form 2970c - texas health and human services commission · web viewsome forms may include special...

Department Family & Protective ServicesEvaluation and Treatment Services Open Enrollment Number: HHS0000071Revision Date: November 17, 2020

Applicant and Contract Information

DFPS uses the PEN Application and Contract (2280PEN) to create a contract between DFPS and a Contractor for the performance of services that were solicited using the Provider Enrollment (PEN) procurement method. The PEN Application and Contract, Form 2280PEN is included as an attachment to the PEN solicitation.

Under §5 of the 2280PEN, DFPS must indicate where the services will be provided. The Contractor will be required to provide services in the geographical area specified in the solicitation, most frequently consistent with a DFPS region.

Department Family & Protective ServicesEvaluation and Treatment Services Open Enrollment Number: HHS0000071

Attachment A-3APPLICATION AND CONTRACT

Evaluation & Treatment HHS0000071

1. Identification Information

Legal Name of Applicant Doing Business As (DBA) Name

If different from Legal Name Attach a copy of Assumed Name Certificate

Vendor ID Number

Federal ID Number – If different from Vendor ID

2. Type of Applicant – Check “√” appropriate box(es) and attach documentation as indicated

Individual/Sole Proprietor Limited Liability Company (LLC) Attach a copy of the Articles of Formation Corporation

Type of Corporation: For Profit Non-ProfitState of Incorporation: Charter Number:

Attach a copy of Certificate of Incorporation Partnership

Type of Partnership: Limited GeneralAttach a copy of Partnership Agreement.

If applicable, also attach a copy of the Signatory Assignment

3. Contact InformationOffice Address (Street-Suite #)

Office Address (City, State, Zip)

Mailing Address (P.O. Box)If different from Office Address above

Mailing Address (City, State, Zip)If different from Office Address above

Phone- Primary Office

Fax- Primary Office

E-Mail- Primary Office

Name-Primary Contact Person

Title-Primary Contact Person

Phone-Primary Contact Person

Alternate Phone-Primary Contract Person

E-Mail- Primary Contract Person

1


Name- Person Authorized to Sign Contract

Title- Person Authorized to Sign Contract

Phone- Person Authorized to Sign Contract

Alternate Phone- Person Authorized to Sign Contract

E-Mail- Person Authorized to Sign Contract

Name-Person Responsible for Billing

Title- Person Responsible for Billing

Phone- Person Responsible for Billing

Alternate Phone- Person Responsible for Billing

E-Mail- Person Responsible for Billing

DFPS will send contract-related communications to the primary contact listed above. The Contractor must maintain and monitor at least one active e-mail address for the receipt of contract-related communications from DFPS.

4. Services to Be Provided

Contractor may provide Psychological Evaluation and Testing and/or Psychosocial Assessment and Treatment Services specified in Provider Enrollment HHS0000071. Contractor must provide all Support Services specified in HHS0000071 upon DFPS request.

Evaluation and Treatment ServicesService Service Type Applying For

Evaluation ServicesTreatment Services

Psychological Evaluation and Testing Yes No

Psychosocial Assessment, Individual, Group and Family Counseling

Yes No

Support ServicesCourt Related ServicesDiagnostic ConsultationTranslator & Interpreter

As requested by DFPS

Battering Intervention and Prevention Program (BIPP) ServicesService Service Type Applying For

Evaluation andIntervention Services

Domestic Violence Assessment and BIPP Group Intervention (Providers must be TDCJ-

Yes No

2


CJAD accredited BIPP program providers who are either an LMSW, LCSW, LPC, LMFT or a TDCJ-CJAD funded BIPP Provider)

Support ServicesCourt Related ServicesDiagnostic ConsultationTranslator & Interpreter

As requested by DFPS

5. Service Delivery Locations

a. You must determine which counties will be served and mark them in Attachment A-4 Service Delivery Areas. Contractor must provide services within each county selected.

b. Will you, your staff, or subcontractors be delivering services from established office sites other than the location listed in Section C of this application?

Yes No

If yes, services from these satellite locations are to be billed as In-Office. Designate any satellite office on Attachment A-4 Service Delivery Areas.

c. Indicate locations in which the Contractor is willing to provide services.

