Provider Resources – Forms

User Agreement

• ‍Provider Network Registration Form – for login access to the BHSI Provider Network.

Significant Incident Report

Providers must report all reportable Significant Incidents following a centralized two-step process:

1. Report the incident by telephone to the assigned BHSI Service Manager or Service Manager’s supervisor within 24 hours of the incident or upon notification of the incident’s occurrence.
2. NEW! A copy of all reportable incidents must be emailed to BHSI.quality@phila.gov or uploaded to the BHSI Quality Provider Portal. You must have an active user name and password to access.Please do not include Protected Health Information (PHI) in the subject line of the submitted documents.

• Philadelphia Department of Behavioral Health Significant Incident Report Form
  

Approvals and Authorizations

• Authorizations Request Instructions effective 2/13/2019 – This document provides instructions for submitting requests for approvals, authorizations and other documents.  BHSI no longer accepts faxes as of 3/1/2016.
• BHSI Claims Appeal Form
• MA Exception Process
• BHSI Concurrent Review Form – To provide information needed for a detoxification authorization
• BHSI Authorization to Release Information Form – This is the only version of the form that will be accepted by BHSI.
• Authorization to Release Provider Notice.
• BHSI Outpatient Short Form -To request approval for .5, 1A and 1B Levels of Care.

PA Department of Drug and Alcohol Programs

• DDAP-EFM-1000 Screening Tool Part 1 Client Profile
• DDAP-EFM-1001 Screening Tool Part 2 Client Screen
• DDAP-EFM-1002 ASAM Summary Sheet
• DDAP-EFM-1004 Authorization
• DDAP-EFM-1005 Client Admission
• DDAP-EFM-1005a Client Admission Licensed Program Codes
• DDAP-EFM-1005b Client Admission Detailed Drug Codes
• DDAP-EFM-1006 Services Rendered
• DDAP-EFM-1007 Client Discharge
• DDAP-EFM-1008 Case Management Service Plan
• DDAP-EFM-1009 Grievance and Appeal Reporting
• DDAP-EFM-3000 Clinical Supervision Training Registration Form  
• DDAP Terms And Conditions Appendices A-E (PA-6)
  Department of Drug and Alcohol Programs specified clauses included in all provider agreements.
• Department of Drug and Alcohol Programs Training Site (DDAP TMS)
  Learn about and sign up for DDAP trainings.
• Department Of Drug And Alcohol Programs Responsibilities of the Provider (PA-4)
• BHSI Authorization to Release Information Form (Consent)

BHSI Service Management
801 Market St., Seventh Floor
Philadelphia, PA 19107
(215) 546-1200

‍PMHCC Case Management
1601 Market St., Seventh Floor
Philadelphia, PA 19109
‍(215) 546-6435

Provider Bulletins

Notices

The OAS has set deadlines for the submission of utilization and the final expense reports for agencies receiving OAS funds for support Cost Reimbursement services. The deadline information can be found here.

New! BHSI Billing for Fiscal Year 2019 and 2020

NEW! Secure FTP (SFTP) Request Forms – Page 1 | Page 2

NEW! BHSI June 2019 Claims Adjudication Information Sessions

NEW! MAT Provision to BHSI Individuals Fiscal Year 2019

‍Authorization to Release Provider Notice

Significant Incident Report Update Provider Notice

‍BHSI POLICY ALERT – ICD-10 Diagnosis Code Requirements

Provider Notice 14-01– Deadlines for claims for all services except Cost Reimbursement.

‍Provider Notice 16-02 – FY 17 BHSI Provider Agreements

‍Provider Notice 16- – Fiscal Updates

‍Provider Notice 15-01 – Deadlines for all Treatment and Recovery Based Services
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Other Resources

NIATx – Removing barriers to treatment and recovery.

‍Selected Papers of William White – Senior research consultant Chestnut Health Systems.

‍N.A.R.R. – National Association of Recovery Residences.

‍NDCI – National Drug Court Institute.

‍NADCP – National Association for Drug Court Progressionals.

‍NIDA – National Institute on Drug Abuse.

‍Addiction Treatment Forum – Reports on substance abuse news of interest to opioid treatment programs.

‍AATOD – American Association for the Treatment of Opioid Dependence.

BHSI Service Management
801 Market St., Seventh Floor
Philadelphia, PA 19107
(215) 546-1200

‍PMHCC Case Management
1601 Market St., Seventh Floor
Philadelphia, PA 19109
‍(215) 546-6435

Mission

The mission of the Behavioral Health Special Initiative (BHSI) Program is to provide assessments, referrals and funding support for persons who are uninsured or underinsured with substance abuse problems and who can access licensed treatment programs. Under the umbrella title of BHSI, the program manages several state and local funding allocations, the largest of which is the Behavioral Health Special Initiative. Programmatically, BHSI operates under the auspices of the City’s Office of Addiction Services (OAS), a component of the Philadelphia Department of Behavioral Health and Intellectual disAbility Services through a contract with PMHCC.

Other Activities

BHSI works closely with the Forensic Intensive Recovery Program and other criminal justice initiatives serving individuals within that system. BHSI staff provides clinical evaluations for forensic clients, identifies community-based treatment sites, and pays for the treatment of those individuals who were mandated by the court to attend treatment in lieu of incarceration.

‍The Office of Addiction Services is also embedded and housed at BHSI that offer non-drug treatment services which support clients while they’re receiving formal treatment in order to address a broad array of needs. The coordination of treatment and core services helps clients maximize their rehabilitation and recovery process.

All Addiction Services-funded outpatient, intensive outpatient, partial hospitalization programs can access core services for clients participating in their treatment program. Core services are also available to criminal justice clients in residential programs, and OAS-funded recovery houses and the Philadelphia Recovery Community Center. These identified services include:

• Domestic violence counseling-victim perpetrator
• Life skills
• GED
• Literacy/education
• Parenting skills training
• Nutrition
• Anger management
• Wellness works
• Therapeutic recreation and housing
• Credit and financial services

BHSI Service Management
801 Market St., Seventh Floor
Philadelphia, PA 19107
(215) 546-1200

‍PMHCC Case Management
1601 Market St., Seventh Floor
Philadelphia, PA 19109
‍(215) 546-6435

Behavioral Health Special Initiative

The BHSI Program functions as a managed care organization authorizing each patient’s care according to clinical/medical necessity (based on the American Society of Addiction Medicine (ASAM) Criteria) and referring them to a network of licensed drug and alcohol treatment providers across the region.

In addition to ongoing coordination with the Office of Addiction Services, the BHSI program works with the other components of the City’s Department of Behavioral Health/MRS: Community Behavioral Health and the Office of Mental Health. This allows the program to better meet the needs of clients whose funding eligibility fluctuates between medical assistance and non-medical assistance status as well as clients who have co-occurring disorders (mental health and subtance use disorders).

Staff of this program is composed of dedicated individuals with significant clinical background and knowledge of substance abuse, mental health and health care issues as well as other staff with expertise in billing and computer skills. BHSI is not an entitlement program and has guidelines for treatment.

PMHCC provides critical administrative support to the BHSI Program through its fiscal component, information and human resources management and a variety of other managerial elements.

BHSI Service Management
801 Market St., Seventh Floor
Philadelphia, PA 19107
(215) 546-1200

‍PMHCC Case Management
1601 Market St., Seventh Floor
Philadelphia, PA 19109
‍(215) 546-6435