PATHWAYS TO BECOMING AN ADDICTION AND RECOVERY …...Complete ARTS Attestation Form 2.1 to 4.0 and ARTS Organizational Staff Roster and submit to Magellan and each of the Medicaid

PATHWAYS TO BECOMING AN ADDICTION AND RECOVERY

TREATMENT SERVICES (ARTS) MEDICAID PROVIDER

Pathways for Providers

Executive and Legislative branches fully support the Medicaid substance use disorder system transformation to address the opioid crisis

DMAS is moving services to evidence based practices models

American Society of Addiction Medicine (ASAM) is nationally recognized evidenced based practice

Importance for Preliminary Work


1. Review the ARTS webpage for information on the substance use disorder services transformation: http://www.dmas.virginia.gov/Content_pgs/bh-sud.aspx

2. Make sure you have or pursue the correct state license, whether through Virginia Department of Health (VDH), Virginia Department of Behavioral Health and Developmental Services (DBHDS) and the Department of Health Professions (DHP) The correct licenses are required as part of the credentialing

and contracting process with the Medicaid health plans and Magellan

3. Credentialing and contracting requirements are also based on the type of service (ASAM Level of Care) you intend to provide in the new ARTS system

Preliminary work:

http://www.dmas.virginia.gov/Content_pgs/bh-sud.aspx


4. Buy/Acquire and review the ASAM Criteria: http://www.asam.org/quality-practice/guidelines-and-consensus-documents/the-asam-criteria/text

5. Attend the DBHDS ASAM Trainings http://www.dbhds.virginia.gov/individuals-and-families/substance-abuse/current-training-initiatives

6. Based on the ASAM Criteria evidence based quality standards, determine what substance use disorder related service (or ASAM Level of Care) you provide or want to provide for Medicaid reimbursement

Preliminary work:

http://www.asam.org/quality-practice/guidelines-and-consensus-documents/the-asam-criteria/texthttp://www.asam.org/quality-practice/guidelines-and-consensus-documents/the-asam-criteria/texthttp://www.dbhds.virginia.gov/individuals-and-families/substance-abuse/current-training-initiativeshttp://www.dbhds.virginia.gov/individuals-and-families/substance-abuse/current-training-initiatives


7. Determine whether you are already credentialed and contracted with the Medicaid health plans and Magellan

8. Determine which Medicaid health plans you need to be credentialed and contract with: http://www.virginiamanagedcare.com/choose/compare-plans

9. All providers should be credentialed and contract with Magellan for ARTS coverage for fee-for-service members

Preliminary work:

http://www.virginiamanagedcare.com/choose/compare-planshttp://www.virginiamanagedcare.com/choose/compare-plans

ASAM Level 4

Complete ARTS Attestation Form for ASAM Level 2.1 to 4.0 and ARTS Organizational Staff Roster.

Submit documentation to Magellan and each of the Medicaid health plans to start the credentialing and contracting process if not already in-network.

Magellan and the Medicaid health plans will request any additional documents required for credentialing and contracting.

6

Medically Managed Intensive Inpatient

ASAM Levels 3.7, 3.5, 3.3, 3.1

Obtain or amend DBHDS license if needed. Add DBHDS Medical Detox license for all ASAM

Level 3.7. Add DBHDS Medical Detox license for ASAM Levels

3.5 and 3.3 only if providing withdrawal management.

7

Residential Treatment Services (RTS)

ASAM Levels 3.7, 3.5, 3.3, 3.1

Providers to also submit completed ARTS Attestation Form for ASAM Levels 2.1 to 4.0, ARTS Organizational Staff Roster and a copy of the appropriate DBHDS license(s) to Magellan and each of the Medicaid health plans to start the credentialing and contracting process .


