ADMINISTRATIVE OVERVIEW

SERVICE SPECIFIC ATTACHMENT

Behavioral Health Services

  1. Please include written verification that your agency has a contract with MassHealth.

(If you do not contract with MassHealth, your agency is not eligible to apply to contract for these services.)

B.What are the days and hours of operation at your community mental health (CMHC) center?

Sunday / Monday / Tuesday / Wednesday / Thursday / Friday / Saturday
AM / AM / AM / AM / AM / AM / AM
PM / PM / PM / PM / PM / PM / P PM M
Emergency, evening, and weekend hours of operation, if applicable:

C.Are there specific towns to which you provide service? If yes, please describe.

Please complete Town Coverage form.

D.What are the qualifications of the individuals(s), employed by your CMHC, who are responsible for developing a plan of care?

E.Do you have the capacity to provide all of the services listed below?

Diagnostic Services Yes No

Individual Therapy Yes No

Couples/Family Therapy Yes No

Group Therapy Yes No

Case Consultation Yes No

Emergency Services Yes No

Re-evaluation Yes No

F.Please describe your quality assurance program/system:

Note regarding Rates: The authorized rates for mental health services provided to our agency are established by the Division of Health Care Finance & Policy (114.3 CMR 6.00). If the consumer has other insurance, we may pay the consumer’s co-pay in lieu of the MassHealth rate if the provider prefers to third party bill.

12-17-20131

SERVICE SPECIFIC ON-SITE REVIEW

Behavioral Health Services

Please note the documents and records that will be required for the client files and/or employee files to be reviewed at the time of on-site evaluation.

Employee Records Review
Provider: ______
Date: ______
Monitor: ______
Start Date
Termination Date
Number of reference checks
Physicals: Date
TB: Date
Orientation: Date
Job Description(s)
Ongoing training: Dates
Annual Performance
Appraisal: Date
CPR/First Aid: Dates
Licenses
CORI Check
Comments

Behavioral Health Services

Please note the documents and records that will be required for the client files and/or employee files to be reviewed at the time of on-site evaluation.

Client Records Review
Provider: ______
Date: ______
Monitor: ______
Current Authorization in file
ID Info: Name, address, phone, DOB
Emergency Contact(s):
Name and phone
Physician(s) name and phone
Hospital name and phone
Medical/social diagnosis
Name of current CM/RN
Service start date
Termination date
Source of referral
Date of referral
Service plan
Comments

12-17-20131