The CMHC organization should work with their designated Certifying State Agency (CSA) in completing the steps to voluntarily withdraw a CMHC Provisional or Full Certificate.
If 50% or more of the funding source for community mental health treatment, for the CMHC organization as a whole, is from the Illinois Department of Human Services (DHS)-Division of Mental Health (DMH) or if the funding source from both DHS-DMH and the Illinois Department of Children and Family Services (DCFS) are considered equal, DHS serves as the designated Certifying State Agency (CSA). If more than 50% of the funding source for community mental health treatment, for the CMHC organization as a whole, is from DCFS, DCFS serves as the designated CSA. Questions regarding who serves as the designated CSA may be forwarded to DHS-DMH Provider Access, Credentialing, and Enrollment Unit (PACE) at DHS.DMHProviderAssist@illinois.gov or DCFS-IPI at DCFS.Medicaid@illinois.gov.
DHS-DMH-PACE and the DHS-Bureau of Accreditation, Licensure and Certification (BALC) shall assist with completion of the requirements if DHS is the designated CSA. The Infant Parent Institute (IPI) shall assist with completion of the requirements if DCFS is the designated CSA.
The following are the steps that a CMHC organization must take to voluntarily withdraw a Provisional or Full Certificate. This withdrawal includes the closing of all certified CMHC sites operating under the organization and listed on the certificate.
1. CMHC Notifies CSA of Voluntary Withdrawal
Written notification of the voluntary withdrawal of certification must be submitted to the designated CSA, DHS-DMH-PACE at DHS.DMHProviderAssist@illinois.gov or DCFS-IPI at DCFS.Medicaid@illinois.gov. The notification should be received within thirty (30) calendar days of closure and include the:
- The Organization Letterhead
- Provider Name
- Employer Identification Number (EIN)/Tax Identification Number (TIN) of the CMHC
- Address of each site
- NPI number for each site
- Effective date of the withdrawal
- Reason for withdrawal
- Primary contact name and title
- Primary contact email address and telephone number
- Handwritten Signature (not electronic)
- Signature of anyone who has signing authority for the business.
- Form 2 (Request for Change to DHS/DMH Provider Record - Site Location Information), top portion of page one (1) only, must be completed for each site and forward to the designated CSA with the notification.
- The form 2 should not be uploaded to IMPACT.
Form 2 serves to notify the Administrative Service Organization (ASO), the Illinois Mental Health Collaborative (Carelon), of data that is necessary for Federal reporting requirements.
Form 2 is located on the DHS Rule 132 website or may be obtained by contacting the designated CSA at the email address above. Please see Instructions for Completing Form 1 and 2 for details on completing and submitting the forms. If questions regarding the notification or Form 2, contact the designated CSA at the email address above.
If DCFS-IPI is the designated CSA, DCFS-IPI shall forward Form 1 and Form 2 to DHS-DMH-PACE.
2. Illinois Medicaid Program Advanced Cloud Technology (IMPACT) System Modified
The IMPACT enrollment must be closed by uploading documentation and completing the Complete Modification Checklist step and submitting the modification to the Illinois Department of Healthcare and Family Services (HFS) for review and approval. Providers are now required to upload a Letter of Intent (LOI) to close the enrollment. Providers will upload the LOI in Step 13. Choose Others for Document Type. Choose Others for Document Name. Then upload the LOI to close the enrollment. The Modification Checklist, Step 14, will still need to be completed. Step 15, Submit Modification Request for Review, will need to be completed so the Modification to close the enrollment is submitted to the IMPACT Provider Enrollment (PE) Unit. The provider will need to upload the LOI to each active enrollment.
The following link accesses the IMPACT System: https://impact.illinois.gov
If questions or needing assistance with IMPACT, contact the designated CSA or the IMPACT Help Desk:
If experiencing difficulties in logging into the IMPACT System, contact:
The IMPACT System serves as the SYSTEM OF RECORD for the receipt of Federal Medicaid funding, therefore, all CMHC organizations are responsible for maintaining their enrollment(s) with up-to-date and accurate information at all times.
3. CSA Issues Notice of Voluntary Withdrawal of Certification
If DHS is the designated CSA, DHS-DMH-PACE shall notify DHS-BALC of the voluntary withdrawal of certification by forwarding a copy of the notification received.
The designated CSA, DHS-BALC or DCFS-IPI, shall issue a "Notice of Voluntary Withdrawal of Certification" to the organization within thirty (30) calendar days of receipt of the CMHC notification. The designated CSA shall also forward a copy of the notice to DHS-DMH-PACE.
4. IMPACT Modifications Processed
HFS-PE shall change the Business Status from "Active" to "In-Active/Closed" in IMPACT with an effective date as listed within the notification.
5. Bureau of Community Programs Notified (applies when DHS is the designated CSA)
When DHS is the designated CSA, DHS-DMH-PACE shall notify the respective Program Manager of the voluntary withdrawal of certification by forwarding a copy of the notification and each Form 2 received.
6. Illinois Mental Health Collaborative Notified
DHS-DMH-PACE shall notify the Illinois Mental Health Collaborative of the voluntary withdrawal of certification by forwarding all Form 2s received.
Other:
- A CMHC organization that has voluntarily withdrawn certification may reapply for certification at any time in accordance with Rule 132 standards.
- Professionally Licensed Employees enrolled in the IMPACT System, and who have associated themselves to sites of a CMHC organization that have voluntarily withdrawn their certification, should end date their association with each site.
- A disassociation of an individual with a CMHC site is accomplished by completing the Associate Billing Provider/Other Associations step and the Complete Modification Checklist step in the employee's individual IMPACT enrollment and submitting the modifications to HFS for review and approval.
- The CMHC organization should notify all associated in-network HFS contracted MCO plans that the organization is no longer functioning as a certified CMHC provider.
