Fillable Behavioral Health Institutional Provider Credentialing Application ONLINE (Blue Cross Blue Shield of North Dakota)

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Behavioral Health Institutional Provider Credentialing Application ONLINE (Blue Cross Blue Shield of North Dakota)

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The Behavioral Health Institutional Provider Credentialing Application ONLINE (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

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Page 1 of 4
29378648A • 8-20
(For UB Claim Submission)
Only psychiatric PHP and IOP facilities are required to attest to the appropriate corresponding program criteria attached.
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
Residential Treatment Center (RTC)
Partial Hospitalization Program (PHP)
Intensive Outpatient Program (IOP)
Hospital
Psychiatric Hospital
Substance Use
Residential Treatment Center (RTC)
Partial Hospitalization Program (PHP)
Intensive Outpatient Program (IOP)
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 Billing/Mailing Address (If dierent from physical address)
Street Street
City State Zip 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 Expiration Date
State
Medicare Certication #
Medicaid
Joint Commission
Accreditation or other
CMS approved accreditation
with deeming authority
Other
Behavioral Health – Institutional Provider
Credentialing Application ONLINE
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Noridian Mutual Insurance Company
Page 2 of 4
29378648A • 8-20
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)
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signature
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Page 3 of 4
29378648A • 8-20
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)
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signature
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Page 4 of 4
29378648A • 8-20
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)
Please double check that the application is complete.
If you are having diculty submitting the form once completed, please send using one
of the following methods:
• Email:
– 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
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Behavioral Health Institutional Provider Credentialing Application ONLINE (Blue Cross Blue Shield of North Dakota)

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Completed 10 June 2021

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