You use the Licensure, Certification, Permit & Grant page to add or edit a group provider's license, certification, specialty, and taxonomy information to an enrollment application.
The Licensure, Certification, Permit & Grant page for Group Provider Enrollment contains the following panels:
| Field | Description |
|---|---|
| To add a new specialty, click Add Specialty. Existing specialties, if any, are displayed in a table. To edit, in the Specialty List table, click the appropriate row. After changing or adding new specialties, on the Specialty action bar, click Save. | |
| Specialty |
Provider's specialty type. A specialty requires completion of the appropriate residency program, board certification, state certification, or eligibility. Examples: OB/GYN, Internal Medicine, Small Hospital, DJJ, Day Treatment, etc. |
| Certification # | The provider's certification number. |
| Certification Agency | Name of the agency who issued the certification. |
| State |
The State that issued the specialty certification number. Example: AK |
| Field | Description |
|---|---|
| To add a new taxonomy, click Add Taxonomy. Existing taxonomy codes, if any, are displayed in a table. To edit, in the Taxonomy table, click the appropriate row. After changing or adding new taxonomy codes, on the Taxonomy action bar, click Save. | |
| Taxonomy |
The 10-digit/alpha taxonomy code of the provider's group. |
| Begin Date |
Date when the taxonomy became effective. Format: MM/DD/YYYY, or click the calendar to select a date. |
| End Date |
Date when the taxonomy expires. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Field | Description |
|---|---|
| Are you a Tribal Provider? | Select Yes or No to indicate if you are a tribal provider. |
| Field | Description |
|---|---|
| Are you a Dispensing Provider? | Select Yes or No to indicate if you are a dispensing provider. |
| The Dispensing Provider's practice location is 45 miles from a retail pharmacy. | Select Yes or No to indicate if the dispensing provider's practice location is 45 miles from a retail pharmacy. |
| The Dispensing Provider is not a covered entity under 42 U.S.C.256b or purchasing outpatient drugs under either the 340b program (section 602) or Federal Supply Schedule pricing (section 603). 7 AAC 145.410. | Select Yes or No to indicate that the dispensing provider is not a covered entity. |
| Field | Description |
|---|---|
| Name of Psychiatrist Operating the Clinic Fields | |
| Last Name | Last name of the psychiatrist who is operating the clinic. |
| First Name | First name of the psychiatrist who is operating the clinic. |
| Middle Name | Middle name of the psychiatrist who is operating the clinic. |
| Psychiatrist SSN | Social Security number of the psychiatrist who is operating the clinic. |
| Occupational License Number | Operational License number of the psychiatrist who is operating the clinic. |
| Licensing Agency | Licensing agency of the psychiatrist who is operating the clinic. |
| Occupational License Effective Date | Occupational License effective date for the psychiatrist who is operating the clinic. |
| Occupational License Expiration Date | Occupational License expiration date for the psychiatrist who is operating the clinic. |
| State | State for the psychiatrist who is operating the clinic. |
|
Supervised Individual Fields To add a Supervised Individual, click Add Supervised Individual. Existing supervised individuals, if any, are displayed in a table. To edit, in the Supervised Individual table, click the appropriate row. After changing or adding new supervised individuals, on the Supervised Individual action bar, click Save. |
|
| Last Name | Supervised individual's last name. |
| First Name | Supervised individual's first name. |
| Middle Name | Supervised individual's middle name. |
| Field | Description |
|---|---|
| Last Name | Last name of pharmacist in charge. |
| First Name | First name of pharmacist in charge. |
| Middle Name | Middle name of pharmacist in charge. |
| Pharmacist SSN | Social Security number of the pharmacist in charge. |
| Occupational License Number | Occupational License number of the pharmacist in charge. |
| Licensing Agency | Licensing agency for the pharmacist in charge. |
| Occupational License Effective Date | Occupational License effective date for the pharmacist in charge. |
| Occupational License Expiration Date | Occupational License expiration date for the pharmacist in charge. |
| State | State for the pharmacist in charge. |
|
Registered Nurse Fields To add a Registered Nurse, click Add Registered Nurse. Existing registered nurses, if any, are displayed in a table. To edit, in the Registered Nurse table, click the appropriate row. After changing or adding new registered nurses, on the Registered Nurse action bar, click Save. |
|
| Last Name | Registered nurse's last name. |
| Middle Name | Registered nurse's middle name. |
| First Name | Registered nurse's first name. |
| Occupational License Number | Registered nurse's occupational license number. |
| Field | Description |
|---|---|
| Is the RPTC licensed by the Office of Children's Services (OCS)? | Select Yes or No to indicate if the residential psychiatric treatment center is licensed by OCS. |
| Is the RPTC accredited by either the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), or the Commission on Accreditation of Rehabilitation Facilities (CARF), or the Council on Accreditation of Services for Families and Children (COA)? | Select Yes or No to indicate if the residential psychiatric treatment center is accredited by either the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), or the Commission on Accreditation of Rehabilitation Facilities (CARF), or the Council on Accreditation of Services for Families and Children (COA). |
| Does the RPTC include dwelling space provided in separate buildings or units with no more than 60 residential beds per building and no more than 30 beds provided for sleeping accommodation per unit; and equipment, supplies, maintenance, and insurance coverage used by residents for program activities and case-specific services? | Select Yes or No to indicate if the residential psychiatric treatment center includes dwelling space provided in separate buildings or units with no more than 60 residential beds per building and no more than 30 beds for sleeping accommodation per unit, and if equipment, supplies, maintenance, and insurance coverage is used by residents for program activities and case-specific services. |
