Organizational Deemed Status Request
TO:
Provider Network Management Department
FROM:
DATE:
SUBJECT:
Provider Enrollment: Organizational Deemed Status Request
I. CURRENT CREDENTIALING STATUS:
_____________________________ is requesting recognition by the Provider Network as
having an approved credentialing and privileging program. As such, we request that our
network practitioners who have already been determined to have the appropriate
“credentials” to provide Medicaid billable services, and who are “privileged” within an
approved scope of practice by our organization, shall be granted ‘deemed status’ by the
Provider Network and enrolled into the Provider Network based upon our approved
organizational credentialing and privileging process. A copy of the organization’s
provider contract is attached and it is realized and agreed to at the time of the Agency’s
annual contract site review that the Provider Network will verify and validate the licensing
and privileges of the below applicant.
Organization:
Licensing Body:
Expiration Date:
Accreditation Body:
Expiration Date:
Each staff that will bill the Provider Network as an individual professional practitioner
must be included in the table on page 2.
Key Executive Staff:
Executive Director:
Medical Director and Clinical/ Program Director(s):
Chief Financial Officer:
Management Information System Director:
Customer Service Director:
Recipient Rights Officer:
Clinical Access: 810-987-6911  Toll-free 1-888-225-4447  TTY 888-225-1973
FORM # 1302 7/15
D:\116105405.doc
Organizational Deemed Status Staffing Table
Staff Name
Employment Type (full-time,
part-time, contractual)
Credential
Type
Expiration Date
(See chart below)
Organizational
Privileges
Expiration
Date
Credential Types
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Psychiatrist
Physician, Non-Psychiatrist
Psychologist
Psychologist
Physician Assistant
Mental Health/Psychiatric Nurse Practitioner
Nurse Practitioner
Licensed Master’s Social Worker
Licensed Bachelor’s Social Worker
Social Service Technician
Limited Social Service Technician
Bach. Degree in Human Service
Mental Health Counselor
Psychiatric Nurse
Registered Nurse, BSN
Registered Nurse
Occupational Therapist
Occupational Therapy Assistant
Physical Therapist
Physical Therapy Assistant
Speech Pathologist or Audiologist
Registered Dietician
Substance Abuse Treatment Specialist
24
25
26
27
28
29
30
31
Non-credentialed Staff
Qualified Mental Health Professional
Qualified Intellectual Disability Professional
Certified Peer Support Specialist
Children’s Mental Health Professional
Family Psycho Education
Peer Recovery Coach
Certified in SUD Prevention
32
33
34
35
36
37
38
Gender Competent
Communicable Disease Trainer
Parent Management Training - Oregon Model
Infant Mental Health Certification
Trauma Focused Cognitive Behavioral Therapy
Board Certified Behavioral Analyst
Board Certified Aide Behavioral Analyst
MD, DO
MD, DO
LP
LLP, TLLP
PA-C
APRN-BE NHNP, PsychNP
APRN-BC ANP, FNP, PedNP
LMSW, LLMSW*
LBSW, LLBSW*
SST
LSST
B.S. or B.A.
LPC, LLPC
MA or MSN in Psych, RN
BSN, RN
RN
OTR
COTA
PTR
PTA
SLP
RD
CADC
CADC-M
CAADC
CCS
CCS-M
CCJP
CCDP
CCDP-D
Development Plan
QMHP
QIDP
PSS
CMHP
Successful Completion of Certified Training
PRC
CPC-R, CPC-M, CPS-R, CPS-M, Development
Plan, CHES
Provider Enrollment & Credentialing Policy 04-005-0001
HAPIS
PMTO
IMH
TFCBT
BCBA
BCaBA
* = LLMSW and LLBSW providers may only provide these services under the supervision of a LMSW
Agency Signature
FORM # 1302 7/15
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Date
II. PROVIDER NETWORK RESPONSE
Your request has been reviewed to allow for deemed status of the above named
organization, allowing the practitioners of the organization to be enrolled and
credentialed as providers for the Provider Network. The review has resulted in the
following:
Your request has been approved for “deemed status” recognition and enrollment into
the Provider Network as an organization with billable practitioners for Medicaid
services within the practitioners’ scope of practice. The Provider Network will
update its database and enroll the practitioner for your organization as requested.
Your request has been denied for the following reason(s):
Credentialing Chair
Date
You may appeal this denial (as applicable) using the appeal form contained in the
Provider Network Credentialing Policy.
cc: Executive Director
Credentialing Committee
Contracts
FORM # 1302 7/15
D:\116105405.doc