus Rule.

g. The Contractor will submit to the Center an invoice of itemized services rendered, including the number of detoxification and/or rehabilitation bed days, and any other required documentation of services.

h. All admissions, discharges, and transfers must include a warm handoff process. The Center’s designated Substance Use Disorder (SUD) Case Manager will coordinate with Contractor staff to ensure continuity of care, direct provider-to-provider communication, and linkage back to Center outpatient, case management, or recovery support services following detoxification and/or rehabilitation.

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3. Definitions Regarding Services,

a. Impatient Detoxification and/or Residential Rehabilitation Services provide individuals with 24-hour structured care including medical monitoring, professional supervision, and behavioral health treatment in a safe and supportive environment.

These services are designed to manage withdrawal symptoms, stabilize individuals, and support their recovery from substance use disorders.

b. The Contractor must ensure that all staff, licensed providers, and facilities delivering detoxification and/or residential rehabilitation services meet all applicable licensing, certification, and regulatory requirements as outlined by Texas Health and Human Services and relevant state laws.

c. The Contractor’s staff will deliver intensive, evidence-based interventions focused on the safe management of withdrawal symptoms, stabilization of the individual, and preparation for continued care in outpatient or community-based settings.

d. Services must be individualized, trauma-informed, and recovery-oriented, emphasizing the least restrictive environment appropriate to the individual's needs, with attention to medical and behavioral health needs, as well as cultural competency.

e. Treatment and care will be guided by comprehensive, person-centered treatment plans that promote recovery, foster independence, incorporate relapse prevention strategies, and facilitate connection to ongoing care or sober living supports when applicable.

f. All services must uphold client rights, privacy, and confidentiality in compliance with applicable laws and regulations, including HIPAA and data use agreements.

g. The Contractor must submit itemized invoices of services rendered, including number of inpatient detox and/or residential days provided, types of services, and any other documentation required by the Grant Agreement.

4. Intended Service Recipients,

a. The Contractor must accept individuals who are presenting both voluntarily and through referral from the Center.

b. The Contractor will not be required to admit:

i. Individuals who have an unstable medical condition of a non-SUD nature that cannot be managed by routine physician services, and

ii. The Center’s referrals that do not otherwise meet the Contractor’s admission requirements.

c. Services provided for SUD detoxification and/or rehabilitation are limited to individuals that meet HHSC eligibility criteria, including priority populations such as:

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i. Youth ages 13-17, adults, pregnant women, and parenting women with dependent children,

ii. Individuals at high risk of overdose, those referred by DFPS, or those experiencing homelessness/housing instability,

iii. Individuals referred through direct admission pathways, and

iv. Admitted into the Contractor’s facility pursuant to applicable provisions of

Tex. Health and Safety Code governing licensed SUD treatment facilities (§§ 464, 466, 448).

5. Specifications Of Standard Services,

a. All examinations and evaluations must be in accordance with,

i. Federal/State/Local/Center Guidelines, which govern the operation of the facility,

ii. all policies, procedures, and standards as required by licensing or accrediting institutions that cover the facility, and

iii. all written procedures of the facility.

b. The Contractor will provide “SUD Detoxification and/or Rehabilitation Services” to individuals referred to the Contractor by the Center. Services include, but are not limited to:

i. a physician or qualified provider on the Contractor’s medical staff must perform a face-to-face substance use disorder diagnostic evaluation and withdrawal management assessment of the individual as soon as possible, and not more than twenty-four (24) hours after the individual is admitted.

ii. a physician or advanced practice nurse must perform a face-to-face preliminary medical examination to determine appropriateness for detoxification and/or rehabilitation as soon as possible, and not more than twenty-four (24) hours after admission.

iii. twenty-four (24) hour medical components including,

1) nursing staff (RN's and/or LVN's under supervision of a full time RN), and

2) on-call psychiatrist/physician coverage,

iv. Medical monitoring by a physician or advanced practice nurse with expertise in withdrawal management and SUD care.

v. Ongoing clinical monitoring by nursing and treatment staff.

vi. Medication-Assisted Treatment (MAT) or other clinically appropriate medications prescribed by a physician/advanced practice nurse, if clinically indicated and accepted by the person being served.

vii. Medication monitoring and withdrawal symptom tracking by qualified nursing staff.

viii. Routine laboratory services.