8

Residential Treatment Services (RTS) continued

ASAM Levels 3.7, 3.5, 3.3, 3.1

Complete the ARTS Attestation Form for ASAM Levels 2.1 to 4.0, ARTS Organizational Staff Roster and submit these documents along with a copy of the appropriate DBHDS license(s) to DMAS via email and then mail in signed copy. Submit by December 15, 2016 to secure timely site review by Contractor. Email: [email protected] Mail signed copy:

DMAS / Addiction and Recovery Treatment Services Attention: Ashley Harrell 600 East Broad Street, Suite 1300 Richmond, Virginia 23219

9


mailto:[email protected]

ASAM Levels 3.7, 3.5, 3.3, 3.1

DMAS will submit documentation to the DMAS Contractor who is performing reviews and site visits to determine if RTS providers meet the attested ASAM Levels of Care.

DMAS Contractor will contact the RTS provider within two weeks of receipt to schedule a site visit and review based on ASAM Criteria and information submitted to DMAS.

DMAS Contractor will provide a Site Visit Report with outcome of their ASAM Level of Care Assessment to the RTS provider after site visit.

10


ASAM Levels 3.7, 3.5, 3.3, 3.1

RTS provider will submit the Site Visit Report verifying that they meet ASAM requirements for the Residential Level of Care to Magellan and each of the Medicaid health plans as part of the credentialing and contracting process

DMAS will notify providers upon approval of Demonstration Waiver from CMS that will allow Medicaid reimbursement for facilities with greater than 16 beds. Providers expanding bed capacity will need to update their DBHDS licenses once staff requirements are met.

11


ASAM Levels 3.7, 3.5, 3.3, 3.1

If RTS provider does not meet ASAM criteria for a specific Residential Level, they will have 60 days or until April 30, 2017 (whichever is sooner) to submit updated information to the Contractor demonstrating that they meet this level

The Contractor will reevaluate the RTS provider based on this updated information and determine if they meet ASAM criteria for the specific level within 60 days or by June 30, 2017 (whichever is sooner)

12


ASAM Levels 2.5 and 2.1

Obtain or amend DBHDS license if needed. Add DBHDS Outpatient Managed Withdrawal

Service License only if performing outpatient withdrawal management

Complete ARTS Attestation Form for ASAM Level 2.1 to 4.0 and ARTS Organizational Staff Roster and submit along with a copy of the appropriate DBHDS license(s) to Magellan and each of the Medicaid health plans to start the credentialing and contracting process if not already in-network.

13

Partial Hospitalization and Intensive Outpatient

ASAM Level 1.0 and 0.5

Must be licensed or credentialed by the Department of Health Professions.

Contact Magellan and each of the Medicaid health plans to start the credentialing and contracting process if not already in-network.


14

Outpatient and SBIRT

ASAM Level Opioid Treatment Services

Must be licensed by DBHDS as OTP Complete ARTS OTP Attestation Form and ARTS

Organizational Staff Roster and submit Magellan and the Medicaid health plans to start the credentialing and contracting process if not already in-network.


15

Opioid Treatment Programs (OTP)

Magellan and Managed Care Organizations Provider Network Relations Contact Information

16

Magellan 800-424-4536 www.magellanofvirginia.com/for-providers-va/join-the-network.aspx

Aetna Better Health of Virginia [email protected]

Anthem HealthKeepers Plus www.anthem.com/wps/portal/ahpprovider?content_path=provider/v

a/f6/s0/t0/pw_e228913.htm&rootLevel=5&state=va&label=Join

Humana John Strube, Network Manager

[email protected]

Office: 804.793.0464 | m. 804.347.5160

http://www.magellanofvirginia.com/for-providers-va/join-the-network.aspxmailto:[email protected]://www.anthem.com/wps/portal/ahpprovider?content_path=provider/va/f6/s0/t0/pw_e228913.htm&rootLevel=5&state=va&label=Joinhttp://www.anthem.com/wps/portal/ahpprovider?content_path=provider/va/f6/s0/t0/pw_e228913.htm&rootLevel=5&state=va&label=Joinmailto:[email protected]

Magellan and Managed Care Organizations Provider Network Relations Contact

Information INTotal

Mary Fountain, Director of Network Management Email- [email protected] Office: 800-231-8076

Kaiser Permanente http://www.providers.kaiserpermanente.org/html/cpp_mas/forms.html Fax Number: 855-414-2621 Email: [email protected]

17

mailto:[email protected]://www.providers.kaiserpermanente.org/html/cpp_mas/forms.htmlmailto:[email protected]

Magellan and Managed Care Organizations Provider Network Relations Contact

Information Optima Family Care

Michael Caylor Email: [email protected] Office: 804-510-7483

Virginia Premier Rick Gordon, Director, Medicare Duals Network Development Office: 804-819-5151 ext 55075 Fax: (804) 819-5366 Email: [email protected] Visit www.vapremier.com and select “Join our Network” under the Provider

tab, complete the recruitment request form and forward to the contracting team.

