2021 UnitedHealthcare Community Plan of Kentucky Evidence-Based Practices Survey/Attestation

IMPORTANT NOTE:

As part of the UnitedHealthcare Community Plan of Kentucky commitment to compliance, UnitedHealthcare Community Plan of Kentucky must ensure that Behavioral providers who contract with us are in compliance with applicable state and federal regulations. As part of UnitedHealthcare's contract with the Department of Medicaid Services, the Cabinet for Health and Family Services, UnitedHealthcare Community Plan of Kentucky is responsible for validating that each contracted provider is in compliance with Medicaid program requirements. Each contracted provider must complete this Attestation in its entirety in order to be in compliance with UnitedHealthcare Community Plan of Kentucky's requirements and render services to Medicaid members.

INSTRUCTIONS:
An authorized representative from each First Tier, Downstream and Related Entities (FDR) or Affiliate is required to complete the UnitedHealthcare Community Plan of Kentucky FDR and Affiliate Compliance Attestation (on behalf of his or her organization) upon contract and annually and thereafter to attest to compliance with the use of Evidence-Based Practices (EBPs) that meet standards of national models in all behavioral health services.

An authorized representative is an individual who has responsibility directly or indirectly for all employees, contracted personnel, providers/practitioners, and vendors who provide healthcare or administrative services under Medicaid and/or Medicare. Authorized representatives may include, but are not limited to, a Compliance Officer, Chief Medical Officer, Practice Manager/Administrator, Provider, an Executive Officer or similar related positions.
This attestation must be completed for each practice location where healthcare or administrative services are provided for Medicaid and/or Medicare members.

Question Title

* 1. I have reviewed and understand the UnitedHealthcare Community Plan of Kentucky's requirement in compliance with the Department of Medicaid Services, The Cabinet for Health and Family Services, for providers to attest to the utilization of evidence-based practices according to Kentucky Cabinet for Health and Family Services, Department of Behavioral Health, Developmental and Intellectual Disabilities Evidence-Based Practices Behavioral Health Best Practices or nationally recognized behavioral health evidence-based practices. My organization will abide by the UnitedHealthcare Community Plan of Kentucky's compliance policies. In addition:

My organization has established and publicized compliance policies and procedures related to Evidence-Based Practices as according to Kentucky Cabinet for Health and Family Services, Department of Behavioral Health, Developmental and Intellectual Disabilities Evidence-Based Practices Behavioral Health Best Practices or nationally recognized behavioral health evidence-based practices. This information is disseminated to employees and contractors upon hire and annually thereafter. A record of all employees and contractors' receipt of the policies, Evidence-Based Practices policies/procedures, and information is maintained for a period of ten years and can be provided upon request.

My organization does not have established compliance policies and procedures related to Evidence-Based Practices as according to Kentucky Cabinet for Health and Family Services, Department of Behavioral Health, Developmental and Intellectual Disabilities Evidence-Based Practices Behavioral Health Best Practices or nationally recognized behavioral health evidence-based practices.

Question Title

* 2. Please indicate the Evidenced-Based Practice that you render in the Kentucky Medicaid Program by checking the corresponding box with the outlined Evidence-Based Practice. Additionally, please check the "Other" box and list any additional Evidence-Based Practices that apply in the comments box.

Assertive Community Treatment (ACT)

Assessing and Managing Suicide Risk (AMSR)

Cognitive Behavioral Therapy (CBT)

Consumer Operated Programs

Coordinated Care Model for Early Interventions For First Episode Psychosis

Dialectical Behavior Therapy (DBT)

Dual Diagnosis Capability in Addiction Treatment (DOCAT)

Eye Movement Desensitization and Reprocessing (EMDR)

Family Psychoeducational

First Episode Psychosis

Functional Family Therapy (FFT)

Individual Placement and Support (IPS) Supported Employment

Integrated Treatment for Co-occurring Disorders (MH and SUD)

Medication Assisted Treatment

Motivational Interviewing *DBH Initiative

NIATx model for addiction treament

Peer Support

Screen, Brief Intervention and Referral to Treatment

Seeking Safety

Supported Employment *DBH Initiative

Supportive Housing

Trauma Informed Therapy

Trauma Recovery and Empowerment Model (TREM)

Treatment for Depression in Older Adults

Other (please specify)

Question Title

* 3. Please supply the following information:

Provider Last / Entity Name:

Provider First Name:

Compliance Contact Name (or person completing the attestation):

Compliance Contact Title:

Email Address:

Phone Number:

Fax Number:

NPI:

Medicaid ID:

Provider County:

Provider Region:

Tax Identification Number(s):

Organization Street Address:

Organization City:

Organization State:

Organization Zip Code:

Question Title

* 4. Select Provider Type:

02 - Mental Health

03 - Behavioral Health Organization (BHSO)

04 - Psychiatric Residential Treatment Facility

05 - Psychiatric Residential Treatment Facility 2

06 - Chemical Dependency

26 - Residential Crisis Treatment Stabilization Unit

30 - Community Mental Health

62 - Licensed Professional Art Therapist (LPAT)

63 - Licensed Behavioral Analyst (LBA)

66 - Behavioral Health Multi-Specialty Group

81 - Licensed Professional Clinical Counselor

82 - Clinical Social Worker

83 - Licensed Marriage and Family Therapist

84 - Licensed Psychological Practitioner

89 - Psychologist

92 - Psychiatrist DPU

64 - MD Psychiatric Specialty

78 - Certified Nurse Practitioner; Psychiatric Specialty

Question Title

* 5. I certify, as an authorized representative who has responsibility...

True

False

Question Title

* 6. Attestation Date

Date / Time

Date