MANAGING MENTAL HEALTH, INTELLECTUAL/DEVELOPMENTAL DISABILITIES AND SUBSTANCE ABUSE SERVICES
910. 6 73. 9 11 1 ■ (F A X ) 9 10. 67 3. 62 02 ■ W W W . S A N D H I L L S C E N T E R . O R G ■ V I C T O R I A W H I T T , C EO
Addendum
to
CAQH/North Carolina Uniform
Credentialing/Re-Credentialing
Application to Participate as a
Health Care Practitioner
For IPRS (State Funding) and Medicaid
Please submit application to:
Sandhills Center for MH, I/DD & SAS
Network Operations Dept.
Credentialing Specialist
P.O. Box 9
West End, NC 27376
P.O. Box 9, West End, NC 27376
Serving Anson, Guilford, Harnett, Hoke, Lee, Montgomery, Moore, Randolph, & Richmond Counties
Available 24 hours a day at 1-800-256-2452
Credentialing & Re-Credentialing Data Form
Name of Practitioner: Click here to enter text.
Name of Practice: Click here to enter text.
Licensure: Click here to enter text.
Solo LIP? Yes ☐
No ☐
Solo LIPs are required to submit a completed original
signed and dated W9 Tax Payer Request for Tax ID #
form for initial credentialing & re-credentialing.
Practice Address: Click here to enter text.
Mailing Address: Click here to enter text.
Email Address (for correspondence): Click here to enter text.
Phone: Click here to enter text.
Are you registered with CAQH? Yes ☐ No ☐
CAQH #: Click here to enter text.
Required Info Below
Date of Birth: Click here to enter a date.
Social Security Number: Click here to enter text.
NPI #: Click here to enter text.
Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application
Revised 05/08/2015QMC052615
Page 2 of 14
Instructions
A Licensed Independent Practitioner must apply for and be credentialed/re-credentialed as a practitioner with
Sandhills Center to qualify for reimbursement of services provided to Sandhills Center members. Additionally,
Practitioners must have a signed contract with Sandhills Center or be employed by an Organization or Group
Practice that has a signed contract with Sandhills Center to qualify for reimbursement of services provided to
Sandhills Center Members.
****Please Identify Areas of Clinical Expertise and Treatment by completing and signing the Practice
Preference Data on the attached Cultural, Racial, Ethnic, Gender, and Linguistic Data Form.****
***LIPs are required to submit two (2) ea. references – see “Provider Evaluation Form”***
The Credentialing/Re-Credentialing process includes the following steps:
1. Provider completes and signs the Licensed Independent Practitioner Credentialing/Re-Credentialing
2.
Application Addendum for Medicaid and IPRS to Participate as a Health Care Practitioner, in addition to
the CAQH LIP application and returns it to:
Sandhills Center for MH/I/DD/SAS
Network Operations Department
Attn: Credentialing Specialist
PO Box 9
West End, NC 27376
A Credentialing/Re-Credentialing Application Addendum to Participate as a Health Care Practitioner is
considered to be invalid if:
 The version date on any of the documents that comprise the provider Credentialing/Re-Credentialing
packet is prior to April 2015.
 All spaces in the application have not been completed. (Please indicate “N/A” or “None”, if the question
is not applicable)
 The Signatures, where required, are not original and dated
 The Signatures are not by the individual applicant.
 The text has been altered, highlighted, struck through, or obstructed through the use of correction
fluids
 The responses are illegible.
 Any of the documents or pages that comprise the Credentialing/Re-Credentialing Application to
participate as a Heath Care Practitioner are missing.
 Any of the requested information in any of the documents that comprise the Credentialing/ReCredentialing Application Addendum to participate as a Health Care Practitioner is missing.
Before submitting the Credentialing/Re-Credentialing Application,
make sure you have completed the following:
☐ Include an answer in all spaces. Indicate “N/A” or “None”, if the question is not applicable.
