DMHAS Fee-For-Service Network
Contract Enrollment Application FY 2014
Part I
AGENCY ADMINISTRATIVE INFORMATION
CONTRACT APPLICATION SIGNATURE PAGE
AGENCY NAME:
ADMINISTRATIVE ADDRESS:
CITY: STATE: ZIP: -
COUNTY:
TELEPHONE NUMBER: () ext
FAX NUMBER: () ext
FEDERAL TAX ID #:
(Will be confirmed upon submission of required contract application documents)
ADMINISTRATIVE CONTACT:
NAME:
TITLE:
EMAIL ADDRESS:
SIGN NAME:
PRINT NAME:
TITLE:
DATE:
Part II
Agency-Specific Information (Attachments I-VII)
I. “Agency-Specific Information Attachment I – Evidence-based Practices” (20 point maximum)
DMHAS encourages agencies to utilize evidence-based practices that are well-supported by research evidence with outcomes that are reliable, valid, and provide transparency to assure that techniques and procedures will provide the best possible interventions or treatment. Please provide a list of evidence-based practices that your agency has implemented or plans to implement. Describe how the agency has implemented or plans to implement these practices and their impact or expected impact on consumer outcomes (500 words maximum).
II. “Agency-Specific Information Attachment II – Policy and Procedure Regarding
Availability of Public Funding and Alternatives” (10 points maximum)
Acceptance into the DMHAS FFS networks does not ensure funds are available for all consumers who meet income eligibility and clinical eligibility for services. In addition, during SFY 2011, SFY 2012 and SFY 2013, the DMHAS non-criminal justice initiatives (Driving Under the Influence (DUII), Medically Assisted Treatment (MATI) and South Jersey (SJI) have managed new consumer enrollment to ensure that resources are available for existing consumers to complete care. Please provide a copy of the agency’s policy and procedure to advise consumers of available public funding options and alternatives when public funds are not available.
III. “Agency-Specific Information Attachment III – Policy and Procedure Regarding
Consumer’s Taking Physician- Prescribed Medications” (20 points maximum)
All DMHAS FFS network agencies are required to support any and all consumers who are referred to or present for admission at the agency who take legitimately prescribed medications including medications for the treatment of opioid dependence. Please provide a copy of the agency’s policy and procedure regarding support for consumers who are taking physician-prescribed medications. If the policy includes referral to another agency for these services, the policy must include specific details regarding the referral process.
IV. “Agency-Specific Information Attachment IV – Sample Treatment Plan” (25 points maximum)
Please provide a sample treatment plan that includes identified problems, related goals, specific objectives to meet the identified goals, and concrete and measurable actions on the part of the counselor and the consumer to achieve the objectives. The sample treatment plan should be an actual treatment plan with consumer identifiers removed and must include a section for consumer signature.
V. “Agency-Specific Information Attachment V – Utilization Rate Performance Criterion” (25 points maximum)
The agency’s utilization rate is a performance criterion that reflects treatment engagement and retention rates, which are correlated with improved consumer treatment outcomes. Please provide a narrative (500 words or less) that describes your agency’s process to monitor its utilization rates, manage FFS authorizations and efforts to improve consumer engagement and retention in treatment.
Agency-Specific Information (Attachments I-VII)
Part II (continued)
VI. “Agency-Specific Information Attachment VI – Consumer Sliding Fee Scale”
Please attach a copy of the agency’s board-approved “Consumer Sliding Fee Scale Policy and Procedure.” Note that consumer fees may not be charged in the Drug Court and MAP-SPB initiatives. The sliding fee scale must start at “zero.”
VII. “Agency-Specific Information Attachment VII – 211 Affiliation Agreement”
Please attach a copy of the agency’s executed 211 Affiliation Agreement. Please be sure the contact information on the agreement is accurate. (Note: If the agency participates ONLY in the MAP-SPB network, an affiliation agreement is not required. The agency may submit a statement attesting to its participation in the MAP networks ONLY in lieu of a 211 affiliation agreement.)
Part III
Site Specific Information -Submission of Staff Information
DMHAS has developed the Clinician Roster Information System (CRIS) a web-based application for the collection of medical and clinical staff information for licensed substance abuse providers. All contractees will be expected to enter clinical and medical staff information into the web-based application. DMHAS will review individual site entries. If providers do not meet licensing requirements for individual sites, the application will not be reviewed.
Part IV
Initiative-Specific Information
1. “DUII – Driving Under the Influence Initiative”
Agencies applying for Enrollment in the DUII must have a current IDRC Affiliation Agreement on file for each participating network site. (Note: Agencies must have a FY 2014 IDRC Affiliation Agreement confirmed for each site). In addition: If approved, agencies enrolling in the DUII must submit an application to enroll in the DMHAS Co-Occurring Network within 60 days of their FFS contract approval.
2. “MATI – Medication-Assisted Treatment Initiative”
Network is open to residential providers statewide, and Ambulatory providers located in Camden or Mercer Counties. If approved, agencies enrolling in the MATI must submit an application to enroll in the DMHAS Co-Occurring Network within 60 days of their FFS contract approval.
3. “DCI – Drug Court Initiative”
Information submitted by agencies will be forwarded to the Administrative Office of Courts (AOC).
a. Agencies applying for Enrollment in the DCI are required to notify DMHAS and the referring Drug Court in writing of consumers’ program admission denials which includes referrals to a more suitable level of care. Please attach a copy of the agency’s Board-approved policy and procedure regarding admission denials labeled “Drug Court Admission Denials Policy.”
b. Agencies must provide an orientation on Drug Court mandates to all non-clinical staff that have contact with Drug Court consumers. Please attach a copy of the agency’s board-approved policy and procedure regarding non-clinical staff orientation to the Drug Court program and mandates labeled “ Drug Court Non-Clinical Staff Orientation Policy. “
c. Agencies are required to notify the referring Drug Court and DMHAS regarding consumer non-adherence to treatment and Drug Court program requirements within 2 hours of any relevant incident and report immediately when a consumer absconds. Please attach a copy of the agency’s Board-approved policy and procedure regarding Drug Court non-adherence to program requirements and client absconding labeled “Drug Court Program Non-Adherence and Consumer Abscond Reporting Policy.”
4. “MAP-DOC – Mutual Agreement Program – State Parole Board”
Information submitted by agencies will be forwarded to the State Parole Board (SPB).
a. Agencies applying for Enrollment are required to provide the name of the staff person responsible for coordinating MAP-SPB services and who serves as a liaison to the MAP-SPB and the DMHAS MAP Coordinator regarding all MAP-SPB issues. Please attach a document that includes the MAP-SPB liaison’s name, job title, phone number, fax number, and email address labeled “MAP-SPB Liaison Contact Information”.
b. Agencies applying for Enrollment are required to notify SPB of any incidents such as parolee absconding or any disciplinary action that requires parolee to be removed from the program. Written notification shall be provided to the SPB including a copy of the incident report. Please attach a copy of the agency’s board-approved policy and procedure regarding MAP-SPB non-adherence to program requirements that may result in a discharge labeled “MAP-SPB Program Non-Adherence Reporting Policy.”
5. “SBIRT – Screening, Brief Intervention & Referral to Treatment” Initiative
Agencies applying for Enrollment in the SBIRT Network must be licensed for OP and/or IOP services, and must be located in Mercer County. Agencies must enter into an Affiliation Agreement with the Henry J. Austin Federally Qualified Health Center, a copy of which must be submitted to the DMHAS, Office of Care Management.
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