Fillable Optum Clinical Expertise Checklist Return the completed form

Fill Online, Printable, Fillable, Blank Optum Clinical Expertise Checklist Return the completed form Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Optum Clinical Expertise Checklist Return the completed form

On average this form takes 27 minutes to complete

The Optum Clinical Expertise Checklist Return the completed form form is 4 pages long and contains:

  • 1 signature
  • 205 check-boxes
  • 7 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS 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
 
1
BH3575_Spec Attest Rev. v.15_092021 United Behavioral Health and United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum
U.S. Behavioral Health Plan, California doing business as OptumHealth Behavioral Solutions of California
Optum
Clinical Expertise Checklist
To add or modify your area(s) of expertise and/or attested specialty(ies):
• Complete and sign this form
•
Return the completed form and any requested supportive documents to your Optum contact.
•
To find your Optum contact, go to providerexpress.com > Contact Us > Network Management >
Network Management Contact Information and select your state
• If you have any questions, contact us at 1-877-614-0484
Clinician Name:
CAQH #
Phone:
Fax:
State:
License:
Clinicians in the credentialing or recredentialing process have the following rights:
to review information submitted to support his/her (re)credentialing application
to correct erroneous information obtained by Optum to evaluate his/her (re)credentialing application (not including
references, recommendations and other peer-review protected information)
to submit any corrections, in writing, within ten (10) days
to obtain, upon request, information regarding the status of their application
Areas of Clinical Expertise
Please check all areas you have clinical training and experience AND are currently willing to treat in your
practice.
Abuse (Physical, Sexual, etc.)
Acute Treatment Services (ATS) for Substance Use
Disorders (ASAM Level 3.7)
Adoption Issues
Anger Management
Anxiety
Assertive Community Treatment (ACT)
Assessment and Referral – Substance Abuse
Attention Deficit Disorders (ADHD)
Autism Spectrum Disorders
Bariatric/Gastric Bypass Evaluation
Behavior Modification
Biofeedback
Bipolar Disorder
Bisexual Issues
Blindness or Visual Impairment
Case Management
Certified Pastoral Counselor
Child Welfare
Christian Counseling
Clinical Support Services for Substance Use
Disorders (ASAM Level 3.5)
Clinically Managed Population-Specific High Intensity
Residential Services (ASAM Level 3.3)
Co-Occurring Disorders Treatment (Dual Diagnosis)
Cognitive Behavioral Therapy
Community Crisis Stabilization
Community Integration Counseling
Community Habilitation
Community Self-Advocacy Training & Support
Community Support Program (CSP)
Community Support Program for People
Experiencing Chronic Homelessness
Compulsive Gambling
Crisis Respite
Day Habilitation
Day Treatment
Depression
Developmental Disabilities
Dialectical Behavioral Therapy
Disability Evaluation/Management (submit the
Memorandum of Understanding, located on
providerexpress.com)
Dissociative Disorders
Domestic Violence
Electroconvulsive Therapy (ECT)
Emergency Services Program (ESP)
Enhanced Outpatient Program (EOP)
Enhanced Residential Rehabilitation Services for
Dually Diagnosed (ASAM Level 3.1 co-occurring
enhanced)
Evaluation and Assessment – Mental Health
Eye Movement Desensitization & Reprocessing
(EMDR)
Family Stabilization Team (FST)
2
BH3575_Spec Attest Rev. v.15_092021 United Behavioral Health and United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum
U.S. Behavioral Health Plan, California doing business as OptumHealth Behavioral Solutions of California
Areas of Expertise (cont.)
