Fillable Provider Enrollment Checklist for Behavioral Health Direct Service (State of Nevada, Department of Information Technology)

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Provider Enrollment Checklist for Behavioral Health Direct Service (State of Nevada, Department of Information Technology)

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Provider Enrollment Checklist for Behavioral Health Direct Service Provider
Updated 10/15/2019 Provider Enrollment Checklist
pv04/01/2015 1 / 3
Provider Type 14:
Licensed Clinical Social Worker (LCSW), Specialty 305
This checklist must be completed and submitted with the attachments listed below. If you have any questions,
please contact the Nevada Medicaid Provider Enrollment Unit at (877) 638-3472 from 8:00 a.m. to 5:00 p.m.
Monday through Friday.
Provider Name: _____________________________________________________Date: ____________________
National Provider Identifier (NPI): _______________________________________________________________
Attachments
Initial each space below to signify that a copy of the specified item is attached.
_____ SS-4, CP575 or W-9 form showing Taxpayer Identification Number (this may be the employer’s tax ID;
individual providers do not need their own tax ID if they are an employee of an entity/agency/group with a
tax ID)
_____ Professional License/Clinical Social Worker License
_____ Provider Enrollment Application and Contract (original document/signatures required)
Policy Declaration
I hereby declare that I have read the current Medicaid Services Manual (MSM) Chapters 100, 400 and 3300 as of
the date above and understand the policies and how they relate (apply) to my scope of practice. I acknowledge
that, as a Nevada Medicaid-contracted provider, I am responsible for complying with the MSM, with any updates
to this policy as may occur from time to time and with applicable state and federal laws.
LCSW/QMHP Signature: _____________________________________________Date: ________________
Policy Acknowledgement
By initialing each of the bolded items below, I agree to conform to these policy requirements.
_____ Rehabilitative Mental Health Services (MSM Chapter 400)
QMHP may provide Basic Skills Training (BST), Program for Assertive Community Treatment (PACT), Day
Treatment, peer-to-peer support, Psychosocial Rehabilitation (PSR) and Crisis Intervention (CI) services.
Day Treatment services may be requested and reimbursed for Provider Type 14 groups who are enrolled
with Specialty 308 and have a Day Treatment Model approved by DHCFP. Day Treatment may not be
performed or reimbursed by individuals enrolled as a Provider Type 14 with specialties 300, 305, 306 and
307.
Provider Enrollment Checklist for Behavioral Health Direct Service Provider
Updated 10/15/2019 Provider Enrollment Checklist
pv04/01/2015 2 / 3
Provider Type 14:
Licensed Clinical Social Worker (LCSW), Specialty 305
_____ Service Delivery Models (MSM Chapter 400)
Independent Professionals - State of Nevada licensed: psychiatrists, psychologists, clinical social workers,
marriage and family therapists and clinical professional counselors: These providers are directly
reimbursed for the professional services they deliver to Medicaid eligible recipients in accordance with
their scope of practice, state licensure requirements and expertise.
Individual Rehabilitative Mental Health (RMH) providers must meet the provider qualifications for the
specific service. If they cannot independently provide clinical and direct supervision, they must arrange for
clinical and direct supervision through a contractual agreement with a Behavioral Health Community
Network (BHCN) or qualified independent professional. These providers may directly bill Nevada Medicaid
or may contract with a BHCN.
_____ Provider Standards (MSM Chapter 400)
All providers must:
1. Provide medically necessary services;
2. Adhere to the regulations prescribed in Chapter 400 and all applicable Division chapters;
3. Provide only those services within the scope of their [the provider’s] practice and expertise;
4. Ensure care coordination to recipients with higher intensity of needs;
5. Comply with recipient confidentiality laws and Health Insurance Portability and Accountability Act (HIPAA);
6. Maintain required records and documentation;
7. Comply with requests from the Quality Improvement Organization (QIO)-like vendor [DXC
Technology, which is referred to as Nevada Medicaid];
8. Ensure client’s [recipient’s] rights; and
9. Cooperate with Division of Health Care Financing and Policy’s (DHCFP’s) review process.
_____ Clinical Supervision (MSM Chapter 400)
Qualified Mental Health Professionals (QMHP), operating within the scope of their practice under state
law, may function as Clinical Supervisors. Clinical Supervisors must have the specific education,