In-Office Out-of-Office Home-Based (client's home) (not allowable for BIPP)

d. Will you, your staff, or subcontractors be delivering services in any of the CPS Designated Underserved Counties identified on Attachment A-4 Service Delivery Areas?

Yes No

e. Will you, your staff, or other subcontractors be delivering telehealth services in addition to at least one of the locations listed in Sections a - d of this application? Note: If you elect to provide telehealth services, you must also provide either In-Office, Out-of-Office or Home-based services in the same region(s) and counties in which you are electing to provide telehealth services.

Yes No

NOTE: If yes, telehealth services must be billed as In-Office.

3


6. Contractor Background

a. Does the Contractor have contracts with DFPS or other State Agencies?

Yes No

If yes, is the Contractor's organization currently under any corrective action plan for any of the contracts with DFPS or State Agencies?

Yes No

b. Have any contracts been terminated for cause in the last five (5) years?

Yes (Provide copy of termination notice) No

7. Insurance

7.1 Review the minimum insurance requirements in PEN §2.16. Applicants must meet all requirements as outlined. Indicate in the table below, if requirement is met:

Commercial General Liability

Yes No

Applicant does not have required Commercial General Liability insurance, but will obtain within the timeframe defined in the PEN:

Yes No

Professional Liability Insurance

Yes No N/A*

Applicant does not carry Professional Liability Insurance for its employees or subcontractors, but will obtain within the timeframe defined in the PEN:

Yes No

Commercial Crime

Yes No N/A*

Applicant does not have required commercial crime insurance, but will obtain within the timeframe defined in the PEN:

Yes No

Attach a copy of the Form 4736, Certificate of Insurance (COI) or equivalent (ACORD Certificate of Insurance, or a copy of the policy) for each policy currently in force and referenced in the table above. Form 4736 has been approved by the Texas Department of Insurance and is the preferred form of insurance verification.

*Business entities with no employees and hospitals are exempt from crime policy insurance requirement.

7.2 For Employees and Subcontractors

Applicant’s organization requires individual professional employees and subcontractors to secure their own Professional Liability Insurance:

4


Yes No N/A

8. Incorporation by Reference

The following documents are incorporated into the Contract for all purposes:

8.1.1. DFPS Vendor Uniform Terms & Conditions, Form 5645V8.1.2. DFPS Vendor Special Conditions, Form 5622V8.1.3. DFPS Vendor Special Conditions, Form 5622V8.1.4. Provider Enrollment HHS0000071, including all addenda and attachments8.1.5. Attachment A-3 and A-4, as completed by the Contractor, including all addenda

and attachments8.1.6. Each Service Authorization Form 2054, prepared by DFPS

9. Order of Precedence

The Contractor will provide the services and deliverables described and required by all the documents listed in this Section. In the event of conflicts or inconsistencies between documents, such conflicts or inconsistencies will be resolved by reference to the documents in the following order of precedence:

9.1.1. This PEN Application and Contract, 2280PEN, and any amendments thereto;9.1.2. DFPS Vendor Uniform Terms & Conditions, Form 5645V9.1.3. DFPS Special Conditions, Form 5622V9.1.4. Provider Enrollment HHS0000071 and any amendments thereto; 9.1.5. Each Service Authorization Form 2054 prepared by DFPS; and 9.1.6. Attachment A-3 and A-4, as completed by the Contractor, including all addenda and attachments, and any amendments thereto.

9 Certification and Signature

I certify that the information provided in this application is, to the best of my knowledge, complete and accurate; that the named legal entity has authorized me, as its representative, to submit this application; and that the legal entity complies with all terms of this Provider Enrollment.

By signing this PEN Application and Contract, applicant certifies that if a Texas address is shown as the address of the applicant, applicant qualifies as a Texas Resident Bidder as defined in Texas Administrative Code, Title 34, Part 1, Chapter 20.

