Download to - Medical Society of Virginia

COMMONWEALTH of VIRGINIA
Virginia Department of Medical Assistance Services
Addiction and Recovery Treatment Services (ARTS)
Office Based Opioid Treatment (OBOT) Provider Attestation and Application
Must accompany the DMAS Requirements for OBOT Providers Checklist and OBOT Staff Roster
Legal Name of Physician Office, CSB, or FQHC:
NPI:
TIN#
Address:
Agency:
Network Organizational Credentialing Standards Attestation
DMAS ARTS program requirements follow the criteria defined by the American Society of Addictions Medicine (ASAM) for the
provision of substance use disorder treatment services. OBOT providers shall provide services consistent with The ASAM National
Practice Guidelines for the Use of Medications in the Treatment of Addiction Involving Opioid Use (http://www.asam.org/docs/defaultsource/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf). If your organization meets
the ARTS requirements for OBOT providers, you must complete and return this attestation to Magellan and/or a Medicaid health plan
to be eligible for participation in the ARTS program. You must also provide all additional credentialing and/or contracting documents
required by Magellan and/or the Medicaid health plan.
Providers must attach hereto an organization staff roster of only those individuals who attest to meet ASAM and DMAS requirements
for OBOTs and attest that only these staff shall treat DMAS-eligible members. By completing and submitting this form, you attest that
your agency meets the DMAS requirements for the OBOT providers’ support systems, staff, and therapies requirements.
Buprenorphine-waivered practitioners and licensed behavioral health providers must enroll with Magellan and the Medicaid
health plans together as a group model to be credentialed and reimbursed as an OBOT provider. All billing must be under the
tax ID number of the buprenorphine-waivered practitioner or the organization employing the practitioner. The practitioner
will only be reimbursed at ARTS rates when practicing at the OBOT location in this attestation and application. There is no
separate Department of Behavioral Health and Developmental Services (DBHDS) licensing requirement for OBOT providers.
Complete and submit the ARTS OBOT Provider Attestation and Application and the DMAS Requirements for OBOT Providers
Checklist to DMAS to be reviewed at Fax: 804-452-5450. Contact Magellan and the Medicaid health plans to start the credentialing
process and submit any additional required credentialing and/or contracting documents to Magellan and the Medicaid health plans.
Magellan or the Medicaid health plan will inform you if you meet their requirements to be enrolled or credentialed as a Medicaid
provider in their network. Attesting to meeting DMAS criteria for OBOT providers does not guarantee enrollment or credentialing as a
Medicaid provider.
I hereby certify that all information contained in this document is true and accurate. I further understand that any information entered
in this document that subsequently is found to be false may result in termination of any agreement that I have or may enter into with
DMAS and/or its contractors. I agree to maintain professional liability insurance coverage for direct care staff as referenced in this
document and to update roster annually.
In compliance with the DMAS Provider Participation Agreement and ARTS Attestation and Application, provider attests that it will
permit only staff members who are fully licensed and/or meet DMAS program requirements established for Addiction Recovery and
Treatment Services to see and treat Medicaid and FAMIS eligible members.
I hereby give permission and consent for DMAS and/or its contractors, to obtain and verify information provided in this form and
consent to the release by any person, organization or other entity to DMAS and/or its contractors, of all information relevant to the
evaluation of my ability to render addiction recovery and treatment services in a cost-effective manner and my moral and ethical
qualifications, and agree to hold harmless any such person or organization from any cause of action based on the release of such
information to DMAS and/or its contractors.
By signing this attestation I agree that all statements are true and agree to abide by any contracted requirements for the services
delivered under the authority of this agreement.
Printed Name:
Title:
Signature:
Last updated 01162017
Date:
Virginia Department of Medical Assistance Services
Addiction and Recovery Treatment Services (ARTS) Provider Attestation Form
Page 1 of 3
CONTRACTED SITES OF CARE / Specific Service Delivery Location:
Please note: Sites of care cannot provide services to eligible members until credentialing is completed.
S1. COMMUNITY SERVICES BOARD / FQHC / PHYSICIAN OFFICE MAIN SITE
Legal Name of Provider:
Program Name (if applicable):
Tax ID#:
Street Address:
Medicare#:
City/State/Zip Code:
Medicaid#:
NPI(s)#
DEA/DEA-X#
Accreditation (if applicable):
AAAHC
HFAP
License#:
CARF
Physician Office
Psychiatry clinic
Department
Primary care clinic
Other:
Site Treatment Setting
(Check one)
COA
CSB
TJC
License Type:
Outpatient health system clinic
FQHC
Health
FQHC
Health
S2. LICENSED BEHAVIORAL HEALTH PROVIDER
Legal Name of Provider:
Program Name (if applicable):
Tax ID#:
Street Address:
Medicare#:
City/State/Zip Code:
Medicaid#:
NPI(s)#
License#:
Accreditation (if applicable):
Site Treatment Setting
(Check one)
Last updated 01162017
AAAHC
HFAP
CARF
Physician Office
Psychiatry clinic
Department
Primary care clinic
Other:
COA
CSB
TJC
License Type:
Outpatient health system clinic
Virginia Department of Medical Assistance Services
Addiction and Recovery Treatment Services (ARTS) Provider Attestation Form
Page 2 of 3
OBOT Provider Application: Model of Care Description
1. Describe the type of contractual relationship between the buprenorphine-waivered
practitioner/organization employing the practitioner and the behavioral health provider.
2. Describe the co-location of the licensed behavioral health provider at the same practice site.
a. Type of behavioral health providers on-site:
b. Frequency of behavioral health providers on-site:
c. Type of counseling providing (e.g., individual, group, family):
3. Describe the roles and functions of each of the members of your OBOT’s interprofessional team.
4. Describe how you will provide interdisciplinary care coordination to patients.
5. Describe how treatment for other physical and mental health conditions is provided as needed either
on-site or through collaboration with other providers.
6. Describe if your OBOT is part of a more comprehensive integrated behavioral health practice.
7. What organizations will you refer to if a higher level of treatment is needed for an unstable
patient (such as Intensive Outpatient Programs, Partial Hospitalization Programs, and/or
Residential Treatment)?
Last updated 01162017
Virginia Department of Medical Assistance Services
Addiction and Recovery Treatment Services (ARTS) Provider Attestation Form
Page 3 of 3