DBT Specialty Provider Rate Application

New Mexico Evidence-Based Practices
Dialectical Behavior Therapy (DBT)
DBT Specialty Provider Rate Application

Dialectical Behavior Therapy (DBT)
Eye Movement Desensitization and Reprocessing Therapy (EMDR)
Functional Family Therapy (FFT)
Multisystemic Therapy (MST)
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

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Application

The NM EBP Qualifications for the DBT specific rate are:

1) Demonstration that provider-based team is offering full DBT with all required components

2) Demonstrated completion of DBT-Linehan Board of Certification for licensed practitioners.

If you meet these standards, complete the application and provide all requested information and supporting documentation. Applications will be reviewed, and qualifications will be verified by the Center of Innovation team, in consultation with EBP experts. Providers may be contacted to provide additional information about their DBT Team. Recommendations for approval of a provider’s EBP qualifications for the EBP specific rate will be made to the State.

Step 1 of 6

16%

I. Agency Service Data

Agency Name(Required)

Primary County of Service(Required)

Primary Address Medicaid Enrollment ID

Primary Agency Address(Required)

Street Address Address Line 2 City State ZIP Code

Is this EBP delivered in a secondary location other than the address provided above?(Required)

Yes

Second County of Service(Required)

Second Address Medicaid Enrollment ID

Second Address where EBP is delivered(Required)

Street Address Address Line 2 City State ZIP Code

Which populations does the DBT team serve?(Required)

Check all that apply

Adolescents

Adults

Does your agency currently work with/accept referrals for children in state custody (child welfare)?(Required)

Yes

Level of care or service where DBT is delivered(Required)

Outpatient

School-based

Residential

Community-based

Other

Please describe level of care or service where DBT is delivered(Required)

Description of DBT Program(Required)

Please indicate which components of DBT your program is currently providing.

DBT Individual Therapy

DBT Skills Group

DBT Skills Coaching

DBT Consultation team for team therapists

Agency is current funded by/contracted with the following:(Required)

Select all that apply.

MCO- Blue Cross Blue Shield of New Mexico (Turquoise Care)

MCO-Molina Healthcare (Turquoise Care)

MCO-Presbyterian Health Plan (Turquoise Care)

MCO-United Healthcare (Turquoise Care)

NM Medicaid Fee for Service

Direct Contract with CYFD

Direct Contract with BHSD

Other

Other funding/contract(Required)

Point of Contact First Name(Required)

Point of Contact Last Name(Required)

Title(Required)

Email(Required)

Phone(Required)

II. Staff Roster and Qualification

List each qualified staff member at the agency.

First Name of Practitioner #1(Required)

First

Last Name of Practitioner #1(Required)

Last

Title(Required)

Email(Required)

Phone(Required)

Degree(Required)

Licensure(Required)

Licensure Number(Required)

License Expiration Date(Required)

MM slash DD slash YYYY

Upload Professional License(Required)

Drop files here or

Max. file size: 100 MB.

Certification Issue Date(Required)

MM slash DD slash YYYY

Certification Expiration Date

MM slash DD slash YYYY

Do you serve the following populations?(Required)

Check all that apply

Children

Adolescents

Adults

Employment status(Required)

Staff

Contractor

Independent Practitioner

Practitioner NPI(Required)

Team Role(Required)

Check all that apply.

Individual Therapist

Participate in Consultation Team

Skills Coaching

Skills Group Leader

Team Leader

Upload certificate of completion of DBT Certification(Required)

Please use this section to Upload Documentation of DBT-Linehan Board of Certification. Visit dbt-lbc.org/ to learn more about certification.

Please DO NOT submit a Continuing Education certificate or a certificate of completion of the DBT didactic training here.

Drop files here or

Max. file size: 100 MB.

Additional Practitioners in this EBP?(Required)

Yes

First Name of Practitioner #2(Required)

First

Last Name of Practitioner #2(Required)

Last

Title(Required)

Email(Required)

Phone(Required)

Degree(Required)

Licensure(Required)

Licensure Number(Required)

License Expiration Date(Required)

MM slash DD slash YYYY

Upload Professional License(Required)

Drop files here or

Max. file size: 100 MB.