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x. Private or semi-private room affording appropriate privacy while permitting immediate staff access for safety.

xi. Individual, group, and family counseling (as applicable).

xii. Recovery-oriented skills building (as applicable).

xiii. Youth-specific engagement strategies (as applicable).

xiv. Transportation of individual (required).

c. When working with individuals, the Contractor will develop a comprehensive treatment plan that utilizes effective, responsive, individualized, culturally competent/appropriate, and least restrictive treatment that includes, but is not limited to,

i. interdisciplinary, goal directed, and evidence-based treatment,

ii. Relapse prevention planning and recovery management strategies.

iii. a promotion of recovery, independence, and self-sufficiency,

iv. communication that facilitates the exchange of information,

v. treatment that guarantees comprehensive client rights consistent with the Joint

Commission’s requirements,

vi. a reasonable and appropriate discharge plan, jointly developed by SUD Leadership and Contractor.

vii. if telemedicine/telepsychiatry services are utilized, they must be provided in accordance with Federal/State/Local/Center Guidelines, and the facilities policies and procedures.

d. The Contractor must demonstrate efforts to reduce trauma, relapse, and emergency medical transfers by adopting the following tools:

i. assessing risk factors for withdrawal complications,

ii. assessing trauma history,

iii. determining relapse and treatment history.

iv. making environmental changes, to include,

1) comfort rooms,

2) sensory rooms, and

3) any other meaningful clinical interventions that assist people in emotional self-management

4) using de-escalation techniques, and

5) using safety survey

e. The Contractor agrees to optimize earned revenues and ensure best cost value through coordination of insurance benefits and third-party revenues.

6. Communication Requirements,

a. All clinical paperwork, reports for admission, reports for discharge, and any other miscellaneous items required for authorizing an individual', must be communicated to the

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Center in a thorough, professional, and timely manner that guarantees an individual’s client rights and is also compliant with the Omnibus Rule and other Federal/State/Local/Center Guidelines regarding PHI.

b. The Contractor's staff must report to Center Staff all changes in treatment needs for an individual referred to the Contractor by the Center that include any treatments other than what has been preauthorized for the individual.

i. Report must be made within twenty-four (24) hours of change, or by the close of business on the next Center business day.

1) Failure to report changes in treatment within the above timeframe will result in withholding payment for services provided before authorization for treatment changes were given.

c. Center Staff must be informed of any pertinent information as it relates to the ability of the Contractor to care for individuals referred to the Contractor by the Center and covered by this Agreement.

i. Report must be made within twenty-four (24) hours of change, or by the close of business on the next Center business day.

1) Failure to report pertinent information within the above timeframe will result in the withholding of payment for services covered by the information.

d. The Contractor must provide Center Staff with reasonable and timely telephone access to all Contractor staff responsible for the care of individuals admitted to the Contractor's facility under this Agreement.

e. The Contractor must notify the Center within one (1) hour of any major safety incidents involving individuals referred by the Center, including the death of an individual.

f. The Contractor must report allegations of abuse/neglect within one (1) hour to the Texas Abuse Hotline, in compliance with HHSC and DFPS requirements.

g. The Contractor must provide the following numbers as needed to provide to the state,

i. Detox completion per quarter,

ii. Rehabilitation completion per quarter,

iii. Individuals served per quarter,

iv. MAT initiations per quarter,

v. Warm handoffs completed per quarter,

vi. Relapse prevention plans completed per quarter, and

vii. Aftercare linkages completed per quarter.

