ࡱ> [ Objbj  4pa!\pa!\.G" " 8dJl ?>>>>>>>$@C@>>4>*!*!*!^>*!>*!*!67z:0mtv8v>>0 ?8D&D8z:Dz:*!>> ?D" > `: Instructions: This form is only for credentialing waiver requests associated with CBHI services. Please complete all fields; incomplete forms will not be considered. Please submit a separate request form for each service where a waiver is being requested. Please submit the following required documents along with this form: Cover letter specifying what you are requesting to be waived Candidates resume Candidates school transcripts when requesting to waive the level of degree or the field of degree For new hires, documentation substantiating the rationale/need for the waiver request Any other supporting materials E-mail all documents to  HYPERLINK "mailto:CBHIWaiverRequests@valueoptions.com" CBHIWaiverRequests@valueoptions.com The waiver materials will be reviewed upon receipt. If a waiver application is incomplete, MBHP will outreach provider for the outstanding items. If provider does not submit necessary documentation within 30 days, waiver will be submitted for determination at that time. Name of Person Submitting Waiver: Email Address of Person Submitting Waiver: Candidates Name: CBHI Component/Service for Which a Waiver Request is Being Submitted: Rationale For Waiver Request: (Please describe the need this candidate will fulfill, how they will address the need and provide separate supporting documentation substantiating the need, in addition to this form) [ ] Ensuring Member Access (please specify): [ ] Meeting Member Linguistic/Cultural Need (please specify): [ ] Meeting Member Need for Specialized Care (please specify): [ ] Other (please specify): Date of Waiver Request: [please insert todays date here] Organization Name: [please insert here] Region(s) Prospective Staff Will Work In: (please check all that apply) [ ] Boston [ ] Metro Boston [ ] Southeast [ ] Northeast [ ] Central [ ] Western Geographic Site(s) Prospective Staff Will Work In: (please specify all) Requirement(s) the Organization Is Requesting To Be Waived: Please check off the requirement(s) that the candidate does not have: CSA Program Director Please waive the following credentialing criteria (check all requirements that the candidate does not have): [ ] Level of Degree: Masters degree [ ] Field of Degree: Mental health field, including counseling, family therapy, social work, psychology from an accredited college or university [ ] Experience: At least three (3) years of supervisory and/or management experience [ ] Experience: At least five (5) years post-graduate experience providing behavioral health services to youth and families [ ] Other: Other credentialing criteria for masters-level clinicians as outlined in the MCEs most current Provider Manual Senior Intensive Care Coordinator Please waive the following credentialing criteria (check all requirements that the candidate does not have): [ ] Level of Degree: Masters degree [ ] Field of Degree: See list of degrees beginning on page 6 for additional information [ ] Experience: At least three (3) years of experience providing outpatient behavioral health services to youth and families [ ] Experience: Experience working collaboratively with state agencies, consumer advocacy groups, and/or behavioral health outpatient facilities [ ] Other: Other credentialing criteria for masters-level clinicians as outlined in the MCEs most current Provider Manual [ ] Supervision Received: Weekly supervision with the CSA Program Director Intensive Care Coordination (ICC), masters-level service Please waive the following credentialing criteria (check all requirements that the candidate does not have): [ ] Level of Degree: Masters degree [ ] Field of Degree: See list of degrees beginning on page 6 for additional information [ ] Experience: Experience in navigating any of the child/family-serving systems and advocating for family members who are involved with behavioral health systems [ ] Supervision Received: Weekly individual supervision with a behavioral health clinician licensed at the independent level and weekly individual, group, or dyad supervision with the Senior ICC Intensive Care Coordination (ICC), non-masters-level service Please waive the following credentialing criteria (check all requirements that the candidate does not have): [ ] Level of Degree/Experience: Bachelors degree and one (1) year of relevant experience working with families and youth [ ] Level of Degree/Experience: Associates degree and minimum of five (5) years of experience working with the target population [ ] Level of Degree/Experience: High school diploma and minimum of five (5) years of experience