Network Participation Request and Specialty ... - Ubhonline.com

PHYSICIAN SPECIALTY REQUIREMENTS
Important Note: Signature on the above Specialty Attestation page is required of all applicants
INFANT MENTAL HEALTH:
• Completion of an ACGME approved Child Fellowship OR recognized certification in Child Psychiatry
And one (1) or more of the following:
• Ten (10) hours of CME in infant mental health/early childhood development in the last twenty-four (24) month period
• Evidence of at least twenty-five percent (25%) of practice experience in the treatment of infant mental health
PRESCHOOL/CHILDREN:
• Completion of an ACGME approved Child Fellowship OR recognized certification in Child Psychiatry
AND one (1) or more of the following:
• Ten (10) hours of CME in preschool/children in the last twenty-four (24) month period
• Evidence of at least twenty-five percent (25%) of practice experience in the treatment of preschool/children
ADOLESCENTS:
• Completion of an ACGME approved Child and Adolescent Fellowship OR recognized certification in Adolescent Psychiatry
AND one (1) or more of the following:
• Ten (10) hours of CME in adolescents in the last twenty-four (24) month period
• Evidence of at least twenty-five percent (25%) of practice experience in treating adolescent patients
GERIATRICS:
• Completion of an ACGME approved Geriatric Fellowship OR recognized certification in Geriatric Psychiatry
AND one (1) or more of the following:
• Ten (10) hours of CME in Geriatrics in the last twenty-four (24) month period
• Evidence of at least twenty-five percent (25%) of practice experience in treating geriatric patients
AUTISM SPECTRUM DISORDERS:
• Six (6) months full-time clinical work in an ASD clinic or structured ASD setting within past five (5) years
OR
• Twenty percent (20%) of current practice involved in the assessment and treatment of patients with ASD
CHEMICAL DEPENDENCY/SUBSTANCE ABUSE:
• Completion of an ACGME approved fellowship in Addiction Medicine OR Certification in Addiction Medicine or ASAM
AND one (1) or more of the following:
• Ten (10) hours of CME in Substance Abuse in the last twenty-four (24) month period
• Evidence of at least twenty-five percent (25%) of practice experience in SA treatment
DISABILITY:
• Experience or training in performing functional capacity evaluations for disability or worker’s compensation, or as a qualified independent medical
examiner.
• Thorough review of the Disability Solutions Psychiatric Disability Management Program Clinician Manual and signed Memorandum of Understanding
in agreement with our Disability Solutions protocols
EATING DISORDERS:
• One (1) year fellowship, internship or practice in Eating Disorders, completed at an accredited institution or approved program AND
• Evidence of at least one (1) year professional experience with at least twenty-five percent (25%) of practice in the treatment of eating disorders
• Ten (10) hours of CME in Eating Disorders in the last twenty-four (24) month period
NEUROPSYCHOLOGICAL TESTING:
• Recognized certification in Neurology through the American Board of Psychiatry and Neurology OR
• Accreditation in Behavioral Neurology and Neuropsychiatry through the American Neuropsychiatric Association
AND all of the following criteria:
• State medical licensure specifically allows for provision of neuropsychological testing service;
• Evidence of professional training and expertise in the specific tests and/or assessment measures for which authorization is requested;
• Physician and supervised psychometrician adhere to the prevailing national professional and ethical standards regarding test administration, scoring,
and interpretation.
SUBOXONE TREATMENT:
• DEA registration certificate with the DATA 2000 prescribing identification number
SUBSTANCE ABUSE EXPERT (SAE) – Nuclear Regulatory Commission (NRC):
• Certificate of NRC SAE qualification training (agencies providing such certification include, but are not limited to, ASAP, Inc, Program Services, and
SAPAA)
TELEPSYCHIATRY SERVICES
• A qualified practitioner at a distant site must be licensed in the state where the member resides, and deliver services in a manner that is consistent
with the Health Insurance Portability and Accountability Act (HIPAA) and other applicable privacy and security regulations and standards
AND
• An interactive telecommunication system must be used and include auditory and visual equipment and transmittal mechanism to facilitate the secure
two-way, real-time interaction between the member at a qualifying originating site and a distant site practitioner
WORKER’S COMPENSATION:
• Twenty-four (24) months experience assessing and treating worker’s compensation cases
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