Qualification Standards. In order to participate with BCBSM under this Agreement, Provider must have and maintain all of the following Qualification Standards at each Approved Site: At a minimum, a multidisciplinary staff consisting of a board-certified or board-eligible psychiatrist, a fully licensed psychologist, and a clinical licensed master’s social worker (CLMSW) with a master’s degree in social work; A community governing or advisory board; A comprehensive range of mental health services offered to the community including individual and group psychotherapy, family counseling, and psychological testing. Additional services required by patients and the community may also be included. Emergency services are available on a 24 hour basis through program staff or referral to other appropriate community agencies; Proof of current licensure, registration, or certification at all times of Professional Providers on staff; Accreditation by at least one national accreditation organization approved by BCBSM, such as, but not limited to the following: The Joint Commission (TJC), Council on Accreditation of Services for Families and Children (COA), Commission on Accreditation of Rehabilitation Facilities (CARF), or American Osteopathic Association (AOA); Significant involvement by a psychiatrist on staff to assure that the psychiatrist assumes overall responsibility for coordinating the care of all patients. Significant involvement by a psychiatrist in an Outpatient Psychiatric Care facility includes, but is not limited to: approval of the initial evaluation, certification of the diagnosis, certification of the treatment plan, evaluation of client progress, intervention for medical reviews, intervention for level of care changes, review at termination of treatment, and approval for psychological testing prior to administration; Michigan licensure for psychiatric partial hospitalization for Outpatient Psychiatric Care facilities providing psychiatric day treatment, Absence of inappropriate utilization or practices as identified through proven subscriber complaints, audits, and peer review, and, Absence of fraud and illegal activities. For each Covered Service performed, BCBSM will pay Provider the lesser of billed charges or the maximum payment level set forth in BCBSM's published Outpatient Psychiatric Care Rate Schedule (Rate Schedule). Most maximum payment levels are based on the Resource Based Relative Value Scale (RBRVS) developed by the Centers for Medicare and Medicaid Services (CMS), which is a schedule of relative procedure values that reflect the resource cost required to perform each service. The resource costs of the RBRVS system include physician time, training, skill, risk, procedure complexity, practice overhead and professional liability insurance costs. Values are assigned to each service in relation to the comparative value of all other services. The relative values are then multiplied by a BCBSM-specific conversion factor to determine overall payment levels. For procedure codes that have no CMS derived RBRVS value, BCBSM’s maximum payment level may be based on BCBSM’s medical consultants’ determination. Other factors that may be used in setting maximum payment levels include, but are not limited to, comparison to similar services, corporate medical policy decisions, analysis of historical charge data and geographic anomalies. BCBSM may adjust maximum payment levels based on factors such as site of care or BCBSM payment policy. Additionally, the maximum payment levels indicated on the Rate Schedule for each type of Professional Provider may vary, commensurate with the rendering provider’s level of licensure. BCBSM will periodically review Outpatient Psychiatric Care facility reimbursement to determine if modifications are necessary. BCBSM does not warrant or guarantee that the review process will result in increased reimbursement.
Appears in 1 contract
Sources: Outpatient Psychiatric Care Facility Participation Agreement
Qualification Standards. In order to participate with BCBSM under this Agreement, Provider must be located in Michigan and must have and maintain all of the following Qualification Standards at each Approved Siteprimary and branch site: At • Provider must provide physical therapy services, and may also provide occupational therapy and/or speech and language pathology services; • Provider has current Medicare certification as a minimumrehabilitation agency for outpatient physical therapy services, or current Medicare participation as a comprehensive outpatient rehabilitation facility (CORF), and can demonstrate it provides services that are restorative and rehabilitative in nature; • Provider, or at least one licensed physical therapist on staff, must have membership in a local or national physical therapy professional organization; • Provider has a Michigan licensed physical therapist on site whenever physical therapy is provided, a multidisciplinary staff consisting of a board-certified or board-eligible psychiatrist, a fully Michigan licensed psychologistoccupational therapist on site whenever occupational therapy is provided, and a clinical Michigan licensed masterspeech therapist on site whenever speech-language pathology therapy is performed, except as may be otherwise permitted in BCBSM’s social worker (CLMSW) with published policies. If the state of Michigan has not released license applications or has not issued licenses for Speech-Language Pathologists, then a master’s degree in social workCertificate of Clinical Competence from the American Speech and Hearing Association is an acceptable alternative until the state issues licenses; A community governing