7. Pre-Authorization, Pre-Admission, and Admission,

a. The Contractor must ensure that the facility and needed staff can be accessed for emergency admissions twenty-four (24) hours per day, seven (7) days per week.

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b. The individual must be admitted to the Contractor’s facility for an authorization period not to exceed seven (7) days for detoxification and/or rehabilitation, unless otherwise authorized under HHSC guidelines.

c. The Contractor must have a physician’s/advanced practice provider’s written order to admit an individual.

i. The examining physician/advanced practice provider must document appropriateness for detoxification and/or rehabilitation according to Tex. Health and Safety §§ 464, 466, and 448.

ii. Failure to accomplish these requirements will result in withholding payment for services related to individual’s admission.

d. The Center can secure appropriate transportation for any individuals needing treatment.

8. Detoxification and/or Rehabilitation Services

a. Medical and Behavioral Examination

i. a physician or advanced practice provider must examine the admitted individual within 24 hours to access withdrawal management, stabilization, and rehabilitation needs.

ii. Diagnostic evaluation must include substance use history, withdrawal risk, medical history, co-occurring mental health conditions, DSM-5 SUD diagnosis, relapse risk, and recovery supports.

iii. The examining provider must issue a written treatment plan and medical necessity documentation to support the course of detoxification and/or rehabilitation.

b. Comprehensive Intake Examination

i. a physician or advanced practice nurse will conduct a face-to-face medical history evaluation upon admission.

ii. a physical exam will be conducted to confirm medical stability for detoxification/rehabilitation and to identify any acute conditions requiring outside treatment.

c. If the individual is not stable for discharge on the previously planned discharge date, the Contractor must consult with SUD Leadership for the authorization of additional days.

i. Additional days can be approved or denied based on clinical need.

ii. The Contractor will submit the Center’s authorization form for additional days by

12:00 PM on the last day of coverage

iii. Requests for clinical clarification must be returned within twenty-four (24) hours.

9. Discharge,

a. Discharge planning must be initiated immediately upon admission and must continue throughout the individual’s stay.

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b. Discharge planning must include the Contractor’s staff, SUD Leadership, the individual, and the individual’s family (if family is applicable), and the SUD Case Manager.

c. The written discharge plan must include,

i. a list of all medications prescribed during hospitalization to include quantity, refills, frequency, and dosages,

ii. the name of the entity responsible for payment of individual’s medication,

iii. for individuals on MAT, the dose and date of the last injection given during hospitalization, and the dose and date for the next injection due,

iv. the date of a scheduled aftercare appointment with the Center, and

v. A transportation and warm handoff plan to ensure direct provider-to-provider communication and continuity of care.

d. The Contractor must consult with SUD Leadership when the individual has achieved the maximum benefit. If the individual stabilizes early, discharge should occur with coordination.

e. Required discharge documentation includes:

i. Discharge summary,

ii. Medical history and physical exam,

iii. SUD evaluation,

iv. Lab results,

v. Written discharge plan.

f. The Contractor must provide prescriptions for medications up to 30 days post-discharge when medically appropriate.

g. If discharge occurs outside of business hours, the Contractor must notify the Center’s on-call staff and connect the individual with aftercare schedule.

h. Not applicable – instead, releases with be managed under HHSC guidelines for voluntary SUD treatment, DFPS or justice referrals, and program completion/termination protocols.

10. Transfer Of an Individual,

a. The Contractor must consult with SUD Leadership when unable to provide the least restrictive or most appropriate environment, so transfer can be coordinated.

b. Transfers may include step-down to outpatient, IOP, or other facilities as clinically indicated.

c. The Contractor must assist individuals experiencing acute medical conditions with emergency transfers under EMTALA.

