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New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date:

Volume:

X

Forms

Chapter:

A

Forms

07-12-2010

Subchapter:

1

Forms

Issuance:

11.28

CP&P Form 11-28, Psychiatrist Certification

 

Click here to view or print the CP&P Form 11-28.

 

POLICY

 

CP&P claims Federal Financial Participation (FFP) when purchasing mental health/psychiatric services for clients who are Title XIX (Medicaid) recipients.  When providing mental/behavioral health services to client families, CP&P strives to make as many claims for reimbursement as possible under this program.  Psychiatrists and neurologists are asked to complete CP&P Form 11-28 when entering into open purchase contract with CP&P.  (Psychologists are asked to complete CP&P Form 11-29, Psychologist Certification, in accordance with its instructions.)

 

For CP&P to make an FFP claim, the provider must be a licensed physician in New Jersey (or in the State in which he or she practices), board certified in psychiatry or neurology, AND certified by CP&P as a specialist in treating abused and/or neglected children, their parents and families.  The provider's designation as a "specialist" is based on his or her professional experience, training, and skills, with that experience, training, and skill documented on CP&P Form 11-28.

 

Note:  This policy pertains to actions taken by CP&P when contracting with individual providers.  If a provider is part of a "professional group," request that each psychiatrist, neurologist or psychologist in the group complete CP&P Form 11-28, Psychiatrist Certification, or CP&P Form 11-29, Psychologist Certification, as applicable, to facilitate CP&P FFP claiming.

 

PURPOSE AND USE

 

The Psychiatrist Certification, CP&P Form 11-28, is used to document that psychiatrists and neurologists who serve CP&P clients are "specialists," i.e., hold expertise in treating abused and/or neglected children, their parents and families.  The form serves to justify that CP&P, when purchasing services from such a specialist, is eligible for FFP.

 

CP&P Form 11-28, once completed, is attached to the provider's contract Annex A (used with individual provider agreements) and filed in the provider's contract packet.

 

INSTRUCTIONS FOR COMPLETING THE FORM

 

GENERAL INSTRUCTIONS

 

The Area Office Contract Administrator forwards the CP&P Form 11-28 to psychiatrists and neurologists who enter into open purchase contracts with the Division.

 

Psychiatrists and neurologists complete CP&P Form 11-28 when completing a contract Annex A.  By signing CP&P Form 11-28 the provider certifies that the information contained therein is accurate.

 

Attach the provider's physician's license and board certification in psychiatry or neurology to CP&P Form 11-28.

 

SPECIFIC INSTRUCTIONS

 

A psychiatrist or neurologist entering into an open purchase contract with CP&P completes the top of CP&P Form 11-28, the certification, sections 1 to 3, and signature/date as follows:

 

"I, (NAME OF PSYCHIATRIST OR NEUROLOGIST) DO CERTIFY. . . ."  The provider enters his or her name.

 

". . . OR BY                    , WHICH IS THE COMPARABLE STATE AGENCY. . ."  The provider enters the name of the State agency that issued and monitors his or her physician's license.

 

CHECK ALL THAT APPLY 

 

The provider enters a check in all the following categories that apply, to reflect his or her experience, training, skills or specialty in treating children, parents and/or families:

 

_______   Sexual abuse (treatment for child victims, adults victimized as children, perpetrators, enablers, families);

 

_______   Family dysfunction, parent/child conflict;

 

_______   Drug or alcohol dependency;

 

_______   Parent effectiveness;

 

_______   Domestic violence/battered women syndrome;

 

_______   Anger management;

 

_______  Disorders, such as anxiety, depression, adjustment, conduct, obsessive/compulsive, eating disorders;

 

_______   Oppositional behavior, delinquency;

 

_______   Phobias;

 

_______   Adoption related issues (identity, abandonment, separation, grief);

 

_______   Children of alcoholics; and

 

_______   School adjustment, peer relationships.

 

SIGNATURE   The provider signs his or her name to certify that the information entered in CP&P Form 11-28 is true.

 

DATE  The provider enters the date he or she signed CP&P Form 11-28.

 

THIS SECTION FOR CP&P USE

 

A CP&P Area Office Contract Administrator enters the following:

 

CONTRACT NUMBER   Enter the contract number issued to the provider.  (Ensure the contract number corresponds to other materials in the provider's contract packet.)

 

EFFECTIVE DATES   Enter the effective dates of the contract -- starting date and termination/renewal date.

 

DISTRIBUTION

 

Original          -           File in provider's contract packet, kept at the Area Office

 

Copy               -           Provider (psychiatrist or neurologist)