Oakland Unified School District (OUSD) looks forward to partnering with you for participation in California's CYBHI Multi-Payer Fee Schedule. This checklist lists the required steps for Fee Schedule participation. Please submit this form to OUSD to indicate which steps you have already completed. The OUSD team will then reach out about appropriate next steps. Thank you!

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* 1. Organization Name

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* 2. Contact Name

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* 3. Contact Email

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* 4. Contact Phone

SPI Roster Information: To designate your organization as an affiliated provider, OUSD must submit the following information on its SPI roster. Please fill provide this information for your organization.

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* 5. Provider Mailing Address

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* 6. Provider Email Address to Include on SPI Roster

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* 7. Provider Phone Number to Include on SPI Roster

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* 8. Provider Tax ID

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* 9. Provider Tax ID Type

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* 10. Provider Group/Facility Name

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* 11. Provider Group/Facility NPI Number

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* 12. Provider Billing Address

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* 13. Service Vendor Name

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* 14. Provider's Service Address

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* 15. Service Address Effective Date

Date

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* 16. Service Address Expiration Date (if applicable)

Date

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* 17. Service Vendor Phone

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* 18. Billing Vendor Name

CYBHI Fee Schedule Onboarding Checklist: Please indicate your progress on each of the following steps for Fee Schedule participation. Note that these steps do not all need to be completed in the order listed here. Instructions for each step can be found in OUSD's Onboarding Checklist Instructions for Affiliated Providers.

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* 19. Provider Participation Agreement (PPA) with DHCS

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* 20. Onboarding Process with Carelon Behavioral Health (including Data Use Agreement)

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* 21. Updated Contract or MOU with OUSD

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* 22. Set up Provider Connect portal account with Carelon

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* 23. Submitted practitioner SPI Roster to Carelon (Note: After submitting to Carelon, please send a copy to Jessica Amador, jessica.amador1@ousd.org, via the method specified by OUSD.)

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* 24. Established Availity account

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* 25. Acquired Electronic Health Record (EHR) system for billing

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* 26. Enrolled as a Medi-Cal provider through PAVE

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* 27. If you have completed a PPA with DHCS, please upload a copy of it.

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* 28. If you have completed a Data Use Agreement with Carelon, please upload a copy of it.

Schools and Practitioners: Please let us know which OUSD schools you are currently working with (if applicable) and a little about your practitioners.

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* 29. Which OUSD schools are you currently working with? (If not applicable, enter "none.")

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* 30. What services do you provide to these schools?

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* 31. Which age group(s) do your practitioners work with?

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* 32. Which language(s) do your practitioners speak?

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* 33. What behavioral health services do you offer for children and youth that OUSD students are eligible to receive? (These may include services beyond those currently provided to OUSD students.)

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* 34. Are you interested in expanding to additional OUSD schools, and if so, do you have sufficient staffing to support this?

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