facility network request form - Ubhonline.com

PLEASE COMPLETE AND FAX THIS DOCUMENT TO YOUR UBH/OPTUMHEALTH
NETWORK MANAGEMENT STAFF
United Behavioral Health/US Behavioral Health Plan, CA
Facility Network Request Form
TO BE COMPLETED BY PROVIDER, OPTUMHEALTH REGIONAL NETWORK MANAGER OR DIRECTOR
Facility Name Facility Type: ( ) Acute ( ) Non-Acute
Facility Contact & Title Phone #
Email Website Secure Fax #
Practice Address
Billing Address
Tax ID#(s)
Street Address City State County Zip
Street Address City State County Zip
Corporation Name
NPI# Medicaid# Medicare#
Current Accreditation: ( ) JCAHO ( ) CARF ( ) COA ( ) Other
Professional Liability Limits
General Liability Limits
Please check all Licensed Levels of Care & Indicate # of Beds/Capacity next to each service checked:
SUBSTANCE ABUSE
MENTAL HEALTH
Geriatric Adult Adolescent Geriatric Adult Adolescent Child
Detox I/P Locked
Rehab I/P Open
Residential Residential
Partial Day Partial Day
SA IOP MH IOP
Home Health Home Health
Methadone Buprenorphine ECT Inpatient Outpatient
Bridge on
Bridge on
Discharge
(BOD)
Discharge
(BOD)
Other
Other
Describe Key Population(s) Served and/or Unique Programming:
List all languages (including sign language) in which you are able to conduct treatment:
6/20/12
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PLEASE COMPLETE AND FAX THIS DOCUMENT TO YOUR UBH/OPTUMHEALTH
NETWORK MANAGEMENT STAFF
List Attending Physicians and/or Attach Staff Roster:
Are the attending physicians employed by the facility? ( ) Yes ( ) No
Provide the names of the primary attending MD’s at your facility:
How many single case agreements have you made with UBH in the last 6 months?
List and/or Attach Current Managed Care Participation
Provide the most recent 4 quarters of average length of stay (ALOS) experience for the levels of care (LOC) your facility
offers (for managed care members only): Inpatient Residential Partial IOP
NOTE: If you are a NEW facility, please complete the information below
Facility Practices
1. Pre-Certification:
A) Please provide a brief description of the facility’s Intake/Pre-Certification process.
B) Can a call be made to UBH from Admission upon Assessment? Yes No
C) How do they assign attending physicians?
D) Will they assign members to UBH contracted physicians? Yes No
E) Do they have personnel and a process to assure pre-cert on nights and
Yes No
weekends?
2. UR Process/Treatment Planning
A) Provide copy of UBH Initial Review Information to facility.
Would staff be willing to use the UBH Initial Review template? Yes No
B) Does staff conduct individualized treatment planning? Please describe.
C) Does staff include family involvement or therapy in treatment? How soon, how often?
D) Please describe the UR process. Do the UR staff round with the MDs?
E) What is the facility’s process regarding peer to peers?
F) How soon do they begin discharge planning?
6/20/12
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PLEASE COMPLETE AND FAX THIS DOCUMENT TO YOUR UBH/OPTUMHEALTH
NETWORK MANAGEMENT STAFF
3. Continuity and Coordination of Care:
A) How does the facility communicate with outpatient mental health providers?
B) How does the facility communicate with PCPs or other medical providers?
C) What is the facility’s process to research and resolve member generated complaints?
D) Any other questions from the facility?
4. Program/Services:
A) Does the facility have appropriate step-down options? Please describe.
B) Does the facility have age/specialty specific LOCs? Yes No
If yes, please describe treatment and staffing for programs.
5. Discharge Plan/Ambulatory follow-up:
A) Please describe the facility’s discharge plan/program.
B) Is the facility able to schedule follow-up appointments within 7 days? Yes No
If no, what are the barriers?
6. Readmission:
A) What is the facility readmission rate? (Target: less than 12%)
B) Do they have a plan to address relapse prevention? Yes No
If yes, please describe.
7. Collaboration:
A) What has been their experience in working with managed care?
B) Do they have any current workflows that would be helpful to UBH or the delivery of care?
C) What is the facility’s process to research and resolve member generated complaints?
D) Any other questions from the facility?
8. UBH Guidelines
A) Have you reviewed the UBH Best Practice/Level of Care Guidelines? Yes No
Any Questions or Concerns?
6/20/12
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PLEASE COMPLETE AND FAX THIS DOCUMENT TO YOUR UBH/OPTUMHEALTH
NETWORK MANAGEMENT STAFF
B) Have you reviewed the Facility Manual? Yes No
Any Questions or Concerns?
Facility Name:
Facility Authorized Signature
Print Name:
Title:
Date:
For Internal Use Only:
Network Manager Signature: ____________________________Date Received:___________ # of Covered Lives:_______________
Date Routed to Care Advocacy Center: ______________________________________________________________( ) Fax ( )Mail
Signature of CAC Representative (approval to panel facility): ________________________________________Date:_____________
Date Routed to Facility Contracting: _________________________________________________________________( ) Fax ( ) Mail
6/20/12
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