3. For Solo Licensed Independent Practitioners only
Solo Licensed Independent Practitioners must furnish a completed original signed and dated W9 Tax
Payer Request for Tax ID #
Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application
Revised 05/08/2015QMC052615
Page 3 of 14
Section 3: Professional Information
Please check (√) yes or no for the following questions. Please complete the attached Supplemental Form for any questions
to which you answer “yes”. Also, please sign and date this application. If this application does not have the provider’s
signature, it cannot be accepted.
1. Has your license to practice in any jurisdiction ever been limited, restricted, reduced, suspended,
voluntarily surrendered, revoked, denied or not renewed; have you ever been reprimanded by a state
licensing agency; or are any of these actions pending with respect to your license; are you under
☐ Yes ☐ No
investigation by any licensing or regulatory agency?
(If yes, please complete Supplemental Question #1.)
2. Has your professional employment or membership in a professional organization ever been subject
to disciplinary proceedings, denied, limited, restricted, reduced, suspended, revoked, not renewed, or
☐ Yes ☐ No
voluntarily relinquished during or under threat of termination for any reason?
(If yes, please complete Supplemental Question #2.)
3. Has your Drug Enforcement Agency registration or other controlled substance authorization ever
been limited, restricted, reduced, suspended, revoked, denied, not renewed, or have you voluntarily
surrendered or limited your registration during or under the threat of an investigation or any such
☐ Yes ☐ No
actions pending?
(If yes, please complete Supplemental Question #3.)
4. Have you ever been sanctioned or suspended by Medicare or Medicaid?
☐ Yes ☐ No
(If yes, please complete Supplemental Question #4.)
5. To your knowledge, have you ever been reported to the National Practitioner Data Bank or the
North/South Carolina Board of Medical Examiners?
☐ Yes ☐ No
(If yes, please complete Supplemental Question #5.)
6. Have you ever been convicted of a felony or misdemeanor, or are you under investigation with
respect to such conduct?
☐ Yes ☐ No
(If yes, please complete Supplemental Question #6.)
7. Has a professional liability claim been assessed against you in the past five years, or are there any
professional liability cases pending against you?
☐ Yes ☐ No
(If yes, please complete Supplemental Question #7.)
8. Has any liability insurance carrier canceled, refused coverage, or rated up because of unusual risk
or have any procedures been excluded from your coverage?
☐ Yes ☐ No
(If yes, please complete Supplemental Question #8.)
9. Have you ever practiced without liability coverage?
☐ Yes ☐ No
(If yes, please complete Supplemental Question #9.)
10. Do you currently have any medical, chemical dependency or psychiatric conditions that might
adversely affect your ability to practice medicine or surgery or to perform the essential functions of
☐ Yes ☐ No
your position without reasonable accommodation?
(If yes, please complete Supplemental Question #10.)
11. Have your Hospital and/or Clinic privileges ever been limited, restricted, reduced, suspended,
revoked, denied, not renewed, or have you voluntarily surrendered or limited your privileges during or
☐ Yes ☐ No
under the threat of an investigation or are any such actions pending?
(If yes, please complete Supplemental Question #11.)
Signature
Date
***Please provide additional detailed information on the following Supplemental Form.
Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application
Revised 05/08/2015QMC052615
Page 4 of 14
Supplemental Form
All spaces in the application must be completed. (Please indicate “N/A” or “None”, if the question is not applicable)
Provider Name:
SHC Provider ID # :
Click here to enter text.
Click here to enter text.
1. License Limited, Reprimanded, etc.:
List State(s) where action took place: Click here to enter text.
Date(s) license revoked, suspended, etc.:
From Click here to enter text.
To Click here to enter text.
Please explain: Click here to enter text.
2. Employment/Membership Suspended, Limited, etc.:
List State(s) where action took place: Click here to enter text.
Date(s) license revoked, suspended, etc.:
From Click here to enter text.
To Click here to enter text.
Please explain: Click here to enter text.
3. Drug Enforcement Agency (DEA) Explanation:
List State(s) where action took place: Click here to enter text.
Date(s) license revoked, suspended, etc.:
From Click here to enter text.
To Click here to enter text.
Please explain: Click here to enter text.
4. Medicare/Medicaid Sanction Disciplinary Action(s):
Disciplined Action(s): Click here to enter text.
