Attestation Form

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.

1. The MHC is enrolled in MassHealth as a provider of mental health center services pursuant to 130 CMR 429.000 and meets all expectations for a Behavioral Health Urgent Care provider included in 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;
8. The MHC is able to provide Evidence Based Practices for populations across the life span, inclusive of the youth and geriatric populations (in certain circumstances this requirement may be waived);
9. The MHC is able to provide Evidence Based Practices for populations with substance use disorder;
10. The MHC is able to provide services in members’ preferred language via multi-lingual staff and or two-way video;
11. The MHC is able to provide access, induction, and prescription for all FDA-approved medications to treat opioid use disorder and alcohol use disorder either directly or through a Qualified Service Organization Agreement (QSOA) with a provider within the catchment area, and the MHC must have a Qualified Service Organization Agreement (QSOA) with at least one Opioid Treatment Program (OTP); and
12. The MHC is able to provide appropriate care coordination for all members, inclusive of member with high acuity needs, including referral pathways and relationships with services across the BH continuum.

• Same-Day appointments: Percent of visits completed on the same clinic day as initial Member contact/request
• Next-Day appointments: Percent of visits completed the next clinic day after initial Member contact/request
• 14-Day Routine and Follow-up Appointments: Percent of routine and follow-up visits completed within 14 calendar days from initial appointment
• Appointments During Extended Hours: Percent of visits completed during extended clinic hours

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.