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MDHHS-5745, Health Home Provider (HHP) Application

Michigan Department of Health and Human Services

Office of Recovery Oriented Systems of Care

(Revised 7-24)

section 1 – organization information

Organization Name

DBA (if applicable)

Physical Address

City

State

Zip Code

Mailing Address

City

State

Zip Code

Phone Number

Facsimile Number

Email Address

Application Date

National Provider ID

CEO/Director Name

section 2 – organization ‘s health home contact person

Contact Name

Phone Number

Email Address

Mailing Address

City

State

Zip Code

section 3 – health home provider agreement

Check all accreditations your organization possesses

CARF	URAC	JCAHO	NCQA

Other

Health Home services will notify members of their right to opt-out of Home Health services at any time.

Health Home Provider agrees with Health Home goal to control costs of members’ benefits while maintaining quality health care by:

Improving patient outcomes and recovery.

Preventing unnecessary hospital, residential, and rehabilitation admissions/readmissions.

Avoiding unnecessary emergency room visits.

Performing regular medication reconciliations.

Coordinating care through electronic means when possible, including electronic health records.

Health Home Provider will maintain the mandatory staffing and credentialing criteria and follow all appropriate Behavioral Health and Developmental Disabilities Administration policies and corresponding State Plan Amendment, if applicable.

Health Home Provider will implement the six health home services:

Comprehensive Care Management

Care Coordination

Health Promotion

Comprehensive Transitional Care

Individual and Family Support Services

Referral to Community and Social Support Services

Home Provider will submit Health Home encounters for payment and reporting outlined in appropriate Behavioral Health and Developmental Disabilities Administration policies and corresponding State Plan Amendment, if applicable.

Health Home Provider will establish and maintain contracts/Memorandums of Understanding with their Lead Entity and pertinent providers to serve Health Home beneficiaries.

Health Home Provider will utilize MDHHS-5515 to obtain beneficiary consent to share information among all providers serving their Home Health beneficiaries.

Health Home Provider has or will utilize an Electronic Health Record in accordance with the CMS Promoting Interoperability Program.

Health Home Provider agrees to follow all requirements set forth in all appropriate Behavioral Health and Development Disabilities Administration policies and corresponding State Plan Amendment, if applicable.

Health Home Service Locations (include city and county of each site)

Check affiliated Health Home

Behavioral Health Home	Substance Use Disorder Health Home

section 4 – affirmation

I affirm, under the penalties for perjury, that the forgoing and following information is true, accurate, and complete. I understand that payments submitted under this NPI number will be from Federal funds, and that any falsification or concealment of material fact may be prosecuted under Federal and State laws. The Michigan Department of Health and Human Services (MDHHS) may ask for additional information regarding any of the information submitted as part of this form and application. MDHHS will pursue repayment in all instances of improper or duplicate payment. By signing this form, the provider attests that he/she has read and understands the policies and procedures set for in the Behavioral Health and Developmental Disabilities Administration policies, the corresponding State Plan Amendment, and all other applicable Medicaid laws and regulations.

The owner or an authorized official of the business entity, directly or ultimately responsible for operating business, is authorized signature of this form.

Print Official’s Name

Official’s Title

Official’s Signature	Date

Email completed and signed applications MDHHS-BHDDAHealthHomes@michigan.gov.

section 5 – MDHHS use only

Receipt Date

Review Date

Reviewer Name

Reviewer Signature

Reviewer Notes

Final Review Outcome

Provider Notification

Lead Entity

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.

MDHHS-5745 (Rev. 7-24) Previous edition obsolete.	1

MDHHS-5745, Health Home Provider (HHP) Application

Health Home Provider (HHP) Application

MDHHS;MDHHS-5745;HHP;Application

Michigan Department of Health and Human Services

2024-10-14

Simmons, Scott (DTMB)

Michigan Department of Health and Human Services (MDHHS)