List State(s) where action took place: Click here to enter text.
Date(s) of Action:
From Click here to enter text.
To Click here to enter text.
Please explain: Click here to enter text.
5. National Practitioner Data Dank Report(s):
Please explain the NPDB report (if you have a copy please attach): Click here to enter text.
6. Felony or Misdemeanor:
Did you serve a sentence: ☐ Yes ☐ No
If Yes, please check (√) how many years ☐1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 ☐ Other: Click here to enter text.
Please explain charge and verdict: Click here to enter text.
List State(s): Click here to enter text.
7. Named in Professional Liability Judgment, Settlement, etc.:
Please explain, include dates & amounts: Click here to enter text.
8. Canceled Refused Coverage, etc.:
Please list Insurance Carrier(s): Click here to enter text.
Please explain: Click here to enter text.
9. Practiced Without Liability Coverage:
Please explain: Click here to enter text.
10. Medical, Chemical Dependency, or Psychiatric Conditions:
Please explain: Click here to enter text.
11. Hospital or Clinic Privileges Revoked, Restricted, etc.:
List Hospitals(s): Click here to enter text.
Date privileges revoked, suspended, etc.:
From Click here to enter text.
To Click here to enter text.
Please explain: Click here to enter text.
Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application
Revised 05/08/2015QMC052615
Page 5 of 14
Section 4: Ownership Information
1. Do you have ownership or control interest of 5% or more in other
organizations that bills Medicaid for services?
If yes, please fill in the following for each organization:
Yes ☐
No ☐
Organization Legal Business Name: Click here to enter text.
Employer ID #: Click here to enter text.
National Provider Identifier (NPI) #: Click here to enter text.
Organization Legal Business Name: Click here to enter text.
Employer ID #: Click here to enter text.
National Provider Identifier (NPI) #: Click here to enter text.
Organization Legal Business Name: Click here to enter text.
Employer ID #: Click here to enter text.
National Provider Identifier (NPI) #: Click here to enter text.
Organization Legal Business Name: Click here to enter text.
Employer ID #: Click here to enter text.
National Provider Identifier (NPI) #: Click here to enter text.
Organization Legal Business Name: Click here to enter text.
Employer ID #: Click here to enter text.
National Provider Identifier (NPI) #: Click here to enter text.
Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application
Revised 05/08/2015QMC052615
Page 6 of 14
Attestation Statement
Important: Submit Original only
No Stamps or Copies Please
This Application is to be signed by the individual provider/clinician applying for Credentialing/Re-Credentialing.
All information submitted by me in this application, as well as any attachments or supplemental information, is true, current, and
complete to my best knowledge and belief as of the date of signature below. I fully understand that any significant misstatement in this
application may constitute cause for denial of my application or termination of a resulting participation agreement.
By application for membership in the Sandhills Center Network, I signify my willingness to appear for interview in regard to my
application. I authorize Sandhills Center to consult with administrators and members of the medical staffs of hospitals or institutions
with which I have been associated and with others, including past and present malpractice carriers, who may have information bearing
on the questions in this application. Upon request, I will obtain and provide to Sandhills Center materials pertaining to my
qualifications and competence, including, materials relating to complaints filed, any disciplinary action, suspension, or action to
curtail my medical-surgical privileges. I further consent to the inspection by representatives of Sandhills Center of all documents that
may be material to an evaluation of my professional qualifications and competence.
I understand and agree that I, as an applicant, have the burden of producing adequate information for proper evaluation of my
professional competence, character, ethics, and other qualifications and for resolving any doubt about such qualifications. I release
from liability all representatives of Sandhills Center for their acts performed in good faith and without malice in connection with
evaluating my application and my credentials and qualifications, and I release from any liability, all individuals and organizations that
provide information to Sandhills Center in good faith and without malice concerning this application and I hereby consent to the
release and verification of information relating to any disciplinary action, suspension, or curtailment of medical-surgical privileges to
Sandhills Center.
I understand that if my application is rejected for reasons relating to my professional conduct or competence, Sandhills Center, may
report the rejection to the appropriate state licensing board and/or National Practitioner Data Bank.