| Does the RPTC provide residential child care and inpatient psychiatric services, in a semi-secure or secure setting of a residential nature, for the diagnosis and treatment of children six years of age or older for mental, emotional, or behavioral disorders? | Select Yes or No to indicate if the residential psychiatric treatment center provides residential child care and inpatient psychiatric services, in a semi-secure or secure setting of a residential nature, for the diagnosis and treatment of children six years of age or older for mental, emotional, or behavioral disorders. |
| Does the RPTC provide therapeutically appropriate, medically necessary diagnostic and treatment services for emotionally disturbed children and severely emotionally disturbed children including intake assessment; individual psychotherapy; group psychotherapy; family psychotherapy; group skill development services; individual skill development services; pharmacologic management; and crisis intervention? | Select Yes or No to indicate if the residential psychiatric treatment center provides therapeutically appropriate, medically necessary diagnostic and treatment services for emotionally disturbed children and severely emotionally disturbed children including intake assessment; individual psychotherapy; group psychotherapy; family psychotherapy; group skill development services; individual skill development services; pharmacologic management; and crisis intervention. |
| Does the RPTC ensure that patients' plans of care developed by interdisciplinary teams include a discharge plan prepared at the time of admission and updated during the inpatient stay as the patients' mental health needs change that specifies the approximate date for discharge, the patients anticipated post-discharge service needs, the patients' prospective service providers, and other provisions necessary for the transition to a less restrictive environment as required in 7 AAC 140.365? | Select Yes or No to indicate if the residential psychiatric treatment center ensures that patients' plans of care developed by interdisciplinary teams include a discharge plan prepared at the time of admission and updated during the inpatient stay as the patients' mental health needs change that specifies the approximate date for discharge, the patients anticipated post-discharge service needs, the patients' prospective service providers, and other provisions necessary for the transition to a less restrictive environment as required in 7 AAC 140.365. |
| Can the RPTC accept the per diem rate as described in Alaska Administrative Code 7 AAC 145.620? | Select Yes or No to indicate if the residential psychiatric treatment center accepts the per diem rate as described in Alaska Administrative Code 7 AAC 145.620. |
| Has an Alaska Medical Assistance recipient been referred to become a patient of the RPTC? | Select Yes or No to indicate if the Alaska Medical Assistance recipient has been referred to become a patient of the RPTC. |
| Total # of RPTC Facility Beds | Total number of residential psychiatric treatment center facility beds. |
| Number of Medicaid residents in the facility | Number of Medicaid residents in the facility. |
| Number of residents for whom the Psych Under 21 benefit is paid by another state | Number of residents for whom the Psych Under 21 benefit is paid for by another state other than Alaska. |
|
Field |
Description |
|---|---|
|
To add new license, certification, permit or grant, click Add LCPG. Existing LCPG information, if any, is displayed in a table. To edit, in the Licensure, Certification, Permit & Grant table, click the appropriate row. After changing or adding new licenses, certifications, permits or grants, on the License, Certification, Permit and Grant action bar, click Save. Note: Enter the information for all states in which you have credentials. |
|
| Are you adding a Licensure, Certification, Permit, or Grant information? | Select License, Certification, Permit or Grant, depending on which you are adding. Additional fields are displayed for you to enter specific information. |
| License Information Fields | |
| License Number | Provider license number. |
| Licensing Agency | Name of the agency who issued the license. |
| State |
The State that issued the license number. Example: AK |
| Effective Date |
Date when the license became effective. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Expiration Date |
Date on when the license expires. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Certification Information Fields | |
| Certification # | Provider's certification number. |
| Certifying Agency | Name of the agency who issued the certification number. |
| State |
The State that issued the certification number. Example: AK |
| Effective Date |
Date when the certification became effective. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Expiration Date |
Date when the certification expires. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Permit Information Fields | |
| Permit # | Provider's permit number. |
| Permit Agency | Name of the agency who issued the permit. |
| State |
The State that issued the permit. Example: AK |
| Effective Date |
Date when the permit became effective. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Expiration Date |
Date when the permit expires. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Grant Information Fields | |
| Grant # | Provider's grant number. |
| Grant Agency | Name of the agency who issued the grant. |
| State |
The State that issued the grant. Example: AK |
| Effective Date |
Date when the grant became effective. Format: MM/DD/YYYY, or click the calendar to select a date. |
| Expiration Date |
Date when the grant expires. Format: MM/DD/YYYY, or click the calendar to select a date. |
Version as of 6/30/2015.
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