18

mailto:[email protected]:[email protected]://www.vapremier.com/

ASAM Level of Care

License Credentialing and Contracting Process

4 Medically Managed Intensive Inpatient

Acute Care General Hospital (12VAC5-410)

1. Complete ARTS Attestation Form 2.1 to 4.0 and ARTS Organizational Staff Roster and submit to Magellan and each of the Medicaid health plans to start the credentialing and contracting process if not already in-network. Magellan and the Medicaid health plans will request any additional documents required for credentialing and contracting.

3.7 Medically Monitored

Intensive Inpatient Services (Adult)

Medically Monitored High-Intensity Inpatient Services

(Adolescent)

Inpatient Psychiatric Unit;

Acute Freestanding Psychiatric Hospital;

Substance Abuse (SA) Residential Treatment Service (RTS) for Adults/Children; and

Residential Crisis Stabilization Unit

Medical Detox License required for all

1. Obtain DBHDS license or addendum to current licenses.

2. Add DBHDS Medical Detox license for all ASAM Level 3.7. Add DBHDS Medical Detox license for ASAM Level 3.5/3.3 if providing withdrawal management.

3. Complete the ARTS Attestation Form for 2.1 to 4.0, ARTS Organizational Staff Roster and submit along with appropriate DBHDS license(s) to DMAS via email: [email protected] and mail hard copy to:

DMAS / Addiction and Recovery Treatment Services Atten: Ashley Harrell 600 East Broad Street, Suite 1300 Richmond, Virginia 23219

4. DMAS Contractor, will contact provider within two weeks of receiving documentation from DMAS to schedule review.

5. Provider to submit ARTS Attestation Form for 2.1 to 4.0, ARTS Organizational Staff Roster and copy of appropriate DBHDS license(s) to Magellan and each of the Medicaid health plans to start the credentialing and contracting process.

6. Magellan and the Medicaid health plans will request any additional documents required for credentialing and contracting.

7. Provider to receive final report from the DMAS Contractor on outcome of ASAM Level of Care assessment. Provider to submit to Magellan and the Medicaid health plans.

3.5 Clinically Managed High-

Intensity Residential Services (Adults) / Medium

Intensity (Adolescent) 3.3

Clinically Managed Population-Specific High-

Intensity Residential Services (Adults)

Inpatient Psychiatric Unit (3.5);

SA RTS for Adults (3.3 or 3.5) and Children (3.5);

SA and MH RTS for Adults and Children (3.3 or 3.5); and

Supervised RTS for Adults (3.3)

Medical Detox License required for those providing withdrawal management

3.1 Clinically Managed Low-

Intensity Residential Services

MH & SA Group Home Service for Adults and Children ; and

SA Halfway House for Adults 19

mailto:[email protected]

ASAM Level of Care

License Credentialing and Contracting Process

2.5 Partial

Hospitalization Services

2.1 Intensive Outpatient

Services

• SA or SA/Mental Health Partial Hospitalization (2.5)

• SA Intensive Outpatient for Adults, Children and Adolescents (2.1)

• Outpatient Managed Withdrawal Service License required for 2WM

1. Obtain DBHDS license or addendum to current licenses. 2. Add DBHDS Outpatient Managed Withdrawal Service License if

doing outpatient withdrawal management 3. Complete ARTS Attestation Form for 2.1 to 4.0 and ARTS

Organizational Staff Roster and submit along with copy of the appropriate DBHDS license(s) to Magellan and each of the Medicaid health plans to start the credentialing and contracting process if not already in-network.


1 Outpatient Services

All Licensed or Credentialed Providers with Department of Health Professions

1. Contact Magellan and each of the Medicaid health plans to start the credentialing and contracting process if not already in-network.