In the event I am accepted for participation in Sandhills Center, I hereby consent to Sandhills Center for inspection of my patient
records relating to Sandhills Center members as necessary for its peer and utilization review purposed as permitted by state or federal
law and regulation I further agree to notify Sandhills Center in a timely manner (not to exceed 30 days) of any changes to the
information requested on the initial application.
Click here to enter a date.
Signature of Applicant
Date
Click here to enter text.
Click here to enter text.
Printed Name of Applicant
Title
If this application does not have the provider’s signature, it cannot be accepted. (Please sign and date this
Attestation Statement).
Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application
Revised 05/08/2015QMC052615
Page 7 of 14
Sandhills Center
Network Operations
Credentialing Specialist
P.O. Box 9, West End, NC 27376
Fax: (910) 673-7013
Provider Evaluation Form
☐ Peer (Licensed Practitioner, not partner)
☐ Referring Physician or Practitioner
☐ Chief of Department/Staff where practitioner has admitting privileges (Not partner)
Name of the Applicant:
Group Name:
☐ Supervisor
The above provider is a Sandhills Center network applicant. Please provide us with information concerning his/her
professional qualifications. All information submitted will be held in strict confidence.
1. What is your specialty/credentials:
2. What is your relationship to the applicant:
3. How long have you known the applicant:
4. How would you rate the applicant’s professional abilities:
☐ Excellent
☐ Very Good
☐ Good
☐ Fair
☐ Poor
5. How would you rate the applicant’s ability to work and communicate with physician and
non physician staff:
☐ Excellent
☐ Very Good
☐ Good
☐ Fair
☐ Poor
6. How would you rate the applicant’s rapport with members:
☐ Excellent
☐ Very Good
☐ Good
☐ Fair
☐ Poor
7. What do you believe to be the applicant’s strengths and weaknesses (if any):
a). Strengths:
b). Weaknesses:
8. To your knowledge, has the applicant had any of the following:
Malpractice claim(s):
☐ Yes
☐ No
Problems with medical licensure, certification or licensing boards:
☐ Yes
☐ No
Revocation, denial or change in hospital privileges:
☐ Yes
☐ No
History of/or current impairment due to drugs and/or alcohol:
☐ Yes
☐ No
***If your answer is yes to any of the abgove questions, please provide details.***
9. Would you recommend this person as a provider for the Sandhills Center network:
☐ Without reservation
☐ With reservation
☐ Would not recommend
10. Please provide any other information that would be helpful to us in evaluating this applicant:
Evaluator’s Signature
Evaluator’s Printed Name
Date
Address:
Street
City
State
Zip
Street
City
State
Zip
Phone #:
Group Name:
Address:
Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application
Revised 05/08/2015QMC052615
Page 8 of 14
SANDHILLS CENTER
Licensed Independent Practitioners
Cultural, Racial, Ethnic, Gender, and Linguistic Data Form
(This information will reside within Sandhills Center’s Provider Directory and the online Provider
Search.This section is self-reported information and requires no backup documentation)
By providing the information below, you will be assisting Sandhills Center with member/provider matching, as
well as providing information necessary for analyzing our Network and its ability to meet our Member’s
cultural, racial, ethnic and linguistic needs.
Name of Practitioner: Click here to enter text.
Name of Practice: Click here to enter text.
Email Address:
Click here to enter text.
Counties Served:
☐ Anson
☐ Guilford
☐ Hoke
☐ Lee
☐ Moore
☐ Randolph
☐ Other: Click here to enter text.
☐ Harnett
☐ Montgomery
☐ Richmond
Provider Type:
☐ APPCNS (Advanced Practice Psychiatric Clinical Nurse Specialist)
☐ DO
☐ LCAS
☐ LCSW
☐ LMFT
☐ LPC
☐ PA
☐ PhD
☐ PsyD
☐ Other (please specify): Click here to enter text.
