Fresno County Behavioral Health Provider Credentialing Guide

CREDENTIALING TRAINING FRESNO COUNTY PLAN ADMINISTRATION

BECOMING A CONTRACTED PROVIDER The Managed Care Division of the Department of Behavioral Health processes credentialing applications for contracted providers and in-house providers. Find the credentialing application on the Fresno County Website Become A Contract Provider | County of Fresno The Fresno County Credentialing Committee reviews and approves (or denies) credentialing applications for all providers, in-house and contracted providers.

MANAGED CARE WHO NEEDS TO BE CREDENTIALED HOW TO CONTACT MANAGED CARE The Managed Care team can be emailed at DBHPACredentialing@fresnocountyca.gov Staff members in your organization who are Licensed, Licensed-Eligible or Associate-Level, Waivered, Certified or Registered should be credentialed. Phone: 559-600-4645 Staff members providing billable services should be credentialed. Fax 559-455-4633 Applications can also be mailed to: Plan Administration Division 1925 E Dakota Ave Fresno CA 93726

TYPES OF APPLICATIONS Organizational Providers. Group or Individual Providers. DBH In-house Application (County Employees Only). Mental Health Rehabilitation Specialist. Non-credentialed/ non-clinical staff. Re-credentialing Application.

THE FRESNO COUNTY ORGANIZATIONAL APPLICATION Most mental health providers and all substance use providers will complete the Organizational Provider application. Once applications are completed, they can be submitted by email, fax or mail. Applications are usually returned for missing information, incomplete information or a combination of both. This presentation is designed to help avoid some common mistakes so applications can be processed in a timely manner.

GETTING AN NPPES ACCOUNT Every applicant must have an active account. Federal Data Base. DBH cannot provide technical support. Required for every provider.

FRESNO COUNTY BEHAVIORAL HEALTH SYSTEM OF CARE ORGANIZATIONAL PROVIDER STAFF APPLICATION INSTRUCTIONS For All Licensed, Unlicensed, Waivered, Certified or Registered Staff ALL FRESNO COUNTY CREDENTIALING APPLICATIONS COME WITH INSTRUCTIONS. Provide Copies of: 1. Government Issued Photo ID (Driver s License, Identification Card, U.S. Passport, etc.). 2. Your Drug Enforcement Agency (DEA) certificate (if applicable). 3. Copies of professional licenses and/or certificates. 4. Your current Curriculum Vitae or Resume. Also include supplemental information stating areas of cultural expertise, cultural training, and foreign languages spoken, read or written. 5. Release of Information (Certification) form. 6. Clinical Profile for Licensed Applicants and support material for any identified areas of specialty. Specialties are not required. 7. For Nurse Practitioners and Medical Residents, please provide a copy of your Standardized Procedures. 8. For Physician Assistants, please provide a copy of your Delegation of Services Agreement. Send the completed Application and additional forms listed above via one of these methods: Hand Deliver: Fresno County Managed Care 1925 E. Dakota Avenue, M/S 271 Fresno, CA 93726 Email: mcare@FresnoCountyCA.gov Send multiple applications separately. If you have any questions regarding this application, please call Managed Care Credentialing at 559-600- 4645. READ THESE OVER BEFORE COMPLETING YOUR APPLICATION. Mail: Fresno County Managed Care Credentialing P.O. Box 45003 Fresno, CA 93718-9886 Fax: 559-455-4633 Fresno County Behavioral Health System of Care Organizational Provider Application Rev. 6/2023 Page 1

REQUIRED DOCUMENTATION In addition to the application, there are documents each credentialing applicant must provide. Provide Copies of: 1. Government Issued Photo ID (Driver s License, Identification Card, U.S. Passport, etc.). 2. Your Drug Enforcement Agency (DEA) certificate (if applicable). 3. Copies of professional licenses and/or certificates. 4. Your current Curriculum Vitae or Resume. Also include supplemental information stating areas of cultural expertise, cultural training, and foreign languages spoken, read or written. 5. Release of Information (Certification) form. 6. Clinical Profile for Licensed Applicants and support material for any identified areas of specialty. Specialties are not required. 7. For Nurse Practitioners and Medical Residents, please provide a copy of your Standardized Procedures. For Physician Assistants, please provide a copy of your Delegation of Services Agreement. The required documents vary depending on the application and the provider type.

