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New Programs: Overview of ODMHSAS Certification Process

The following highlights the general processes to achieve an ODMHSAS Certification status. Please call Provider Certification at 405-248-9029 or email cladd@odmhsas.org, for additional information in Chapter 1, Subchapter 9 of OAC 450. Specific information is also available on the Administrative Code page

For New Programs Applying for Initial Certification

  1. Upon receiving a request from a provider, the Provider Certification (PC) division of ODMHSAS will electronically forward a current Certification Application Packet. After ensuring that all requested materials are compiled, the Provider can then submit the application, along with the required materials and fee in accordance with the instructions.
  2. Provider Certification staff will review submitted materials, verify receipt of the required fee, and determine if additional information is needed.  Then, a certification self-survey and site review protocol will be electronically provided to the provider.  Once completed and submitted back to Provider Certification along with policy and procedure, a lead reviewer will be assigned.  The reviewer will then conduct a review of the policy and procedure which entails standards and criteria related to overall organizational and operational functions. Policy that relates to clinical documentation will also be reviewed.  (However, clinical record and staff record documentation will be reviewed at a later phase of the Certification process – see Step 5 below.)  Once policy and procedure is approved, an initial site visit is scheduled to ensure compliance with health and safety standards in the chapter.
  3. If deficiencies are cited as a result of the review, Provider Certification will provide an electronic report to outline their findings and will provide this to the provider.  The provider will have ten working days to notify Provider Certification that the deficiencies have been corrected.
  4. A reviewer will then conduct a review to verify deficiencies are corrected. After corrections are deemed satisfactory, a Permit for Temporary Operation (PTO) will be considered by the ODMHSAS Board of Directors at one of the board’s meetings.  (Please refer to the ODMHSAS website for board meeting dates.)  The PTO is actually a license to allow the provider to begin offering services.  Medicaid, as a billing source, will not be available during this time since the PTO is not a full certification.  Other billing sources, such as private insurance, self-pay and pro bono, will have to be explored.  (Provider Certification can offer no other information regarding billing.)  PTOs expire in six months.
  5. Prior to expiration of the PTO, a subsequent review will be scheduled to review records and services that have been provided to determine compliance with Quality Clinical standards.  A minimum of five active (open), complete records will be requested as well as discharge records.  If a facility does not have the requisite number of active records, they can still be certified but it will affect the length of their certification (see Step 7 below).
  6. If deficiencies are cited as a result of the review, Provider Certification will provide an electronic report to outline findings at the subsequent review.  The provider will be requested to prepare a written report to ODMHSAS that outlines the plan it will follow to correct the deficiencies
    • One-year Certification if less than five records were available for review and if compliance on 75% of Clinical Standards at the time of the subsequent review (and all deficiencies were corrected on all standards)
    • Two-year Certification if five or more records were available for review and if compliance on 75% of Clinical Standards at the time of the subsequent review (and all deficiencies were corrected on all standards)

FAQ’S Regarding the Application Process

When can I begin billing for services rendered?

  • Title 43A requires providers to be certified in order to provide alcohol and drug treatment services. (43A O.S. §3-415(A)(1). Certification is required regardless of funding source. Because of this, certification must take place prior to billing. The first step of the certification process is obtaining a Permit for Temporary Operations (PTO). This phase lasts for approximately six months, enabling you to begin providing services - developing your caseload and preparing the appropriate documentation for services rendered. Towards the end of the PTO period, you will receive a subsequent review, during which time, ODMHSAS will review your clinical documentation. At the conclusion of this review process, if you are able to clear all deficiencies, we will make a recommendation to our board that you become certified. Upon Board approval, as well as completion of any billing requirements from any other parties, i.e. Medicaid, private insurance, you will be able to bill.
  • Mental health treatment providers who are seeking certification through ODMHSAS must also go through the PTO process, outlined above. During the six month time period, providers cannot bill OHCA for services rendered.

What is the certification process? Can you please tell me the steps involved?

I provide therapy from a non-commercial site. Will the site be suitable for certification?

  • Depending on the type of program for which you are seeking certification, the applicable chapter will have several standards that relate to the physical property as well as how the site will accommodate your consumers and the functioning of your agency. Relevant standards may include ADA compliance, confidentiality, physical environment and record storage. Please refer to the applicable chapter for the standards that pertain to the type of program for which certification is desired.

I will be providing therapy exclusively in homes, schools, and in community settings. Do I need to have a physical site certified?

  • The following chapters offer certifications for programs only: Chapters 16, 17, 18, 23, 24, 27, 55, 60, 65, and 70. These chapters do not offer certifications on an individual basis. Therefore, you will need to have a program site that is compliant with all relevant standards of the programs' chapter for which you are seeking certification.

The fire inspection that I would like to submit cites deficiencies. Will this be accepted as part of my application?

