Requirements for Provider Type 19 - Psychologist
Transcript Of Requirements for Provider Type 19 - Psychologist
Requirements for Provider Type 19 - Psychologist
Specialty Code
Please choose from the following for the specialty and code:
• 190 – General Psychologist • 191 – Clinical Neuropsychologist • 192 – Clinical Health Psychologist • 193 – Psychoanalytic Psychologist • 194 – School Psychologist • 195 – Clinical Psychologist • 196 – Clinical Child Psychologist • 197 – Counseling Psychologist • 198 – Industrial Organizational Psychologist • 199 – Behavioral Psychologist • 201 – Forensic Psychologist
•
202 – Family Psychologist
•
204 – Clinical Geropsychologist
•
206 – Treatment of Alcohol and Other
Psychoactive Substance Use Disorders
•
2•07 – Cognitive Therapist
•
208 – Behavioral Therapist Consultant
•
370 – Tobacco Cessation
•
425 – Autism Certified Psychologist
•
572 – Early Intervention Services
Provider Eligibility Program (PEP)
The following chart categorizes each PEP by the specialties that may be associated with it. Please choose at least one PEP for each selected specialty.
FeeforService Enrollment Consolidated ID Base
Not Paid Wavier
Program
All specialties All
208
208
may select specialties
Fee-for-
may select
Service
Enrollment
Not Paid
Per/Fam Directed Services
208
Adult Autism Waiver
425
ITF Waiver
572
Early Intervention MA
Early Intervention Maintenance
572
572
Required Documents for an Individual Provider Type 19:
The following documents and supporting information are required by the Bureau of Fee-For-Service Programs to enroll as a provider (please ensure all documents are legible):
• Completed application for the enrollment of an Individual Provider—application must include:
o Signed copy of the Outpatient Provider Agreement with the original signature of enrolling Provider; o Completed Ownership or Control Interest Disclosure form
• Copy of license issued by Department of State • If application is for an Out-of-State Provider, submit proof of current home state Medicaid participation • If applying for specialty 425, Autism Certified Psychologist, include a copy of the provider’s SPeCTRUM training certificate
5.19.2021
Required Documents for Provider Type 19 Group: • Completed application for the enrollment of a Group Provider--applications must include:
o A signed copy of the Outpatient Provider Agreement, signed by an authorized representative; o Completed Ownership or Control Interest Disclosure form; and o Group Member form with Provider ID number and original signature of at least one Provider
• Documentation generated by the IRS, showing both the Group’s legal name and FEIN – documentation must come from
the IRS; this Department does not accept W-9s
• If Provider is tax-exempt, submit IRS 501 (c)(3) letter confirming this status • If the application is for an Out-of-State Provider, submit proof of current home state Medicaid participation • If the Group operates under a fictitious name, submit a copy of the DBA filing with Department of State Corporation Bureau • Copy of Corporation paperwork issued by the Department of State Corporation Bureau or copy of business partnership
agreement
Psychologists (19) are encouraged to apply online via our Electronic Provider Portal at https://provider.enrollment.dpw.state.pa.us . If circumstances do not allow online submission, send application and documents to:
DHS Provider Enrollment PO Box 8045
Harrisburg, PA 17105-8045 Fax: (717) 265-8284
E-mail: [email protected]
5.19.2021
Specialty Code
Please choose from the following for the specialty and code:
• 190 – General Psychologist • 191 – Clinical Neuropsychologist • 192 – Clinical Health Psychologist • 193 – Psychoanalytic Psychologist • 194 – School Psychologist • 195 – Clinical Psychologist • 196 – Clinical Child Psychologist • 197 – Counseling Psychologist • 198 – Industrial Organizational Psychologist • 199 – Behavioral Psychologist • 201 – Forensic Psychologist
•
202 – Family Psychologist
•
204 – Clinical Geropsychologist
•
206 – Treatment of Alcohol and Other
Psychoactive Substance Use Disorders
•
2•07 – Cognitive Therapist
•
208 – Behavioral Therapist Consultant
•
370 – Tobacco Cessation
•
425 – Autism Certified Psychologist
•
572 – Early Intervention Services
Provider Eligibility Program (PEP)
The following chart categorizes each PEP by the specialties that may be associated with it. Please choose at least one PEP for each selected specialty.
FeeforService Enrollment Consolidated ID Base
Not Paid Wavier
Program
All specialties All
208
208
may select specialties
Fee-for-
may select
Service
Enrollment
Not Paid
Per/Fam Directed Services
208
Adult Autism Waiver
425
ITF Waiver
572
Early Intervention MA
Early Intervention Maintenance
572
572
Required Documents for an Individual Provider Type 19:
The following documents and supporting information are required by the Bureau of Fee-For-Service Programs to enroll as a provider (please ensure all documents are legible):
• Completed application for the enrollment of an Individual Provider—application must include:
o Signed copy of the Outpatient Provider Agreement with the original signature of enrolling Provider; o Completed Ownership or Control Interest Disclosure form
• Copy of license issued by Department of State • If application is for an Out-of-State Provider, submit proof of current home state Medicaid participation • If applying for specialty 425, Autism Certified Psychologist, include a copy of the provider’s SPeCTRUM training certificate
5.19.2021
Required Documents for Provider Type 19 Group: • Completed application for the enrollment of a Group Provider--applications must include:
o A signed copy of the Outpatient Provider Agreement, signed by an authorized representative; o Completed Ownership or Control Interest Disclosure form; and o Group Member form with Provider ID number and original signature of at least one Provider
• Documentation generated by the IRS, showing both the Group’s legal name and FEIN – documentation must come from
the IRS; this Department does not accept W-9s
• If Provider is tax-exempt, submit IRS 501 (c)(3) letter confirming this status • If the application is for an Out-of-State Provider, submit proof of current home state Medicaid participation • If the Group operates under a fictitious name, submit a copy of the DBA filing with Department of State Corporation Bureau • Copy of Corporation paperwork issued by the Department of State Corporation Bureau or copy of business partnership
agreement
Psychologists (19) are encouraged to apply online via our Electronic Provider Portal at https://provider.enrollment.dpw.state.pa.us . If circumstances do not allow online submission, send application and documents to:
DHS Provider Enrollment PO Box 8045
Harrisburg, PA 17105-8045 Fax: (717) 265-8284
E-mail: [email protected]
5.19.2021