Certification Issue Date(Required)

MM slash DD slash YYYY

Certification Expiration Date

MM slash DD slash YYYY

Do you serve the following populations?(Required)

Check all that apply

Children

Adolescents

Adults

Employment status(Required)

Staff

Contractor

Independent Practitioner

Practitioner NPI(Required)

Team Role(Required)

Check all that apply.

Individual Therapist

Participate in Consultation Team

Skills Coaching

Skills Group Leader

Team Leader

Upload certificate of completion of DBT Certification Program(Required)

Drop files here or

Max. file size: 100 MB.

Additional Practitioners in this EBP?(Required)

Yes

First Name of Practitioner #3(Required)

First

Last Name of Practitioner #3(Required)

Last

Title(Required)

Email(Required)

Phone(Required)

Degree(Required)

Licensure(Required)

Licensure Number(Required)

License Expiration Date(Required)

MM slash DD slash YYYY

Upload Professional License(Required)

Drop files here or

Max. file size: 100 MB.

Certification Issue Date(Required)

MM slash DD slash YYYY

Certification Expiration Date

MM slash DD slash YYYY

Do you serve the following populations?(Required)

Check all that apply

Children

Adolescents

Adults

Employment status(Required)

Staff

Contractor

Independent Practitioner

Practitioner NPI(Required)

Team Role(Required)

Check all that apply.

Individual Therapist

Participate in Consultation Team

Skills Coaching

Skills Group Leader

Team Leader

Upload certificate of completion of DBT Certification Program(Required)

Drop files here or

Max. file size: 100 MB.

Additional Practitioners in this EBP?(Required)

Yes

First Name of Practitioner #4(Required)

First

Last Name of Practitioner #4(Required)

Last

Title(Required)

Email(Required)

Phone(Required)

Degree(Required)

Licensure(Required)

Licensure Number(Required)

License Expiration Date(Required)

MM slash DD slash YYYY

Upload Professional License(Required)

Drop files here or

Max. file size: 100 MB.

Certification Issue Date(Required)

MM slash DD slash YYYY

Certification Expiration Date

MM slash DD slash YYYY

Do you serve the following populations?(Required)

Check all that apply

Children

Adolescents

Adults

Employment status(Required)

Staff

Contractor

Independent Practitioner

Practitioner NPI(Required)

Team Role(Required)

Check all that apply.

Individual Therapist

Participate in Consultation Team

Skills Coaching

Skills Group Leader

Team Leader

Upload certificate of completion of DBT Certification Program(Required)

Drop files here or

Max. file size: 100 MB.

Additional Practitioners in this EBP?(Required)

Yes

First Name of Practitioner #5(Required)

First

Last Name of Practitioner #5(Required)

Last

Title(Required)

Email(Required)

Phone(Required)

Degree(Required)

Licensure(Required)

Licensure Number(Required)

License Expiration Date(Required)

MM slash DD slash YYYY

Upload Professional License(Required)

Drop files here or

Max. file size: 100 MB.

Certification Issue Date(Required)

MM slash DD slash YYYY

Certification Expiration Date

MM slash DD slash YYYY

Do you serve the following populations?(Required)

Check all that apply

Children

Adolescents

Adults

Employment status(Required)

Staff

Contractor

Independent Practitioner

Practitioner NPI(Required)

Team Role(Required)

Check all that apply.

Individual Therapist

Participate in Consultation Team

Skills Coaching

Skills Group Leader

Team Leader

Upload certificate of completion of DBT Certification(Required)

Drop files here or

Max. file size: 100 MB.

Additional Practitioners in this EBP?(Required)

Yes

The limit for the number of practitioners per application has been met.

Please email centerofinnovationnm@nmsu.edu if DBT team is greater than five.

Go to DBT Training page

DBT Specialty Provider Rate Application

Application

I. Agency Service Data

II. Staff Roster and Qualification

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