Participation criteria for substance abuse treatment providers

Individuals who provide counseling services as part of a contracted Substance Abuse program do not need to be individually credentialed.  Providers participating with Priority Health as of March 1, 2002, who have been designated as a Dual Diagnosis provider, are grandfathered.

Substance Abuse / Dual Diagnosis Counselor

1. Practitioners in a public or private firm, association, organization, or group offering or purporting to offer specific substance abuse treatment, rehabilitation, case finding, or prevention services, must submit evidence that the facility or site at which the practitioner will provide substance abuse services is licensed (or granted exception) by the State of Michigan as a Substance Abuse Program.
2. Successful completion of a master's degree in social work or counseling;
3. CAC (Certified Addictions Counselor) credentials, minimum Level I; if not certified as an addictions counselor, provider must demonstrate all of the following: a., 3,000 hours of counseling experience, providing direct services to clients in substance abuse or related human services; b., 135 hours of training or continuing education specific to alcohol and other drug abuse issues; c., 150 hours of direct supervision; and d., services are provided in an underserved area;
4. If recovering, at least three (3) years of continuing sobriety;
5. Practitioner must maintain current professional liability insurance coverage meeting minimum limits of $1,000,000 per occurrence and $3,000,000 aggregate (should a practitioner not meet the coverage limit requirements, Priority Health will consider exceptions based on need of practitioner type or geographic needs);
6. Practitioner must have an absence of a history of involvement in a malpractice suit, arbitration or settlement; or in the case of a practitioner with this history, evidence must be provided that the history of malpractice involvement is not indicative of probable future substandard professional performance;
7. Practitioner must have an absence of a history of denial or cancellation of professional liability insurance; or in the case of a practitioner with this history, evidence must be provided that the history is not indicative of probable future Practitioner must meet contractual requirements for after hours coverage for specialty care practitioners;
8. Practitioner must have an absence of a history of involuntary termination of employment or contract as a health care practitioner; or in the case of a practitioner with this history, evidence must be provided that this history is not indicative of probable future substandard professional performance;
9. Practitioner must have an absence of a history of professional disciplinary action; or in the case of a practitioner with this history, evidence must be provided that this history is not indicative of probable future substandard professional performance;
10. Practitioner must have an absence of a history of failing to conduct themselves with a professional demeanor or of engaging in abusive or destructive behavior in professional matters.  Practitioner must avoid conduct which reflects adversely on their professional fitness;
11. Practitioner must have an absence of a history indicating (in the sole discretion of Priority Health) a tendency toward inappropriate utilization management of medical resources;
12. Practitioner must have an absence of a history of criminal conviction or indictment; or in the case of a practitioner with this history; evidence must be provided that this history is not indicative of probable future substandard professional performance.  A conviction within the meaning of this criterion includes a plea or verdict of guilty or a conviction following a plea of no contest;
13. Practitioner must have an absence of any history, in addition to that specified in other Criteria, that in any way is indicative of probable future substandard professional performance;
14. Practitioner must have an absence, or adequate control of, physical, mental health, or substance abuse problems which may interfere with their ability to practice their profession or facilitate cooperative working relationships, or which may pose a threat to their patients.  In conjunction with this requirement, practitioner must cooperate openly and fully with any required health assessment and must provide any reasonably requested evidence of health status.
15. Practitioner must comply with all Priority Health rules, regulations, bylaws, and the terms of their practitioner participation agreements.
16. Practitioner must demonstrate their willingness to provide appropriate and necessary emergency or non-emergency medical treatment within the scope of their expertise to any Priority Health member seeking treatment.
17. Practitioner shall not be known to have made any misrepresentations to Priority Health's Board of Directors, employees, agents, or enrollees regarding the provision of services to enrollees.
18. Practitioner shall not have falsified information on their applications or failed to notify the Physician Credentialing Committee regarding relevant changes in their status.
19. Three references, preferably to include a psychiatrist, who has had direct working experience with the Substance Abuse Treatment Provider.