"Justification for Use of out-Of-Network Provider" - Delaware

This "Justification for Use of out-Of-Network Provider" is a document issued by the Delaware Department of Services for Children, Youth and their Families specifically for Delaware residents with its latest version released on September 1, 2011.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Delaware Department of Services for Children, Youth and their Families.

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Download "Justification for Use of out-Of-Network Provider" - Delaware

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State of Delaware
Division of Prevention and Behavioral Health Services
The Department of Services
For Children, Youth and
Using Out-Of-Network Providers
Their Families
Definitions
Network Providers - The network of DPBHS providers are those who have been selected through established
processes in compliance with applicable policies and procedures, e.g., DPBHS Provider Network Membership
ADM # 007, DSCYF Bids and Contracts Policy, and who are listed as network providers.
Use of Out-of-Network Providers
Out-of-Network providers shall be used only in the following situations:
1. The client is currently active with Clinical Services Management (CSMT) and, because of a psychiatric
emergency occurring in another state, must be hospitalized in that state.
2. The client is active with CSMT and has unique or unusual problems and/or circumstances which cannot be
treated by the current network providers. Examples may include but not necessarily be limited to:
a.
severe eating disorders
b. hearing impaired clients
c.
clients and families who are not fluent in English
d. complex medical conditions seriously complicated by behavioral health disorders
Process
The process for determining that it is necessary to seek a provider outside of the established DPBHS network
will be a collaborative one between the CMST and a program administrator.
The service system administrators for each level of care are as follows:
Residential and Hospital Treatment – Jennifer Tse
Non-Residential Services – Vanessa Bennifield
1.
When a CSMT member believes that it is necessary to find a provider outside of the established network to serve
a particular client, he/she should contact the appropriate administrator.
2.
The administrator and the CSMT members will work together to discover whether there is an existing provider in
the DPBHS network to serve the client.
3.
If there is mutual agreement that an out-of-network provider is required:
a.
The CSMT member will complete the enclosed form, specifying the reason why an out-of-network
provider is being sought. (This will also be used to document gaps in services which may exist).
b. The form must be signed by both administration and clinical before further action can be taken on the
out-of-network request.
4. The CSMT member will:
a.
Obtain the name and number of a clinician liaison at the target agency and call said person to discuss the
clinical feasibility of the proposed admission.
b. Discuss any clinical reports or other deliverables which are necessary for DPBHS continuing stay
determinations.
c.
Establish with the clinical liaison DPBHS continuing stay expectations.
d. Authorize the service in FACTS as soon as the provider is available.
e.
The CSMT member may provide other assistance/recommendations to the administrator since the
service being requested is a specialty or otherwise clinically unique service.
Revised September 2011
State of Delaware
Division of Prevention and Behavioral Health Services
The Department of Services
For Children, Youth and
Using Out-Of-Network Providers
Their Families
Definitions
Network Providers - The network of DPBHS providers are those who have been selected through established
processes in compliance with applicable policies and procedures, e.g., DPBHS Provider Network Membership
ADM # 007, DSCYF Bids and Contracts Policy, and who are listed as network providers.
Use of Out-of-Network Providers
Out-of-Network providers shall be used only in the following situations:
1. The client is currently active with Clinical Services Management (CSMT) and, because of a psychiatric
emergency occurring in another state, must be hospitalized in that state.
2. The client is active with CSMT and has unique or unusual problems and/or circumstances which cannot be
treated by the current network providers. Examples may include but not necessarily be limited to:
a.
severe eating disorders
b. hearing impaired clients
c.
clients and families who are not fluent in English
d. complex medical conditions seriously complicated by behavioral health disorders
Process
The process for determining that it is necessary to seek a provider outside of the established DPBHS network
will be a collaborative one between the CMST and a program administrator.
The service system administrators for each level of care are as follows:
Residential and Hospital Treatment – Jennifer Tse
Non-Residential Services – Vanessa Bennifield
1.
When a CSMT member believes that it is necessary to find a provider outside of the established network to serve
a particular client, he/she should contact the appropriate administrator.
2.
The administrator and the CSMT members will work together to discover whether there is an existing provider in
the DPBHS network to serve the client.
3.
If there is mutual agreement that an out-of-network provider is required:
a.
The CSMT member will complete the enclosed form, specifying the reason why an out-of-network
provider is being sought. (This will also be used to document gaps in services which may exist).
b. The form must be signed by both administration and clinical before further action can be taken on the
out-of-network request.
4. The CSMT member will:
a.
Obtain the name and number of a clinician liaison at the target agency and call said person to discuss the
clinical feasibility of the proposed admission.
b. Discuss any clinical reports or other deliverables which are necessary for DPBHS continuing stay
determinations.
c.
Establish with the clinical liaison DPBHS continuing stay expectations.
d. Authorize the service in FACTS as soon as the provider is available.
e.
The CSMT member may provide other assistance/recommendations to the administrator since the
service being requested is a specialty or otherwise clinically unique service.
Revised September 2011
5. The service system administrator will:
a.
Call the relevant provider representative to determine whether he/she/they are willing to do business with
DPBHS, under the requirements established by the CSMT.
b.
Determine the method, e.g., contract, direct claim, P.O., letter of agreement, required to establish the
business relationship with the provider.
c.
Ensure that provider is entered in FACTS and assure that the DPBHS data office and the DMS cost-
recovery office are notified.
d.
The FACTS liaison will let the CSMT member know when the provider is in FACTS so they can authorize
services.
Revised September 2011
State of Delaware
Division of Prevention and Behavioral Health Services
The Department of Services
For Children, Youth and
Justification for Use of Out-Of-Network Provider
Their Families
Date
Level of service needed:
Residential/Hospital
Non-Residential
Client Name
DOB
Reason for seeking out-of-network provider:
The client is currently active with DPBHS and, because of a psychiatric emergency occurring in another
state, must be hospitalized in that state.
Name of Hospital
Location of Hospital
Telephone Number of Hospital
The client has unique or unusual problems and/or circumstances which cannot be treated by the current
panel of providers. Examples may include but not necessarily be limited to:
severe eating disorders
hearing impaired
not fluent in English - Language needed
complex medical conditions seriously complicated by behavioral health disorders
other - Please explain
Suggested provider (if any):
Clinical requirements (e.g., reports, length of stay, etc.)
___________________________________________________________________________________
___________________________________________________________________________________
Signatures of those participating in the decision:
Service System Administrator
Date
Clinical Service Management Team Leader
Date
Revised September 2011
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