DFPS will post all official communication regarding this PEN on the Electronic State Business Daily (ESBD). DFPS reserves the right to revise the PEN at any time. Contractors must comply with any changes, amendments, or clarifications posted to ESBD. It is the responsibility of the Contractor to periodically check the ESBD for

5

http://esbd.cpa.state.tx.us/

http://esbd.cpa.state.tx.us/


updates to the procurement. The Contractor’s failure to periodically check the ESBD will not release the Contractor from “addenda or additional information” resulting in additional costs to meet the requirements of the PEN.

The undersigned representative agrees to all the terms and conditions specified in the Contract and by signing below agrees to execute the terms and conditions of the Contract upon receipt of a 2054 from the Department.

Signature of Authorized Representative

Date

Name of Authorized Representative (Printed)

Title of Authorized Representative (Printed)

DFPS Approval Signature:Signature of Authorized DFPS Representative

Date

Name of Authorized DFPS Representative (Printed)

Title of Authorized DFPS Representative (Printed)

Contract Information – For DFPS Use ONLY

DFPS will complete the information below once Application is screened, reviewed, and accepted for contract.

9.1 Notices

Any notice required or permitted under this contract by the Contractor to DFPS must be in writing and submitted to the DFPS address below:

DFPS Office Address (Street;-Suite #; or P.O. Box)

9.2 Contract Term

6


Contract Number (DFPS staff will complete)

The initial contract period will begin on the effective date stated below, with the total contract term not to exceed sixty (60) months.

Effective Date of Contract

End Date of Contract August 31, 2021

7


Attachment A-4 Service Delivery Area

Service Delivery AreaCounties To Be Served – Region 1

Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.

***CPS Designated Underserved County

Regional Counties☐ Armstrong*** ☐ Hockley***☐ Bailey*** ☐ Hutchinson***☐ Briscoe*** ☐ King***☐ Carson*** ☐ Lamb***☐ Castro*** ☐ Lipscomb***☐ Childress*** ☐ Lubbock☐ Cochran*** ☐ Lynn***☐ Collingsworth*** ☐ Moore***☐ Crosby*** ☐ Motley***☐ Dallam*** ☐ Ochiltree***☐ Deaf Smith*** ☐ Oldham***☐ Dickens*** ☐ Parmer***☐ Donley*** ☐ Potter☐ Floyd*** ☐ Randall☐ Garza*** ☐ Roberts***☐ Gray*** ☐ Sherman***☐ Hale*** ☐ Swisher***☐ Hall*** ☐ Terry***☐ Hansford*** ☐ Wheeler***☐ Hartley*** ☐ Yoakum***☐ Hemphill***

8





Regional Counties☐ Archer*** ☐ Kent***☐ Baylor*** ☐ Knox***☐ Brown*** ☐ Mitchell***☐ Callahan*** ☐ Montague***☐ Clay*** ☐ Nolan***☐ Coleman*** ☐ Runnels***☐ Comanche*** ☐ Scurry***☐ Cottle*** ☐ Shackelford***☐ Eastland*** ☐ Stephens***☐ Fisher*** ☐ Stonewall***☐ Foard*** ☐ Taylor***☐ Hardeman*** ☐ Throckmorton***☐ Haskell*** ☐ Wichita***☐ Jack*** ☐ Wilbarger***☐ Jones*** ☐ Young***

9





Regional Counties☐ Collin ☐ Johnson***☐ Cooke*** ☐ Kaufman***☐ Dallas ☐ Navarro***☐ Denton ☐ Palo Pinto***☐ Ellis*** ☐ Parker***☐ Erath*** ☐ Rockwall***☐ Fannin*** ☐ Somervell☐ Grayson*** ☐ Tarrant☐ Hood*** ☐ Wise***☐ Hunt***

10





Regional Counties☐ Anderson ☐ Marion☐ Bowie ☐ Morris***☐ Camp*** ☐ Panola***☐ Cass*** ☐ Rains***☐ Cherokee ☐ Red River***☐ Delta ☐ Rusk☐ Franklin*** ☐ Smith☐ Gregg ☐ Titus☐ Harrison ☐ Upshur☐ Henderson ☐ Van Zandt☐ Hopkins ☐ Wood***☐ Lamar