11. Procedures For Compliance and Center Monitoring, Commented [JP1]: Duplicate phrase as above, is this intentional?

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a. Pursuant to Tex. Health and Safety Code § 534.060, the Contractor agrees to allow unrestricted access by the Center, HHSC, auditors, and other authorized agencies to facilitates, data, and information necessary for audits, monitoring, and reviews.

b. Compliance Program,

i. The Contractor acknowledges awareness of the Center’s compliance program and agrees to abide by it.

ii. The Contractor acknowledges receipt of the Center’s Code of Conduct and participation requirements.

c. Quality Management and Monitoring,

i. The Contractor agrees to conduct quality management activities, including satisfaction surveys,

ii. To comply with utilization management requirements,

iii. To comply with the Center’s monitoring procedures, including submission of reports and data.

d. When Center Staff visit individuals on-site:

i. Staff must sign in/out,

ii. Visits must be scheduled through the therapist or case manager,

iii. Staff must be escorted unless the individual requests a private meeting. In such cases, a private office must be provided.

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Attachment A Denton County MHMR Center Rates

The per diem rate shall begin at the same time as the client is admitted with preauthorization only into the Contractors(s) hospital/facility and shall end when client is dismissed. Payment will be made after services have been rendered and after medical billing has been pursued and is not applicable and cannot be recouped.

The Center will pay for specified services as written and documented in a contract agreement, at a negotiated daily per diem rate. All services and products rendered under contract to the Center must be preauthorized in writing by the Center, or the Center will not assume responsibility in the payment or collection of such services.

A contract provider must invoice the Center only one time per calendar month and each invoice must be accompanied by supporting documentation as required by the Center. The Center reserves the right to withhold any payments to contractor until services are completed to the satisfaction of the Center.

Treatment Type – Adult

Adult Residential Intensive Service $120.72 per day

Adult Residential Detoxification Service $237.01 per day

Treatment Type – Specialized Female

Adult Specialized Female (Woman w/ Children) Residential Intensive $233.82 per day Adult Specialized Female Residential Detoxification Service

$238.75 per day

Treatment Type – Youth

Youth Residential Intensive Services $197.04 per day

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General Definition of Services Substance Use Disorder (SUD) Inpatient Services include medically supervised Detoxification (ASAM Level 4.0 or 3.7) and clinically managed Residential Rehabilitation (ASAM Level 3.5 or above). These services are provided in licensed facilities operating twenty-four hours per day, seven days per week, under the supervision of a licensed physician, and staffed in accordance with the requirements of 25 TAC Chapter 448.

All services must be person-centered, trauma-informed, culturally competent, and designed to promote stabilization, engagement in recovery, and transition to the next appropriate level of care.

TRA – Treatment for Adults Adult Residential Detoxification Service Rate- $237.01 per day Detoxification for adults provides medically monitored withdrawal management for individuals aged 18 and older who meet ASAM criteria for Level 4.0 or 3.7.

Services include:

A. A medical and psychosocial assessment within twenty-four hours of admission.

B. Withdrawal management and stabilization under physician supervision.

C. Medication-Assisted Treatment (MAT) or other clinically appropriate medications when indicated.

D. Continuous nursing assessment and monitoring of withdrawal symptoms.

E. Individual and group counseling focused on engagement and motivation for continued treatment.

F. Coordination of discharge and transition to residential or outpatient treatment.

Adult Residential Intensive Service Rate- $120.72 per day Residential rehabilitation for adults provides structured, twenty-four-hour treatment for individuals requiring ASAM Level 3.5 or higher care.

Services include:

A. Individualized treatment planning and clinical assessment within twenty-four hours of admission.

B. Individual, group, and family counseling utilizing evidence-based approaches.

C. Recovery skills, relapse prevention, and life skills development.

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D. MAT continuation when clinically indicated.

E. Coordination with the LMHA for aftercare and recovery support linkages.

F. Discharge planning consistent with HHSC and ASAM guidelines.

TRY – Treatment for Youth Youth Residential Intensive Services Rate- $197.04 per day Residential rehabilitation for youth provides ASAM Level 3.5 or higher treatment in a trauma-informed, family-centered environment.