  • No, any deficiencies cited on the fire inspection must be cleared and this documented by the fire inspection personnel.

I have a fire inspection from a private company or landlord approving the location.  Is that acceptable?

  • No, the fire inspection must be conducted by a local fire department or the State Fire Marshal.

What do I need to do if my program is relocating to a different address?  

  • Written notice must be provided to Provider Certification with the effective date of the relocation, locations moving from and to, and a current and approved fire inspection for the new location.  (AS A REMNDER, THE NEW LOCATION IS NOT APPROVED UNTIL PROVIDER CERTIFICATION COMPLETES A SITE VISIT AND ISSUES THE APPROVAL NOTICE.)

Do I have to put the names of the employees in the organizational chart, can I just put the positions?

  • You must have both the names and the positions in the organizational chart.  

My agency is an LLC. Do I have to have a Board of Directors?

  • No.   

My agency is a corporation (Inc.). Do I have to have a Board of Directors?

  • Yes

Can I use my business address and phone number for the Board Members?

  • No, The Board Members’ own addresses and phone numbers must be used.

Instead of sending you the Certificate of Incorporation (or Limited Liability Company) certificate, can I just send you the online receipt that shows I paid for it.

  • No. A copy of the actual Certificate must be sent in with your application documentation.

What kind of zoning information do you want and where can I get it?  (This is for A/D applications only.)

  • You must contact the local zoning entity of your town.  That will vary with the size of the town.   It may be the zoning board, city manager, public works division, or some other entity designated by your town.
  • You must request a written statement on official letterhead that each of your treatment facilities is located in compliance with applicable zoning ordinances.  

Is a program description the same as a Mission Statement?

  • No. The program description must describe, not list, each of the services your agency will be providing, including those your agency is required to provide and those optional services you may have selected on the application form. It must also address how and by whom that service will be provided.  

Can I send you just the one letter from my national accreditation company that says how long we will be accredited and what kinds of programs for which we are accredited?

  • No. You must send all of the following information when you submit your application:  current accreditation status, the programs included in the most recent accreditation survey, survey reports, reports of subsequent actions initiated by the accrediting organization, plans of correction if applicable, and the time period for which accreditation has been granted.

I’ve been asked to provide a “full record” for my review. What does that mean?

  • A complete record shows the full range of services, from intake and assessment, to treatment plan to progress notes that show provision of services.

My review for Chapter 18, Alcohol and Drug Treatment, is coming up. What type of files will be looked at for a Chapter 18, Alcohol and Drug Treatment review?

  • The reviewers will look at records in which the primary diagnosis is substance abuse/dependence and the documentation in the record (assessments and progress notes), supports that this is a substance abuse treatment record.

I’ve been told that I need to provide five open records but I only have three. Can I still be reviewed?

  • Yes, you can still be reviewed. However, not having five records will impact the length of your certification and you must still achieve a score of 75% on your initial clinical record review in order to move forward with certification.

When the reviewers look at my clinical records, which consumer records will they be reviewing?

  • The reviewers will examine selected records that have been opened since the last certification. For the closed record portion, they will be looking at records that have been closed since the last certification.

In the chapter that I am seeking certification, it asks for staff to receive trainings. Does this apply to contract therapists and administrative positions?

  • Yes, it applies to all staff.

The ASAM form that I want to utilize, at admission, only screens for the level of care that I have. Will this form be compliant for 18-7-21?

  • No, this standard requires a list of symptoms for all six dimensions and each level of care to be present on the ASAM form that is utilized.  The purpose of the ASAM form is to see where a consumer lies in the spectrum of the levels of care. Upon performing the ASAM, the consumer may not require your level of care. However, from screening for all levels of care, this will allow the provider to see which level of care the consumer requires and they can then refer the consumer to where they need to go. Some type of decision tree/documentation connecting the symptoms with the outcome (level of care) is also required to show how the clinician arrived at their decision.

The ASAM form that I want to utilize, at discharge, only screens out for the level of care that I have. Will this form be compliant for 18-7-121?

  • No, for the above reasons. The purpose is to see which level of care the consumer requires, upon leaving your facility. As above, some type of decision tree/documentation is required which connects the symptoms with the outcome (level of care), to show how the clinician arrived at their decision.

I would like to utilize the ODASL for my ASAM instrument. Is the ODASL compliant with the standards which refer to ASAM?

  • Yes, the ODASL is compliant. Please ensure that, with the ODASL, you also utilize the ODASL Treatment Service Level Placement sheet which will serve as the decision tree/documentation connecting the dots between how the consumer scored and the level for care that was chosen. The ODASL Treatment Service Level Placement Sheet is a separate sheet that can be found here: http://www.odmhsas.org/picis/TraningInfo/arc_Training_Information.htm

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