Fillable Behavioral Health - Institutional Provider Recredentialing Application (Blue Cross Blue Shield of North Dakota)

Fill Online, Printable, Fillable, Blank Behavioral Health - Institutional Provider Recredentialing Application (Blue Cross Blue Shield of North Dakota) Form

Use Fill to complete blank online BLUE CROSS BLUE SHIELD OF NORTH DAKOTA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Behavioral Health - Institutional Provider Recredentialing Application (Blue Cross Blue Shield of North Dakota)

On average this form takes 15 minutes to complete

The Behavioral Health - Institutional Provider Recredentialing Application (Blue Cross Blue Shield of North Dakota) form is 4 pages long and contains:

  • 3 signatures
  • 10 check-boxes
  • 44 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Blue Cross Blue Shield of North Dakota forms online.

BROWSE BLUE CROSS BLUE SHIELD OF NORTH DAKOTA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of 4
29376949 • 6-20
Behavioral Health - Institutional Provider
Recredentialing Application
(For UB Claim Submission)
Only psychiatric PHP and IOP facilities are required to attest to the appropriate corresponding program criteria attached.
Recredentialing is conducted every three years and unless you are notied, participation will remain eective with no gaps.
If you have any questions, please call 800-756-2749 or send an email to prov.net@bcbsnd.com.
Institutional Provider Type (Place a check next to ALL correct classications)
Psychiatric Substance Use
Residential Treatment Center (RTC) Residential Treatment Center (RTC)
Partial Hospitalization Program (PHP) Partial Hospitalization Program (PHP)
Intensive Outpatient Program (IOP) Intensive Outpatient Program (IOP)
Hospital
Psychiatric Hospital
Institutional Provider Information (Please complete a separate application for each practicing location)
Name of Facility Federal TIN
NPI Eective Date of Group
Physical Street Address
Street
City State Zip
Billing/Mailing Address (If dierent from physical address)
Street
City State Zip
Patient Appointment Phone # Oce Fax # Billing Phone # Billing Fax #
Credentialing Contact Name and Phone # Credentialing Contact Email
Name and Title of Chief Administrator Total Licensed Bed Capacity
Facility accepts (Check all that apply): Credit Card Debit Card Neither
Current License/Certicate (Attach a current copy of all licenses and certicates that apply)
Issued By
Current State License
Or Certication #
Original Issue Date
(MM/DD/YYYY)
Expiration Date
(MM/DD/YYYY)
State
Medicare Certication #
Medicaid
Joint Commission
Accreditation or other
CMS approved accreditation
with deeming authority
Other
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Page 2 of 4
29376949 • 6-20
Malpractice/Liability Insurance
Attach a copy of malpractice insurance face sheet.
Release and Attestation
The undersigned is authorized to act on behalf of the institution/facility (Entity), and certies that all information submitted
on this application and all attachments hereto are correct, true and complete to the best of my knowledge.
The Entity consents to complete disclosure of and authorization to make available to Blue Cross Blue Shield of North Dakota
(BCBSND), its aliates or any of their agents, all relevant information pertaining to and deemed necessary and appropriate
in the investigation and processing of this application, including but not limited to, information obtained through a third party
such as an insurance company, licensing authority, accrediting agency or governmental agency.
The Entity releases and discharges BCBSND, its aliates and their representatives, credentials committees, administrators,
governing bodies, agents, employees and all other persons or entities supplying information to them, from liability or claims
of any kind or character in any way arising out of inquiries or disclosures made in good faith in connection with this application.
The Entity agrees to update this application while it is being processed should there be any change in the information provided
regarding the Entity that could aect the application or its outcome. A photocopy of this document shall be as eective as the original.
Name (Print or Type) Title
Signature Date (MM/DD/YYYY)
click to sign
signature
click to edit
Page 3 of 4
29376949 • 6-20
Psychiatric - Partial Hospitalization Program (PHP) (Please ensure your program meets criteria specied below for
the type of services you provide. Signature is required)
• Continuous structured treatment of psychiatric illness by a multidisciplinary health care treatment team. PHP is typically
held during daytime hours and provides 20 or more hours per week to treat multidimensional instability not requiring
24-hour care.
• Multidisciplinary assessment with a treatment plan which addresses psychological, social, medical, cognitive and substance
use needs. This should include coordination of care with patient’s outpatient providers.
• Partial Hospital Programs are staed by a multidisciplinary treatment team under the leadership of a qualied physician.
• Clinical assessment at least once per day.
• Individual or group family modalities must be provided.
• Psychiatric or medication evaluation at least once per week and more frequent as clinically indicated.
