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Clinician Expertise/Specialty Attestation form

Optum Clinical Expertise Checklist To add or modify your area(s) of expertise and/or attested specialty (ies): Complete and sign this form Fax completed form and any requested supportive documents to Network Management for your state To find the fax number, go to > Contact Us > Network Management > Network Management Contact Information and select your state If you have any questions, contact us at 877-614-0484. Clinician Name: CAQH #. Phone: Fax: State: License: Clinicians in the credentialing or recredentialing process have the following rights: to review information submitted to support his/her (re)credentialing application to correct erroneous information obtained by Optum to evaluate his/her (re)credentialing application (not including references, recommendations and other peer-review protected information).

1 BH2417_Spec Attest Rev. v7_10/2019 United Behavioral Health and United Behavioral Health of New York, I.P.A., Inc. operating under the brand Optum

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Transcription of Clinician Expertise/Specialty Attestation form

1 Optum Clinical Expertise Checklist To add or modify your area(s) of expertise and/or attested specialty (ies): Complete and sign this form Fax completed form and any requested supportive documents to Network Management for your state To find the fax number, go to > Contact Us > Network Management > Network Management Contact Information and select your state If you have any questions, contact us at 877-614-0484. Clinician Name: CAQH #. Phone: Fax: State: License: Clinicians in the credentialing or recredentialing process have the following rights: to review information submitted to support his/her (re)credentialing application to correct erroneous information obtained by Optum to evaluate his/her (re)credentialing application (not including references, recommendations and other peer-review protected information).

2 To submit any corrections, in writing, within ten (10) days to obtain, upon request, information regarding the status of their application Areas of Clinical Expertise Please check all areas you have clinical training and experience AND are currently willing to treat in your practice. Abuse (Physical, Sexual, etc.) Community Support Program (CSP). Acute Treatment Services (ATS) for Substance Use Community Support Program for People Disorders (ASAM Level ) Experiencing Chronic Homelessness Adoption Issues Compulsive Gambling Anger Management Crisis Respite Anxiety Day Habilitation Assessment and Referral Substance Abuse Day Treatment Attention Deficit Disorders (ADHD) Depression Autism Spectrum Disorders Developmental Disabilities Bariatric/Gastric Bypass Evaluation Dialectical Behavioral Therapy Behavior Modification Disability Evaluation/Management (submit the Biofeedback Memorandum of Understanding, located on Bipolar Disorder ).

3 Bisexual Issues Dissociative Disorders Blindness or Visual Impairment Domestic Violence Case Management Electroconvulsive Therapy (ECT). Certified Pastoral Counselor Emergency Services Program (ESP). Child Welfare Emergency Outpatient Program (EOP). Christian Counseling Enhanced Residential Rehabilitation Services for Dually Diagnosed (ASAM Level co-occurring Clinical Support Services for Substance Use enhanced). Disorders (ASAM Level ). Evaluation and Assessment Mental health Co-Occurring Disorders Treatment (Dual Diagnosis). Eye Movement Desensitization & Reprocessing Cognitive Behavioral Therapy (EMDR). Community Crisis Stabilization Family Stabilization Team (FST). Community Integration Counseling Feeding and Eating Disorders Community Habilitation Fetal Alcohol Syndrome Community Self-Advocacy Training & Support 1.

4 BH2878_Spec Attest Rev. v10_07/2020 United Behavioral health and United Behavioral health of New York, , Inc. operating under the brand Optum Behavioral health Plan, California doing business as OptumHealth Behavioral Solutions of California Areas of Expertise (cont.) Planned Respite Fire Setter Evaluation Police/Fire Fighters Forensic Positive Behavioral Interventions & Supports Foster Care Post-Partum Depression Gay/Lesbian Identified Clinician Post-Traumatic Stress Disorder (PTSD). Gay/Lesbian Issues Program of Assertive Community Treatment Grief/Bereavement Psych Testing health and Behavior Assessment and Intervention Psychiatric Day Treatment Services Psychotic/Schizophrenic Disorders Hearing Impaired Populations Race-Based Trauma HIV/AIDS/ARC Rape Issues Home Care/Home Visits Recovery Coaching Hypnosis Recovery Support Navigators (RSN).