Feeding and Eating Disorders
Fetal Alcohol Syndrome
Fire Setter Evaluation
Forensic
Foster Care
Gay/Lesbian Issues
Grief/Bereavement
Health and Behavior Assessment and Intervention
Services
Hearing Impaired Populations
HIV/AIDS/ARC
Home Care/Home Visits
Hypnosis
In Home Behavioral Services (IHBS)
In Home Therapy (IHT)
Independent/Qualified Medical Examiner
Infertility
Intellectual and Developmental Disability
Intensive Care Coordination (ICC)
Intensive Individual Support
Learning Disabilities
LGBTQ Identified Clinician
Long Term Care
Long-Acting Injectable (LAI) Administrator
Medical Illness/Disease Management
Medicaid Opioid Treatment Program (OTP) –
Physicians Only
Medication Management
Military/Veterans Treatment
Mobile Crisis Intervention (MCI)
Mobile Mental Health Treatment
Mood Disorder
Multi-Systemic Therapy (MST)
Naltrexone Injectable MAT
Native American Traditional Healing Systems
Nursing Home Visits
Obsessive Compulsive Disorder
Organic Disorders
Pain Management
Parent Support and Training
Parent-Child Evaluation
Personality Disorders
Phobia
Physical Disabilities
Planned Respite
Police/Fire Fighters
Positive Behavioral Interventions & Supports
Post-Partum Depression
Post-Traumatic Stress Disorder (PTSD)
Program of Assertive Community Treatment
Psych Testing
Psychiatric Day Treatment
Psychotic/Schizophrenic Disorders
Race-Based Trauma
Recovery Coaching
Recovery Support Navigators (RSN)
Regional Behavioral Health Authority (RHBA)
Relaxation Techniques
Residential Rehabilitation Services (ASAM Level 3.1)
School Based Services
Serious Mental Illness
Sex Offender Treatment
Sexual Abuse Evaluation
Sexual Dysfunction
Sexual Trauma
Sleep-Wake Disorders
Somatoform Disorders
SPRAVATO™ (prescribers only)
Structured Outpatient Addiction Program (SOAP)
Targeted Case Management
TBI Waiver – Case Management
TBI Waiver – Community Integration Counseling
TBI Waiver – Positive Behavior
Therapeutic Monitoring (TM)
Transitional Support Services (TSS) for Substance
Use Disorders (ASAM Level 3.1)
Trauma Therapy
Traumatic Brain Injury
Weapons Clearance
Workers’ Compensation
Youth Mobile Crisis (Mobile Crisis Intervention
(YMCI)
Youth Stabilization Services (YSS)
Youth Support
Population(s) Treated (check all that apply):
Adult
Child
Adolescent
Geriatric
Couples/Marriage Therapy
Family Therapy
Group Therapy
Inpatient
Caregiver
3
BH3575_Spec Attest Rev. v.15_092021 United Behavioral Health and United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum
U.S. Behavioral Health Plan, California doing business as OptumHealth Behavioral Solutions of California
Optum Attested Expertise
You must sign this document even if you are not requesting any of these specialty designations in your provider record.
Additional training, experience, requirements, and/or outside agency approval is required for the following populations, professional
certifications, and specialties. Please review Specialty Requirements on pages 5-7.
If you are not requesting a specialty designation, please check the “No Specialties” box at the bottom of the list to indicate you have
read this form and acknowledge that you have not requested these specialties.
I have reviewed the Optum Specialty Requirements criteria that a Clinician must meet to be considered a specialist in the following
treatment areas. After reviewing the criteria, I hereby attest that by placing a check next to a specialty or specialties, I meet Optum
requirements for that treatment area.