• Recovery oriented individualized treatment plan.
• Safety plan developed.
• Prompt family or support system involvement is expected at every level of treatment plan development, unless
clinically contraindicated.
• Coordination of care with other clinicians, relevant to the treatment being provided, is documented.
• Linkage and/or coordination with the patient’s community resources with the goal of returning the patient to his/her
regular social environment as soon as possible, unless contraindicated. School contact should address Individualized
Educational Plan/s as appropriate, for school age children.
• Treatment is individualized and not determined by a programmatic timeframe. It is expected that the focus will
be preparing the patient for adaptive function in the community setting.
• Goals are clear, achievable and time-limited with a focus on reduction of the symptoms that led to admission.
• Skilled nursing care is on-site and a qualied physician is available during all program treatment hours to assist
with crisis intervention and to assess and treat medical and psychiatric problems.
• Blood or urine drug screening is considered if clinical progress is not occurring or when substance misuse is suspected.
• All therapeutic services are provided by licensed or certied professionals in accordance with state laws.
• Discharge planning is initiated on the day of admission and includes coordination with family and community resources
to allow a smooth transition back to outpatient services, family integration, and continuation of the recovery process.
• Documentation standards include individualized progress notes in the patient’s record that clearly reect implementation
of the treatment plan and the patient’s response to the therapeutic intervention for all disorders treated, as well as
subsequent amendments to the plan.
I attest that the Institution/Facility below meets all of the above program criteria.
Name (Print or Type) Title
Signature Date (MM/DD/YYYY)
click to sign
signature
click to edit
Page 4 of 4
29376949 • 6-20
Psychiatric - Intensive Outpatient Program (IOP) (Please ensure your program meets criteria specied below
for the type of services you provide. Signature is required)
• A short-term structured treatment for psychiatric illness is provided by a multidisciplinary health care treatment team. The
treatment is more intensive than outpatient treatment but less intensive than partial hospital programming. Treatment
will include a minimum duration of 3 hours per treatment day and will not exceed 19 hours per week.Multidisciplinary
assessment with an individualized treatment plan which addresses psychological, social, medical, cognitive, and
substance use needs. This should include coordination of care with patient’s outpatient providers.
• Blood or urine drug screening is considered if clinical progress is not occurring or when substance misuse is suspected.
• Psychoeducation is provided.
• Structured clinical programming is provided.
• Goal-directed treatment plan. Goals are clear, achievable and time-limited with a focus on reduction
of the symptoms that led to admission.
• Prompt family or support system involvement is expected at every level of treatment plan development,
unless doing so is clinically contraindicated.
• Coordination of care with other clinicians, relevant to the treatment being provided, is documented.
• Linkage and/or coordination with the patient’s community resources with the goal of returning the patient to his/her
regular social environment as soon as possible, unless contraindicated. School contact should address Individualized
Educational Plan(s) as appropriate for school children.
• Treatment is individualized and not determined by a programmatic timeframe. It is expected that the focus will
be preparing the patient for adaptive functioning in the community setting.
• Discharge planning is initiated on the day of admission and includes coordination with family and community resources
to allow a smooth transition back to outpatient services, family integration, and continuation of the recovery process.
• Documentation standards include individualized progress notes in the patient’s record that clearly reect implementation
of the treatment plan and the patient’s response to the therapeutic intervention for all disorders treated, as well as
subsequent amendments to the plan.
I attest that the Institution/Facility below meets all of the above program criteria.
Name (Print or Type) Title
Signature Date (MM/DD/YYYY)
SUBMIT INSTRUCTIONS
If you are having diculty submitting the form once completed, please send using one of the following methods:
• Email (Please follow these steps):
- Click on ‘File’ at the top of your screen
- Click on ‘Save As’
- Save the completed form on your computer
- Attach the completed form to an email and send to providerforms@bcbsnd.com
• Fax: 701-282-1910
• Mail: 4510 13th Ave S
Fargo, ND 58121
SUBMIT FORM
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Behavioral Health - Institutional Provider Recredentialing Application (Blue Cross Blue Shield of North Dakota)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 10 June 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document