working with the target population [ ] Field of Degree: See list of degrees beginning on page 8 for additional information [ ] Experience: Experience in navigating any of the child/family-serving systems and advocating for family members who are involved with behavioral health systems [ ] Supervision Received: Weekly individual supervision with a behavioral health clinician licensed at the independent level and weekly individual, group, or dyad supervision with the Senior ICC Senior Family Partner Please waive the following credentialing criteria (check all requirements that the candidate does not have): [ ] Experience: Experience as a caregiver of a youth with special needs, preferably a youth with mental health needs [ ] Level of Degree/Experience: Bachelors degree in a human services field from an accredited university and one (1) year of experience working with the target population; See list of degrees beginning on page 8 for additional information. [ ] Level of Degree/Experience: Associates degree in a human service field from an accredited school and one (1) year of experience working with children/adolescents/transition age youth; See list of degrees beginning on page 8 for additional information [ ] Level of Degree/Experience: High school diploma or GED and a minimum of two (2) years of experience working with children/adolescents/transition age youth [ ] Experience: Minimum of two (2) years supervisory experience [ ] Experience: Experience working collaboratively with state agencies, consumer advocacy groups, and/or behavioral health outpatient facilities [ ] Supervision Received: Weekly supervision with the CSA Program Director Family Support and Training (FS&T) Family Partner Please waive the following credentialing criteria (check all requirements that the candidate does not have): [ ] Experience: Experience as a caregiver of a youth with special needs, and preferably a youth with mental health needs [ ] Level of Degree/Experience: Bachelors degree in a human services field from an accredited university and one (1) year of experience working with the target population; See list of degrees beginning on page 8 for additional information. [ ] Level of Degree/Experience: Associates degree in a human service field from an accredited school and one (1) year of experience working with children/adolescents/transition age youth; See list of degrees beginning on page 8 for additional information [ ] Level of Degree/Experience: High school diploma or GED and two (2) years of experience working with children/adolescents/transition age youth [ ] Experience: Experience in navigating any of the child and family-serving systems and teaching family members who are involved with the child- and family-serving systems [ ] Other: In possession of a current/valid drivers license and an automobile with proof of auto insurance [ ] Supervision Received: Weekly individual, group, or dyad supervision with a licensed behavioral health clinician with specialized training and weekly individual supervision with the Senior Family Partner In-Home Therapy (IHT), licensed clinician (the professional component) Please waive the following credentialing criteria (check all requirements that the candidate does not have): [ ] Level of Degree: Masters degree [ ] Field of Degree: See list of degrees beginning on page 8 for additional information [ ] Training: Training in working with youth, and their families, including training in family therapy [ ] Supervision Received: Weekly supervision commensurate with licensure level provided by a licensed, masters-level, senior clinician (*NOTE: All unlicensed masters-level counselors and/or interns must provide services under the direct supervision of a LICSW, LMFT, LMHC, LCSW, LADC I, Psychologist, Psychiatric Nurse, or Nurse Clinical Specialist consistent with applicable state licensure requirements.) In-Home Therapy (IHT), Therapeutic Training and Support (TT&S) (the paraprofessional component) Please waive the following credentialing criteria (check all requirements that the candidate does not have): [ ] Level of Degree: Bachelors or associates degree from an accredited institution [ ] Field of Degree: See list of degrees beginning on page 8 for additional information [ ] Experience: One (1) year of relevant experience working with families or youth [ ] Supervision Received: Weekly supervision commensurate with licensure level provided by a licensed, masters-level, senior clinician In-Home Behavioral Services (IHBS), Behavior Management Therapist (the professional component) Please waive the following credentialing criteria (check all requirements that the candidate