Section A of the application is the organizational provider information. Please be sure to complete the top portion of the application as well with dates and type of provider info. Also of note, Have you previously applied for credentialing with FCMHP or DMC-ODS is new to the application. Please answer this question. The organizational provider information can be standardized for your program. Complete Section A for your applicants; they do not usually have access to this information and this section cannot be left blank.

SECTION B IDENTIFYING INFORMATION B - APPLICANT INFORMATION Name (Full name as it appears on license and NPI): DOB: Practice Address (Must match NPI): Gender: City: State: ZIP: Phone: E-mail Address: Website: Is site ADA Compliant? Choose an answer Please include the applicant s name, birthdate, gender and practice address. The practice address is where the services will be provided. That same address must be on the applicant s NPI profile. Social Security Number: Ethnicity: Previous (Full) Name(s) You ve Worked Under: Languages spoken fluently (besides English): Select your discipline from the following categories: A. MEDICAL STAFF-Prescribing Please choose one of the following B. LICENSED/CERTIFIED CLINICAL STAFF Please choose one of the following C. UNLICENSED/REGISTERED CLINICAL STAFF Please choose one of the following Answer all the questions, including the ADA question, and whether the applicant has worked under any other names. Enter your licensing information Licensing, Certifying or Registering Organization Licensure, Certification or Registration Number Type of Licensure, Certification or Registration State Expiration Date All questions should be answered, include N/A where applicable. For all Unlicensed or Registered Clinical Staff: Please provide the name and license/certification information of your supervisor. Your supervisor must be a BHSOC credentialed provider and be able to supervise according to your licensing/certifying organization. Supervisor s Name: Licensing/Certifying Organization and Number: Unlicensed and registered staff must indicate a supervisor. That supervisor must be credentialed by the FCMHP.

SECTIONS C-H C - NATIONAL PROVIDER IDENTIFIER (NPI) AND TAXONOMY NUMBER Practice address(es) on NPI Registry must match practice address(es) on Credentialing Application. NPI Number: Taxonomy Number: Choose an item D - EMPLOYMENT/WORK HISTORY Current and/or previous last 10 years (must match resume) Dates From - To Supervisor Organization Reason for Leaving Name, Title, Phone No. Section C-NPI and Taxonomy-This information will be verified on the NPPES website. Make certain staff update their NPI accounts to include the practice address indicated on the application, their licensing number and state. E - PROFESSIONAL EDUCATION Please attach Curriculum Vitae(add additional rows as needed) Institution City/State Type of Program Graduation Year Degree Type F - PROVIDER NUMBERS - Complete only if applicable. Medi-Cal Provider No.: Medicare UPIN: Medicare Effective Date: Section D-Work history needs to encompass the past 10 years and match resumes. DEA Number: DEA Issuance Date: DEA Expiration Date: ECFMG No.: ECFMG Issuance Date: ECFMG Recertification Date: G - BOARD CERTIFICATIONS - Complete only if applicable Name of Board Certification Date Expiration Date (if applicable) Section E-Professional Education. H - HOSPITAL PRIVILEGES Current and Previous Hospital Sections F-H should be completed as applicable. Most applicants will not have information for F-H. Withdrawal Date (if applicable) City/State Appointment Date