or advisory board; A comprehensive range • Provider has written policies and procedures that meet generally acceptable standards for outpatient physical therapy to assure the quality of mental health services offered to the community including individual and group psychotherapy, family counselingpatient care, and psychological testing. Additional services required by patients Provider demonstrates compliance with such policies and procedures; • Provider can demonstrate that it conducts program evaluation and utilization review to assess the community may also be included. Emergency services are available on a 24 hour basis through appropriateness, adequacy and effectiveness of the program’s administrative and clinical components; • Provider’s outpatient physical therapy program staff or referral has been in operation for six months prior to other appropriate community agencies; Proof of current licensure, registration, or certification at all times of Professional Providers on staff; Accreditation by at least one national accreditation organization approved by BCBSM, such as, but not limited application to the following: The Joint Commission (TJC), Council on Accreditation of Services BCBSM for Families and Children (COA), Commission on Accreditation of Rehabilitation Facilities (CARF), or American Osteopathic Association (AOA); Significant involvement by a psychiatrist on staff to assure that the psychiatrist assumes overall responsibility for coordinating the care of all patients. Significant involvement by a psychiatrist in participation as an Outpatient Psychiatric Care facility includesPhysical Therapy Facility and has sufficient patient volume to enable BCBSM to determine Provider’s compliance with BCBSM’s Qualification Standards; • Provider meets BCBSM’s Evidence of Necessity (EON) requirements, but is not limited to: approval as applicable; • Provider complies with Certificate of Need (CON) requirements of the initial evaluationMichigan Public Health Code, certification as applicable; • Provider has a governing board that is legally responsible for the total operation of the diagnosis, certification of the treatment plan, evaluation of client progress, intervention for medical reviews, intervention for level of care changes, review at termination of treatmentfacility, and approval for psychological testing prior to administrationensuring that quality care is provided in a safe environment; Michigan licensure for psychiatric partial hospitalization for Outpatient Psychiatric Care facilities providing psychiatric day treatment, Absence • Provider has an absence of inappropriate utilization or practices practice patterns, as identified through proven valid subscriber complaints, audits, audits and peer review, and, Absence ; and • Provider has an absence of fraud and or illegal activities. For each Covered Service performedServices performed that are within Provider’s scope of practice, BCBSM will pay Provider the lesser of the billed charges charge or the published maximum payment level per service, less any Deductible or Copayment for which the Member is responsible. The published maximum payment is set forth in BCBSM's published Outpatient Psychiatric Care Rate ’s Maximum Payment Schedule (Rate “Payment Schedule”). BCBSM will make the Payment Schedule available to Providers via web-DENIS. Most of the maximum payment levels are based on the Resource Based Relative Value Scale (RBRVS) system developed by the Centers for Medicare and Medicaid Services (CMS)Services, in which is a schedule of relative procedure values that reflect services are ranked according to the resource cost required costs needed to perform each serviceprovide them. The resource costs of the RBRVS system include physician time, training, skill, risk, procedure complexity, practice overhead and professional liability insurance costsinsurance. Values are assigned to each service in relation to the comparative value of all other services. The relative values are then multiplied by a BCBSM-BCBSM- specific conversion factor to determine overall payment levels. For procedure codes that have no CMS derived RBRVS value, BCBSM’s maximum payment level may be based on BCBSM’s medical consultants’ determination. Other factors that may be used in setting maximum payment levels include, but are not limited to, include comparison to similar services, corporate medical policy decisions, analysis of historical charge data and geographic anomalies. BCBSM may adjust maximum payment levels based on factors such as site of care or BCBSM payment policy. AdditionallyNationally imposed changes to the nomenclature and national coding system (HCPCS) for procedural codes, and corrections of typographical errors may result in immediate modifications to the maximum payment levels indicated Payment Schedule without prior notice. No other modification to the Payment Schedule will become effective until after 90 days have elapsed from the date of BCBSM’s notice to Providers. Notice may be provided either in written or electronic form. Written form shall include publication in the Record or other appropriate BCBSM provider publication. Electronic notice shall include, but not be limited to, publication on the Rate Schedule for each type of Professional Provider may vary, commensurate with the rendering provider’s level of licensureweb-DENIS. BCBSM will review Provider reimbursement levels periodically review Outpatient Psychiatric Care facility reimbursement to determine and may adjust them if BCBSM determines modifications are necessary. BCBSM does not warrant or guarantee that the review process will result in increased reimbursement.