does not have): [ ] Level/Field of Clinical Degree: See list of degrees beginning on page 7 for additional information [ ] Level of Behavioral Experience: Board-Certified Behavior Analyst (BCBA); OR Enrolled in a behavior analyst training program and eligible for certification within nine months; OR A psychologist licensed by the Massachusetts Board of Registration in Psychology with experience performing functional behavioral assessments and implementing and evaluating intervention strategies; OR A masters-level mental health practitioner working under the supervision of a BCBA; OR A masters-level mental health practitioner with relevant training and two (2) years experience inclusive of but not limited to: Conducting functional behavioral assessments (FBA) of youth with serious emotional and behavioral disturbances that include observing and analyzing behavior in settings where the behavior is naturally occurring; evaluating specific antecedent stimuli and consequences; and understanding the values, skills, and resources of those who are responsible for implementing the behavior plan; and Selecting interventions and strategies based on the results of the FBA and designing behavior plans that include intensive behaviorally oriented interventions; and Evaluating progress based on both qualitative and quantitative data and making adjustments to the behavior plan as needed; and Working with parents/caregivers and paraprofessional staff in homes and other community-based settings to implement behavior plans using techniques grounded in principles of positive behavior support (PBS) and/or applied behavioral analysis (ABA) with an aim toward extinguishing a wide range of challenging behaviors and increasing more socially acceptable behaviors that are age or developmentally appropriate. [ ] Supervision Received: Supervision provided to all unlicensed, masters-level behavior management therapists and/or interns by a licensed, senior clinician with the following credentials: LICSW, LMFT, LMHC, LCSW, LADC I, psychologist, psychiatric nurse, or nurse clinical specialist consistent with applicable state licensure requirements. In-Home Behavioral Services (IHBS), Behavior Management Monitor (the paraprofessional component) Please waive the following credentialing criteria (check all requirements that the candidate does not have): [ ] Level of Degree/Experience: A bachelors degree from an accredited university and one (1) year of direct relevant experience working with youth and families who require behavior management to address mental health needs [ ] Level of Degree/Experience: An associates degree and a minimum of two (2) years of relevant direct service experience working with youth and families who require behavior management to address mental health needs [ ] Field of Degree: See list of degrees beginning on page 8 for additional information [ ] Supervision Received: Supervision by a clinician meeting the Behavior Management Therapist criteria (with the exception of interns, who are not qualified to supervise Behavior Management Monitors) Therapeutic Mentoring (TM) - Please waive the following credentialing criteria (check all requirements that the candidate does not have): [ ] Age: 21 years of age or older [ ] Level of Degree/Experience: Bachelors degree from an accredited university and one (1) year experience working with children/adolescents/transition age youth. [ ] Level of Degree/Experience: Associates degree from an accredited school and one (1) year of experience working with the target population [ ] Level of Degree/Experience: High school diploma or GED and a minimum of two (2) years of experience working with children/adolescents/transition age youth [ ] Field of Degree: See list of degrees beginning on page 8 for additional information [ ] Supervision Received: Weekly individual supervision provided by a licensed clinician with specialized training in child/adolescent issues, child-serving agencies, mental health, family-centered treatment, strengths-based interventions, and Wraparound planning process consistent with Systems of Care philosophy Mobile Crisis Intervention (MCI), masters-level service (the professional component) Please waive the following credentialing criteria (check all requirements that the candidate does not have): [ ] Level of Degree: Masters degree [ ] Field of Degree: Mental health or human services field [ ] Experience: Training in working with youth and families, with experience and/or training in nonviolent crisis intervention, crisis theory/crisis intervention, solution-focused intervention, motivational interviewing, behavior management, conflict