Credentialing Client Discovery Form - Outpatient Behavioral Health Credentialing

Credentialing Client Discovery Form

(Outpatient Behavioral Health Credentialing)

Purpose: This form collects organization, provider, services, location, clinical program, documentation, payer, billing, credentialing, contracting, and compliance details needed to assess outpatient therapy, medication management, behavioral health counseling, SUD counseling, co-occurring care, and related payer enrollment requirements.

Completion does not guarantee payer approval, network participation, contract acceptance, reimbursement, or effective dates.

Instructions:

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

• Items marked “if applicable” may not apply to every program or organization.

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

• Use the Additional Notes section for payer-specific concerns, special program requests, state-specific licensing considerations, or enrollment barriers.

1. Organization & Program Information

Primary Practice Address *

Billing Address

Mailing Address

States Where Services Are Rendered *

Entity / Ownership Type

Accreditation Status

2. Behavioral Health Services Provided

A. Core Behavioral Health Services

B. Special Programs / Clinical Tracks

3. Populations Served

4. Practice Operations & Service Delivery

Add each practice location below. Check “Same as Primary Practice Address” to copy the primary address automatically.*

Service Delivery Methods

Crisis Coverage

5. Clinical Staffing & Provider Enrollment Roster

Complete one row per psychiatrist, psychiatric NP/PA, psychologist, therapist, counselor, SUD counselor, peer specialist, case manager, or other staff member requiring credentialing, enrollment, rostering, or payer review.

Provider / Staff NameCredential / RoleIndividual NPILicense / Cert State / # / Exp.CAQH ID / AttestationEnrollment ScopeSupervision / NotesAction

Licensed / Certified Provider Types

6. Clinical Program Details

Intake / Assessment Process

Medication Management Delivery

UDS Frequency

7. Billing, Coding & Enrollment Details

Coding Types Used

Common Billing / Service Codes

Place of Service Codes Used

8. Insurance Participation & Contracting Needs

Requested Payer Enrollment / Contracting

9. Compliance, Policies & Clinical Protocols

Policies / Protocols Available

10. Additional Notes / Special Programs

11. Secure Supporting Documents

Documents containing protected health information, personally identifiable information, or other sensitive data must be uploaded only through the approved secure process and should not be sent through unsecured email.

Privacy, Security & Technology Requirements

Please review the following requirements carefully before submitting this credentialing discovery form.

Privacy, Confidentiality, and Security of Credentialing Documents

To maintain compliance with HIPAA and to safeguard Client privacy, confidentiality, and data security, TriumpHealth strictly prohibits the transmission of credentialing documents (including but not limited to Licenses, DEA certificates, IRS forms, and other personal information or sensitive documents) via email, postal mail, or fax.

Technology Platform Usage Requirements

All credentialing documents required to complete the credentialing process must be uploaded directly by the Client to TriumpHealth’s HIPAA-compliant ShareFile portal during the onboarding process. Failure to comply with this process may result in delays or inability to proceed with our credentialing services.

If the Client is unable to navigate or upload the required documentation through ShareFile after the initial onboarding and workflow training, TriumpHealth will provide one additional training session at no additional cost.

Despite the training provided, if the Client does not effectively use the ShareFile portal and fails or refuses to upload the required credentialing documentation within three (3) months of the initial onboarding date, the following shall apply:

  • TriumpHealth shall have no obligation to continue processing the credentialing services.
  • The Client shall not be entitled to any refund or credit of amounts paid to TriumpHealth under this Agreement.

This provision is intended to ensure operational efficiency, data security, and adherence to TriumpHealth’s credentialing processes.

CAQH or ADA Access

If the Client is not willing or able to provide access to provider’s existing CAQH Council for Affordable Quality Healthcare or ADA American Dental Association profile, then TriumpHealth is not liable for any credentialing application denials or removal of provider from the network panel due to incomplete profile and/or lack of attestation.

Primary Location Address

I verify that the primary location address provided above is not a virtual office, mail drop, P.O. Box, mailbox service, or other address that fails to meet the enrollment requirements of any payer. I understand that the failure to disclose the exact type of physical location can result in delays, denials, enrollment rejections, site visit failures, or sanctions resulting from inaccurate, incomplete, or non-compliant information provided.

Pricing Terms

The pricing set forth in the Agreement you signed with TriumpHealth is contingent upon the Client’s adherence to the use of TriumpHealth recommended technology platforms and workflows, including the ShareFile portal process.

Scope of Work Precedence

In the event of any conflict, inconsistency, or discrepancy between the Scope of Work set forth in the executed Service Agreement and any project-scope information provided in this Outpatient Behavioral Health Discovery Form, the terms of the executed Service Agreement shall control and be deemed final and binding.

Please fill and sign below to confirm that all information you completed above is true and correct, and that you have reviewed and agree with the requirements above.

12. Signature & Authorization

Choose Signature Method

Completion does not guarantee payer approval, network participation, contract acceptance, reimbursement, or effective dates.

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