11





Regional Counties☐ Angelina ☐ Polk***☐ Hardin ☐ Sabine***☐ Houston*** ☐ San Augustine***☐ Jasper*** ☐ San Jacinto***☐ Jefferson ☐ Shelby***☐ Nacogdoches ☐ Trinity***☐ Newton*** ☐ Tyler***☐ Orange

12


Service Delivery AreaCounties To Be Served – Region 6 Closed



All Regional Counties ClosedAustin*** Liberty***Brazoria*** Matagorda***Chambers*** MontgomeryColorado*** Walker***Fort Bend Waller***Galveston*** WhartonHarris

13





Regional Counties☐ Bastrop*** ☐ Hill***☐ Bell ☐ Lampasas***☐ Blanco*** ☐ Lee***☐ Bosque*** ☐ Leon***☐ Brazos*** ☐ Limestone***☐ Burleson*** ☐ Llano***☐ Burnet*** ☐ Madison***☐ Caldwell ☐ McLennan☐ Coryell*** ☐ Milam***☐ Falls*** ☐ Mills☐ Fayette*** ☐ Robertson***☐ Freestone*** ☐ San Saba***☐ Grimes*** ☐ Travis☐ Hamilton*** ☐ Washington***☐ Hays ☐ Williamson

14





Regional Counties☐ Atascosa ☐ Karnes☐ Bandera ☐ Kendall☐ Bexar ☐ Kerr☐ Calhoun*** ☐ Kinney☐ Comal ☐ La Salle☐ De Witt*** ☐ Lavaca***☐ Dimmit ☐ Maverick***☐ Edwards ☐ Medina***☐ Frio*** ☐ Real☐ Gillespie ☐ Uvalde***☐ Goliad ☐ Val Verde***☐ Gonzales*** ☐ Victoria***☐ Guadalupe ☐ Wilson***☐ Jackson ☐ Zavala***

15





Regional Counties☐ Andrews*** ☐ Mason***☐ Borden*** ☐ McCulloch***☐ Coke*** ☐ Menard***☐ Concho*** ☐ Midland☐ Crane*** ☐ Pecos***☐ Crockett*** ☐ Reagan***☐ Dawson*** ☐ Reeves***☐ Ector ☐ Schleicher***☐ Gaines*** ☐ Sterling***☐ Glasscock*** ☐ Sutton***☐ Howard*** ☐ Terrell***☐ Irion*** ☐ Tom Green☐ Kimble*** ☐ Upton***☐ Loving*** ☐ Ward☐ Martin*** ☐ Winkler***

16





Regional Counties☐ Brewster*** ☐ Hudspeth***☐ Culberson*** ☐ Jeff Davis***☐ El Paso*** ☐ Presidio***

17





Regional Counties☐ Aransas*** ☐ Live Oak***☐ Bee*** ☐ McMullen***☐ Brook***s ☐ Nueces☐ Cameron ☐ Refugio***☐ Duval*** ☐ San Patricio***☐ Hidalgo ☐ Starr***☐ Jim Hogg*** ☐ Webb***☐ Jim Wells*** ☐ Willacy***☐ Kenedy ☐ Zapata***☐ Kleberg***

18


Satellite Offices and Additional Office Information:

Please provide a schedule in the table(s) below indicating days and times routinely available to provide services at each service location. These represent only routine days and times. Applicant will be expected to adjust schedule to accommodate the needs of clients and DFPS. Refer to PEN Section 2.5 for additional information. Use additional copies of this section, as necessary, to provide complete information.

Name of Applicant/Contractor

1.

Service Delivery Address

City, State, Zip

Phone Fax

Contact Person E-mail

HOURSDAY From To From To

Example 7 AM Noon 2 PM 7 PMMonday Tuesday Wednesday Thursday Friday Saturday Sunday

2.


City, State, Zip

Phone Fax



Monday Tuesday Wednesday Thursday

19



Friday Saturday Sunday

3.