Priority Populations:
☐ MH – Adult
☐ MH – Child
Your Gender:
☐ Female
☐ SA – Adult
☐ SA – Child
☐ LPA
☐ MDNP - Psychiatric
☐ I/DD - Adult
☐ I/DD - Child
☐ Male
Your Race and/or Ethnicity (please check (√) all appropriate categories):
☐ White
☐ Black or African American
☐ American Indian and Alaska Native
☐ Asian, Pacific Islander
☐ Hispanic or Latino
☐ Other: Click here to enter text.
Populations(s) that you serve (please check (√) all that apply):
☐ Early Childhood (0-4)
☐ Child & Adolescent (5-21)
☐ Geriatrics (55+)
☐ Women
☐ HIV/Aids
☐ Hearing Impaired
☐ Gender Identity Issues
☐ Sexually Reactive/Aggressive Youth
☐ Other: Click here to enter text.
Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application
Revised 05/08/2015QMC052615
☐ Adult (22+)
☐ Gay & Lesbian
☐ Men
☐ Visually Impaired
Page 9 of 14
Cultural, Racial, Ethnic, Gender, and Linguistic Data Form (continued)
(This information will reside within Sandhills Center’s Provider Directory and the online Provider Search)
Culturally diverse populations that you feel competent to treat (please check (√) all that apply):
☐ White
☐ Black or African American
☐ American Indian and Alaska Native
☐ Asian, Pacific Islander
☐ Hispanic or Latino
☐ Other
Practice Preference Data
Language(s) you are able to communicate in fluently (please check (√) all that apply)
☐ American Sign Language
☐ English
☐ French
☐ German
☐ Hmong
☐ Portuguese
☐ Russian
☐ Spanish
☐ Telugu
☐ Other: Click here to enter text.
(The sections below must have backup documentation to be listed with Sandhills Center)
Focus of Treatments You Provide (please check (√) all that apply):
☐ Amnestic Disorder
☐ Anxiety/Phobias
☐ Attention Deficit Hyperactivity Disorder
☐ Autism – Asperger
☐ Bipolar Disorder (manic-depressive illness)
☐ Chemical Dependency/Substance Abuse
☐ Conduct Disorder
☐ Co-Occurring/Dual DX-Mental Retardation/Mental
☐ Dementia Disorder
☐ Depression
☐ Eating Disorders
☐ Factitious Disorders
☐ Impulse Control
☐ Mentally Retarded/Developmentally Disabled
☐ Obsessive-Compulsive Disorder
☐ Personality Disorders
☐ Post Traumatic Stress Disorder
☐ Schizophrenia and other Psychotic Disorders
☐ Sexual & Gender Identity Disorders Illness, Mental
Health/Substance Abuse
☐ Sleep Disorders
☐ Somatoform Disorders
Clinician Expertise/Certified Specialties (please check (√) all that apply):
Psychological Testing
☐ Cognitive/IQ
Therapy/Service Type
☐ Anger Management
☐ Developmental limited/extended
☐ Forensic Screening/Evaluation
☐ Neuro Psych
☐ Personality
☐ Assessment Evaluation
☐ Caree/Vocational Counseling
☐ Cognitive Behavioral Therapy
☐ Crisis/Solution focused Brief
Therapy
☐ Dialectial Behavior Therapy
☐ Faith Based Counseling
☐ General Psychiatry
☐ General Psychology
☐ Gero Psychiatry
☐ Grief and Loss Therapy
☐ Health Psychology – Chronic
Medical Conditions
☐ Marriage and Family
Counseling
☐ Play Therapy, Filial Relaxation/
Meditation-Hypnotherapy
☐ Self-Direction
Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application
Revised 05/08/2015QMC052615
Trauma Focused
☐ Abuse-Physical, Sexual, and/or
Emotional
☐ Maltreatment
☐ Neglect
☐ Rape
Page 10 of 14
Practice Preference Data
Clinician Expertise/Certified Specialties that Require Verification (please check (√) all that apply):
Verification of specific expertise(s) and/or training(s) selected below must accompany this form for
Sandhills Center recognition, i.e. training certificates, certification, supervisor letters verifying training,
or proof of experience. If standard training for clinician’s licensure does not include area of identified
expertise, additional documentation to support expertise will be required, e.g. a Psychiatrist who does
psychological testing.