Services include:

A. Biopsychosocial assessment and treatment planning involving family participation.

B. Individual, group, and family therapy focused on recovery and resilience.

C. Coordination with educational services to maintain academic progress.

D. Developmentally appropriate relapse prevention and life skills training.

E. Ongoing family engagement and transition planning to LMHA/community-based supports.

TRF – Treatment for Specialized Female Adult Specialized Female Residential Detoxification Service Rate- $238.75 per day Detoxification for women and parenting individuals provides medically supervised withdrawal management under ASAM Level 4.0 or 3.7, with additional focus on family safety and maternal health.

Services include:

A. Medical stabilization under physician supervision.

B. MAT or other appropriate medications prescribed by a physician or advanced practice provider.

C. Nursing monitoring and symptom management.

D. Counseling and case management addressing family needs, pregnancy, or childcare coordination.

E. Linkages to residential rehabilitation, housing, or wraparound recovery supports following discharge.

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Adult Specialized Female (Woman with Children) Residential Intensive Rate- $233.82 per day Residential rehabilitation for women and parenting individuals provides ASAM Level 3.5 or higher care in a gender-responsive, trauma-informed environment emphasizing family preservation.

Services include:

A. Comprehensive assessment and individualized treatment planning addressing parenting and family stability.

B. Individual, group, and family counseling integrating trauma recovery and relapse prevention.

C. Parenting education, life skills, and case management.

D. Coordination of childcare, visitation, and family reunification as applicable.

E. Discharge and aftercare planning that connect individuals to LMHA/ongoing supports.

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ATTACHMENT B

Application

Substance Use Disorders Services RFA – Provider Application

Application Section Applicant Instructions:

Please indicate the service or services for which you are applying by checking the appropriate box or boxes below. Applicants may select one or multiple service categories consistent with their licensure and service capacity.

Substance Use Disorder (SUD) Inpatient Services – Open Enrollment

[ ] TRA – Inpatient Detoxification (Adult) [ ] TRA – Inpatient Rehabilitation (Adult) [ ] TRY – Inpatient Detoxification (Youth) [ ] TRY – Inpatient Rehabilitation (Youth) [ ] TRF – Inpatient Detoxification (Female/Parenting) [ ] TRF – Inpatient Rehabilitation (Female/Parenting)

GENERAL INFORMATION:

Organization/Individual Name: _____________________________________________ DBA: ______________________________Federal Tax ID #____________________________ Agency NPI Number: ______________________ Business Address: ____________________

Contact/Title: _____________________ Email Address: _____________________ Address: _____________________Phone: ___________________Fax#: ____________

Executive Director-Owner/Title: _____ ______Email Address: _______________ Address: _____________________Phone: ___________________Fax#: _____________

Service Contact/Title: _____________________Email Address: _____________________ Address: _____________________Phone: ___________________Fax#: _______________

Billing Contact/Title: _____________________Email Address: _____________________ Address: ____________________Phone: ___________________Fax#: ______________

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Business locations in this market area:

Street City County Zip Code 1.__________________________________________________________________________ 2.__________________________________________________________________________ 3.__________________________________________________________________________ 4.__________________________________________________________________________

Indicate if you provide any of the following:

1. TTY/TTD (Hearing Impaired Services/Capabilities □Yes □ No

2. American Sign Language □Yes □ No

3. Handicap Accessible □Yes □ No

4. Public Transportation Access □Yes □ No

5. Bilingual Services (please list below) □Yes □ No

Is the business owner a current or former DCMHMR board member or employee? □Yes □ No Is the business owner related to a current DCMHMR board member or employee? □Yes □ No If yes, who: __________________ Owners/Partners:

Name % Ownership If corporate, list Organization 1.__________________________________________________________________________ 2.__________________________________________________________________________ 3.__________________________________________________________________________ 4.__________________________________________________________________________

Type of organization (i.e., non-profit corporation, limited liability company, general partnership, etc.): _______________________________________________________________________

Certification Number if a Historically Underutilized Business (i.e., Women Owned Business, Minority Owned Business): ______________________, or qualifications if HUB eligible, but not certified: ________________________________

FINANCIAL

Is the organization/provider incorporated as “Profit,” “Not for Profit,” or “Other”?