experience, training, credentials, and licensure to coordinate and oversee an array of mental and
behavioral health services. Clinical Supervisors must assure that the mental and/or behavioral health
services provided are medically necessary and clinically appropriate. Clinical Supervisors assume
professional responsibility for the mental and/or behavioral health services provided.
Clinical Supervisors can supervise QMHP, Qualified Mental Health Associates (QMHA) and Qualified
Behavioral Aides (QBA). Clinical Supervisors may also function as Direct Supervisors.
Clinical supervisors must assure the following:
1. An up to date (within 30 days) case record is maintained on the recipient;
2. A comprehensive mental and/or behavioral health assessment and diagnosis is accomplished prior to
providing mental and/or behavioral health services (with the exception of Crisis Intervention services);
3. A comprehensive and progressive treatment plan and/or rehabilitation plan is developed and
approved by the clinical supervisor and/or a direct supervisor, who is a QMHP;
Provider Enrollment Checklist for Behavioral Health Direct Service Provider
Updated 10/15/2019 Provider Enrollment Checklist
pv04/01/2015 3 / 3
Provider Type 14:
Licensed Clinical Social Worker (LCSW), Specialty 305
4. Goals and objectives are time specific, measurable (observable), achievable, realistic, time limited,
outcome driven, individualized, progressive, and age and developmentally appropriate;
5. The recipient and their family/legal guardian (in the case of legal minors) participate in all aspects of
care planning, that the recipient and their family/legal guardian (in the case of legal minors) sign the
treatment and/or rehabilitation plans, and that the recipient and their family/legal guardian (in the
case of legal minors) receive a copy of the treatment and/or rehabilitation plans;
6. The recipient and their family/legal guardian (in the case of legal minors) acknowledge in writing that
they understand their right to select a qualified provider of their choosing;
7. Only qualified providers provide prescribed services within scope of their practice under state law; and
8. Recipients receive mental and/or behavioral health services in a safe and efficient manner.
Qualifications
I have read, understand and meet the qualifications as outlined in MSM Chapter 400, Provider Qualifications for a
QMHP.
LCSW/QMHP Signature: _____________________________________________Date: _______________________
Changes to Medicaid Information
If your direct supervisor, clinical supervisor or employer change or any other pertinent information changes from
what is presented above and on your enrollment application, you are required to notify Nevada Medicaid within
five working days. All changes must be reported by using the Provider Web Portal at
https://www.medicaid.nv.gov/hcp/provider/Home/tabid/135/Default.aspx. After logging in, click on the
“Revalidate – Update Provider” link under Provider Services. The Online Provider Enrollment User Manual Chapter
3 Revalidation and Updates on the Provider Enrollment webpage at https://www.medicaid.nv.gov provides
instructions on navigating the Update Provider tool.
Per MSM Chapter 100, Medicaid providers, and any pending contract approval, are required to report, in writing
within five working days, any change in ownership, address, or addition or removal of practitioners, or any other
information pertinent to the receipt of Medicaid funds. Failure to do so may result in termination of the contract
at the time of discovery.
I hereby accept Nevada Medicaid’s change notification requirements:
LCSW/QMHP Signature: ____________________________________________ Date: ________________________
Reporting Fraud
I understand that Nevada Medicaid payments are made from federal and state funds and that any falsification, or
concealment of a material fact, may be prosecuted under federal and state laws. Providers have an obligation to
report to the Division of Health Care Financing and Policy (DHCFP) any suspicion of fraud or abuse in DHCFP
programs, including fraud or abuse associated with recipients or other providers (MSM Chapter 3300). Examples of
fraudulent acts, false claims and abusive billing practices are listed in MSM Chapter 3300. Alleged fraud, abuse or
improper payment may be reported by calling (775) 687-8405.
I hereby agree to abide by Nevada Medicaid’s fraud reporting requirements:
LCSW/QMHP Signature: _____________________________________________ Date: _______________________
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Provider Enrollment Checklist for Behavioral Health Direct Service (State of Nevada, Department of Information Technology)

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Completed 15 March 2022

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