☐ Addiction Psychiatry (Fellowship in addiction Psychiatry/Board Certification/ASAM Certification/Experience)
☐ Eye Movement Desensitization and Reprocessing Therapy (Training Certificate/Experience)
☐ Addiction Treatment (LCAS/CAS/CCS/Experience)
☐ Forensic Psychology/Psychiatry (Fellowship in Forensic Psychiatry/Board Certification/Training/Experience)
☐ Child Psychiatry (Fellowship in child Psychiatry/Board Certification/Training/Experience)
☐ Trauma Focused Cognitive Behavioral Therapy (Course Completion at MUSC, Duke or NCTSN)
☐ Dialectical Behavior Therapy (Certification, Supervision, and Experience)
☐ Neuro Psych Assessment (Training, Supervision, and Experience)
Services Provided in Office: ☐ Yes
☐ No
Services Provided in the Community: ☐ Yes
☐ No
Thank you for taking the time to submit this form. If this form is not completed and returned, your provider
information will not appear within the Sandhills Center online Provider Search or Provider Handbook.
To the best of my knowledge, I am able to meet all requirements necessary to apply for Sandhills Center
Credentialing/Re-Credentialing for Licensed Independent Practitioner. I am submitting the attached
Sandhills Center Licensed Independent Practitioner Credentialing/Re-Credentialing Application, which,
to my knowledge, is a true and complete representation of the required materials.
This Licensed Independent Practitioner Credentialing/Re-Credentialing Application is submitted by:
Click here to enter a date.
Authorized Signature
Date
Click here to enter text.
Title
Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application
Revised 05/08/2015QMC052615
Page 11 of 14
Outpatient Behavioral Health Service Codes for IPRS & Medicaid
Please check (√) all that apply (only the services you have an existing agreement with Sandhills Center)
Procedure
Code
90785
☐
90791
☐
90792
☐
90832
☐
90833
☐
90834
☐
90836
☐
90837
☐
90838
☐
90839
☐
90840
☐
90845
☐
90846
☐
90847
☐
90849
☐
90853
☐
90857
☐
96101
☐
96110
☐
96111
☐
96116
☐
96118
☐
96372
☐
H0001
☐
H0004
☐
☐ H0004HQ
☐ H0004HR
☐ H0004HS
H0005
☐
H0031
☐
Description
Interactive Complexity Add On
Psychiatric Diagnostic Evaluation
Psychiatric Diagnostic Evaluation with Medical Services
Psychotherapy 30 Minutes
Psychotherapy 30 Minutes Add On
Psychotherapy 45 Minutes
Psychotherapy 45 Minutes Add On
Psychotherapy 60 Minutes
Psychotherapy 60 Minutes Add On
Crisis Psychotherapy first 60 Minutes
Crisis Add For Each Additional 30 Minutes
Psychoanalysis
Family therapy w/o Patient
Family therapy with Patient
Group Therapy (Multiple Family)
Group Therapy (Non-Multi- Family)
Interactive Group Therapy
Psychological Testing F-T-F
Developmental Testing Limited
Developmental Testing Extended
Neurobehavioral Status Exam
Neuropsychological Testing
Therapeutic, Prophylactic, or DX Injection Intra-Muscular
Behavioral Health Assessment
Behavioral Health Counseling/Therapy
Outpatient Treatment Group
Outpatient Tx Family Therapy w/ Client
Outpatient Tx Family Therapy w/o Client
Alcohol and/or Drug Group Counseling
Mental Health Assessment
Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application
Revised 05/08/2015QMC052615
Available to Benefit Plan
State (IPRS)
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
N/A
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
N/A
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
State
Medicaid
Page 12 of 14
IPRS (State) Funds Only for Services for Non-Licensed Substance Abuse Professionals
Please check (√) all that applies (only the services you have an existing agreement with Sandhills Center):
Check
(√)
☐
☐
☐
☐
☐
☐
Procedure
Code
YP830
YP831
YP832
YP833
YP834
YP835
Description
Behavioral health Assessment
Behavioral health Counseling and Therapy
DMH Outpatient Treatment Group
DMH Outpatient Tx Family Therapy w/ Client
DMH Outpatient Tx Family Therapy w/o Client
Alcohol and/or Drug Services; Group Counseling by Clinician
Evaluation & Management Codes
***Evaluation & Management Codes are only provided by Physicians Assistants,
Cert. Nurse Practitioners and Physicians (only check (√) what services you are currently providing). ***
Check
(√)
Procedure
Code
☐
90865
☐
95970
☐
95971
☐
95972
☐
95973
☐
95974
☐
95975
☐
95978
☐
95979
☐
96125
☐
96150
☐
95151
☐
96372
☐
96373
☐
96374
☐
96375
Description
Narcosynthesis for Psychiatric Diagnostic
and Therapeutic Purposes
Electronic Analysis of Implanted
Neurostimulator
Electronic Analysis of Implanted
Neurostimulator Simple Spinal Cord
Electronic Analysis of Implanted
Neurostimulator Complex Spinal Cord
(1hr.)