City, State, Zip

Phone Fax



Monday Tuesday Wednesday Thursday Friday Saturday Sunday

20


Attachment A-5 Required Forms

Appendix A – Application Instructions

1. Applicant must submit a completed Application and Required Forms, as applicable, in the order listed below for File Folder 1 and File Folder 2.

2. Access the forms by the link or icon provided below by holding down the "Ctrl" key while clicking on the link.

3. Save forms in an electronic file.4. For the Application and the forms that require signature, print, sign and scan in

an electronic format. Scanned documents must be clear and legible.5. Attach File Folders 1 and 2 to email and submit the completed Application to the

Point of Contact listed in the Open Enrollment Section 1.2.

Appendix B – Required Forms

File Folder 1: Application

Electronic File Name

Description Required or If Applicable

Application Application for Enrollment RequiredLicensure and Credentials

Clinical License Required

Experience Evaluation & Treatment Experience Summary (Form K-5627 Experience and Summary)

Required

Reference Letters

Two (2) reference letters for direct service providers

Required

TF-CBT Web TF-CBT Web Certificate of Completion RequiredInsurance Insurance Documentation RequiredDBA Assumed Name Certificate Attachment If applicableIncorporation Certificate of Incorporation Attachment If applicableLLC LLC Articles of Formation Attachment If applicablePartnership Partnership Agreement Attachment If applicablePartners Names and addresses and for each partner If applicableHUB HUB Certification Form If applicable

21


File Folder 2: Required Forms

The following forms are located on the DFPS public website, Doing Business with DFPS, Contracting Forms: https://www.dfps.state.tx.us/Doing_Business/forms.asp


Form Number and Name Purpose

74-176 74-176, Vendor Direct Deposit Form Direct Deposit Authorization9007FFS 9007FFS, Internal Control Structure

Questionnaire Contractor's disclosure of internal controls. Instructions included.

9105RAQ 9105RAQ, Risk Analysis Questionnaire

Questionnaire for provider to assist staff with the completion of the Risk Assessment Instrument (RAI).

AP-152 AP-152, Application for Texas Identification Number [If you already have a Vendor ID set up for another DFPS contract, print form, note “Already Set Up” at top of page, and provide number]

Application for identification number

The following form is located on the DFPS public website, Doing Business with DFPS, Contracting Forms, Regional CPS Contracting Forms, General Documents: https://www.dfps.state.tx.us/Doing_Business/Purchased_Client_Services/Regional_CPS_Contracts/forms.asp


Form Number and Name

Purpose

PCS-102ET

PCS-102ET, Contracting Entity and List of Staff, Subcontractors and Volunteers

Contractors must list the contracting entity, all service providers, and requested provider information on this form and submit it electronically to DFPS.

2970c Disclosure and Consent to Release of Information Regarding Criminal or Abuse/Neglect History For Applicants, Employees or Volunteers of DFPS Contractors and Subcontractors

Release of information regarding criminal history or DFPS abuse and neglect history.

2971c Request for Background Check for

Application for requesting criminal history and DFPS abuse or neglect history.

22

https://www.dfps.state.tx.us/Doing_Business/Purchased_Client_Services/Regional_CPS_Contracts/forms.asp

https://www.dfps.state.tx.us/Doing_Business/Purchased_Client_Services/Regional_CPS_Contracts/forms.asp

https://www.dfps.state.tx.us/Doing_Business/forms.asp


Purchased Client Services

4736 Certificate of Insurance

Contractor submits this form to contract manager to show proof of insurance. The Certificate of Insurance has been approved by the Texas Department of Insurance; it is the only proof of insurance accepted by DFPS, unless the contractor is self-insured.

23


BIPP Application Checklist

STEP 1: Read the Evaluation & Treatment Open Enrollment for details of the terms and conditions of this contract. Focus on the sections that apply to BIPP Applicants. http://esbd.cpa.state.tx.us/bid_show.cfm?bidid=126949

STEP 2: Organization of Electronic Submission of ApplicationApplicant must organize its scanned and signed Application packet in the following order and format. Each flash drive or compact disc submission of the Application packet must include the following three (3) file folders with the respective listed documents included, and the documents must be in the following order, and numbered and labeled accordingly. Refer to Section 5, Information and Submission Instructions in the Open Enrollment and Section 8, Attachments and Forms (p.94).