Physician Specialties
Non-Physician Specialties
Child/Adolescent (please specify all ages that you treat)
Infant Mental Health (0-3 years)
Preschool (0-5 years)
Children (6-12 years)
Adolescents (13-18 years)
Geriatrics
Buprenorphine – Medication Assisted Treatment (MAT)
(submit DEA registration with the DATA 2000
prescribing identification number)
Certified Group Psychotherapist (CGP) (submit
Certification from IBCGP)
Chemical Dependency / Substance Abuse / Substance
Use Disorder (SUD)
Child and Adolescent Strengths and Needs (CANS) 2.0
Assessor (submit documentation verifying
completion of training and certification as Assessor)
Child and Adolescent Strengths and Needs (CANS) 2.0
(Child Welfare) Assessor (submit documentation
verifying completion of training and certification as
Assessor)
Child-Parent Psychotherapy (CPP)
Cognitive Processing Therapy (CPT)
Community Support Team Treatment (CST)
Comprehensive Multi-Disciplinary Evaluation (CMDE)
Coordinated Specialty Care for First Episode Psychosis
(CSC)
Developmental Relationship-Based Intervention (DRBI)
(submit copy of certification)
Early Intensive Developmental and Behavioral
Intervention (EIDBI)
Early Intervention Provider (Virginia Medicaid Only –
submit applicable certification)
Medicaid Office-Based Opioid Treatment Program
(OBOT)
Neuropsychological Testing
Office-Based Addictions Treatment (OBAT)
Parent-Child Interaction Therapy (PCIT)
Preschool PTSD Treatment (PPT)
Prolonged Exposure (PE)
Substance Abuse Expert (submit Nuclear Regulatory
Commission qualification training certificate)
Transcranial Magnetic Stimulation (TMS)
Trauma-Focused Cognitive Behavioral Therapy (TF-
CBT) (submit copy of TF-CBT certification)
Child/Adolescent (please specify all ages that you
treat) – Psychologists only
Infant Mental Health (0-3 years)
Preschool (0-5 years)
Children (6-12 years)
Adolescents (13-18 years)
Certified Group Psychotherapist (CGP) (submit
Certification from IBCGP)
Chemical Dependency / Substance Abuse /
Substance Use Disorder (SUD)
Child and Adolescent Strengths and Needs (CANS)
2.0 Assessor (submit documentation verifying
completion of training and certification as
Assessor)
Child and Adolescent Strengths and Needs (CANS)
2.0 (Child Welfare) Assessor (submit documentation
verifying completion of training and certification
as Assessor)
Child-Parent Psychotherapy (CPP)
Cognitive Processing Therapy (CPT)
Community Support Team Treatment (CST)
Comprehensive Multi-Disciplinary Evaluation (CMDE
Coordinated Specialty Care for First Episode
Psychosis (CSC)
Critical Incident Stress Debriefing (submit CISD
certificate)
Early Intensive Developmental and Behavioral
Intervention (EIDBI)
Early Intervention Provider (Virginia Medicaid Only –
submit applicable certification)
Employee Assistance Professional
Neuropsychological Testing – Psychologists only
Nurses and Physician Assistants – Buprenorphine –
Medication Assisted Treatment (MAT) (submit
certification email from DEA)
Nurses–Prescriptive Privileges (submit ANCC
certificate, Prescriptive Authority, DEA certificate
and/or State
Controlled Substance certificate, based upon state
requirement)
Office-Based Addictions Treatment (OBAT)
Parent-Child Interaction Therapy (PCIT)
Preschool PTSD Treatment (PPT)
Prolonged Exposure (PE)
4
BH3575_Spec Attest Rev. v.15_092021 United Behavioral Health and United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum
U.S. Behavioral Health Plan, California doing business as OptumHealth Behavioral Solutions of California
Physician Specialties (cont.)
Non-Physician Specialties (cont.)
