Open Network: ASAM 4.0 and ASAM 4.0 WM, Medically Managed Intensive Inpatient Services

Open Network: ASAM 4.0 and ASAM 4.0 WM, Medically Managed Intensive Inpatient Services

CBH is seeking American Society of Addiction Medicine (ASAM) 4.0, Medically Managed Intensive Inpatient Services, providers and ASAM 4.0 Withdrawal Management providers currently enrolled in Medicare and Medicaid programs, as well as licensed through the Department of Drug and Alcohol Programs (DDAP) as an ASAM 4.0 and/or ASAM 4.0 WM provider. Interested qualified applicants should complete the below application. CBH will review all submissions and contact all qualified applicants.

Person Completing Form*

Please include your name and title.

Provider Name*

Please include the name of the organization/facility interested in joining the CBH provider network.

ASAM 4.0 and/or ASAM 4.0 WM Provider*

Please indicate whether you are applying to join the CBH provider network as an ASAM 4.0 and/or ASAM 4.0 WM (select all that apply)

Select

Contact Email*

Please enter the email of the point person responsible for credentialing. Follow-up regarding next steps will be emailed to this address.

PA Department of Drug and Alcohol (DDAP) Licensure*

Are you currently licensed by the PA Department of Drug and Alcohol as an ASAM 4.0 Medically Managed Intensive Inpatient Services provider?

Select

Medicaid and Medicare Enrollment*

Are you currently enrolled in PROMISe with the appropriate Provider Type and Specialty?

Select

Guidelines & Performance Standards*

Do you agree to adhere to CBH’s Clinical Practice Guidelines and Performance Standards included in the CBH Provider Manual?

Select

DDAP License*

Please attach a copy of your ASAM 4.0 Medically Managed Intensive Inpatient Services license.

Drag and drop files here or

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