Rate Increase Request Submission

Rate Increase Request Submission

Date of submission*

Provider Name*

Location of Service*

Level of Care*

Person Submitting Request*

Title*

Phone Number*

Email*

Is this a new program?*

Select or enter value

Current Rate*

Rate request amount*

Check list (Must have all to qualify)*

Corresponding letter justifying the need

Rate Request Documentation Package (Appendix A-D)

Most recent audited Financial Statement

Please upload the requested documents to this dropbox*

Drag and drop files here or

Expected Outcomes and Monitoring Methods

It is the hope of Community Behavioral Health (CBH) that awarded rate increases lead to improved clinical outcomes and/or improved quality measures. Please outline below the outcomes and monitoring methods that are anticipated as a direct or indirect result of the requested rate increase. Please include target dates for each outcome.

All fields are required; however, should you have less than four outcomes please enter N/A in the required fields. Should you have more than four outcomes please upload an Expected Outcomes and Monitoring Methods form (Appendix E) via PDF.

https://cbhphilly.org/cbh-providers/provider-network/rates-and-out-of-network-information

Measure 1*

What is being measured?

Anticipated Outcome 1*

Is the measure expected to increase or decrease? By how much?

Measurement Mechanism 1*

How is this measured?

Frequency and Reporting 1*

How often is it measured? Is it regularly reported?

Target Dates 1*

Measure 2*

What is being measured?

Anticipated Outcome 2*

Is the measure expected to increase or decrease? By how much?

Measurement Mechanism 2*

How is this measured?

Frequency and Reporting 2*

How often is it measured? Is it regularly reported?

Target Dates 2*

Measure 3*

What is being measured?

Anticipated Outcome 3*

Is the measure expected to increase or decrease? By how much?

Measurement Mechanism 3*

How is this measured?

Frequency and Reporting 3*

How often is it measured? Is it regularly reported?

Target Dates 3*

Measure 4*

What is being measured?

Anticipated Outcome 4*

Is the measure expected to increase or decrease? By how much?

Measurement Mechanism 4*

How is this measured?

Frequency and Reporting 4*

How often is it measured? Is it regularly reported?

Target Dates 4*

Please note that if applicable, CBH will consider the following performance data when reviewing a provider’s request:

1. Follow-up after hospitalization for mental illness at 7-Days

2. Follow-up after hospitalization for mental illness at 30-Days

3. Readmission within 30 days of inpatient psychiatric discharge

4. Initiation and engagement of alcohol and other drug dependence treatment

4A. Initiation rate

4B. Engagement rate

5. Adherence to antipsychotic medications for individuals with schizophrenia

6. Combined behavioral health and physical health inpatient 30-day readmission rate for individuals with serious and persistent mental illness (SPMI)

7. Emergency department utilization for individuals with SPMI

8. Combined behavioral health and physical health inpatient admission utilization for individuals with SPMI

9. Diabetes screening for people with SPMI who are using antipsychotic medications

10. Diabetes care for people with SPMI: Hemoglobin A1c (HbA1c) Poor Control (>9/0%)

11. Cardiovascular monitoring for people with cardiovascular disease and SPMI

12. Follow-up after emergency department visit for alcohol and other drug abuse or dependence for individuals with SPMI

13. Follow-up after emergency department visit for mental illness for individuals with SPMI

Comments*

Please enter N/A if not applicable

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