2. Magellan and the Medicaid health plans will request any additional documents required for credentialing and contracting..

0.5 Early Intervention

Opioid Treatment Program (OTP)

• Opioid Treatment Program licensed by DBHDS

1. Complete ARTS OTP Attestation Form and ARTS Organizational Staff Roster and submit along with copy of the appropriate DBHDS license(s) to Magellan and each of the Medicaid health plans to start the credentialing and contracting process if not already in-network.


20

ASAM WM / LOC / DBHDS License Crosswalk

ASAM LOC Placement ASAM Level of WM VDH/DBHDS License

4 Medically Managed Intensive Inpatient

4-WM Medically Managed Intensive Inpatient

Withdrawal Management

• Acute Care General Hospital (12VAC5-410)

3.7 Medically Monitored Intensive

Inpatient Services (Adult) Medically Monitored High-Intensity

Inpatient Services (Adolescent)

3.7-WM Medically Monitored Inpatient


• Inpatient Psychiatric Unit • Acute Freestanding Psychiatric Hospital • Substance Abuse (SA) Residential Treatment Service

(RTS) for Adults/Children • Residential Crisis Stabilization Unit • Medical Detox License required for all

3.5 Clinically Managed High-Intensity

Residential Services (Adults) / Medium Intensity (Adolescent)

3.3 Clinically Managed Population-Specific

High-Intensity Residential Services (Adults)

3.2-WM Clinically Managed Residential


• Inpatient Psychiatric Unit (3.5) )/Required for co-occurring enhanced programs

• SA RTS for Adults (3.3 or 3.5) and Children (3.5) • SA and MH RTS for Adults and Children (3.3 or

3.5)/Required for co-occurring enhanced programs • Supervised RTS for Adults (3.3) • Medical Detox License required for 3.2 WM

3.1 Clinically Managed Low-Intensity

Residential Services n/a

• MH & SA Group Home Service for Adults and Children (Required for co-occurring enhanced programs)

• SA Halfway House for Adults

2.5 Partial Hospitalization Services

2.1 Intensive Outpatient Services

2-WM Ambulatory Withdrawal Management w/

Extended On-site Monitoring

• SA or SA/Mental Health Partial Hospitalization (2.5) • SA Intensive Outpatient for Adults, Children and

Adolescents (2.1) • Outpatient Managed Withdrawal Service Licensed

required for 2WM

Additional Documentation to Submit to Magellan and the Medicaid Health Plans

Recent State Site Survey Certificate of Insurance (Malpractice and General

Liability) Current Business License State License(s) (DBHDS) and Federal DEA

License Copy of W-9 Full Disclosure of Ownership Form (CMS 1513) CLIA certification for laboratories

22

QUESTIONS? [email protected]

mailto:[email protected]:[email protected]

Virginia Department of Medical Assistance Services Addiction and Recovery Treatment Services (ARTS) Provider Attestation Form Last updated 11212016 Page 1 of 3

COMMONWEALTH of VIRGINIA Virginia Department of Medical Assistance Services

Addiction and Recovery Treatment Services (ARTS) Opioid Treatment Program (OTP) Attestation Form

Corporate Entity Legal Name:

NPI: TIN#

Address:

Agency:

Network Organizational Credentialing Standards Attestation

DMAS ARTS program requirements follow the criteria defined by the American Society of Addictions Medicine (ASAM) for the provision of substance use disorder treatment services. ARTS providers shall have a current version of The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, 3rd ed., and provide services that meet these criteria. If your organization meets the a specific level of care based on the ASAM Criteria, and have trained and knowledgeable staff in applying the ASAM Criteria, you must complete and return this attestation to Magellan or a Medicaid health plan to be eligible for participation in the ARTS program. You must also complete and provide all additional credentialing and/or contracting documents required by Magellan or the Medicaid health plan you are enrolling with. Providers must attach hereto an organization staff roster of only those individuals who attest to meet ASAM requirements for each specified level of care and attest only these staff shall treat DMAS-eligible members. By completing and submitting this form you attest that your agency meets the ASAM Level of Care requirements and that for each level of care specified herein the facility meets all of the support systems, staff, and therapies requirements as required in The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, 3rd ed.. Complete and submit the ARTS Opioid Treatment Program (OTP) Provider Attestation Form and any additional required credentialing and/or contracting documents to Magellan and the Medicaid health plans to start the credentialing process. Magellan and each Medicaid health plan will inform you if you meet their requirements to be enrolled or credentialed as a Medicaid provider in their network. Attesting to meeting ASAM Criteria does not guarantee enrollment or credentialing as a Medicaid provider.

