SINGLE CASE AGREEMENT (SCA) Yvonne Joyner, QP, BS Chauncey - PowerPoint PPT Presentation

SINGLE CASE AGREEMENT (SCA) Yvonne Joyner, QP, BS Chauncey Dameron, MBA Provider Relations Specialist Provider Relations Specialist Network Operations Network Operations

If there is a member who needs a specific Medicaid or state funded service for a specific period of time and there is not a provider in the network available to provide the needed service a Single Case Agreement (SCA) can be requested.

The SCA is submitted by the provider along with the Electronic Funds Transfer Form (EFT), Trading Partner Agreement (TPA), current Copies of Certificates of Insurance (COI), copies of required licenses, W-9, copy of voided check or an official letter from the bank providing the account and routing numbers and a paper TAR if the requested service must be authorized.

• Application is available in two formats: printable and web submission. • Downloadable format www.eastpointe.net  Provider  Manuals and Forms  Forms  Single Case Agreement . • This format should be submitted via fax to 252-407-2450 or via secure email to networkoperations@eastpointe.net.

• Electronic submission format: www.eastpointe.net  Provider  Manuals and Forms  Electronic Forms  Single Case Agreement . • When using this format, the required documents listed under Attachment B should be uploaded to the application under the section provided for additional documents.

• These documents are available on the Eastpointe website at www.eastpointe.net  Provider  Manuals and Forms  Forms. • You should be able to save them to your desktop and once complete, they can be attached to both the Downloadable and/or Electronic Form.  they can be attached to the formdesk form.  them to your desktop and once complete, they can be attached to the formdesk form.

Medical necessity must be determined for services requiring pre-authorization before the SCA can be approved. Members should not be placed or receive services until the Single Case Agreement is approved. Provider will not receive payment for services until the SCA is approved and set up in Alpha.

Corporate Office: 514 East Main Street Post Office Box 369 Beulaville, N.C. 28518 Administration: 800-513-4002 Access to Care: 800-913-6109 Sarah N. Stroud, CEO SINGLE CASE AGREEMENT (Must select one) Funding Source: ☐ Medicaid ☐ IPRS Date of Request: (date you submit application to Eastpointe) Section:1 (This information should be the same as the information in NC Tracks) Provider Information: Provider Legal Name: Click here to enter text. DBA Name: Click here to enter text. Federal Tax ID: Click here to enter text. Agency NPI#: Click here to enter text. CEO/ Director Name: Click here to enter text.

Mailing Address: Click here to enter text. City: Click here to enter text. State: Click here to enter text. Zip + 4: (both zip and plus 4 required) Click here to enter County: Click here to enter text. text. Telephone Number: Click here to enter text. Email: Click here to enter text. Primary Clinical Contact: Click here to enter text. Telephone Number: Click here to enter text. Email: Click here to enter text. Are you working with a Care Coordinator on this case? ☐ Coordinator’s name: Click or tap here to enter text. Yes ☐ No Section: 2 (must select one) Provider Type: ☐ Agency / Licensed Facility ☐ Licensed Independent Practitioner (LIP)-Solo ☐ CABHA ☐ ICF-IDD ☐ Hospital ☐ Facility only IDD, PRTF

Section: 3 (Must select One) Organization Legal Entity Type: ☐ C-Corp ☐ S-Corp ☐ Limited Liability Partnership(LLC) ☐ Sole Proprietorship ☐ Cooperative ☐ General Partnership ☐ For Profit ☐ Not for profit ☐ Government Section: 4 (Person to contact for billing questions) Billing Information:5 Billing Contact: Billing Address: City: State: Zip: (both zip and plus 4 required) County:

Section: 5 (Location where service will be provided) Service Location: Site Address: City: State: Zip + 4: (both zip and plus 4 required) County: NPI Number: Taxonomy Number: List Service requested at this site for member (Include): (Both service and billing code required for each service requested) Service Description: (Can request more than one Billing Code: ( a code must be provided for each service service) requested) License type (if applicable):

Section: 6 (One member per application) Client Information: Full Client Name: Client Medicaid #: Client DOB: Client Medicaid County of Origin: (if applicable) (Must be one of the twelve counties in the Eastpointe catchment area) Requested Service Begin Date: (begin date required. This date should not be prior to submission date) Requested Service End Date (if known): Section: 7 (Responses required) Accreditation Organization: Number of years Accredited: Accreditation Expiration Date: OR ☐ We are not required to be Accredited for the services we provide. Do you currently have a Contract with another LME-MCO? ☐ Yes ☐ No ☐ If yes, please list all LME- MCO’s: Have you ever been sanctioned, placed on probation, and lost accreditation/certification.