Trauma Informed Care (TIC) (submit documentation of
completion of TIC training)
Triple P (Positive Parenting Program) (submit copy of
certification in Triple P – Standards Level 4)
Trust-Based Relational Intervention (TBRI) (submit
documentation of completion of TBRI training)
Youth PTSD Treatment (YPT)
Substance Abuse Expert (submit Nuclear
Regulatory Commission qualification training
certificate)
Substance Abuse Professional (submit Department
of Transportation certificate)
Trauma-Focused Cognitive Behavioral Therapy (TF-
CBT) (submit copy of TF-CBT certification)
Trauma Informed Care (TIC) (submit documentation
of completion of TIC training)
Triple P (Positive Parenting Program) (submit copy of
certification in Triple P – Standards Level 4)
Trust-Based Relational Intervention (TBRI) (submit
documentation of completion of TBRI training)
Veterans Administration Mental Health Disability
Examination –Psychologists only
Youth PTSD Treatment (YPT)
Employee Assistance Program (non-prescribers)
An Employee Assistance Program (EAP) is a health and wellness service provided by an employer. A member receiving
this service has no financial responsibility–no deductible, co-payment or coinsurance amount. EAP is designed to
provide assessment and referral, as well as a brief counseling intervention for Members and/or their families. All Optum-
contracted therapists are allowed to provide and bill for EAP services. All Optum in-network therapists are expected to
support and accept Members who request an EAP benefit (in compliance with your Agreement). (There are limitations
around the use of EAP benefits with prescribers.) Please select your area of expertise for EAP from the list below:
Provides Employee Assistance Program services – By checking this box, you acknowledge that, as a contracted
Optum therapist, you are expected to support and accept Members who request an EAP appointment, in accordance
with your Agreement. (Not applicable to prescribers.)
Providers who have additional EAP training or certification may attest to meeting requirements shown below and be
designated with the expertise in Optum’s online provider directory. If you meet the requirements of either of the two
designations shown below, select the one you meet. NOTE: neither of the two designations listed below is required in
order to provide EAP services.
Certified Employee Assistance Professional (submit Certificate from the Employee Assistance Certification
Commission)
Employee Assistance Professional requires:
Minimum of two (2) years’ experience in the delivery of EAP core technology as defined by EAPA, and
Minimum of one (1) annual training (CEU credits or professional development hours) in any of the eight (8) EAP content
areas
No Specialties (must be checked if no other specialties are being designated)
I understand that Optum may require documentation to verify that I meet the criteria outlined under Specialty
Requirements pertaining to the specialty or specialties I have designated above. I will cooperate with an Optum
documentation audit, if requested, to verify that I meet the required criteria.
I hereby attest that all of the information above is true and accurate to the best of my knowledge. I understand that any
information provided pursuant to this attestation that is subsequently found to be untrue and/or incorrect could result in my
termination from the Optum network
.
Please note that standard credentialing criteria must be met before specialty designation can be considered. All clinicians
must sign this form whether specialties are applicable or not. Failure to sign this form may cause a delay in the processing of
your initial credentialing file.
I acknowledge that I have read the Agreement, Network Manual, and, if applicable for my state, the State Regulatory
Attachment, Medicare Regulatory Attachment and/or Medicaid Regulatory Attachment.
Printed Name of Applicant:
Signature of Applicant
Signature stamps are not accepted.
click to sign
signature
click to edit
Important Note: Signature on the above Attestation is required of all applicants
5
BH3575_Spec Attest Rev. v.15_092021 United Behavioral Health and United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum
U.S. Behavioral Health Plan, California doing business as OptumHealth Behavioral Solutions of California