SECTION I-DATA ATTESTATION I - PROFESSIONAL HISTORICAL DATA ATTESTATION You must answer all questions below if they do not apply mark N/A. If you answer Yes to any of the questions 1-14, please provide a detailed explanation on a separate page. The explanation should include dates, circumstances of the incident, outcome, current disposition, etc. 1 Yes No suspension is voluntary) Any professional license, certification, or registration ever denied, revoked, limited, suspended? (Even if 2 Yes No N/A DEA registration ever suspended, revoked, or otherwise limited in any state? 3 Yes No N/A Has your professional liability insurance coverage ever been terminated by action of an insurance company? Have you ever been denied professional liability insurance coverage or rated in a high-risk class for your professional specialty? 4 Yes No N/A Do you suffer from any physical or psychological illness, problem, injury, or health condition that may limit, impair, or affect your ability to practice? To your knowledge, has any information pertaining to you ever been reported to the National Practitioner Data Bank? Have you ever been denied membership or renewal thereof, been subject to probation, reprimanded, censured, sanctioned, investigated or disciplined by any health care organization, including but not limited to: Fresno County or another county mental health plan, hospital, health care facility, HMO, PPO, independent practitioner association, professional association, group/society, ethics committee, state licensing board, certification board/exam, professional standards review organization (PSRO), peer-review organization (PRO), or educational/training institution? Are you currently or have you ever been excluded, debarred, suspended or otherwise ineligible to participate in Federal (Medicare & Medi-Cal) health care programs, i.e., are you considered an ineligible person in regard to billing Federal health care programs? 5 Yes No 6 Yes No Staff should answer all 21 questions with Yes/No/or NA (don t leave any blank). 7 Yes No 8 Yes No Have you been convicted of a criminal offense that will make you an ineligible person, but you are not yet excluded from participating in Federal health care programs? Have you ever been convicted, suspended, or assessed a civil penalty under the anti-fraud and abuse provision of the Medicare or Medicaid program? 9 Yes No Questions 1-14, if answered yes, should be accompanied with an explanation. 10 Yes No 11 Yes No Are you currently under investigation by the Medicare and/or Medicaid programs? 12 Yes No N/A Have any malpractice claims been filed against you during the past seven (7) years? 13 Yes No Have you ever been convicted of gross misconduct, a felony, or a crime of moral turpitude? See Attachment 14 Yes No Are you presently using any illegal drugs? Have you completed continuing education requirements for license/certification/registration renewal per your State professional board? (Credentialing Committee may request evidence of CEU completion for auditing purposes). Have you completed Cultural Competency Training? (Evidence of CEU completion may be requested for auditing purposes by the Credentialing Committee) 15 Yes No N/A Associate Level (unlicensed) staff and registered SUD counselors should Mark N/A to question 15. 16 Yes No N/A For medical residents only: If you are not Board certified or eligible, are you working under the direction of a Board-certified physician? Name of this physician: 17 Yes No N/A For medical residents only: Are you a medical resident in Fresno County? If No, List State & County: 18 Yes No N/A For SUD Medical Directors only: I acknowledge that as part of the credentialing process I must be screened in accordance with 42 CFR 455.450(a) as a limited categorical risk within a year prior to serving as a SUD Medical Director under the Intergovernmental Agency Agreement. 19 Yes No N/A For SUD Medical Directors only: I have signed a Medicaid provider agreement with DHCS as required by 42 CFR 431.107. Make certain staff sign and date the page attesting the information they provided was true to the best of their knowledge. 20 Yes No N/A For SUD Medical Directors only: I hereby certify that I meet SUD medical director requirements as specified, and will comply with duties as outlined in CCR Title 22, 51000.24.4, 51000.70 and 51341.1(b)(28). J - SIGNATURE Please read this statement before signing: 21 Yes No N/A Information provided on this application may be verified, including but not limited to, by contacting former employers. My signature certifies that all the information on this Application, the Clinical Profile and any attached explanation page(s) is true, correct and complete. I understand and agree that any misstatements or omissions of material facts herein may cause forfeiture on my part of my right to participate as a provider with the Fresno County DMC-ODS & Mental Health Plan.

RELEASE OF INFORMATION CERTIFICATION Make certain staff complete the entire release of information page, with a signature, date and title. The title of the staff is the role they will be occupying inside your organization, for example, admissions specialist, rather than SUD counselor.

