Skip Navigation Links
Text Size A A A
Skip Navigation Links

Attestation Form

for the MassHealth Behavioral Health Urgent Care Program

Commonwealth of Massachusetts | Executive Office of Health and Human Services | www.mass.gov/masshealth


Section I: INSTRUCTIONS

Mental Health Centers (MHCs) interested in participating in the MassHealth Behavioral Health Urgent Care Program must submit this attestation of clinical and programmatic requirements. MHCs that are interested in participating in the Behavioral Health Urgent Care Program for multiple site locations must submit a separate attestation form for each location that meets the requirements outlined in Section III. For provider organizations with multiple locations, only the site listed on this form will be designated a Behavioral Health Urgent Care provider.

Any provider that fails to fulfill any of the requirements below or that is unable to serve Members as intended will not be considered a Behavioral Health Urgent Care provider. In addition, if at any point, the MHC is unable to meet the requirements, the MHC must provide notice immediately. Notice shall include the date on which the MHC stopped meeting the requirements for participation in this program.

Questions about this form can be addressed to BHUrgentCareAttestation@carelon.com. All information is subject to audit and verification by MassHealth.

MHCs interested in participating in the Behavioral Health Urgent Care program must submit this form. Eligibility will be determined and effective within 30 days of date of submission.


Section II: PRACTICE INFORMATION
Name:
 Business Name(if applicable):
Address:
 City:
 State:
Zip Code:
Business Telephone No:
 Business Email Address:
Contact Name:
 Contact Telephone:
 Contact Email Address:
MassHealth Provider ID:
Provider NPI:

SECTION III: REQUIREMENTS FOR BEHAVIORAL HEALTH URGENT CARE DESIGNATION
To participate in the Behavioral Health Urgent Care Program, the MHC must satisfy the following requirements:
  1. The MHC is enrolled in MassHealth as a provider of mental health center services pursuant to 130 CMR 429.000;
  2. The MHC is able to provide appointments for diagnostic evaluations for new clients on the same or next day of clinic operation, when clinically indicated based on initial intake;
  3. The MHC is able to provide appointments for all existing clients with an urgent behavioral health need on the same or next day of clinic operation;
    1. Urgent behavioral health needs are characterized by changes in behavior or thinking, role dysfunction, emerging intent of self-injury, or threats to others, but do not include immediate risk of harm to self or others;
  4. The MHC is able to provide urgent psychopharmacology appointments and Medication for Addiction Treatment evaluation within 72 hours of an initial diagnostic evaluation and based on a psychosocial assessment;
  5. The MHC is able to provide all other treatment appointments, including follow-up appointments, within 14 calendar days;
  6. The MHC has extended appointment availability, including:
    • A minimum of 8 hours of extended appointments on Mondays through Fridays outside the hours of 9 a.m. -- 5 p.m.; and
    • A minimum of two 4-hour blocks of appointments on weekends per month;
  7. The MHC meets the reporting requirements below; and
  8. The MHC makes Member experience surveys available to all clients.

SECTION IV: REPORTING REQUIREMENTS
Behavioral Health Urgent Care providers must submit a quarterly report. The report is submitted using a template provided by MBHP which includes the following data. MBHP will provide an updated template if reporting requirements are modified.
  • Percentage of total quarterly visits during extended appointment hours;
  • Percentage of total quarterly initial evaluations completed within 1 day of clinic operation following the first contact;
  • Percentage of total quarterly urgent visits for clients completed within 1 day of clinic operation;
  • Percentage of total quarterly urgent appointments that occur within 72 hours of initial diagnostic evaluation;
  • Percentage of total quarterly routine or follow-up visits completed within 14 calendar days of initial contact
These requirements are subject to change, as directed by EOHHS.

SECTION V: ATTESTATION

By completing Section V, you attest to compliance with the Behavioral Health Urgent Care requirements.

I certify under the pains and penalties of perjury that the information on this form that I have provided has been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.


Printed legal name of authorized practice representative

Confirm legal name of authorized practice representative (Confirmation serves as your legal signature.)
Date