PHYSICIAN SPECIALTY REQUIREMENTS
CHILD/ADOLESCENT:
• Completion of an ACGME approved Child and Adolescent Fellowship OR recognized certification in Child Psychiatry (This specialty includes Infants,
Preschool, Children and Adolescents)
GERIATRICS:
• Completion of an ACGME approved Geriatric Fellowship OR recognized certification in Geriatric Psychiatry
BUPRENORPHINE – MEDICATION ASSISTED TREATMENT:
• DEA registration certificate with the DATA 2000 prescribing identification number
CERTIFIED GROUP PSYCHOTHERAPIST:
• Must have Board Certification from the International Board for Certification of Group Psychotherapists (IBCGP_
CHEMICAL DEPENDENCY / SUBSTANCE ABUSE / SUBSTANCE USE DISORDER:
• Completion of an ACGME Board certification in addiction psychiatry OR certified by the American Society of Addiction Medicine (ASAM)/renamed
American Board of Addiction Medicine (ABAM)
CHILD and ADOLESCENT NEEDS AND STRENGTHS (CANS) 2.0 ASSESSOR
• Must have completed training on CANS and be certified as an Assessor
CHILD and ADOLESCENT NEEDS AND STRENGTHS (CANS) 2.0 (CHILD WELFARE) ASSESSOR
• Must have completed training on CANS and be certified as an Assessor
CHILD-PARENT PSYCHOTHERAPY (CPP):
• Must have Certificate of Completion of Child-Parent Psychotherapy from a trainer endorsed by the University of California, San Francisco
COGNITIVE PROCESSING THERAPY (CPT):
• Licensed mental health provider must complete training in CPT by approved trainer
•
Must complete 2 cases to acceptable fidelity to the model under consultation with an expert consultant
COMMUNITY SUPPORT TEAM TREATMENT (CST):
• Must be certified to provide CST by the Illinois Department of Human Services’ Division of Mental Health and approved to provide CST by the
Department of Healthcare and Family Services, or its designee, in accordance with 89 Ill. Adm. Code 140
COMPREHENSIVE MULTI-DISCIPLINARY EVALUATION (CMDE):
• Must meet Department of Human Services (DHS) Early Intensive Developmental and Behavioral Intervention (EIDBI) requirements
COORDINATED SPECIALTY CARE for FIRST EPISODE PSYCHOSIS (CSC):
• Must be contracted with the Illinois Department of Human Services’ Division of Mental Health to be FIRST.IL provider to deliver coordinated specialty
care for first episode psychosis treatment
DEVELOPMENTAL RELATIONSHIP-BASED INTERVENTION (DRBI):
• Requires certification in DRBI
EARLY INTENSIVE DEVELOPMENTAL AND BEHAVIORAL INTERVENTION (EIDBI):
• Must meet Department of Human Services (DHS) Early Intensive Developmental and Behavioral Intervention (EIDBI) requirements
EARLY INTERVENTION PROVIDER (Virginia Medicaid Only):
• Must be certified by the Department of Behavioral Health and Developmental Services (DBHDS) to provide Early Intervention services in accordance
with 12 VAC 30-50-131
• Providers of Early Intervention Care Management/Service Coordination must be certified through DBHDS as a Service Coordinator
MEDICAID OFFICE-BASED OPIOID TREATMENT PROGRAM (OBOT):
• State certificate, if applicable in your state
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.
OFFICE-BASED ADDITIONS TREATMENT (OBAT)
• Provider must have hired a Navigator to assist with OBAT services
PARENT-CHILD INTERACTION THERAPY (PCIT):
• Must be certified by PCIT International
PRESCHOOL PTSD TREATMENT (PPT):
• Must have Advanced Certificate from Tulane Psychiatry in Youth PTSD Treatment
PROLONGED EXPOSURE (PE):
• Licensed mental health provider must complete training in PE by approved trainer
• Must complete 2 cases to acceptable fidelity to the model under consultation with an expert consultant
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)
TRANSCRANIAL MAGNETIC STIMULATION (TMS)
• Completed all training related to FDA-cleared device(s) to be used in accordance with FDA-labeled indications
• In order to include this specialty on your provider record, we require an Amendment to your Agreement. If you designate this specialty, the Amendment
will be sent to you separately for your signature
Important Note: Signature on the above Attestation is required of all applicants
6
BH3575_Spec Attest Rev. v.15_092021 United Behavioral Health and United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum
U.S. Behavioral Health Plan, California doing business as OptumHealth Behavioral Solutions of California
PHYSICIAN SPECIALTY REQUIREMENTS (cont.)