I hereby certify that all information contained in this document is true and accurate. I further understand that any information entered in this document that subsequently is found to be false may result in termination of any agreement that I have or may enter into with DMAS and/or its contractors. I agree to maintain professional liability insurance coverage for direct care staff as referenced in this document and to update roster annually. In compliance with the DMAS ARTS Provider Attestation Form, the Facility attests that it will permit only staff members who are fully licensed and/or meet DMAS program requirements established for Addiction Recovery and Treatment Services (ARTS) to see and treat Medicaid eligible members. I hereby give permission and consent for DMAS and/or its contractors, to obtain and verify information provided in this form and consent to the release by any person, organization or other entity to DMAS and/or its contractors, of all information relevant to the evaluation of my ability to render addiction recovery and treatment services in a cost-effective manner and my moral and ethical qualifications, and agree to hold harmless any such person or organization from any cause of action based on the release of such information to DMAS and/or its contractors. By signing this attestation I agree that all statements are true and agree to abide by any contracted requirements for the services delivered under the authority of this agreement.

Printed Name:

Title:

Signature: Date:


CONTRACTED SITES OF CARE / Specific Service Delivery Location: Please note: Sites of care cannot provide services to eligible members until credentialing and contracting is completed. S1. MAIN SITE

Legal Name of Provider:

Program Name (if applicable): Tax ID#:

Street Address: Medicare#:

City/State/Zip Code: Medicaid#:

NPI(s)# License#:

Accreditation (if applicable): AAAHC HFAP CARF COA TJC License Type:

Site Treatment Setting (Check one)

General Hospital Freestanding Psychiatric Hospital Physician Office Psychiatry clinic CSB Outpatient health system clinic FQHC Health Department Primary care clinic Other:

S2





NPI(s)# License#:




S3





NPI(s)# License#:





CONTRACTED SITES OF CARE / Specific Service Delivery Location: Please note: Sites of care cannot provide services to eligible members until credentialing and contracting is completed. S4





NPI(s)# License#:




S5





NPI(s)# License#:




S6





NPI(s)# License#:





COMMONWEALTH of VIRGINIA Virginia Department of Medical Assistance Services

Addiction and Recovery Treatment Services (ARTS)

Provider Attestation Form ASAM Levels 2.1 to 4.0

Corporate Entity Legal Name:

NPI: TIN#

Address:

Agency:

Network Organizational Credentialing Standards Attestation

DMAS ARTS program requirements follow the criteria defined by the American Society of Addictions Medicine (ASAM) for the provision of substance use disorder treatment services. ARTS providers shall have a current version of The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, 3rd ed., and provide services that meet these criteria. Providers must attach hereto the ARTS Organizational Staff Roster of only those individuals who attest to meet ASAM requirements for each specified level of care and attest only these staff shall treat Medicaid eligible members. By completing and submitting this form you attest that your agency meets the ASAM Level of Care requirements and that for each level of care specified herein the facility meets all of the support systems, staff, and therapies requirements as required in The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, 3rd ed. If your organization meets the a specific level of care based on the ASAM Criteria, and have trained and knowledgeable staff in applying the ASAM Criteria, you must complete this ARTS Provider Attestation Form, ARTS Organizational Staff Roster and any additional required credentialing and/or contracting documents and submit to Magellan and each Medicaid health plans you are enrolling with to start the credentialing process. Providers attesting to meet the ASAM Levels 3.1, 3.3, 3.5, or 3.7 are also required to submit this ARTS Provider Attestation Form, ARTS Organizational Staff Roster, and a copy of the provider’s DBHDS license to the DMAS contact listed on next page. Magellan and the Medicaid health plans will inform you if you meet their requirements to be enrolled or credentialed as a Medicaid provider in their network. Attesting to meeting ASAM Criteria does not guarantee enrollment or credentialing as a Medicaid provider.