CLINICAL PROFILE Clinical Profile for LMFTs, LCSWs, LPCCs, Certified AOD Counselors & Licensed Psychologists (page 1 of 2) Please mark with an X all areas in which you have been trained, are clinically experienced, and are willing to treat. "Standard" areas do not require explanation, but for each area under "Specialties / Specialized Experience" you must provide specific information, including details such as where, when and time spent (part time = 16-31 hrs/wk) (full time = 32+ hrs/wk). Specialties indicate extensive practice in the area substantiated by a credential, certification and/or documented clinical experience. Use page 2 to provide this information. Please attach supporting documentation of your specialty in addition to your resume. I. Populations Treated/Cultural Focus Standard Children (6-11) Adolescents (12-17) Adults (18-64) Senior Adults (65+) African American Latino-Hispanic Asian / Pacific Islander Men Women Lesbian/Gay/Bisexual/Transgender Deaf & Hard of Hearing Other: part-time post-licensure experience. II. Problems/Disorders Treated Standard Adjustment Disorders Anxiety Disorders Attention Deficit Disorders Acute & Post Traumatic Disorders ACA/Co-Dependency Dissociative Disorders Mood Disorders Personality Disorders Psychotic Disorders Attachment Impulse Control Disorders Gender Identity Disorders HIV / AIDS Aging Substance Use Disorders Other: III. Service Areas/Techniques Standard Individual Therapy Family Therapy Couples Therapy Group Therapy Targeted Case Management Cognitive Behavioral Therapy Religious/Spiritual Court Services Motivational Interviewing Relapse Prevention Psychoeducation Trauma-informed Treatment Other: hours training and a minimum of 6 months full-time or 1 year part- time post-licensure experience. Specialties / Specialized Experience Infants/Toddlers (0-5) (certification) Developmental Delay/Cognitive Impaired Autism Spectrum Disorder (BCBA) Sexual Abuse - Victim/Survivor Sexual Abuse - Offender Other: * When not specified, to claim any "Specialty" area, the professional must be licensed and demonstrate a minimum of 32 hours training and a minimum of 6 months full-time or 1 year All licensed staff must complete a clinical profile. Specialties / Specialized Experience Domestic Violence (40hr training) MH w/Substance Abuse Disorders CADAC Eating Disorders Pain Management (40hr training or certification) Forensic (40training or certification) Anger Management Medication Monitoring Other: * When not specified, to claim any "Specialty" area, the professional must be licensed and demonstrate a minimum of 32 hours training and a minimum of 6 months full-time or 1 year part-time post-licensure experience. Any specialties listed required additional certifications and documentation to verify the specialties. Specialties / Specialized Experience Trauma-Focused CBT (certification) Play Therapy/Theraplay (certification) Biofeedback (certification) Hypnosis (certification) EMDR Therapy (certification) Psychological Testing (Psychologist license accepted.) LMFT/LCSW/LPCC must justify) Neuropsychological Testing (Psychologist license accepted; LMFT/LCSW/LPCC must justify) Other: * When not specified, to claim any "Specialty" area, the professional must be licensed and demonstrate a minimum of 32 Registered and/or unlicensed staff need not complete a clinical profile. Either omit the clinical profile pages or leave them blank.

INDIVIDUAL AND GROUP PROVIDER APPLICATIONS FRESNO COUNTY BEHAVIORAL HEALTH SYSTEM OF CARE INDIVIDUAL/GROUP PROVIDER APPLICATION Submission Date: Click or tap to enter a date Have you previously applied for credentialing with the FCMHP or DMC-ODS? Yes No Please complete all sections. Enter N/A if not applicable. Verify all elements of the application are included or it will not be processed. Please print or type information. Approval of credentialing is based on regulatory requirements being met. No services can be provided until applicant has been approved. A - PROVIDER INFORMATION Name (Full name as it appears on license and NPI): DOB: Practice Address (must match NPI): Gender: These application must be completed as thoroughly as organizational provider applications. City: State: ZIP: Phone: E-mail Address: Website: Is site ADA Compliant? Choose an answer Social Security Number: Ethnicity: Previous (Full) Name(s) You ve Worked Under: Languages spoken fluently (besides English): Select your discipline from the following categories: MEDICAL STAFF-Prescribing Please choose one of the following LICENSED/CERTIFIED CLINICAL STAFF Please choose one of the following UNLICENSED/REGISTERED CLINICAL STAFF Enter your licensing information Please choose one of the following Licensing, Certifying or Registering Organization Licensure, Certification or Registration Number Type of Licensure, Certification or Registration State Expiration Date A few different items will be requested. For all Unlicensed or Registered Clinical Staff: Please provide the name and license/certification information of your supervisor. Your supervisor must be a BHSOC credentialed provider and be able to supervise according to your licensing/certifying organization. Supervisor s Name: Licensing/Certifying Organization and Number: B - NATIONAL PROVIDER IDENTIFIER (NPI) Practice address must match primary practice address AND TAXONOMY NUMBER NPI Number: Taxonomy Number: Choose an item C - PRACTICE LOCATION(S) (MUST MATCH NPI) Office #1 Office #2 Street Address: Street Address: City, State, ZIP: City, State, ZIP: Tax ID: (if different from SSN) Tax ID: (if different from SSN) Phone: Phone:

Type of Practice: Please choose one of the following Legal Name of Practice: Please provide the names and disciplines of other providers in the group: (Add additional rows as needed) INDIVIDUAL AND GROUP PROVIDER APPLICATIONS Name Discipline Name Discipline D EMPLOYMENT/WORK HISTORY Current and/or previous last 10 years (must match resume) Dates From To Supervisor Organization Reason for Leaving Name, Title, Phone No. Insurance information is required. E PROFESSIONAL EDUCATION Please attach Curriculum Vitae (add additional rows as needed) Institution City/State Type of Program Graduation Year Degree Along with the availability of all the individuals who work for the group. F PROVIDER NUMBERS - Complete only if applicable Medi-Cal Provider No.: Medicare UPIN: Medicare Effective Date: DEA Number: DEA Issuance Date: DEA Expiration Date: ECFMG No.: ECFMG Issuance Date: ECFMG Recertification Date: G BOARD CERTIFICATIONS - Complete only if applicable Name of Board Certification Date Expiration Date (if applicable) H HOSPITAL PRIVILEGES Current and Previous Hospital City/State Appointment Date Withdrawal Date (if applicable) I INSURANCE/MALPRACTICE LIABILITY INFORMATION Current Insurance Company and Coverage Information - Please attach a copy of the current policy Carrier Name: Phone No.: Street Address: City/State/ZIP: Effective Date: Expiration Date: Previous Insurance Company Please list all Insurance Companies within the past five (5) years Carrier Name: Phone No.: Street Address: City/State/ZIP: Effective Date: Expiration Date: J AVAILABILITY/ACCESSIBILITY Are you currently accepting new clients? Yes Days Available Fax No: Claim Limit: Aggregate Limit: Fax No.: Claim Limit: Aggregate Limit: No No Wheelchair accessible? Thursday Yes Monday Tuesday Friday Wednesday Saturday Sunday

IN-HOUSE APPLICATION FRESNO COUNTY BEHAVIORAL HEALTH SYSTEM OF CARE Pre-Employment License & Background Verification Form IN-HOUSE PROGRAMS Submission Date:Click or tap to enter a dateProjected Start Date:Click or tap to enter a date Please choose the type of provider: Choose type of provider Have you previously applied to be credentialed with the FCMH or DMC-ODS? Yes No Please complete all sections. Enter N/A if not applicable. Verify all elements of the application are included or it will not be processed. Please type or print information. Approval of credentialing is based on regulatory requirements being met. No services can be provided until applicant has been approved. A APPLICANT INFORMATION For DBH employees only. Name (As it appears on professional license and NPI): DOB: Practice Address (Must match NPI): Gender: City: State: ZIP: All document requirements are the same. Phone: E-mail Address: Website: Is site ADA Compliant? Choose an answer Social Security Number: Ethnicity: Previous (Full) Name(s) You ve Worked Under: No work history section, so county application required. Languages spoken fluently (besides English): Select your discipline from the following categories MEDICAL STAFF-Prescribing Please choose one of the following LICENSED/CERTIFIED CLINICAL STAFF Please choose one of the following UNLICENSED/REGISTERED CLINICAL STAFF Please choose one of the following Used for new employees as well as internal promotions. Enter your licensing information Licensing, Certifying or Registering Organization Licensure, Certification or Registration Number Type of Licensure, Certification or Registration State Expiration Date For all Unlicensed or Registered Clinical Staff: Please provide the name and license/certification information of your supervisor. Supervisor s Name: Licensing/Certifying Organization and Number: B - NATIONAL PROVIDER IDENTIFIER (NPI) AND TAXONOMY Practice address(es) on NPI Registry must match practice address(es) on this application. NUMBER