TRAUMA-FOCUSED COGNITIVE BEHAVIORAL THERAPY (TF-CBT)
•
Must have obtain a certification from the Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program
TRAUMA INFORMED CARE (TIC)
• Must have completed training in Trauma Informed Care
TRIPLE P (Positive Parenting Program)
• Must have an accreditation certification in Triple P – Standards Level 4, issued by Triple P America
TRUST-BASED RELATIONAL INTERVENTION (TBRI)
• Must have completed training in Trust-Based Relational Intervention
YOUTH PTSD TREATMENT (YPT):
• Must have Advanced Certificate from Tulane Psychiatry in Youth PTSD Treatment
PSYCHOLOGISTS, NURSES & MASTER’S LEVEL CLINICIANS SPECIALTY REQUIREMENTS
CHILD/ADOLESCENT – Psychologists Only:
• Completion of an APA approved or other accepted training/certification program in Clinical Child Psychology (This specialty includes Infants, Preschool,
Children and Adolescents)
CERTIFIED GROUP PSYCHOTHERAPIST:
• Must have Board Certification from the International Board of Certification of Group Psychotherapists (IBCGP)
CHEMICAL DEPENDENCY / SUBSTANCE ABUSE / SUBSTANCE USE DISORDER:
• Completion an APA or other accepted training in Addictionology
OR
• Certification in Addiction Counseling
AND one (1) or more of the following:
• Ten (10) hours of CEU in Substance Abuse in the last twenty-four (24) month period
• Evidence of twenty-five percent (25%) practice experience in substance abuse
CHILD and ADOLESCENT NEEDS AND STRENGTHS (CANS) 2.0 ASSESSOR
• Must have completed training on CANS and be certified as an Assessor
CHILD and ADOLESCENT NEEDS AND STRENGTHS (CANS) 2.0 (CHILD WELFARE) ASSESSOR
• Must have completed training on CANS and be certified as an Assessor
CHILD-PARENT PSYCHOTHERAPY (CPP):
• Must have Certificate of Completion of Child-Parent Psychotherapy from a trainer endorsed by the University of California, San Francisco
COGNITIVE PROCESSING THERAPY (CPT):
• Licensed mental health provider must complete training in CPT by approved trainer
• Must complete 2 cases to acceptable fidelity to the model under consultation with an expert consultant
COMMUNITY SUPPORT TEAM TREATMENT (CST)
• Must be certified to provide CST by the Illinois Department of Human Services’ Division of Mental Health and approved to provide CST by the
Department of Healthcare and Family Services, or its designee, in accordance with 89 Ill. Adm. Code 140
COORDINATED SPECIALTY CARE for FIRST EPISODE PSYCHOSIS (CSC)
• Must be contracted with the Illinois Department of Human Services’ Division of Mental Health to be FIRST.IL provider to deliver coordinated specialty
care for first episode psychosis treatment
CRITICAL INCIDENT STRESS DEBRIEFING:
• Certificate of CISD training from American Red Cross or Mitchell model
•
Documentation of training and CEU units in the provision of CISD services
DEVELOPMENTAL RELATIONSHIP-BASED INTERVENTION (DRBI)
• Requires certification in DRBI
EARLY INTERVENTION PROVIDER (Virginia Medicaid Only)
• Must be certified by the Department of Behavioral Health and Developmental Services (DBHDS) to provide Early Intervention services in accordance
with 12 VAC 30-50-131
• Providers of Early Intervention Care Management/Service Coordination must be certified through DBHDS as a Service Coordinator
EMPLOYEE ASSISTANCE PROFESSIONAL (EAP):
• Minimum of two (2) years’ experience in the delivery of EAP core technology as defined by EAPA, and
•
Minimum of one (1) annual training (CEU credits or professional development hours) in any of the eight (8) EAP content areas
NEUROPSYCHOLOGICAL TESTING – Psychologists Only:
• Member of the American Board of Clinical Neuropsychology OR the American Board of Professional Neuropsychology
OR
• Completion of courses in Neuropsychology including: Neuroanatomy, Neuropsychological testing, Neuropathology, or Neuropharmacology
• Completion of an internship, fellowship, or practicum in Neuropsychological Assessment at an accredited institution
AND
• Two (2) years of supervised professional experience in Neuropsychological Assessment
NURSES & PHYSICIAN ASSISTANTS - BUPRENORPHINE – MEDICATION ASSISTED TREATMENT:
• Certification from DEA
NURSES REQUESTING PRESCRIPTIVE AUTHORITY MUST:
• Possess a currently valid license as a Registered Nurse in the state(s) in which you practice
• Be authorized for prescriptive authority in the state in which you practice
• Meet state specific mandates for the state in which you practice regarding DEA license and physician supervision
• Attest that you meet your state’s collaborative or supervisory agreement requirements
•
Specifically request prescriptive privileges on the Optum application above
Important Note: Signature on the above Attestation is required of all applicants
7
BH3575_Spec Attest Rev. v.15_092021 United Behavioral Health and United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum
U.S. Behavioral Health Plan, California doing business as OptumHealth Behavioral Solutions of California
PSYCHOLOGISTS, NURSES & MASTER’S LEVEL CLINICIANS SPECIALTY REQUIREMENTS (cont.)