Electronic Analysis of Implanted
Neurostimulator Complex Spinal Cord (30
min.)
Electronic Analysis of Implanted
Neurostimulator Complex Cranial
(1 hr.)
Electronic Analysis of Implanted
Neurostimulator Complex Cranial
(30 min.)
Electronic Analysis of Implanted
Neurostimulator
Electronic Analysis of Implanted
Neurostimulator (30 min.)
Standardized Cognitive Performance
Testing
Physical Health and Behavior Assessment
F-T-F (15 min.)
Physical Health and Behavior Reassessment
Therapeutic, Prophylactic, or Diagnostic
Injection
Intra-Muscular
Therapeutic, Prophylactic, or Diagnostic
Injection Intra-Arterial
Therapeutic, Prophylactic, or Diagnostic
Injection Intravenous Push
Therapeutic, Prophylactic, or Diagnostic
Injection Subsequent Intravenous Push
Check
(√)
Procedure
Code
☐
99220
Hospital Initial Observation Care High
Complexity
☐
99221
Hospital Initial Care MD (30 min.)
☐
99222
Hospital Initial Care MD (50 min.)
☐
99223
Hospital Initial Care MD (70 min.)
☐
99231
Hospital Subsequent Hospital Care MD
Low Complexity (15 min.)
☐
99232
Hospital Subsequent Hospital Care MD
Moderate Complexity (25 min.)
☐
99233
Hospital Subsequent Hospital Care MD
High Complexity (35 min.)
☐
99234
☐
99235
☐
99236
Observation/Inpatient Care High Complexity
☐
99238
Hospital Discharge Services (<30 min.)
☐
99239
Hospital Discharge Services (>30 min.)
☐
99241
Outpatient Consultation MD Minor
(15 min.)
☐
99242
☐
99243
☐
99244
Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application
Revised 05/08/2015QMC052615
Description
Hospital Observation/Inpatient Care
Low Complexity
Hospital Observation/Inpatient Care
Moderate Complexity
Outpatient Consultation MD Moderate
(30 min.)
Outpatient Consultation MD Severe
(40 min.)
Outpatient Consultation MD Severe
(60 min.)
Page 13 of 14
Evaluation & Management Codes (continued)
***Evaluation & Management Codes are only provided by Physicians Assistants,
Cert. Nurse Practitioners and Physicians (only check (√) what services you are currently providing). ***
Check
(√)
Procedure
Code
Check
(√)
Procedure
Code
☐
99201
☐
99245
Outpatient Consultation MD Severe
(80 min.)
☐
99251
Inpatient Consultation MD Minor (20 min.)
☐
99252
Inpatient Consultation MD Low Severity
(40 min.)
☐
99253
Inpatient Consultation MD Moderate (55 min.)
☐
99254
☐
99255
99212
99213
99214
99215
Outpatient E&M New Patient F-T-F (10
min.)
Outpatient E&M New Patient F-T-F
(20 min.)
Outpatient E&M New Patient F-T-F
(30 min.)
Outpatient E&M New Patient F-T-F
(45 min.)
Outpatient E&M New Patient F-T-F
(60 min.)