I hereby certify that all information contained in this document is true and accurate. I further understand that any information entered in this document that subsequently is found to be false may result in termination of any agreement that I have or may enter into with DMAS and/or its contractors. I agree to maintain professional liability insurance coverage for direct care staff as referenced in this document and to update roster annually. In compliance with the DMAS ARTS Provider Attestation Form, the Facility attests that it will permit only staff members who are fully licensed and/or meet DMAS program requirements established for Addiction Recovery and Treatment Services (ARTS) to see and treat Medicaid eligible members. I hereby give permission and consent for DMAS and/or its contractors, to obtain and verify information provided in this form and consent to the release by any person, organization or other entity to DMAS and/or its contractors, of all information relevant to the evaluation of my ability to render addiction recovery and treatment services in a cost-effective manner and my moral and ethical qualifications, and agree to hold harmless any such person or organization from any cause of action based on the release of such information to DMAS and/or its contractors. By signing this attestation I agree that all statements are true and agree to abide by any contracted requirements for the services delivered under the authority of this agreement.

Printed Name:

Title:

Signature: Date:


Providers attesting to ASAM Level 3.1, 3.3, 3.5 and 3.7 are required to submit the ARTS Attestation Form, DBHDS license and ARTS Organizational Staff Roster to DMAS via email (to expedite the review) and also mail in signed copy. Please include name of primary contact, email, and phone for contractor to coordinate the review.

Name: Email: Telephone: Indicate MCO Region(s) served:

ARTS Managed Care Regions: http://www.dmas.virginia.gov/Content_atchs/mc/gmap14.gif

Email: [email protected]

Mail signed copy: DMAS / Addiction and Recovery Treatment Services (ARTS) Attention: Ashley Harrell 600 East Broad Street, Suite 1300, Richmond, Virginia 23219

Program Type Treatment Setting

ASAM LOC

Crosswalk

Site of Care Codes

(List S1, S2, etc.) Population

(Check all that apply)

Medically Manage Intensive Inpatient Setting Virginia Department of Health licensed Acute Care General Hospital

4.0 Adults

Adolescents/Children

Medically Monitored Intensive Inpatient Services (Adult) High Intensity Inpatient (Adolescents) Department of Behavioral Health and Developmental Services (DBHDS) Licensed: Inpatient Psychiatric Unit with a DBHDS Medical Detoxification License Substance Abuse Residential Treatment Services (RTS) for Adults/Children

with a DBHDS Medical Detoxification License Residential Crisis Stabilization Unit with DBHDS Medical Detoxification

License

3.7 Adults


Clinically Managed High Intensity Residential Services (Adults) Medium Intensity (Adolescents) DBHDS Licensed: Substance Abuse Residential Treatment Service for Adults or Children Psychiatric Unit (Required for co-occurring enhanced programs) Substance Abuse and Mental Health RTS for Adults and Children (Required

for co-occurring enhanced programs)

3.5 Adults


Clinically Managed Population Specific High Intensity Residential Services (Adult Only) DBHDS Licensed: Supervised Residential Treatment Service (RTS) for Adults Substance Abuse RTS for Adults Substance Abuse and Mental Health RTS for Adults (Required for co-

occurring enhanced programs).

3.3 Adults, population specific

Clinically Managed Population Low Intensity Residential Services DBHDS Licensed: Mental Health and Substance Abuse Group Home Service for Adults and

Children (Required for co-occurring enhanced programs) Substance Abuse Halfway House for Adults

3.1 Adults


Day Treatment/Partial Hospitalization DBHDS licensed Substance Abuse or Substance Abuse/Mental Health Partial

Hospitalization 2.5

Adults


Intensive Outpatient Services DBHDS licensed Substance Abuse Intensive Outpatient for Adults, Children

and Adolescents 2.1

Adults



CONTRACTED SITES OF CARE / Specific Service Delivery Location: Please note: Sites of care cannot provide services to eligible members until credentialing and contracting is completed. S1. MAIN SITE