(If it is a Not for Profit, attach a valid 501C IRS Exemption Form)

Provide name of Workers’ Compensation carrier if organization has Workers' Compensation

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Has the organization/provider declared any type of bankruptcy in the prior seven (7) years?

Has the organization/provider received a "qualified" opinion on a financial statement in the past three (3) years? _______If yes, please explain:

Is the organization/provider currently under investigation, or have a license or accreditation revoked by any state/federal/DCMHMR or licensure agency, within the last five (5) years If yes, please explain:

Has the organization/provider had any judgments or settlements against it within the last ten (10) years? __________ If yes, please explain:

Has the organization/provider been placed on "vendor hold" by any agency or government? If yes, please explain:

SERVICES

Will the Hospital have qualified staff available to administer medications or to supervise individuals in the self-administration of medication?

How many individuals can the hospital serve?

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Are there any restrictions on who the hospital will serve?

How long do people currently have to wait to get into the hospital’s services?

Describe the frequency and type of in-service training currently offered by the Proposer or provided to employees including, but not limited to, training related to patient rights and standards of services.

Describe the Proposer’s ability to work with persons who are hearing impaired, persons who have limited language skills and persons who speak a language other than English. Describe how the Proposer ensures cultural competency on the part of staff with regard to ethnic, racial, religious, and sexual orientation differences. Include how you will meet the cultural and linguistic needs of the consumers in the Center's local service area.

Describe or attach policies and procedure which describe any process the Proposer presently has to receive communication from clients, family members and advocates, and to receive and resolve complaints and grievances.

Describe the facility(ies) proximity to public transportation or the Proposer’s ability to facilitate access to public transportation.

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Describe where and when you will provide Services within the Center's local service area, and how persons with disabilities will be able to access those Services.

RISK ASSESSMENT

Describe the process, if any, the organization/provider uses to check on previous convictions of employees. Describe or attach any policies and procedures regarding the hiring of a retention of people with criminal histories:

Has the organization/provider or its employees had any validated client abuse, client neglect, or rights violations claims in the last three (3) years? If yes, explain in detail:

Describe or attach any current policies and procedures regarding client abuse, client neglect, or rights violations and the training of staff in these issues:

Does the organization/provider currently have any malpractice claims pending or closed during the past five (5) years? ________ If yes, please supply the following information:

1. Letter from your attorney explaining the facts of the case.

2. Copies of the complaint and judgment

3. Name of malpractice carrier that handled the claim and firm representing the carrier.

QUALITY MANAGEMENT/UTILIZATION MANAGEMENT

List all licenses, credentials, certifications, and/or accreditations the Proposer currently holds related to the Services. Provide copies of all licenses, certifications, accreditations.

Describe the Proposer’s internal utilization management procedures. Describe methods for ensuring that individuals are receiving services in accordance with internal standards of care.

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Provide copies of recent reports to payors showing the Proposer’s performance relative to its utilization management requirements.

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Attachment C

ATTESTATION

Are there any reasons you would be unable to perform the essential functions required with or without accommodation?

꙱ Yes, if yes, please explain on a separate sheet ꙱ No

I hereby attest to the following:

I do not currently use any illegal drug.

I have reported accurately and completely any reason(s) for any inability to perform the essential functions required with, or without, accommodation.

I have reported accurately any history of felony convictions or client abuse and neglect.

I have reported accurately any chronological work history.

I consent to the inspection of records and documents pertinent to this Application, including the release by any person to Denton County My Health My Resources Center, dba Denton MHMR Center (the Center) of all information that may reasonably be relevant to an evaluation and verification of this Application or evaluation of professionals or institutions with which Organization/Individual has been or is currently associated.