E & M Estab. Patient, w/wo MD
(approx. 5 min.)
Outpatient Visit Estab. Minor (10 min.)
Outpatient Visit Estab. Moderate (15 min.)
Outpatient Visit Estab. Severe (25 min.)
Outpatient Visit Estab. Severe (40 min.)
☐
99202
☐
99203
☐
99204
☐
99205
☐
99211
☐
☐
☐
☐
☐
☐
☐
☐
99281
99282
99283
99284
☐
99217
Hospital Observation Care - Discharge
☐
99285
☐
99218
☐
99304
☐
99219
☐
99305
☐
99306
☐
99337
☐
99307
☐
99341
☐
99308
☐
99342
☐
99309
☐
99343
☐
99310
☐
99344
☐
99315
☐
99345
☐
99316
☐
99347
☐
99318
☐
99348
☐
99324
☐
99349
☐
99325
☐
99350
☐
99326
☐
99354
☐
99327
☐
99355
☐
99328
☐
99356
☐
99334
☐
99357
☐
99335
☐
Q3014GT
☐
99336
Hospital Initial Observation Care
Low Complexity
Hospital initial Observation Care Moderate
Complexity
Initial Nursing Facility Care E&M high
Complexity (45 min.)
Subsequent Nursing facility Care E&M
Review of Case (10 min.)
Subsequent Nursing Facility Care E&M
Low Complexity (15 min.)
Subsequent Nursing Facility Care E&M
Moderate Complexity (25 min.)
Subsequent Nursing Facility Care E&M
High Complexity (35 min.)
Nursing Facility Discharge Management
(<30 min.)
Nursing Facility Discharge Management
(>30 min.)
Nursing Facility, E&M Low to Moderate
Complexity (30 min.)
New Patient Domiciliary/Rest Home E&M
Low Severity (20 min.)
New Patient Domiciliary/Rest Home E&M
Low Complexity (30 min.)
New Patient Domiciliary/Rest Home E M
Moderate Complexity (45 min.)
New Patient Domiciliary/Rest Home E&M
High Severity (60 min.)
New patient Domiciliary/Rest Home E&M
High Complexity (75 min.)
Estab. Patient Domiciliary/Rest Home
E&M (15 min.)
Estab. Patient Domiciliary/Rest Home
E&M Low Complexity (25 min.)
Estab. Patient Domiciliary/Rest Home
E&M Moderate Complexity (40 min.)
Description
Addendum to CAQH/NC Uniform LIP Credentialing/Re-Credentialing Application
Revised 05/08/2015QMC052615
Description
Inpatient Consultation MD Moderate –
High Severity (80 min.)
Inpatient Consultation MD Moderate –
High Severity (110 min.)
ER Visit, Minor
ER Visit, Low Severity
ER Visit, Moderate Severity
ER Visit, High Severity
ER Visit for the evaluation and management
of a patient
Initial Nursing Facility Care E&M
Low Complexity (25 min.)
Initial Nursing Facility Care E&M Moderate
Complexity (35 min.)
Estab. Patient Domiciliary/Rest Home E&M
Moderate to High Severity (60 min.)
New Patient Home Visit E&M Low Severity
(20 min.)
New Patient Home Visit E&M Low
Complexity (30 min.)
New Patient Home Visit E&M Low Moderate
Complexity (45 min.)
New Patient Home Visit E&M High Severity
(60 min.)
New Patient Home Visit E&M High
Complexity (75 min.)
Estab. Patient Home Visit E&M (15 min.)
Estab. Patient Home Visit E&M Low
Complexity (25 min.)
Estab. Patient Home Visit E&M Moderate
Complexity (40 min.)
Estab. Patient Home Visit E M High
Complexity (60 min.)
Prolonged MD Service w/F-T-F Patient Contact
in Office (60 min.)
Prolonged MD Service w/F-T-F Patient Contact
in Office (30 min.)
Prolonged MD Service w/F-T-F Patient Contact
Inpatient (60 min.)
Prolonged MD Service w/F-T-F Patient Contact
Inpatient (30 min.)
TelePsych Site Facility Fee
Page 14 of 14