City/State/Zip/FIPS: Medicaid#:

NPI(s)# License#:




S2





NPI(s)# License#:




S3





NPI(s)# License#:





CONTRACTED SITES OF CARE / Specific Service Delivery Location: Please note: Sites of care cannot provide services to eligible members until credentialing and contracting is completed. S4





NPI(s)# License#:




S5





NPI(s)# License#:




S6





NPI(s)# License#:




Virginia Medicaid Addiction and Recovery Treatment Services (ARTS) Confidential Staff Roster

Lastupdate11062016

ThisrostershouldaccompanytheMedicaidAddictionandRecoveryTreatmntServices(ARTS)ProviderAttestationFormand reflect all approved activeproviders that performMedicaidARTS services for your organization. Theinitial roster should be a full listing of providers. You may submit subsequent staff rosters withadditions/terminationsandupdates to the rosterbymarking theappropriate request in the first columnof thisdocument.

Organizations shall notify theMedicaidhealthplans andMagellan inwritingwithin10days in the event of: (a) any change in the licensure or privileges of anyOrganizationstaffmember,includingbutnotlimitedtosuspension,revocation,condition,limitation,qualificationorotherrestriction,oruponinitiationofanyactionthatcouldreasonablyleadtosuchrestrictionofsuchOrganization’sstaffmember’slicense,certificationandpermitbyfederalauthoritiesorbyanystateinwhichsuchOrganization’sstaffmemberisauthorizedtoprovidehealthcareservices;(b)anysuspension,revocationorrestrictionofstaffprivilegesatanylicensedhospitalorotherOrganizationatwhichanOrganizationstaffmemberemployedbyorundercontractwiththeOrganizationhasstaffprivileges.Withtheexceptionoftheabovecircumstances,thisrostershallbeupdatedasnecessarytoreflectchangesinstaffstatus,butnolessthanquarterly.

Provider

Change of Status

(List: Add, Term,

Update or N/A)

Staff Provider Name

Degree (e.g., MA,

MSW, Ph.D., MD)

Professional Licensure or Credential

License Number

Social Security #

Date of Birth (M/F) Billing NPI

Age Groups Serviced

Minimum Age

Served

Maximum Age

Served

Virginia Medicaid Addiction and Recovery Treatment Services (ARTS) Confidential Staff Roster

Lastupdate11062016

Provider Change of

Status (List: Add,

Term, Update or

N/A)

Staff Provider Name

Degree (e.g., MA,

MSW, Ph.D., MD)

Professional Licensure or Credential

License Number

Social Security #

Date of Birth (M/F) Billing NPI

Age Groups Serviced

Minimum Age

Served

Maximum Age

Served

Pathways to becoming aN�Addiction and Recovery Treatment Services (ARTS)� MEDICAID providerPathways for ProvidersPathways for ProvidersPathways for ProvidersPathways for ProvidersASAM Level 4�ASAM Levels 3.7, 3.5, 3.3, 3.1ASAM Levels 3.7, 3.5, 3.3, 3.1ASAM Levels 3.7, 3.5, 3.3, 3.1ASAM Levels 3.7, 3.5, 3.3, 3.1ASAM Levels 3.7, 3.5, 3.3, 3.1ASAM Levels 3.7, 3.5, 3.3, 3.1ASAM Levels 2.5 and 2.1�ASAM Level 1.0 and 0.5ASAM Level Opioid Treatment ServicesMagellan and Managed Care Organizations�Provider Network Relations Contact Information�Magellan and Managed Care Organizations�Provider Network Relations Contact Information�Magellan and Managed Care Organizations�Provider Network Relations Contact Information�Slide Number 19Slide Number 20ASAM WM / LOC / DBHDS License CrosswalkAdditional Documentation to Submit to Magellan and the Medicaid Health PlansQuestions?�[email protected]

Documents

PATHWAYS TO BECOMING AN ADDICTION AND RECOVERY …...Complete ARTS Attestation Form 2.1 to 4.0 and ARTS Organizational Staff Roster and submit to Magellan and each of the Medicaid