The information submitted in and with the application is complete and correct to the best of my knowledge.

Signature of Individual or Organization’s Authorized Representative

Date

Printed Name

Title (if applicable)

Organization/Program Name (if applicable)

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Attachment D

GENERAL AUTHORIZATION FOR RELEASE OF INFORMATION

I, the undersigned Individual, or authorized representative of Organization (acting on Organization’s behalf), hereby authorize Denton County My Health My Resource Center dba Denton County MHMR Center (The Center) to obtain any and all information required to complete a review and primary source verification of Organization/Individual’s credentials. Information and documents to be reviewed include, but are not limited to, licensure/certification, accreditations, education, and claims made against licensure/certification, malpractice insurance and claims.

I, the undersigned Individual or authorized representative of Organization, hereby release from liability and hold harmless for the consequences of any disclosure, to the fullest extent permitted by law, the named references in this Application and Denton County My Health My Resource dba Denton County MHMR Center (The Center) for their written and oral statements, decisions, and actions in connection with evaluating Organization/Individual’s Application for network approval including, without limitation, Organization/Individual’s experience, competencies and qualifications, health status, emotional stability, professional ethics, and character. Organization/Individual hereby releases from liability any and all individuals and organizations reviewing this Application for their acts performed in good faith and without malice in connection with evaluating this Application and the credentials and qualifications.

Organization/Individual also released from any liability any and all individuals and organizations who provide information in good faith and without malice concerning the above release items.

A photostat, electronic or facsimile copy of this original statement constitutes Organization/Individual’s written authorization and requests to release any and all documentation relevant to Denton County My Health My Resource Center dba Denton County MHMR Center credentialing and/or network approval process. Such photostat, electronic or facsimile copy shall have the same force and effect as the signed original.

Signature of Individual or Organization’s Authorized Representative

Date

Printed Name

Title (if applicable)

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Attachment E

ASSURANCES DOCUMENT

Applicant assures the following:

1. That all addenda and attachments to the Application as distributed by MHMR have been received.

2. No attempt will be made by the Applicant to induce any person or firm to submit or not to submit an

Application, unless so described in the response document.

3. The Applicant does not discriminate in its services or employment practices based on race, color, religion, sex, national origin, ethnicity, disability, veteran status, or age.

4. That no employee of Denton County MHMR and/or no member of Denton County MHMR’s Board of Trustees will directly or indirectly receive any pecuniary interest from an award of the proposed contract. If the applicant is unable to make the affirmation, then the applicant must disclose any knowledge of such interests.

5. All cost and pricing information is reflected in the Application response document or attachments.

6. Applicants accept the terms, conditions, criteria, and requirements set forth in the Application.

7. Applicants accept Denton County MHMR’s right to cancel the Application at any time prior to contract award.

8. Applicant accepts Denton County MHMR's right to alter the timetables for procurement as set forth in the Application.

9. The application submitted by the Applicant has been arrived at independently without consultation, communication, or agreement for the purpose of restricting competition.

10. Unless otherwise required by law, the information in the application submitted by the Applicant has not been knowingly disclosed by the Applicant to any other Applicant(s) prior to the notice of intent to award.

11. No claim will be made for payment to cover costs incurred in the preparation of the submission of the application or any other associated costs.

12. Denton County MHMR has the right to complete background checks and verify information.

13. The individual signing this document and the contract is authorized to legally bind the Applicant.

14. The address submitted by the Applicant to be used for all notices sent by Denton County MHMR is current and correct.

Signature of Authorized Representative Title (if applicable) Date

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Attachment F

CERTIFICATION REGARDING LOBBYING, GRANTS, LOANS, &

COOPERATIVE AGREEMENTS

The undersigned certifies, to the best of his or her knowledge and belief that:

1. No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or an employee of any agency, a member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement.

2. If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress an officer or employee of Congress or an…