5 In Home Behavioral Services (IHBS) Regional Behavioral health Authority (RHBA). In Home Therapy (IHT) Relaxation Techniques Independent/Qualified Medical Examiner Residential Rehabilitation Services (ASAM Level ). Infertility School Based Services Intellectual and Developmental Disability Serious Mental Illness Intensive Care Coordination (ICC) Sex Offender Treatment Intensive Individual Support Sexual Abuse Evaluation Learning Disabilities Sexual Dysfunction Long Term Care Sleep-Wake Disorders Long-Acting Injectable (LAI) Administrator Somatoform Disorders Medical Illness/Disease Management SPRAVATO (prescribers only). Medicaid Opioid Treatment Program (OTP) Structured Outpatient Addiction Program (SOAP). Physicians Only Targeted Case Management Medication Management TBI Waiver Case Management Military/Veterans Treatment TBI Waiver Community Integration Counseling Mobile Crisis Intervention (MCI) TBI Waiver Positive Behavior Mobile Mental health Treatment Therapeutic Monitoring (TM).

6 Mood Disorder Transgender Multi-Systemic Therapy (MST) Transitional Support Services (TSS) for Substance Naltrexone Injectable MAT Use Disorders (ASAM Level ). Native American Traditional Healing Systems Trauma Therapy Nursing Home Visits Traumatic Brain Injury Obsessive Compulsive Disorder Weapons Clearance Organic Disorders Workers' Compensation Pain Management Youth Mobile Crisis (Mobile Crisis Intervention Parent Support and Training (YMCI). Parent-Child Evaluation Youth Stabilization Services (YSS). Personality Disorders Youth Support Phobia Physical Disabilities Population(s) Treated (check all that apply): Adult Geriatric Group Therapy Child Couples/Marriage Therapy Inpatient Adolescent Family Therapy Caregiver 2. BH2878_Spec Attest Rev. v10_07/2020 United Behavioral health and United Behavioral health of New York, , Inc.)

7 Operating under the brand Optum Behavioral health Plan, California doing business as OptumHealth Behavioral Solutions of California Optum Attested Expertise You must sign this document even if you are not requesting any of these specialty designations in your provider record. Additional training, experience, requirements, and/or outside agency approval is required for the following populations, professional certifications, and specialties. Please review specialty Requirements on pages 5-7. If you are not requesting a specialty designation, please check the No Specialties box at the bottom of the list to indicate you have read this form and acknowledge that you have not requested these specialties. I have reviewed the Optum specialty Requirements criteria that a Clinician must meet to be considered a specialist in the following treatment areas.

8 After reviewing the criteria, I hereby attest that by placing a check next to a specialty or specialties, I meet Optum requirements for that treatment area. Physician Specialties Non-Physician Specialties Child/Adolescent (please specify all ages that you treat) Child/Adolescent (please specify all ages that you treat). Infant Mental health (0-3 years) Psychologists only Preschool (0-5 years) Infant Mental health (0-3 years). Children (6-12 years) Preschool (0-5 years). Adolescents (13-18 years) Children (6-12 years). Geriatrics Adolescents (13-18 years). Buprenorphine Medication Assisted Treatment (MAT) Certified Employee Assistance Professional (submit (submit DEA registration with the DATA 2000 CEAP certificate). prescribing identification number) Certified Group Psychotherapist (CGP) (submit Certified Group Psychotherapist (CGP) (submit Certification from IBCGP).)

9 Certification from IBCGP) Chemical Dependency / Substance Abuse / Substance Chemical Dependency / Substance Abuse / Substance Use Disorder (SUD). Use Disorder (SUD) Child and Adolescent Strengths and Needs (CANS) Child and Adolescent Strengths and Needs (CANS) Assessor (submit documentation verifying Assessor (submit documentation verifying completion of training and certification as completion of training and certification as Assessor). Assessor) Child and Adolescent Strengths and Needs (CANS) Child and Adolescent Strengths and Needs (CANS) (Child Welfare) Assessor (submit documentation (Child Welfare) Assessor (submit documentation verifying completion of training and certification as verifying completion of training and certification as Assessor). Assessor) Child-Parent Psychotherapy (CPP).

10 Child-Parent Psychotherapy (CPP) Cognitive Processing Therapy (CPT). Cognitive Processing Therapy (CPT) Critical Incident Stress Debriefing (submit CISD. Early Intervention Provider (Virginia Medicaid Only certificate). submit applicable certification) Early Intervention Provider (Virginia Medicaid Only . Medicaid Office-Based Opioid Treatment Program submit applicable certification). (OBOT) Employee Assistance Professional Neuropsychological Testing Neuropsychological Testing Psychologists only Parent-Child Interaction Therapy (PCIT) Nurses and Physician Assistants Buprenorphine . Preschool PTSD Treatment (PPT) Medication Assisted Treatment (MAT) (submit certification email from DEA). Prolonged Exposure (PE). Nurses Prescriptive Privileges (submit ANCC. Substance Abuse Expert (submit Nuclear Regulatory certificate, Prescriptive Authority, DEA certificate Commission qualification training certificate).)


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