OFFICE-BASED ADDITIONS TREATMENT (OBAT)
• Provider must have hired a Navigator to assist with OBAT services
PARENT-CHILD INTERACTION THERAPY (PCIT):
• Must be certified by PCIT International
PRESCHOOL PTSD TREATMENT (PPT):
• Must have Advanced Certificate from Tulane Psychiatry in Youth PTSD Treatment
PROLONGED EXPOSURE (PE):
• Licensed mental health provider must complete training in PE by approved trainer
• Must complete 2 cases to acceptable fidelity to the model under consultation with an expert consultant
SUBSTANCE ABUSE EXPERT (SAE) - Nuclear Regulatory Commission (NRC):
• To qualify as an SAE for the NRC, you must possess one of the following credentials:
• Licensed or certified social worker
• Licensed or certified psychologist
• Licensed or certified employee assistance professional
• Certified alcohol and drug abuse counselor - The NRC recognizes alcohol and drug abuse certification by the National Association of Alcoholism and
Drug Abuse Counselors Certification Commission (NAADAC) or by the International Certification Reciprocity Consortium/Alcohol and Other Drug Abuse
(ICRC/AODA).
AND
• Certificate of NRC SAE qualification training (agencies providing such certification include, but are not limited to, ASAP, Inc., Program Services, and
SAPAA)
SUBSTANCE ABUSE PROFESSIONAL (SAP):
• Certificate of training in federal Department of Transportation SAP functions and regulatory requirements (agencies providing such certification include,
but not limited to, Blair and Burke, EAPA and NMDAC)
TRAUMA-FOCUSED COGNITIVE BEHAVIORAL THERAPY (TF-CBT)
• Must have obtain a certification from the Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program
TRAUMA INFORMED CARE (TIC)
• Must have completed training in Trauma Informed Care
TRIPLE P (Positive Parenting Program)
• Must have an accreditation certification in Triple P – Standards Level 4, issued by Triple P America
TRUST-BASED RELATIONAL INTERVENTION (TBRI)
•
Must have completed training in Trust-Based Relational Intervention
VETERANS ADMINISTRATION MENTAL HEALTH DISABILITY EXAMINATION – Psychologists Only:
• Graduate of an American Psychological Association accredited university (qualification counts even if accreditation occurred after date of graduation)
• Wheelchair accessible office
• PC user (Macintosh/Mac computers do not interface with the testing software used in the Disability Examination)
• Agree to participate in initial and annual training programs as required by LHI
• Agree to offer appointments within 10 to 14 days of the request for services
• Agree that beneficiary will not wait longer than 20 minutes in the office before being tested
YOUTH PTSD TREATMENT (YPT):
• Must have Advanced Certificate from Tulane Psychiatry in Youth PTSD Treatment
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

Optum Clinical Expertise Checklist Return the completed form

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 4 September 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document