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Attestation Form
for the MassHealth Behavioral Health Urgent Care Program
Commonwealth of Massachusetts | Executive Office of Health and Human Services |
www.mass.gov/masshealth
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.
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To participate in the Behavioral Health Urgent Care Program, the MHC must satisfy
the following requirements:
- The MHC is enrolled in MassHealth as a provider of mental health center services
pursuant to 130 CMR 429.000;
- 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;
- 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;
- 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;
- 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;
- The MHC is able to provide all other treatment appointments, including follow-up
appointments, within 14 calendar days;
- 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;
- The MHC meets the reporting requirements below; and
- The MHC makes Member experience surveys available to all clients.
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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.
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By completing Section V, you attest to compliance with the Behavioral Health Urgent
Care requirements.
*Required
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.
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