Provider Application – Substance Use Disorder Provider

Instructions:

Please complete the below application and provide comments as appropriate.

All information is confidential.

Required fields are marked with an asterisk (*)

The information entered on this page can be saved to allow for completion at a later date. Incomplete requests will automatically delete from the system after 30 days of inactivity.

Date*

Contact Name*

Contact Title*

Contact Phone Number*

Contact Email Address*

Enter Email Confirm Email

Section 1: Provider Information

Provider Name*

Include First Name, Middle Initial, and Last Name

Specialty*

NPI (Type I)*

10 Digit Number

Degree*

Section 2: Practice/Facility Information

Practice/Facility Name*

Title Role of Practice Owner

(i.e., Director, CEO, etc.)

Practice Owner's Full Name

NPI (Type II)*

10 Digit Number

Tax ID*

Address*

Street Address Address Line 2 City State ZIP

Office Phone Number*

Extension

Mailing Address (If different than above)

Street Address Address Line 2 City State ZIP

Website URL

Start with https://

Medical Director*

First Last

Section 3: Other Provider Information

Has the provider ever been excluded from participating with Medicare/Medicaid*

Has the provider ever been excluded from participating with Medicare/Medicaid *

Yes
No

Per regulatory requirements any provider who is excluded from participation with Medicaid and/or Medicare is unable to join the network. We encourage you to apply in the future should circumstances change.

Practice and its practitioners are enrolled with Rhode Island Medicaid*

Practice and its practitioners are enrolled with Rhode Island Medicaid *

Yes
No

Per federal requirements, all providers participating in the Neighborhood network are required to be enrolled with Rhode Island Medicaid. If you are currently not enrolled with Rhode Island Medicaid, please visit the Rhode Island Executive Office of Health and Human Services Provider Enrollment Page for additional information on how to enroll: Rhode Island Medicaid Provider Enrollment Application.

If you have any questions please address them in the below section.

Please Attach A Current W-9. W-9 Must have been completed within 6 months of today’s date.*

Accepted file types: pdf, Max. file size: 5 MB.

SUD Provider Participation Criteria

All practitioners requesting network participation must meet Neighborhood Health Plan of Rhode Island’s (Neighborhood) credentialing criteria (available upon request). Providers requesting to provider substance use disorder (SUD) treatment must meet the criteria below and, have a DEA waiver to prescribe for SUD treatment registered in each state the provider is proposing to treat Neighborhood’s members. Neighborhood retains the right to conduct a quality onsite assessment at any time

1. Practice is considered a Program under 42 CFR Part 2.*

1. Practice is considered a Program under 42 CFR Part 2. *

Yes
No

Practice is considered a Program under 42 CFR Part 2 - Comment

2. Practice employs clinicians who have completed appropriate training to provide formal SUD care.*

2. Practice employs clinicians who have completed appropriate training to provide formal SUD care. *

Yes
No

Practice employs clinicians who have completed appropriate training to provide formal SUD care - Comment

3. Practice has a mechanism to notify patient’s primary care practitioner of services being provided about the treatment given and arranging for appropriate follow up care.*

3. Practice has a mechanism to notify patient’s primary care practitioner of services being provided about the treatment given and arranging for appropriate follow up care. *

Yes
No

Practice has a mechanism to notify patient’s primary care practitioner of services being provided about the treatment given and arranging for appropriate follow up care - Comment

4. Practice provides preventive health counseling and anticipatory guidance including but not limited to: smoking avoidance/cessation, healthy eating habits, and reducing/avoiding alcohol use.*

4. Practice provides preventive health counseling and anticipatory guidance including but not limited to: smoking avoidance/cessation, healthy eating habits, and reducing/avoiding alcohol use. *

Yes
No

Practice provides preventive health counseling and anticipatory guidance including but not limited to: smoking avoidance/cessation, healthy eating habits, and reducing/avoiding alcohol use - Comment

5. Practice is open for 40 hours of appointment availability per week.*

5. Practice is open for 40 hours of appointment availability per week. *

Yes
No

If not: Please describe the process to ensure access to care.

6. Member has ability to obtain treatment within 24 hours*

6. Member has ability to obtain treatment within 24 hours *

Yes
No

Member has ability to obtain treatment within 24 hours - Comment

7. Practice has an Appointment System that promotes and provides same-day access.*

7. Practice has an Appointment System that promotes and provides same-day access. *

Yes
No

Practice has an Appointment System that promotes and provides same-day access - Comment

8. Practitioner coverage is available 24 hours per day 7 days per week.*

8. Practitioner coverage is available 24 hours per day 7 days per week. *

Yes
No

Practitioner coverage is available 24 hours per day 7 days per week - Comment

9. Practice has an electronic medical record (EMR) with: Evidence- and guideline-based protocols embedded in the medical record and Capability to E-prescribe*

9. Practice has an electronic medical record (EMR) with: Evidence- and guideline-based protocols embedded in the medical record and Capability to E-prescribe *

Yes
No

Practice has an electronic medical record (EMR) with: Evidence- and guideline-based protocols embedded in the medical record and Capability to E-prescribe - Comment

10. Office is handicapped accessible (including restrooms) and compliant with ADA*

10. Office is handicapped accessible (including restrooms) and compliant with ADA *

Yes
No

Office is handicapped accessible (including restrooms) and compliant with ADA - Comment

11. If injectable medication is administered – there is a process for regular disposal of needle/syringes.*

11. If injectable medication is administered – there is a process for regular disposal of needle/syringes. *

Yes
No

If injectable medication is administered – there is a process for regular disposal of needle/syringes - Comment

12. Containers are out of reach of children.*

12. Containers are out of reach of children. *

Yes
No

Containers are out of reach of children - Comment

13. Narcotics are stored in double locked storage.*

13. Narcotics are stored in double locked storage. *

Yes
No

Narcotics are stored in double locked storage - Comment

14. Process for checking medication validation is in place.*

14. Process for checking medication validation is in place. *

Yes
No

Process for checking medication validation is in place - Comment

15. There is a process in place for discarding narcotics.*

15. There is a process in place for discarding narcotics. *

Yes
No

There is a process in place for discarding narcotics - Comment

16. Please upload policy for handling unexpected medical emergencies.*

Accepted file types: pdf, Max. file size: 5 MB.

Comment for Policy for handling unexpected medical emergencies

17. Please upload policy for transferring patients to an inpatient detox*

Accepted file types: pdf, Max. file size: 5 MB.

Comment for Policy for transferring patients to an inpatient detox

18. Please upload policy for transferring patients to an outpatient detox*

Accepted file types: pdf, Max. file size: 5 MB.

Comment for Policy for transferring patients to an outpatient detox

19. Please upload policy for transferring patient to a partial hospital*

Accepted file types: pdf, Max. file size: 5 MB.

Comment for Policy for transferring patient to a partial hospital

As an authorized representative of the practice, indicated above, I have reviewed and attest the information given above is accurate and complete to the best of my knowledge.

Name/Title (print)*

Signature*

Signature Date*

Submission of this form does not guarantee participation in the Neighborhood Health Plan of Rhode Island network.

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