The Mental Health Rehabilitation Specialist (MHRS) is usually responsible for providing therapeutic behavioral interventions and replacement skill-building strategies for clients, assisting as a mental health worker with intake summaries, case management services to in accordance with client treatment plans. MENTAL HEALTH REHABILITATION SPECIALIST APPLICATIONS Specific educational and experience requirements according to CCR Title 9 630: A mental health rehabilitation specialist shall be an individual who has a baccalaureate degree and four years of experience in a mental health setting as a specialist in the fields of physical restoration, social adjustment, or vocational adjustment. Up to two years of graduate professional education may be substituted for the experience requirement on a year-for-year basis; up to two years of post associate arts clinical experience may be substituted for the required educational experience in addition to the requirement of four years' experience in a mental health setting. Not all applicants will qualify for this specialized position. Use the MHRS application. Applicant must include proof of academic degrees earned.

MENTAL HEALTH REHABILITATION SPECIALIST FRESNO COUNTY BEHAVIORAL HEALTH SYSTEM OF CARE ORGANIZATIONAL PROVIDER MENTAL HEALTH REHABLITATION SPECALIST NO clinical services are to be provided by these individuals Submission Date:Click or tap to enter a date Have you previously applied for credentialing with the FCMHP or DMC-ODS? Yes No A ORGANIZATIONAL INFORMATION Organization Name: Location: Program Name: Cost Center: The MHRS application is a shorter application. B - APPLICANT INFORMATION Name (As it appears on NPI profile): DOB: Practice Address (Must match NPI): Gender: City: State: ZIP: The academic degrees and transcripts must be clear and match the resume and application. Phone: E-mail Address: Website: Is site ADA Compliant? Choose an answer Social Security Number: Ethnicity: Previous (Full) Name(s) You ve Worked Under: Languages spoken fluently (besides English): Clinical Supervisor s Name & Discipline: The resume must clearly communicate the applicant's work history. C - NATIONAL PROVIDER IDENTIFIER (NPI) Practice address must match primary practice address AND TAXONOMY NUMBER NPI Number: Taxonomy Number: Choose an item D CONTACT PERSON FOR THIS REQUEST Name: Phone #: Email: E - EMPLOYMENT/WORK HISTORY Current and/or previous last 10 years (add additional rows as needed) Dates From - To Supervisor Organization Reason for Leaving Name, Title, Phone No.

NON-CREDENTIALING APPLICATION NON-CLINICAL AND NON- CREDENTIALED STAFF Used for CMHS or Pre-reg UMHC National Plan and Provider Enumeration System (NPPES) profile and NPI number required. No clinical services can be provided by these applicants. Will allow applicant to receive an Avatar number and bill for case management or counselor services.

THE PROCESS Once the application and all accompanying documentation are received, the credentialing process can begin. Department staff will contact contracted entities if there are questions or missing information. Contracted entities will have 10 business days to resubmit missing or inaccurate information before the application is withdrawn and will need to be resubmitted in its entirety. When all documentation has been verified and processed, the application is sent to a Credentialing Committee Member who will review the application. Applications which contain an affirmative answer to questions 1-14 on the data attestation will need to be approved by the credentialing committee at large. When the application is approved by the committee member, the applicant will be notified. An Avatar number will be requested for the provider. If the application is pended, the provider will be notified and given an opportunity to make the needed corrections. If applications are denied by the committee, staff will be notified in writing. Instructions will be included with the denial on how to appeal the committee s decision if that is an available option.