Appears in 1 contract
Sources: Outpatient Physical Therapy Facility Traditional Participation Agreement
Qualification Standards. In order to participate with BCBSM under this Agreement, Provider must have and maintain all of the following Qualification Standards at each Approved Site: At a minimum, a multidisciplinary staff consisting Full accreditation in all components of a board-certified or board-eligible psychiatrist, a fully licensed psychologist, and a clinical licensed master’s social worker (CLMSW) with a master’s degree in social work; A community governing or advisory board; A comprehensive range of mental health services offered to the community including individual and group psychotherapy, family counseling, and psychological testing. Additional services required by patients and the community may also be included. Emergency services are available on a 24 hour basis through program staff or referral to other appropriate community agencies; Proof of current licensure, registration, or certification at all times of Professional Providers on staff; Accreditation ambulatory infusion therapy by at least one national accreditation organization approved by BCBSM, such as, but not limited to to, the following: • The Joint Commission (TJC)) • The Accreditation Commission for Health Care (ACHC) • Community Health Accreditation Program (CHAP) Direct employment, Council unless otherwise indicated below, of a multi-disciplinary staff composed of the following: • A registered pharmacist, licensed in Michigan, to coordinate the patient’s pharmaceutical plan of care with the nurse, the medical director, and the patient’s physician or licensed health care practitioner. • An employed or subcontracted Michigan licensed physician medical director who has expertise in infusion therapy services, to provide overall direction for the clinical aspect of the ambulatory infusion therapy services delivered. • A registered nurse that will develop, coordinate, and supervise all activities of nursing services, including responsibility for assuring that only qualified individuals administer the intravenous drugs. The nurse will also consult with the pharmacist and the patient’s licensed health care practitioner to coordinate the patient’s care • A registered nurse or certified phlebotomist to draw blood samples for testing. • Registered nurses who provide patient care must have specialized education or training in infusion services. The provider may subcontract additional nursing services on Accreditation an as-needed basis if such registered nurses have specialized education or training in infusion therapy services. Current Michigan pharmacy license. Have in place documented program evaluation, utilization review and peer review processes to assess the appropriateness, adequacy and effectiveness of Services the program’s administrative and clinical components applicable to all patient services in accordance with the requirements of BCBSM and the appropriate accrediting and regulatory agencies. Written policies and procedures that meet generally acceptable standards, as determined by BCBSM, for Families and Children (COA), Commission on Accreditation of Rehabilitation Facilities (CARF), or American Osteopathic Association (AOA); Significant involvement by a psychiatrist on staff ambulatory infusion services to assure the quality of patient care, and demonstrate compliance with such policies and procedures. Maintenance of a physical location on an appropriate site in Michigan, as determined by BCBSM, where the provider conducts business as a supplier of ambulatory infusion therapy. A toll free emergency telephone number, available during business hours. A system that ensures prompt delivery and appropriate storage of pharmaceuticals and medical supplies and dependable maintenance and servicing of infusion equipment. A documented recall policy and procedure in the psychiatrist assumes overall responsibility for coordinating event of a Food and Drug Administration recall of an infusion product. Maintenance of adequate patient and financial records. Assurance that care is provided under the care of all patients. Significant involvement by a psychiatrist in an Outpatient Psychiatric Care facility includes, but is not limited to: approval general supervision of the initial evaluation, certification patient’s physician or licensed health care practitioner and follows a written and signed plan of the diagnosis, certification of the treatment plan, evaluation of client progress, intervention for medical reviews, intervention for level of care changes, review at termination of treatment, and approval for psychological testing prior to administration; Michigan licensure for psychiatric partial hospitalization for Outpatient Psychiatric Care facilities providing psychiatric day treatment, that meets BCBSM’s requirements. The treatment plan must be signed yearly. Absence of inappropriate utilization or practices practice patterns, as identified through proven valid subscriber complaints, audits, and peer review, and, and Absence of fraud and or illegal activities. For each Covered Service performed, BCBSM will pay Provider the lesser of billed charges or the maximum payment level set forth in BCBSM's published Outpatient Psychiatric Care Rate Schedule (Rate Schedule). Most maximum payment levels are based on the Resource Based Relative Value Scale (RBRVS) developed by the Centers Reimbursement for Medicare covered ambulatory infusion services includes two components: pharmaceuticals and Medicaid Services (CMS), which is a schedule of relative procedure values that reflect the resource cost required to perform each service. The resource costs of the RBRVS system include physician time, training, skill, risk, procedure complexity, practice overhead and professional liability insurance costs. Values are assigned to each service in relation to the comparative value of all other services. The relative values are then multiplied by a BCBSM-specific conversion factor to determine overall payment levels. For procedure codes that have no CMS derived RBRVS value, BCBSM’s maximum payment level may be based on BCBSM’s medical consultants’ determination. Other factors that may be used in setting maximum payment levels include, but are not limited to, comparison to similar services, corporate medical policy decisions, analysis of historical charge data and geographic anomalies. BCBSM may adjust maximum payment levels based on factors such as site of care or BCBSM payment policy. Additionally, the maximum payment levels indicated on the Rate Schedule for each type of Professional Provider may vary, commensurate with the rendering provider’s level of licensure. BCBSM will periodically review Outpatient Psychiatric Care facility reimbursement to determine if modifications are necessary. BCBSM does not warrant or guarantee that the review process will result in increased reimbursementadministration.
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