Mental & Behavioral Health Provider/Group Credentialing - Client Discovery Form

Credentialing Client Discovery Form

(Mental & Behavioral Health Provider/Group Credentialing)

Purpose:

This form focuses on gathering information on the wound care providers, practice, services offered, location, documentation, and payer details needed to assess Medicare/Medicaid, Medicare Advantage, Medicaid MCO and commercial payers credentialing and enrollment requirements.

Instructions:

• Complete every applicable field. Select only services currently provided or planned.

• Upload supporting documents through the secure upload fields. Do not email protected or sensitive documents.

• Items marked “if applicable” may not apply to every provider or practice. Upload documentation through the secure portal only.

• Submission does not guarantee payer approval, network participation, or reimbursement.

Step 1 of 14Practice & Organization Information

Section 1 - Practice & Organization Information

Section 2 - Contact Information

Physical Practice Address

Billing Address

Mailing Address

Section 3 - Practice Identifiers & Enrollment Status

Section 4 - Ownership, Management & Administrative Structure

Providers Requiring Credentialing / Enrollment

Section 5 - Patient Populations Served

Check all populations served.

Section 6 - Mental Health & Behavioral Health Services Rendered

Section 7 - Practice Operations & Service Delivery

Section 8 - Facility, Program, Licensure & Accreditation Considerations

Section 9 - Billing, Coding & Enrollment Details

Section 10 - Payer Network & Contracting Goals

Commercial Plan Details
Medicaid Details
Medicaid MCO Details
Medicare Advantage Details
Exchange / Marketplace Details
EAP Details
Behavioral Health Carve-Outs
Medicare Details
Workers Compensation Details

Section 11 - Scope of Work Requested

Section 12 - Required Credentialing Documentation

Organization-Level Documents

Provider-Level Documents

Section 13 - Authorization & Acknowledgment

HIPAA / Secure Upload Requirement: To maintain privacy and security, credentialing documents containing protected, personal, or sensitive information should be uploaded through TriumpHealth’s HIPAA-compliant secure portal. Do not email, fax, or mail sensitive credentialing documents unless specifically instructed through a secure process.

Use your mouse, touch screen, or stylus to sign inside the box below.

Section 14 - Discovery of Services Rendered (Detailed Worksheet)

Thank You!

Your Mental & Behavioral Health Credentialing Discovery Form has been submitted successfully.

Our credentialing team will review the information and contact you if clarification or additional documentation is required.

Organization:

Secure document reminder: Do not email sensitive credentialing documents. Use the approved HIPAA-compliant secure upload process.

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