Items to include in Application Packet Yes No

File Folder 1: ApplicationExhibit 1 - Application and Contract (Form 2280PEN) Exhibit 2 - Attachment A-4 Service Delivery Areas

File Folder 2: Supporting DocumentationExhibit 1 - Verification of Business Entity (Copy of: Certificate of Incorporation, Articles of Formation, Partnership Agreement, or Assumed Name Certificate)Exhibit 2 - BIPP Providers will have a 2-hour Child Welfare Trauma Informed Training Certificate from the completion of webinar http://www.dfps.state.tx.us/training/trauma_informed_care/

Exhibits 3 - 7 do not apply to BIPP Applicants

Exhibit 8 - Copy of Professional Licenses of direct providers listed on PCS-102ET (2.15.2) if applicable http://www.dfps.state.tx.us/PCS/Regional_Contracts/forms.asp#Evaluation_Treatment

Exhibit 9 - Verification of Required Insurance coverage including A.M. Best rating (subsection 2.16)

File Folder 3: Required Forms Applicants may also access the list of Required Forms at the following alternative link: http://www.dfps.state.tx.us/PCS/Regional_Contracts/forms.asp

Exhibit 1 – Form 2970c Disclosure and Consent to Release of Information --background checkExhibit 2 – Form 2971c Request for Criminal History & DFPS History Check--background checkExhibit 3 – Form 4108x Vendor Direct Deposit --allows DFPS to pay your bank accountExhibit 4 – Form 4109x Application of Texas Identification Number -- needed to identify contracted provider for paymentExhibit 5 – PCS-102ET Contracting Entity - lets us know who is working under your contract

24

http://www.dfps.state.tx.us/PCS/Regional_Contracts/forms.asp

http://www.dfps.state.tx.us/PCS/Regional_Contracts/forms.asp#Evaluation_Treatment

http://www.dfps.state.tx.us/training/trauma_informed_care/

http://esbd.cpa.state.tx.us/bid_show.cfm?bidid=126949


Exhibit 6 – 9007FFS Internal Control Structure Questionnaire - lets us know how you manage your business financesExhibit 7 – 4736 Certificate of Insurance- or applicant can submit the Certificate of Insurance - ACCORD form in place of this form.

NOTE: Each individual document requested in File Folders 1, 2, and 3 must be collated; in sequential order; labeled; and submitted as delineated in this subsection.

25


ATTACHMENT A-2 –TABLE AFEE SCHEDULE – EVALUATION SERVICES

Payment is based on “unit of service." The allowable unit rate for the type of service delivered is the rate consistent with the highest credential held by the service provider.

LICENSED PSYCHOLOGIST (LP), PROVISIONAL LICENSED PSYCHOLOGIST (PLP), LICENSED PSYCHOLOGICAL ASSOCIATE (LPA)Psychological Evaluation & Testing

Category Service - Service CodeLocation & Unit Rate

In Office Home Based Out of Office Telehealth

Psychological Evaluation Psychological Testing-86A $113.91 $159.25 $113.91

Psychological Evaluation by Licensed Psychological Associate (LPA)

Psychological Testing (LPA)-86A $79.74 $111.48 $79.74

Incomplete Psychological Evaluation1

Psychological Testing-86AMaximum 2 hours $113.91 $159.25 $113.91

Incomplete Psychological Evaluation by Licensed Psychological Associate1

Psychological Testing (LPA)-86AMaximum 2 hours $79.74 $111.48 $79.74

Court Related ServicesCourt Testimony-86HDeposition-86HMediation-86H

$157.57 $157.57 $157.57

Diagnostic Consultation Diagnostic Consultation - 81H $112.70 $157.57 $112.70

Translator/Interpreter Services Service Code 98L Cost Reimbursement-Requires Contract Manager prior

authorization1NOTE: Incomplete Psychological Evaluations are defined as after conducting a private individualized face-to-face clinical interview, extenuating circumstances impacted the ability to complete the testing.