Section: 8 Note: For all LIP’s whose NPI numbers you will be using for Outpatient Services please complete this section. Please use Attachment A for additional LIP’s. Licensed Clinician Information: (All requested information must be provided) Legal Name: Address: City: State: Zip + 4 (both zip and plus 4 required) Date of Birth: Social Security No.: Gender: Felony/Misdemeanor or Investigation: (If yes please explain) ☐ Yes ☐ No Professional Schools attended: Graduation: License Type: License Number: Date Issued: Expiration Date: DEA Number: (if applicable) NPI number: Taxonomy Number: Do you currently have a Contract with another LME-MCO? ☐ Yes ☐ No ☐ If yes, please list all LME- MCO’s:

(Responses required) Please identify your Insurance Carrier(s): Professional Liability: Name: Telephone No.: Policy #: Are there any claims? ☐ Yes ☐ No Are there any current or unsettled claims? ☐ Yes ☐ No Are there any circumstances that may result in a claim? ☐ Yes ☐ No Are any of the policies cancelled? ☐ Yes ☐ No Commercial General Liability Insurance: Name: Telephone No.: Policy #: Worker’s Compensation Insurance: Name: Telephone No.: Policy #:

(documents required when submitting the Single Case Agreement request) Required Attachments: ( Attachment B ) 1. Electronic Funds Transfer (EFT) Agreement – (please complete and sign) 2. Trading Partner Agreement (TPA) – (please complete and sign) 3. Copies of Certificate(s) of Insurance (COI) or Accord-25 or associated form. 4. Copies of required Licenses. 5. Request for Taxpayer Identification Number (W-9) 6. Copy of voided check or bank letter with account and routing number. Section:11 (explanation required for all Yes responses) Investigation and Sanction Attached Questions: (1) Are there any actions or investigations against you/ any owner or QP in your organization, privileges, billing organizations or sanctions? ☐ Yes ☐ No (if yes please describe) Click here to enter text. Do you have any adverse actions been filed against you? This would include Medicaid, Medicare or other Insurances. ☐ Yes ☐ No (1) (if yes please describe) Click here to enter text. (1) Has anyone in your company who has an ownership, managerial, or clinical role, ever been sanctioned by any professional organization or government organization for violation of ethics, professional misconduct, unprofessional conduct, incompetence or negligence in any state or county? ☐ Yes ☐ No (if yes please describe) Click here to enter text. Are you aware of any circumstances that may result in such action? ☐ Yes ☐ No (1) (if yes please describe) Click here to enter text. (1) Have you ever had a contract canceled by another LME-MCO, Area Authority, and County Program in NC or a similar entity in another state? ☐ Yes ☐ No (if yes please describe) Click here to enter text. (1) Please Provide a listing of shareholders/partners with 5% or more ownership AND officers, directors, managers, EFT authorized individuals. (See Attachment C) .

Investigation and Sanction Attached Questions: (explanation required for all Yes responses) (1) Are there any actions or investigations against you/ any owner or QP in your organization, privileges, billing organizations or sanctions? ☐ Yes ☐ No (if yes please describe) (2) Do you have any adverse actions been filed against you? This would include Medicaid, Medicare or other Insurances. ☐ Yes ☐ No (if yes please describe) (3) Has anyone in your company who has an ownership, managerial, or clinical role, ever been sanctioned by any professional organization or government organization for violation of ethics, professional misconduct, unprofessional conduct, incompetence or negligence in any state or county? ☐ Yes ☐ No (if yes please describe) (4) Are you aware of any circumstances that may result in such action? ☐ Yes ☐ No (if yes please describe) (5) Have you ever had a contract canceled by another LME-MCO, Area Authority, and County Program in NC or a similar entity in another state? ☐ Yes ☐ No (if yes please describe) Please Provide a listing of shareholders/partners with 5% or more ownership AND officers, directors, managers, EFT authorized individuals. (See Attachment C) .