NJ Screening, Brief Intervention and Referral to Treatment (SBIRT)
Specialty Treatment FFS Network
Provider Affiliation Agreement
between
Henry J. Austin Health Center, Inc.Treatment Agency Name
321 N. Warren StreetAddress
Trenton, NJ 08618andCity, NJ zip
Main (609) 278-5900Telephone
Administration (609) 989-3599Fax
Fax (609) xxx-xxxx
Beginning April xx, 2013, it is agreed that the above named treatment agency will acceptreferrals of SBIRTconsumers from the Henry J. Austin Health Center, Inc. (HJA) during regularly scheduled hours of operation. SBIRT consumers will be referred by HJA from any of the five SBIRT project sites listed below:
321 N. Warren St., Trenton(insert hours of operation)
112 Ewing St., Trenton(insert hours of operation)
317 Chambers St., Trenton(insert hours of operation)
433 Bellevue Ave., Trenton(insert hours of operation)
601 Hamilton Ave., Trenton(insert hours of operation)
Designated HJA staff from any of the five SBIRT project sites will facilitate a “warm hand-off” to the treatment agency on behalf of the SBIRT consumer. The treatment agency agrees to cooperate with designated HJA staff in scheduling intake appointmentson behalf of the SBIRT consumer. At the time of intake, the treatment agency will complete income and program eligibility determinations, and level of care determinations on all referred SBIRT consumers using the NJSAMS DASIE Plus and LOCI.
The treatment agency will request service authorizations, as appropriate for all SBIRT consumers determined as needing outpatient or intensive outpatient levels of care(ASAM Level I or Level II.1). Federal funding for treatment services under the NJ SBIRT FFS Initiative provided to SBIRT consumers may be accessed as the payer of last resort.
The roles and responsibilities of each of the parties are as follows:
HJA will:
- Obtain and maintain authorization of patient consent for records release/exchange prior to contacting the treatment agency on behalf of SBIRT consumers
- Contact the treatment agency by phone during regularly scheduled hours of operation to arrange for an intake appointment on behalf of SBIRT consumers
- Arrange to transport SBIRT consumers to their initial intake appointment at treatment agency
- Routinely verify the referral status of SBIRT consumers via the NJSAMS SBIRT module
- In the event the referral status is delayed or incomplete, HJA will follow-up by telephone call to the treatment agency to ascertain the disposition of the referred SBIRT consumer
Treatment agency will:
- Accept direct, facilitated referral of SBIRT consumers from any of the five listed SBIRT project sites during regularly scheduled hours of operation
- In cooperation with designated HJA staff, schedule intake appointments for SBIRT consumers within reasonable timeframes
- Complete income and program eligibility determinations, and level of care determinations on all referred SBIRT consumers using the NJSAMS DASIE Plus and LOCI
- Only request authorization for services provided to eligible consumers through the NJ SBIRT FFS Initiative when no other payer is available
- Accept payment for services authorized through the NJ SBIRT FFS Initiative as payment in full
- If the treatment agency cannot/fails to admit the SBIRT consumer for treatment services, reasons must be documented in the NJSAMS
- If the treatment agency admits an SBIRT consumer for outpatient or intensive outpatient services (ASAM Level I or Level II.1),FFS authorizations must be requested in accordance with Division of Mental Health and Addiction Services(DMHAS) FFS contract specifications
- If the treatment agency determines an SBIRT consumer needs a level of care other than outpatient or intensive outpatient services (ASAM Level I or Level II.1), the treatment agency will refer the SBIRT consumer to another licensed substance abuse provider for a more appropriate level of care, with notification to HJA through NJSMAS
- Prepare agency Policy and Procedures for accepting a “warm handoff” from NJ SBIRT project sites
- Maintain its status as a NJ Department of Human Services (DHS) licensed substance abuse treatment facility, and a DMHAS contracted FFS provider for the duration of this affiliation agreement
The undersigned hereby agree to the terms described in this document and to the DHS licensure standards, and the DMHAScontracted fee-for-service network requirements.
The Treatment Agency may terminate this agreement by providing the HJA with at least four (4) months written notice.
Treatment Agency: ______
DHS License Number: ______
Location of Program:______
(if more than one location, list on reverse side)
Hours of Operation: ______
Mailing Address:______
______
Phone Number: ______
Contact Person: ______
Sliding Fee Scale Available:______Yes ______No
Third Party Payment Available:______Yes ______No
Signing for the HJA______
Executive Director
______
Date
Signing for the Treatment Agency______
Name and Title (please print)______
______
______
Date
Revised 4/2/13