resolution, family systems, and de-escalation techniques [ ] Supervision Received: Supervision provided commensurate with licensure level and consistent with credentialing criteria Mobile Crisis Intervention (MCI), bachelors-level service (the paraprofessional component) Please waive the following credentialing criteria (check all requirements that the candidate does not have): [ ] Level of Degree: Bachelors degree [ ] Field of Degree: Mental health or human services field [ ] Experience: Experience or training in providing ongoing in-home crisis stabilization services and in navigating the behavioral health crisis response system that support brief interventions that address behavior and safety [ ] Supervision Received: Supervision provided commensurate with licensure level and consistent with credentialing criteria Statement of Agreement: Please read and check the following, acknowledging agreement: [ ] My organization will ensure that additional oversight, guidance, and training will be provided to candidates who have been waived by the MCEs, above and beyond that which is provided to adequately credentialed staff. Effective October 8, 2014, the below list contains degrees for each CBHI service that meet MassHealth MCE credentialing criteria. MA-Level ICC* Addictions Counseling Applied Educational Psychology Art/Dance Therapy Child Development/Family Relations Childhood Education Clinical Psychology Community Mental Health Community Psychology Counseling/Guidance Drama Therapy Early Childhood Education Education Education, with a Concentration in School Psychology Educational Psychology Elementary School Education Family Therapy Forensic Psychology MA-Level ICC*, continued Health Administration Health Education Human Services Industrial Psychology Marriage & Family Therapy Music Therapy Nursing/Medicine Pastoral Counseling Psychology Recreational Therapy Rehabilitation Counseling School Psychology Social Work Special Education Special Needs Vocational Counseling *Staff who hold a license in the following: LICSW, LMHC, LMFT, LADC I, may hold a degree in a field of study not listed above. MA-Level IHBS BMT* Addictions Counseling Applied Behavioral Analysis Autism Disorders Clinical Psychology Counseling Counseling Psychology Education, with a Concentration in Counseling Psychology Education, in Counseling Mental Health Education, in Deaf Studies Education, in Severe Disabilities Education, in Moderate Disabilities Education, in Special Needs Family Therapy Marriage & Family Therapy Psychology Social Work Special Education *Staff who hold a license in the following: LICSW, LMHC, LMFT, LADC I, may hold a degree in a field of study not listed above. MA-Level IHT* Addictions Counseling Clinical Psychology Counseling Counseling Psychology Education, with a Concentration in Counseling Psychology Education, in Counseling Mental Health Family Therapy Marriage & Family Therapy Psychology Social Work *Staff who hold a license in the following: LICSW, LMHC, LMFT, LADC I, may hold a degree in a field of study not listed above. Bachelors/Associates Degrees in Human Services for: ICC, TT&S, BMM, TM and FS&T Addictions Counseling Anthropology Applied Educational Psychology Art/Dance Therapy Child Development/Family Relations Childhood Education Clinical Psychology Counseling/Guidance Criminal Justice Divinity/Religion/Theology Drama Therapy Early Childhood Education Education Education, with a Concentration in School Psychology Educational Psychology Elementary School Education Family Therapy Forensic Psychology Health Administration Health Education Human Services Industrial Psychology Marriage & Family Therapy Music Therapy Nursing/Medicine Nutrition Bachelors/Associates Degrees in Human Services for: ICC, TT&S, BMM, TM and FS&T, continued Occupational Therapy Pastoral Counseling Psychology Recreational Therapy Rehabilitation Counseling School Psychology Social Work Sociology Special Education Special Needs Vocational Counseling     CBHI Staff Credentialing Waiver Request Form For MassHealth Managed Care Entity (MCE) Contracts Revised October 2014 Page  PAGE \* MERGEFORMAT 6   $29A_`arz{˺{jYj{H hGhL]CJOJQJ^JaJ hGh+FCJOJQJ^JaJ hGhNjCJOJQJ^JaJh\VCJOJQJ^JaJhCJOJQJ^JaJ#hGhO>*CJOJQJ^JaJ hGhOCJOJQJ^JaJ hGhtCJOJQJ^JaJ#huht5CJOJQJ^JaJhu5CJOJQJ^JaJ&hGht5>*CJOJQJ^JaJa E P o   F G [ \ gdHLgd9L & F8^8gd T & F8^8gd9L & F h^`gd9L & F H$h^`gd9L Hgd9L  % Q b i * 4 8 O P o p q п~p___M?hrCJOJQJ^JaJ#jhrCJOJQJU^JaJ h Th TCJOJQJ^JaJhCJOJQJ^JaJ hGhtVCJOJQJ^JaJ hGh(QCJOJQJ^JaJ hGhnRCJOJQJ^JaJh TCJOJQJ^JaJ hGhtCJOJQJ^JaJ hGhgCJOJQJ^JaJh\VCJOJQJ^JaJ hGhL@CJOJQJ^JaJ    ? 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