Additional reimbursement for services provided in CPS DESIGNATED UNDERSERVED COUNTIES: Missed Appointments: Refer to Section 2.13.1

Travel: Refer to Section 2.13.3

26


ATTACHMENT A-2 - TABLE BFEE SCHEDULE –TREATMENT SERVICES

LICENSED PSYCHOLOGIST (LP)Psychological Counseling Services



Psychosocial Psychosocial Assessment – 86U $79.74 $111.48 $111.48 $79.74

IndividualIndividual Counseling - 86C $95.93 $134.11 $95.93

Home Based Counseling - Individual - 88K $134.11

FamilyFamily Counseling - 86F $79.93 $111.75 $79.93

Home Based Counseling - Family - 88K $111.75

Group Group Counseling - 86E $23.52 $32.88 $23.52

Court Related Services

Court Testimony - 86H $91.19

Deposition - 86H $91.19

Mediation – 86H $91.19

Diagnostic Consultation Diagnostic Consultation - 81H $65.22 $91.19 $65.22

Translator/Interpreter Services

Service Code 98L Cost Reimbursement-Requires Contract Manager prior authorization

Additional reimbursement for services provided in CPS DESIGNATED UNDERSERVED AREAS: Missed Appointments: Refer to Section 2.13.1

Travel to Underserved County: Refer to Section 2.13.3

27


ATTACHMENT A-2 –TABLE CFEE SCHEDULE – EVALUATION AND TREATMENT SERVICES

Payment is based on “unit of service." The allowable unit rate for the type of service delivered is the rate consistent with the highest credential held by the service provider.

LCSW, LMFT, LPC & LSOTP – Psychosocial Assessment & Counseling



Psychosocial Psychosocial Assessment – 86U $67.15 $93.88 $93.88 $67.15

IndividualIndividual Counseling – 86C $67.15 $93.88 $67.15

Home Based Counseling-Individual – 88K $93.88

FamilyFamily Counseling – 86F $55.95 $78.22 $55.95

Home Based Counseling-Family – 88K $78.22

Group Group Counseling – 86E $16.46 $23.01 $16.46


Court Testimony – 86HDeposition – 86HMediation – 86H

$63.82

Diagnostic Consultation Diagnostic Consultation – 81H $63.82

Translator/Interpreter Services

Service Code 98L Cost Reimbursement-Requires Contract Manager prior authorization

Additional reimbursement for services provided in CPS DESIGNATED UNDERSERVED COUNTIES:

Missed Appointments: Refer to Section 2.13.1 Travel: Refer to Section 2.13.3

28


ATTACHMENT A-2 –TABLE DFEE SCHEDULE – EVALUATION AND TREATMENT SERVICESBATTERING INTERVENTION PREVENTION PROGRAM (BIPP)

Payment is based on “unit of service." The allowable unit rate is based on information in the Unit Rate column in the table below.The identified BIPP provider types must maintain accreditation through TDCJ-CJAD.

LMSW, LCSW, LMFT & LPC or a TDCJ-CJAD funded BIPP


In Office Out-of-Office Telehealth

Domestic Violence Assessment Report 1 unit = 1 assessment

Domestic Violence Assessment Report – 86K $75.00 $75.00

Group1 unit = 1 hour sessions are 2 hours long (2 units)

Orientation and Battering Intervention Prevention Program (BIPP) – 86L

$16.46(2 units = $32.92)

$23.01(2 units = $46.02)

$16.46(2 units = $32.92)


Court Testimony – 86HDeposition – 86HMediation – 86H

$63.82

Diagnostic Consultation Diagnostic Consultation – 81H $63.82

Translator/Interpreter Services Service Code 98L Cost Reimbursement-Requires Contract Manager

prior authorization

Additional reimbursement for services provided in CPS DESIGNATED UNDERSERVED COUNTIES: Refer to Billing Requirements in Sections 2.9.6.3.1.4.2 and 2.9.7.2.5.10.

Out-of-Office rate applies in accordance with Section 2.5 and is payable when travel exceeds 60 miles and travel to underserved areas has not been claimed. Refer to Section 2.13.3 for details.

29